Every finding on record at Mill Valley Care Center

Based on observation, record review, staff interview, and policy review the facility failed to follow appropriate transfer techniques resulting in injury for 1 of 1 resident reviewed (Resident #184). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) report dated 9/21/23 for Resident #184 documented a Brief Interview for Mental Status score of 6/15 indicating severe cognitive impairment. The MDS further indicated diagnoses including: non-traumatic brain dysfunction, non-Alzheimer's dementia, and arthritis. The Therapy Progress Note dated 10/8/23 reported Resident #184 attempted two stand pivot transfers with two assist but was unable to do it adequately, causing termination of transfer to prevent rolling an ankle. Consultation with nursing and aide staff regarding current level of function was done. The Therapy Communication form dated 10/08/23 and signed by Staff A, Physical Therapist (PT) indicated the resident was an assist of two and total body lift. The Restorative - MDS Communication Log entry dated 10/11/23 signed off by the Restorative Aide and the Director of Nursing (DON) documented Resident #184 was an assist of two with full body lift. The Health Status note dated 10/11/23 at 1:55 PM noted a nurse was called into Resident #184's room by the Certified Nursing Assistant (CNA) for a skin tear to the Lower Left Extremity (LLE). The CNAs stated they were transferring the resident via two assist with a gait belt and walker and the resident's feet got twisted together, causing the skin to tear on the LLE. In an interview on 7/24/24 at 8:02 AM with Staff B, Certified Occupational Therapy Assistant clarified full body lift meant a Hoyer lift. In an interview on 7/24/24 at 8:16 AM Staff C, Speech Therapist explained nurses and CNA's are allowed to provide more assistance with transfers, not less than prescribed. When a transfer level changes, the PT communicates the change with the DON and Restorative Nurse via the communication form. The Restorative Aide then puts a sign in the resident's room with the new transfer level. During an interview on 7/24/24 at 12:24 PM Staff A, PT explained Resident #184 was on her therapy caseload in April as an assist of 1. They picked her back up for right knee pain in the fall and changed her to assist of 2. She had a subluxated patella (partial dislocation) and they got an order for a brace. The resident had a cognitive decline towards the end and therapy wasn't benefiting her. They turned her into a full body lift. Staff A confirmed information is passed through a communication sheet and handed to the Restorative Nurse. The Nurse then gives it to the DON and it is signed off. The DON/Aide updates the sheet in the resident's room. All changes are discussed during the weekly Medicare meeting. The MDS Nurse notes the change on the Care Plan in the Electronic Health Record. In an interview on 7/24/24 at 12:30 PM the MDS Nurse reported she works with the restorative team. She updates the Care Plan after she gets the communication note from therapy. They keep a running sheet between them all to make sure nothing gets missed and they date when it is added to the Care Plan. During an interview on 7/24/24 at 2:04 PM the DON explained there was a lot of change over at the time the resident was transferred incorrectly and that might have played a part in the delay of the information being passed from PT to the team. They also did not have a Restorative Nurse at the time, just the aide, so that too might have impacted the delay. The facility lacked a policy on resident transfers.

Based on clinical record review, staff interview, and facility policy review, the facility failed to document Weekly Pressure Ulcer Assessments for 2 of 3 residents reviewed with pressure ulcers (Residents #2 and #3). The pressure ulcers for these 2 residents worsened during the missed assessment. The facility reported a census of 34. The Minimum Data Set (MDS) Assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: Inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Findings Include: 1. Review of a Wound/Skin Healing Record dated 11/14/23, documented Resident #2 had a Stage II Pressure Ulcer on her left buttock which measured 0.7 centimeters (cm) x 1.9 cm. Review of a Wound/Skin Healing Record dated 11/28/23, documented Resident #2 had a Stage II Pressure Ulcer on her left buttock which measured 1 cm x 1.8 cm. No noted assessments completed between these 2 dates, showing a 2 week timeframe between assessments. 2. A Wound/Skin Healing Record dated 1/11/24, documented Resident #3 had a Stage II Pressure Ulcer on coccyx which measured 0.5 cm x 0.25 cm. A Wound/Skin Healing Record dated 1/22/24, documented Resident #3 had a Stage II Pressure Ulcer on coccyx which measured 1.5 cm x 1 cm. No noted assessments completed between these dates, showing an 11 day gap between assessments. On 2/7/24 at 3:45 p.m., the Director of Nursing (DON) stated they were unable to find the weekly pressure ulcers requested for Resident #2 and Resident #3. The DON stated she did not know why the assessments were missed and acknowledged the assessments should have been done. A Skin Care: Management of Wounds and Pressure Injuries policy dated 6/20/23, directed staff: a. Wound management involves assessment and proper treatment of wounds to promote healing, minimize pain, and prevent infection. b. Visual assessment with every dressing change. Documented assessment at least weekly.

Based on observation, record review, resident and staff interview, the facility failed to answer call lights in a timely manner for two or fourteen residents reviewed. (Residents #4 and #12) The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #4 as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 6 out of 15 and had the following diagnoses: COVID-19, Coronary Artery Disease and Chronic Obstructive Pulmonary Disease. The MDS identified the resident required extensive staff assist with most activities of daily living and totally dependent on staff for locomotion on the unit and bathing. Observations of the resident revealed the following on 5/15/23 at the following times: a. At 3:00 PM, the call light to resident's room on, not flashing. Resident laid in bed lying on back, did not appear to be in distress, bed in high position. Currently no staff in hallway. b. At 3:07 PM, the call light remained on, the Activity Coordinator walked past the room without checking on the resident. c. At 3:09 PM, the call light remained on, the Activity Coordinator walked by the room again without checking on the resident d. At 3:13 PM, male Physical Therapy Staff Member assisted another resident to ambulate past this room, did not check on resident in room [ROOM NUMBER]. Call light remains on. One of the residents in the room yelled out help! e. At 3:14 PM, the Activity Coordinator again walked past the resident's room without checking on the resident. f. At 3:21 PM, Staff G, Certified Nursing Assistant (CNA) in the hallway and assisted another resident to walk into another room then closed the door. The call light to Resident #4's room has now been on for 21 minutes g. At 3:28 PM, Staff C, CNA walked into the room, turned off the call light and checked on the resident who asked for a snack. The call light had been on for 28 minutes. On 6/29/17, the Care Plan identified the resident with the problem of risk for falling (revised 3/28/23) and did not direct staff to answer call lights in a timely manner or address resident's needs if they see the call light on. 2. The MDS dated [DATE] identified Resident #12 as cognitively intact with a BIMS score of 13 out of 15 and with the following diagnoses: Anemia, Hyponatremia and Malnutrition. The MDS identified the resident required extensive staff assistance with most activities of daily living and totally dependent on staff for locomotion on and off the unit and the resident continent of bladder and bowel. In an interview on 5/15/23 at 10:15 AM, as the resident laid in her recliner and reported some staff will answer her call light right away and some will not. The longest she had to wait to get the light answered was an hour and usually happens at least once a week. Resident #12 reported problems with filling her pants waiting for help to the bathroom and this made her feel terrible. It's always the same girl who makes me wait, all different shifts. In an interview on 5/17/23 at 10:10 AM, as the resident rested in her recliner in her room, when asked how staff had responded to her call lights the past few days, she reported she has had to wait as long as 40 minutes. It always happens when one staff person works who she chose not to identify. The unidentified staff will come to her room after she turns on the call light, turn it off and says she'll come back. Then she won't come back until after the resident had already wet her pants and she did not like that feeling at all. In an interview on 5/17/23 at 11:11 AM, the resident requested to talk to Surveyor again. She reported there are two CNAs who will talk on their cell phones while taking care of her. She had not reported this to anyone about it because she felt it would not do any good. On 1/17/22, the Care Plan identified the resident with the problem of ability to complete Activities of Daily Living (ADL's), had deteriorated related to impaired mobility, weakness, debility, unsteady gait, chronic pain, and advanced age. The Care Plan updated on 2/23/23 failed to address the issue to answer call light in a timely manner. A review of the Nurse's Notes had the following documentation: On 4/19/2023 at 6:46 a.m., the MDS charting ongoing for unspecified anemia. Resident requires one person assist with transfers to and from the restroom. Continent of bowel and bladder. Resident uses pull-ups for incontinence supply needs. Uses restroom around every 3 to 4 hours. In an interview on 5/17/23 at 1:53 PM, Staff G, CNA reported call lights should be answered within 15 minutes and staff should address the resident's needs right away. On 5/17/23 at 2:02 PM, Staff E, CNA reported staff should answer call lights within 10 to 15 minutes and address the resident's needs while in the room answering the light. In an interview on 5/17/23 at 2:34 PM, Staff F, Licensed Practical Nurse (LPN) reported staff should answer call lights within 10 minutes. In an interview on 5/17/23 at 3:15 PM, the Director of Nursing (DON) reported any staff member can answer call lights. If the person can not address the resident's needs, they would be expected to let a Nursing Staff Member know. She would expect staff to answer call lights within 10 minutes. The DON reported Resident #12 had complained to her about her call lights not being answered in a timely manner. In an interview on 5/18/23 at 1:15 PM, the DON reported the facility did not have a policy on call lights.

Based on observation, record review, resident and staff interviews, the facility failed to maintain dignity for two of fourteen residents reviewed (Residents #8 and #12). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #12 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 13 out of 15 and had the following diagnoses: Anemia, Hyponatremia and Malnutrition. The MDS identified the resident required extensive staff assistance with most activities of daily living and totally dependent on staff for locomotion on and off the unit and documented the resident as continent of bladder and bowel. In an interview on 5/15/23 at 10:15 AM, as Resident #12 laid in her recliner, she reported some staff will answer her call light right away and some will not. The longest she had to wait to get the light answered was an hour and usually happens at least once a week. She had problems with filling her pants waiting for help to the bathroom, this made her feel terrible. The resident stated it is always the same girl who makes her wait on all different shifts. In an interview on 5/17/23 at 10:10 AM, while Resident #12 rested in her recliner in her room, when asked how staff had responded to her call lights the past few days, she reported she has had to wait as long as 40 minutes. The resident reported this happens when the same staff person works and she chose not to identify. The staff person will come to her room after she turns on the call light, turn it off and says she'll come back. Then she won't come back until after the resident had already wet her pants. The resident commented she did not like that feeling at all. She also reported there are two staff members who will talk on their cellular phones in her room while providing cares. In an interview on 5/17/23 at 11:11 AM, the resident requested to talk to surveyor again. She reported there are two Certified Nursing Assistants (CNA's) who will talk on their cell phones while taking care of her. She had not reported this to anyone about it because she felt it would not do any good. The Care Plan dated 1/17/22 identified the resident with the problem of ability to complete Activities of Daily Living (ADL's) had deteriorated related to impaired mobility, weakness, debility, unsteady gait, chronic pain, and advanced age. The Care Plan updated 2/23/23 and failed to address the issue to answer call lights in a timely manner. A review of the Nurse's Notes documented on 4/19/23, at 6:46 AM, the MDS charted the following: a. Ongoing for unspecified anemia. b. Resident requires one person assist with transfers to and from the restroom. c. Continent of bowel and bladder. Resident uses pull-ups for incontinence supply needs. d. Uses restroom around every 3 to 4 hours. In an interview on 5/17/23 at 1:53 PM, Staff G, CNA reported call lights should be answered within 15 minutes, that staff should address the resident's needs right away. On 5/17/23 at 2:02 PM, Staff E, CNA reported staff should answer call lights within 10 to 15 minutes and address the resident's needs while in the room answering the light. In an interview on 5/17/23 at 2:34 PM, Staff F, Licensed Practical Nurse (LPN) reported staff should answer call lights within 10 minutes. In an interview on 5/17/23 at 3:15 PM, the Director of Nursing (DON) reported any staff member can answer call lights. If the person can not address the resident's needs, they would be expected to let a nursing staff member know. The DON would expect staff to answer call lights within 10 minutes and also reported Resident #12 complained to her about her call lights not being answered in a timely manner. The facility provided an undated Form titled: Resident Rights which documented the following: a. The resident has the right to be treated with respect and dignity including. b. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents. 45775 2. The MDS Assessment Tool dated 4/10/23, listed diagnoses for Resident #8 that included: severe cognitive disability, dysphagia (difficulty swallowing), and muscle weakness. The MDS revealed the resident totally dependent on staff to eat, and complete personal hygiene tasks. The MDS listed the BIMS score as 00 out of 15, indicating severe impaired cognition. During a lunch observation on 5/17/23 at 12:5 5 PM , Staff H, CNA used a spoon to wipe the residents mouth after a bite of food. Staff H repeated this action after the next bite. On 5/17/23 at 12:56 PM, Staff H used a spoon to wipe the residents mouth after a bite of food. Staff H repeated this action after the next bite. During an interview on 5/17/23 at 1:50 PM, Staff G, CNA stated she would use a napkin to wipe a resident's mouth. She stated she has used a spoon before, but does not know if that is correct. During an interview on 5/17/23 at 2:10 PM, Staff E, CNA stated when she assisted Resident #8 to eat she made sure to have napkins. She added she has never used a spoon to wipe a resident's mouth. During an interview on 5/17/23 at 2:45 PM, the DON stated she would expect staff to use a napkin to wipe a resident's mouth when assisting with eating a meal, and it is not acceptable to use a spoon. The policy, dated January 2023, titled Residents' [NAME] of Rights under point A documented the facility must treat each resident with respect and dignity and care for each resident in the manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observation, record review and staff interview, the facility failed to complete a significant change MDS (Minimum Data Set) within 14 days after the resident experienced a significant weight loss for one of two residents reviewed (Resident #20). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #20 as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15 and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), Coronary Artery Disease and Non-Alzheimer's Dementia. The MDS identified the resident required extensive staff assistance with transfers, locomotion on the unit, dressing, toileting, personal hygiene and bathing. Resident #20 totally dependent on staff for locomotion off the unit. The MDS identified the resident with a weight loss of 5% or more in the past month and not on a prescribed weight loss program. A review of the weights documented in the electronic medical record revealed the following: a. On 1/5/2023 at 3:27 PM = 178.8 pounds (lbs) b. On 2/17/2023 at 1:38 PM = 166.0 lbs A review of the Dietitian Progress Notes revealed the following: a. On 1/12/23 10:35 AM - Resident hospitalized [DATE] through 1/5/23 for acute diverticulitis with evidence of perforation and abscess. She returned to facility on a mechanical soft diet (previously on a general diet) Routine snacks offered. Consider nutrition supplement if needed. b. On 2/17/23 2:09 PM, Monthly Weights: February = 166 lbs, January = 178.8 lbs, November = 182 lbs, August = 188 lbs. Triggered for 7.2% weight loss in 1 month, 8.8% weight loss in 3 months, and 11.7% weight loss in 6 months. Noted to have a decrease in food intake last month and nutrition supplement daily (QD) set up for her. Had good intakes of vanilla supplement mixed with milk. Will increase nutrition supplement to three times daily (TID). Will notify the Doctor of significant weight loss and continue to monitor as needed (PRN). c. On 3/10/23 at 11:37 AM, Significant change: Resident has variable intake on the mechanical soft diet with no peas, corn, nuts, or seeds. Her weight is 167.5 lbs, which triggers for 12.1% weight loss in 6 months. Weight History: February = 166 lbs, December = 180 lbs, September = 190.5 lbs. Nutrition supplement QD added in Jan after observing decreased intakes following her hospitalization for diverticulitis and new colostomy. She had significant weight loss in Feb and nutrition supplement increased to TID. Weight stable over 1 month with increase in nutrition supplements. Meds noted; she has Multi-Vitamin supplement in place. No recent labs available. Skin intact. She dines independently in the Main Dining Room (MDR) and is assisted with set up as needed. No chewing or swallowing difficulties with current diet texture. Routine snacks offered. She has good to excellent intake of the nutrition supplement TID. Continue current diet order and interventions. Will notify the Doctor of significant weight loss and continue to monitor PRN. See nutrition assessment. The Significant Weight Loss MDS had not been completed until 20 days after the significant weight loss identified. The Care Plan entry initiated on 3/3/20, documented the resident with variable intake and potential for significant weight change due to pain, weakness, need for texture modified diet. No new interventions had been added to the Care Plan after the Dietitian identified the significant weight loss on 2/17/23 until 3/3/23. On 5/15/23 12:20 PM, Resident #20 now sitting up in wheelchair in the main dining room with continuous oxygen maintained at 3 liters per nasal cannula, per concentrator, respirations even and unlabored. Properly positioned and appears comfortable. Condiments on table, has one cup of coffee and one glass of water in front of her. Waiting to be served lunch. On 5/15/23 12:27 PM, sitting at table with plate of barbecue pork sandwich and mashed potatoes and one dessert bowl of cottage cheese (half eaten) flagged down surveyor and said I'm throwing up again surveyor informed Staff F, Licensed Practical Nurse (LPN) who then pushed the resident out of the main dining room. In an interview on 5/17/23 at 2:34 PM, Staff F, LPN did not know when a Significant Change MDS should be completed after a significant weight loss is identified. In an interview on 5/17/23 at 3:15 PM, the Director of Nursing (DON) did not know when a Significant Change MDS should be completed after a significant weight loss is identified. In an interview on 5/18/23 at 1:15 PM, the Director of Nursing reported the facility did not have a policy on updating MDS forms.

Based on observation, record review and staff interview, the facility failed to develop a Comprehensive Care Plan to address the indwelling catheter the resident had for one of one residents reviewed (Resident #83). The facility reported a census of 35 residents. Findings Include: 1. The resident did not have a completed Minimum Data Set during the survey. The Electronic Medical Record revealed an admitted [DATE] and identified the following diagnoses for Resident #83: spinal stenosis, benign prostatic hyperplasia (BPH) and overflow incontinence. On 5/9/23 the Care Plan identified the resident with the only problem of involved in activities of choice and did not address the indwelling catheter. The initial observation of the resident on 5/15/23 at 10:25 AM, revealed as the resident sat up in his wheelchair with an indwelling catheter and the catheter bag not placed in a dignity bag and touching the carpeted floor. A review of the Nurse's Notes revealed no documentation of Nurse's Admission Assessment Note or any mention of the catheter until 5/16/23. On 5/16/23 at 9:15 AM, a Nurse's Note documented a call placed to Home Health Nurse to find out when the resident's catheter was last changed. In an interview on 5/17/23 at 2:34 PM, Staff F, Licensed Practical Nurse reported the indwelling catheter should have been addressed on the Care Plan. In an interview on 5/17/23 at 3:15 PM, the Director of Nursing (DON) reported she would expect the Care Plan to address the indwelling catheter. A review of the facility policy titled: Comprehensive Care Plan with the last revision date of 7/18/22 had documentation of the following: a. Within 7 days of completion of the comprehensive assessments, all residents should have a computerized Care Plan.

Based on clinical record review, staff interviews and policy review, the facility failed to revise a Care Plan with significant weight loss interventions for one of two residents reviewed for Care Plans (Resident #20). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #20 as cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15 and had the following diagnoses: Atrial Fibrillation (an abnormal heart rhythm), coronary artery disease and Non-Alzheimer's Dementia. The MDS identified the resident required extensive staff assistance with transfers, locomotion on the unit, dressing, toileting, personal hygiene and bathing. Resident #20 totally dependent on staff for locomotion off the unit. The MDS identified the resident with a weight loss of 5% or more in the past month and not on a prescribed weight loss program. A review of the weights documented in the electronic medical record revealed the following: a. On 1/5/2023 at 3:27 PM = 178.8 pounds (lbs) b. On 2/17/2023 at 1:38 PM = 166.0 lbs A review of the Dietitian Progress Notes revealed the following: a. On 1/12/23 10:35 AM - Resident hospitalized [DATE] through 1/5/23 for acute diverticulitis with evidence of perforation and abscess. She returned to facility on a mechanical soft diet (previously on a general diet) Routine snacks offered. Consider nutrition supplement if needed. b. On 2/17/23 2:09 PM, Monthly Weights: February = 166 lbs, January = 178.8 lbs, November = 182 lbs, August = 188 lbs. Triggered for 7.2% weight loss in 1 month, 8.8% weight loss in 3 months, and 11.7% weight loss in 6 months. Noted to have a decrease in food intake last month and nutrition supplement daily (QD) set up for her. Had good intakes of vanilla supplement mixed with milk. Will increase nutrition supplement to three times daily (TID). Will notify the Doctor of significant weight loss and continue to monitor as needed (PRN). c. On 3/10/23 at 11:37 AM, Significant change: Resident has variable intake on the mechanical soft diet with no peas, corn, nuts, or seeds. Her weight is 167.5 lbs, which triggers for 12.1% weight loss in 6 months. Weight History: February = 166 lbs, December = 180 lbs, September = 190.5 lbs. Nutrition supplement QD added in Jan after observing decreased intakes following her hospitalization for diverticulitis and new colostomy. She had significant weight loss in Feb and nutrition supplement increased to TID. Weight stable over 1 month with increase in nutrition supplements. Meds noted; she has Multi-Vitamin supplement in place. No recent labs available. Skin intact. She dines independently in the Main Dining Room (MDR) and is assisted with set up as needed. No chewing or swallowing difficulties with current diet texture. Routine snacks offered. She has good to excellent intake of the nutrition supplement TID. Continue current diet order and interventions. Will notify the Doctor of significant weight loss and continue to monitor PRN. See nutrition assessment. The Care Plan entry initiated on 3/3/20, documented the resident with variable intake and potential for significant weight change due to pain, weakness, need for texture modified diet. No new interventions had been added to the Care Plan after the Dietitian identified the significant weight loss on 2/17/23 until 3/3/23. In an interview on 5/17/23 at 2:34 PM, Staff F, Licensed Practical Nurse (LPN) reported the Care Plan should be revised when a significant weight loss is identified. In an interview on 5/17/23 at 3:15 PM, the Director of Nursing (DON) reported she would expect the Care Plan to be revised when a significant weight loss is identified. She would expect Nursing Staff to update the Care Plans. The facility policy titled: Comprehensive Care Plans with the last revision date of 7/18/22 documented the following: a. The Care Plan shall be periodically reviewed and revised by a team of qualified persons after each assessment. b. The Care Plan shall be updated if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse

Based on observations, record review and staff interviews, the facility staff failed to properly maintain a Foley catheter bag off the floor to prevent potential urinary tract infections for one of one residents reviewed with an indwelling catheter (Resident #83). The facility reported a census of 35 residents. Findings Include: 1. Resident #83 did not have a completed Minimum Data Set during the survey. The Electronic Medical Record revealed an admitted [DATE] and had the following diagnoses: spinal stenosis, benign prostatic hyperplasia (BPH) and overflow incontinence. Random observations of the resident revealed the following: a. On 5/15/23 at 10:25 AM, as the resident in a wheelchair in the lobby area near the entrance, the Foley (catheter) bag not properly placed as it touched the carpeted floor. b. On 5/15/23 at 10:39 AM, assessment unchanged, Staff A, Certified Nursing Assistant (CNA) walked by the edge of the main dining room and did not reposition the bag off the floor. c. On 5/15/23 at 10:47 AM, assessment unchanged, Staff B, CNA walked by residents near edge of the main dining room and did not reposition bag off floor. d. On 5/15/23 at 11:15 AM, now sitting up in wheelchair in his room with Foley bag lying on the floor. e. On 5/15/23 at 11:30 AM, assessment unchanged, bag remains on floor. f. On 5/15/23 at 11:48 AM, assessment unchanged, bag remains on floor. g. On 5/15/23 at 12:06 PM, now sitting up in wheelchair at main dining room table with both feet on the floor, Foley bag remains laying on the floor. h. On 5/15/23 at 12:38 PM, the Restorative Nurse stood at the resident's table, talking to resident's wife who is also a resident, the Restorative Nurse did not reposition bag off floor. CNA's at other tables assisted residents to eat and failed to address the catheter bag lying on the floor. i. On 5/15/23 at 12:55 PM, resident able to push himself away from the main dining room table with the Foley bag still on the floor. j. On 5/15/23 at 1:44 PM, resident sitting in wheelchair outside his room, talking on his cell phone. Foley bag remains on the floor. Staff D, CNA and Staff E, CNA walked out of the room next door, neither one adjusted the position of the bag. k. On 5/15/23 at 1:47 PM, Staff C, CNA stood in doorway to the resident's room, did not adjust the bag off the floor, resident then self propelled into the room with bag dragging across the carpeting then the floor in the room. l. On 5/16/23 at 10:40 AM, the resident sitting up in wheelchair in common area by front door, Foley bag in dignity bag below wheelchair seat, however, tubing noted on the floor. m. On 5/16/23 at 11:04 AM, assessment unchanged, tubing remains on the floor n. On /16/23 at 11:08 AM, noted the resident's daughter pushed his wheelchair around to face the TV, tubing remains on the floor. o. On 5/16/23 at 11:33 AM, assessment unchanged, with tubing on the floor. p. On 5/16/23 at 11:35 AM, resident remains in wheelchair and able to self propel to his room with tubing dragging on the floor. In an interview on 5/17/23 at 1:53 PM, Staff G, CNA reported if a resident had an indwelling catheter, she would need to put the bag in the privacy bag and make sure the tubing doesn't get twisted. In an interview on 5/17/23 at 2:02 PM, Staff E, CNA reported if a resident had an indwelling catheter, she would need to make sure tubing is below the bladder that it's not kinked up and place in a privacy bag. The tubing should also be kept off the floor. In an interview on 5/18/23 at 12:31 PM, the Director of Nursing (DON) reported she would expect her staff to ensure residents with indwelling catheters that the bag and tubing were kept below the level of the bladder, ensure the tubing isn't kinked and when out of the room, make sure the bag is in a dignity bag. A review of the facility policy titled: Catheter Care dated as effective 10/1/18 had documentation of the following: Tubing and bag should not touch the floor.

Based on observation, record review and staff interview, facility staff failed to provide proper incontinence care in a manner to prevent potential urinary tract infections for one of one residents reviewed (Resident #2). The facility reported a census of 35 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #2 as cognitively impaired with a Brief Interview for Mental Status (BIMS) of 0 and had the following diagnoses: Non-traumatic Brain Dysfunction, Unspecified Dementia and Coronary Artery Disease. The MDS identified the resident required extensive staff assist with bed mobility, dressing and personal hygiene and totally dependent on staff for transfers, locomotion on the unit and bathing. The MDS identified the resident as occasionally incontinent of bladder and always incontinent of bowel. During an observation on 5/15/23 of incontinence care for Resident #2 revealed the following: a. At 1:24 PM, Staff E, Certified Nursing Assistant (CNA), used the correct technique, changed surfaces with each wipe then cleansed peri area then both turned resident to her right side. Staff D, CNA held resident up to her side as Staff E, CNA cleansed resident's rectal crease which had a smear of bowel movement (BM). b. At 1:35 PM, Staff D did not change gloves after she cleansed rectal crease and applied barrier ointment to the resident's peri rectal area. c. At 1:43 PM Staff D, donned gloves, emptied basin into sink, (instead of the toilet) In an interview on 5/17/23 at 1:53 PM, Staff G, CNA reported when providing peri cares after a resident had a BM, she would change gloves whenever her gloves got soiled and would empty the basin of water used into the toilet. In an interview on 5/17/23 at 2:02 PM, Staff E, CNA reported when providing peri cares after a resident had a BM, she would change gloves whenever her gloves got soiled and would empty the basin of water used into the toilet. In an interview on 5/18/23 at 12:31 PM, the Director of Nursing (DON) reported she would expect her staff when providing incontinence care after a resident had a BM, to change gloves after they had dealt with the BM and before touching anything clean. She would also expect the CNA's to empty the wash basin into the toilet afterward. A review of the facility policy titled: Incontinence Care dated as effective 10/1/18 documented the following under Procedure: a. Wash hands and don gloves. b. Cleanse all areas of skin that are soiled. c. Remove gloves, wash hands and apply new gloves. d. Apply skin barrier, remove gloves, clean area, make sure resident is comfortable. The policy did not direct staff where to empty the water from the wash basin.

Based on record review, staff interviews and policy review the facility failed to report allegations of alleged abuse in a timely manner for 1 of 2 residents reviewed (Resident #3). The facility reported a census of 33 residents. Findings Include: Resident #3's Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses that included: anemia, coronary artery disease, seizure disorder and depression. The MDS reflected Resident #3 as rarely understood, and continuously distracted. The Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicated moderately impaired cognitive status for the resident. The MDS indicated Resident #3 required limited assist of one staff with transfer, toileting and personal hygiene. Review of the 5 day Investigative Summary revealed on 2/12/23 Staff A, Certified Nursing Assistant (CNA) reported to Administration, Staff B, Registered Nurse (RN) roughly pushed Resident #3 back into his wheelchair when he attempted to get up from the chair on 2/3/23. She did not immediately report the abuse to a supervisor due to threats from Staff B, RN. The Psychosocial Progress Note for Resident #3 dated 2/14/23 revealed follow up for a nurse who allegedly roughly shoved resident into his wheelchair and was told to sit down. During an interview on 4/11/23 at 11:01 AM, Staff A, CNA stated she heard Resident #3 scream and then she saw Staff B, RN push Resident #3 back into his wheelchair when he attempted to get up. Staff yelled at Resident #3 and used profanity in an angry voice to make the resident sit back down. Staff A failed to report the incident to a Supervisor at the time of the incident related to threats Staff B, RN made to her. Staff A stated she was not educated to report Abuse when she started to work at the facility. During an interview on 4/12/23 at 9:39 AM with Staff C, CNA stated the facility never directed him to report Abuse but he is aware to report it as soon as you are able. During an interview on 4/13/23 at 2:20 PM, Staff D, RN, Nurse Consultant, reported would expect the facility to do an investigation and suspend the staff. Also staff should report it immediately if they suspect abuse. During an interview on 4/13/23 at 2:35 PM, the Administrator stated she would expect staff to report immediately to the Supervisor and as the Administrator, would like to be informed immediately if staff witness abuse or suspect abuse to a resident. Review of the facility policy dated October 2022 titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy directed staff all allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Charge Nurse. The Charge Nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or the designated representative.

Based on observation, record review, and staff interviews the facility failed to follow the Care Plan for one of four residents (Resident#4), and failed implement a Care Plan for 3 of 3 residents (Resident #14,#21, and #22). The facility reported a census of 27 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident#4 required total assistance of two staff members for transfers, and bathing and the resident required extensive assistance of one staff for personal hygiene. The MDS documented the resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan documented the resident experienced occasional incontinence related to impaired mobility and diuretic medication. The Care Plan directed staff to check and change the resident every two hours, and as needed. The Care Plan documented that the resident would not exhibit skin breakdown secondary to incontinence. On 01/10/22 11:21 a.m., revealed the resident sitting in his wheelchair with wetness to the groin area of his pants easily visible. On 01/10/22 at 11:21 a.m., the resident reported that it hurt under his leg, noting the resident pulled on the lift sling under his leg and reported the sling digging into his leg. On 01/10/22 at 1:00 p.m. the resident propelled himself away from the dinning room table and headed down the North Hallway, observing the resident with increased wetness to his groin area. On 1/10/22 at 3:15 p.m., Staff A, Certified Nurses Aide (CNA) and Staff B, CNA transferred the resident from the wheelchair to the bed. The residents brief saturated with urine, and his pants were also wet with urine. Staff A and Staff B provided incontinence care to the resident, but the staff failed to clean the residents right hip. The residents skin had a dark pink mark below the residents left buttock, approximately the same location where the sling lift would have been between the resident and the wheelchair. Also, the residents buttocks looked macerated, with wrinkled skin, and the resident pointed to his left buttock, and complained of itching. On 1/10/22 during continuous observations from 11:21 a.m. to 3:15 p.m., revealed the resident did not get checked and changed every two hours as directed per the Care Plan. On 1/12/22 at 2:37 p.m. Staff A, CNA reported the resident is to be toileted every two hours. On 1/13/22 at 9:42 a.m. Staff C, CNA reported the resident taken to the bathroom after meals, and he will also push his call light if he needs to use the urinal On 1/12/22 at 9:43 a.m. Staff D, Licensed Practical Nurse (LPN) reported the resident does use his call light to ask for assistance to use his urinal, and is checked after meal times. 2. The 11/30/21 Modified Admission Minimum Data Set (MDS) for Resident #14 indicated a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. The MDS documented a hearing aid used for hearing to be adequate, and Activities of Daily Living (ADL) requires extensive assistance. Care Areas Assessments (CAA) identified: cognitive loss/dementia, and communication. Resident #14 documented with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/10/21 at 2:42 PM, observation revealed the resident wore one (right) hearing aide and a second (left) hearing aid not worn and observed to be on Resident #14's end table in room. The second hearing aid noted without the hearing piece attached. The resident's Care Plan did not address communication/hearing aids for the resident. Staff K, Registered Nurse (RN) MDS and Care Plan Coordinator reported on 1/13/22 at 12:14 PM, the facility Assistant Director of Nursing (ADON) or Director of Nursing (DON) complete Baseline Care Plans upon resident admission. Staff K reported she completes the Initial Care plan. The Initial Care Plans are often pre-populated goals and interventions. If a need is not addressed by the pre-populated goals and interventions it is a case by case basis to add a unique need. Staff K stated that if a resident has communication and ADL needs and wears bilateral hearing aids it is a yes and no, depends if that is added to the Care Plan. Staff K stated that it is common sense for the staff to assist the resident with hearing aids. Staff K agreed that restorative care should be included on a resident's Care Plan The DON stated on 1/13/22 at 1:35 PM, if a resident has a need in ADL's and communication she expects this to be on the resident's Care Plan. On 1/18/22 at 1:20 PM, the DON provided a Care Plan Audit Tool that is a comprehensive list of items to be included on the residents' Care Plans. Some of the items listed on the audit tool are: transfers, hearing aids, restorative program, and incontinence. An Order Summary Report signed by the physician on 1/4/22 showed an order dated 11/24/21 for [MEDICATION(S)] Solution -0.1 unit per milliliter (ml) ([MEDICATION(S)] B-[MEDICATION(S)], antibiotic eye drop for bacterial infections). Instill 1 drop in both eyes four times a day for bacterial infection. The November 2021, December 2021 and January 2022 Medication Administration records documented the [MEDICATION(S)] Solution antibiotic eye medication administered from 11/24/21 thru 1/13/21 per the Physician Order. A review of the Care Plan on 1/13/22 revealed the Care Plan failed to address Resident #14 had a bacterial eye infection or the scheduled use of the [MEDICATION(S)] Solution antibiotic eye drop. During an interview on 1/13/21 at 12:08 p.m., the DON reported she would expect an acute or chronic condition that is being treated to be on the Care Plan. 3. According to the Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 shown diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #21 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident with severe impaired cognitive status. The MDS indicated the resident needed extensive assist of 2 staff with transfers, bed mobility and with limited range of motion on side to upper and lower extremities. The Occupational Therapy Discharge Summary with date of service 9/27/21 through 11/9/21 listed discharge recommendations and status with Restorative Program established/trained: restorative range of motion program to both lower extremity due to patient not ambulating and using lift for transfers. The facility Care Plan with an approach dated 9/23/21 directed staff to have Physical Therapy and Occupational Therapy evaluate and treat. The Care Plan failed to have any Restorative Nursing Programs listed to direct staff to provide range of motion exercises. During an interview with the Nurse Consultant 1/13/22 at 9:39 AM, she states unable to find therapy recommendations on the Care Plan for Resident #21. During an interview on 1/18/22 at 10:00 AM, the Nurse Consultant states Therapy writes a Communication Sheet and then the (MDS) Nurse should add it to the Care Plan and initiate the program. If Therapy recommended range of motion I would expect to find it on the Care Plan. During an interview on 1/18/22 at 11:13 AM, the Director of Nursing stated she would expect the Therapy recommendations to be on the Care Plan. 4. The MDS for Resident #22 dated 11/30/21 showed a BIMS score of 11 indicating moderate cognitive loss with no behaviors present. The resident required extensive assistance for bed mobility, transfer, dressing, toileting and personal hygiene. The Care Plan revealed an intervention/task with date initiated 9/7/21 - Transfer with sit to stand lift and assist of two. During an interview on 1/13/22 at 1:10 PM with Staff N, Certified Nursing Assistant (CNA) states she transferred the resident using a mechanical lift with only herself or one person.

Based on observation, clinical record review, staff interviews, and facility policy the facility failed to provide complete incontinence care for 2 of 3 residents reviewed for incontinence care (Resident#4 ,22). The facility also failed to properly transfer a resident with a mechanical list for 1 out of 4 observed for assistance with transfers (Resident#22). The facility reported a resident census of 27. Findings Include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident#4 required total assistance of two staff members for transfers, and bathing and the resident required extensive assistance of one staff for personal hygiene. The MDS documented the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan documented the resident experienced occasional incontinence related to impaired mobility and diuretic. The Care Plan directed staff to check and change the resident every two hours, and as needed. The Care Plan documented that the resident would not exhibit skin breakdown secondary to incontinence. Observation on 1/10/22 11:21 a.m. revealed the resident sitting in his wheelchair with wetness to the groin area of his pants easily visible. On 1/10/22 at 11:21 a.m., the resident reported it hurt under his leg, the resident pulled on the lift sling under his leg and reported the sling had been digging into his leg. On 1/10/22 at 1:00 p.m., the resident propelled himself away from the dinning room table and headed down the north hallway, noting the resident with increased wetness to his groin area. On 1/10/22 at 3:15 p.m. Staff A, Certified Nurses Aide (CNA) and Staff B CNA transferred the resident from the wheelchair to the bed. The residents brief saturated with urine, and his pants were also wet with urine. Staff A and Staff B provided incontinence care to the resident, but the staff failed to clean the residents right hip. The residents skin had a dark pink mark below the residents left buttock, approximately the same location where the sling lift would have been between the resident and the wheelchair. Also, the residents buttocks looked macerated, with wrinkled skin and the resident pointed to his left buttock, and complained of itching. On 1/12/22 at 2:37 p.m. Staff A, Certified Nurses Aid (CNA) reported the resident is to be toileted every two hours. On 1/13/22 at 9:42 a.m. Staff C, CNA reported the resident is taken to the bathroom after meals and he will also push his call light if he needs to use the urinal On 1/12/22 at 9:43 a.m. Staff D, Licensed Practical Nurse (LPN) reported the resident does use his call light to ask for assistance to use his urinal, and is checked after meal times. The undated Skills Check List for Incontinence Care included directions for the staff to roll the resident onto each side, and to wash the top hip, and top buttock. 2. According to the MDS dated [DATE] for Resident #22 shown diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #21 scored a 11 out of 15 on the BIMS, indicating the resident had moderately impaired cognitive status. The MDS indicated the resident needed extensive assist of 2 staff with transfers and toileting. The Care Plan intervention/task with a initiated date of 9/7/21 directed staff to provide toileting assistance before and after meals, at bedtime and as needed. The Care Card which hangs above the bed in the resident room dated 1/4/22 directed staff to transfer with 2 staff with a Easy Stand Lift. During an observation on 1/12/22 at 2:30 PM, Staff O, CNA and Staff P, CNA provided incontinent cares to Resident #22. Staff P wiped the front of the perineal area appropriately using front to back wiping motion and changing the surface of the cloth with each wipe. Staff O assisted the resident to roll onto right buttock and then wiped the buttocks including the left hip. Staff O then assisted resident to roll onto back and assisted to put clean brief on the resident. Staff P failed to cleanse the right buttock or hip. The resident had a dressing on right buttock that was rolled up underneath her and staff placed clean brief over it and assisted to get the resident up out of bed and into recliner chair in room. During an interview on 1/18/22 at 10:02 AM, the Assistant Director of Nursing (ADON) stated when completing peri cares on an incontinent resident, staff need to make sure to cleanse the buttocks and the hip areas totally. During an interview on 1/18/22 at 10:20 AM, Staff F, CNA stated staff need to make sure to cleanse both sides of the buttocks and the thighs when providing incontinent cares. During an interview on 1/18/22 at 11:16 AM, the Director of Nursing (DON) stated she would expect staff to cleanse both buttocks when providing peri cares. During an observation on 1/12/22 at 2:22 PM, Staff N, CNA and Staff O, CNA provided assistance to transfer Resident #22 with a sit to stand with EZ Stand transfer onto toilet and then into bed with the use of the EZ Stand. During an interview on 1/13/22 at 9:10 AM Interview with Staff M, Occupational Therapy (OT) she states staff can down grade a transfer. Resident #22 was back in the COVID unit recently and was made a 2 person EZ Stand lift for transfers due to she had become weak. Staff M stated feels Resident #22 appropriate for the EZ Stand, but did have some concern related to the resident's shoulder range of motion but feels she does well with it. During an interview on 1/13/22 10:44 AM, the Administrator states she would expect staff to follow the policy and use 2 staff for transfers with mechanical lifts and follow manufacturer recommendations. The Administrator provided a list of orientation for agency CNA. During an interview on 1/13/22 at 1:10 PM, Staff N, CNA stated she transferred Resident #22 on 1/7/22 with the sit to stand lift with one person and failed to get a second person to assist with the transfer. Staff N stated it was told to her by other staff it was okay to use one assist on certain residents with the sit to stand lift. During an interview on 1/13/22 at 1:38 PM, Staff Q, Licensed Practical Nurse (LPN) stated the training for agency CNA's is provided by a Facility CNA, who goes around with them and tells them what the resident needs for assistance for transfer. The Facility CNA will let them know if a resident is a check and change. The Agency Staff are given a Resident Roster (just the resident names and room #). Staff Q reported not aware of any other kind of documents or education provided to Agency Staff when they initially start. During an interview on 1/18/22 10:08 AM, the ADON stated the stand lift should be assist of 2 if a mechanical lift. Education provided to Agency Staff. The ADON could not say it was done for every Agency Staff but should have a lift and transfer education packet for all staff. It goes over all the lifts and the proper transfer technique. The record we keep is a packet and the instructor and the employee has to sign each page. Then it is kept in the Employee File. During an interview on 1/18/22 at 10:17 AM, Staff F, CNA stated the orientation for Agency Staff consists of telling them about residents and needs, show them the utility room and supplies where to find them. Staff reported, no, we do not do any transfer training, no paperwork is filled out or given to the Agency Staff and mechanical lifts should have 2 people at all times. Never transfer with one person for a mechanical lift. During an interview on 1/18/22 at 11:09 AM, the Director of Nursing (DON) stated, initially the Agency Staff come in and train with a CNA and they are vested with their company and trained with the skills of a CNA. We do not provide any documentation or training to the Agency Staff they just follow a Facility CNA. The Facility CNA should educate them about the Care Sheet and how the resident transfers. They should educate them on using 2 persons for a mechanical lift and how to locate the Care Sheet. The DON reported the facility does not have a written policy on what to train or how to orientate the Agency Staff to in regards to mechanical lifts.

Based on observation, record review, and staff interviews the facility failed to implement a Restorative Program recommended by Therapy for 1 out of 2 residents reviewed (Resident #21). The facility identified a census of 27 residents Findings Include: According to the Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #21 shown diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #21 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident with severe impaired cognitive status. The MDS indicated the resident needed extensive assist of 2 staff with transfers and bed mobility and with limited range of motion on one side to upper and lower extremities. The Occupational Therapy Discharge Summary with date of service 9/27/21 through 11/9/21 listed discharge recommendations and status with Restorative Program established/trained: Restorative Range of Motion Program to both lower extremities due to patient not ambulating and using lift for transfers. During an observation on 1/10/22 at 2:46 PM, Resident #21 sitting up right in wheelchair in room with feet on foot pedals. During an interview on 1/12/22 at 12:12 PM, Staff M, Occupational Therapy (OT) stated if lower extremity Restorative Program is the recommendation it would mean staff should provide it 3-5 times a week. Passive range of motion to both lower extremities. Staff M reported Therapy recommends this intervention for anyone who can not ambulate to have range of motion to both lower extremities. During an interview on 1/12/22 1:34 PM Staff L, Nurse Consultant stated Restorative documentation should be completed in point click care. During an interview on 1/13/22 10:39 AM Staff L, stated unable to find Restorative Nursing documentation and it also was not on the Care Plan. The staff would be expected to be doing it since the last note from Therapy is to continue range of motion. During an interview on 1/18/22 at 10:00 AM, Staff L stated therapy writes a Communication Sheet and then the MDS Nurse should add it to the Care Plan and initiate the program for restorative. During an interview on 1/18/22 at 11:13 AM, the Director of Nursing (DON) stated she would expect staff to put Therapy Recommendations on the Care Sheet and the staff would complete the range of motion. If Therapy recommends a program staff should have a book and be documenting Therapy Recommendations and expect it to be on the Care Plan also. During an interview on 1/18/22 at 1:42 PM, the Assistant Director of Nursing (ADON) stated on 9/21/21 ambulation put on hold for the resident due to Therapy put him on sit to stand lift. Then in October range of motion was put in place for 3 x's weekly then in November, the ADON got COVID. The ADON reported completed the range of motion until 11/26/21 when sick and then on 12/20/21 the range of motion quit being done. The ADON stated no further documentation found after these dates.

Based on observation, staff interviews, and facility policy review the facility failed to date or document when the oxygen tubing had been changed for one of three residents reviewed for oxygen therapy (Resident#16). The facility reported a resident census of 27. Findings Include: The Medicare Five Day Minimum Data Set (MDS) dated [DATE] for Resident#16 documented the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented that the resident required assistance of one staff member for ambulation along with use of a walker. The resident scored a 15 out of 15 for a Brief Interview of Mental Status (BIMS), indicating intact cognition. The MDS documented that the resident had oxygen therapy. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan for the resident documented that the resident had altered respiratory status related to congestive heart failure, [CONDITION(S)], and chronic [CONDITION(S)]. The Care Plan directed staff to provide oxygen per order. Clinical record review of the December 2021 and January 2022 Medication Administration Record (MAR), and Treatment Administration Records (TAR) lacked documentation that the residents oxygen tubing had been changed. On 1/10/22 at 12:37 p.m., the resident noted sitting up in his recliner with oxygen on at 3 liters per nasal canula and the oxygen tubing undated. On 1/10/22 at 3:03 p.m., observed the resident with oxygen on at 3 litters per nasal canula per concentrator, and the oxygen tubing remained undated. On 1/11/22 at 1:27 p.m., revealed the resident sitting in his recliner with his oxygen on at 3 liters per nasal canula with oxygen tubing undated. On 1/12/22 at 8:02 a.m., Staff C, Licensed Practical Nurse (LPN) reported that the oxygen tubing is changed by the night shift every week and as needed. On 01/13/22 at 2:10 p.m., the Director of Nursing (DON) reported that the oxygen tubing is changed every Monday (weekly) and it would be documented on the TAR. On 1/18/22 10:14 a.m. Staff, E Registered Nurse (RN) reported that the oxygen tubing is changed weekly on the night shift, and it should be documented on the MAR when changed. The facility's policy titled Oxygen Administering by Concentrator and Cylinder with a revision date of 8/27/21 failed to direct staff when to change the oxygen tubing. The policy did document that the oxygen supply company will replace canulas, masks, humidifiers, tubing and other equipment routinely.

Based on observation, record review and staff interviews, the facility failed to assure a resident with an identified pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 3 residents reviewed with pressure ulcers (Resident #22). The facility reported a census of 27 residents. Findings Include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 shown diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #22 scored an 11 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident with moderately impaired cognitive status. The MDS documented the resident needed extensive assist of 2 staff with transfers, bed mobility and toileting and the resident also identified with a Stage II pressure ulcer. The resident had a pressure reducing device for the chair and device for the bed, but did not have a turning and repositioning program. Review of the following Braden Scale for Predicting Pressure Ulcer Forms revealed: a. On 8/30/21 a score of 22 noted which indicated not at risk for pressure ulcer. b. On 9/14/21 revealed a score of 20 which indicated not at risk for pressure ulcer. c. On 12/15 21 revealed a score of 19 which indicated not at risk for pressure ulcer. The facility failed to complete a new Braden Scale after 12/15/21 to assess the resident's risk for pressure sores. Review of Non-Pressure Skin Condition Reports documented the following: a. On 11/2/21 reveals a 4 centimeter(cm) by 2 cm excoriation area. b. On 11/7/21 through 11/28/21 reports revealed the area measured 5 cm by 3 cm. c. On 12/5/21 the area measured 2.5 cm by 2 cm with a 0.1 cm depth and as a Stage II pressure ulcer with no odor or drainage. d. On 12/16/21 measured 2 cm by 1.8 cm with less than 0.1 cm depth, Stage II pressure injury with no drainage or odor. Review of the Wound Skin Healing Record Forms documented the following: a. On 12/2/21 the form initiated with the excoriation opening measured at 2 cm by 1.5 cm with a depth of less than 0.1 cm., Stage II pressure area with scant amount of serous drainage. Date of onset was 11/2/21. The resident rated pain as a 2, stated hurts a little bit. b. On 1/7/22 the form failed to reveal any previous documentation of the wound until 1/7/22 and the wound was 1.4 cm by 1.2 cm Stage II pressure ulcer. c. On 1/13/22 the wound measured 1.5 cm by 1.2 cm Stage II pressure ulcer with less than 0.1 cm depth. The Care Plan with a revision date of 12/17/21 documented the resident is at risk for skin breakdown related to impaired mobility and pain. The interventions directed staff to assess resident for presence of risk. Treat, reduce, and eliminate risk factors to extent possible. Assist with repositioning. Encourage physical activity, mobility and range of motion to maximum potential. Keep clean and dry as possible. Minimize skin exposure to moisture. The Care Plan initiated 12/17/21 revealed resident with an actual pressure ulcer related to limited mobility, pain and incontinence and identified as a Stage II on right buttock. The interventions directed staff to assess the pressure ulcer for location, stage, size (length, width, depth), presence and absence of granulation tissue and epithelization, and condition of surrounding skin weekly. A facsimile (fax) to the physician dated 1/7/22 revealed a new order request for the open area to right inner buttock not responding to wound gel with a request to change the treatment to Collagen infused hydrogel change every 48 hours and as needed until healed. Observation of Resident #22 on 1/12/22 revealed the following: a. At 8:58 AM, sitting up in wheelchair in room eating breakfast. b. At 9:55 AM, sitting up in wheelchair in room watching television position unchanged. c. At 10:55 AM, remains sitting up in wheelchair in room position unchanged. d. At 11:57 AM, Resident # 22 Remains sitting in wheelchair in room with no position changes. e. At 12:17 PM, she was in same place in room, position unchanged sitting in her wheelchair next to the bed. f. At 12:35 PM, the resident in wheelchair in the room in the same place with lunch tray of liquids and soup in front of her and sitting with her head in her hand, eyes closed, tray untouched. g. At 1:17 PM, she remains in wheelchair in her room with over-the-bed table in front of her with lunch tray on it. h. At 1:30 PM, the Director of Nursing (DON) removed the lunch tray from the room and the resident remains sitting in wheelchair position unchanged. i. At 1:48 PM, remains in room up in wheelchair over-the-bed table in front of her position unchanged. During an observation on 1/12/22 at 2:30 PM, Staff O, Certified Nursing Assistant (CNA) and Staff P, CNA provided incontinence cares to Resident #22. The dressing was rolled and bunched up on resident's right buttocks. Staff O and Staff P placed clean incontinence brief on the resident and never had the nurse complete a dressing change or clean the wound. Staff assisted resident back into her recliner chair in the room sitting on buttocks. The staff failed to provide repositioning or toileting between 8:58 AM until 2:30 PM on 1/12/22. The Treatment Administration Record (TAR) revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR failed to document the as needed order for the wound. The facility staff did not provide wound treatment after incontinence cares on 1/12/22 at 2:30 PM. During an observation on 1/13/22 at 9:46 AM, Staff D, Licensed Practical Nurse (LPN) provided wound care appropriately. The wound on right buttock measured 1.5 cm x 1.0 cm with 0.1 cm depth. The wound base was red with surrounding area pink and no drainage noted from the wound. During an interview on 1/18/22 9:59 AM, the Assistant Director of Nursing (ADON) stated staff should reposition residents every 2 hours and pressure wounds should be measured every 7 days. During an interview on 1/18/22 at 10:23 AM, Staff F, CNA reported all residents should be repositioned every 2 hours. During an interview on 1/18/22 at 11:05 AM, the DON stated she would expect the residents to be repositioned and toileted every 2 hours when in a wheelchair and transferred to bed. Residents should be on side and not on the back and if incontinent, toileted every 2 hours. The Nursing Staff should be completing measurements at least weekly unless there is a change in condition, then needs to be assessed sooner. During an interview on 1/18/22 at 11:30 AM, the DON stated she took on the responsibility of wound measurements when started in December and a Traveling Nurse was here at the time and he was in the COVID Unit and apparently he did not complete Resident # 22 measurements. The DON reported she looked at the TAR and seen they were using the hydro gel for a while so we requested a new treatment since area was not improving. The Director of Nursing on 1/18/22 at 1:20 PM, stated the facility did not have policies regarding pressure sores they follow the standards of practice.

Based on record review and staff interview the facility failed to follow Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 27 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no impaired cognitive status. The resident required extensive assistance of two staff for bed mobility, transfer, dressing, toileting and personal hygiene. The MDS documented Resident #26 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the residents Health Record revealed the residents weight on 9/14/21 was 259.6 pounds. The next weight obtained was 9/27/21 and was 283 pounds. The health record failed to reveal any weights between these dates. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was not administered until 9/29/21. The Care Plan dated 9/27/21 reveals Resident #26 receives diuretic therapy related to [CONDITION(S)], [CONDITION(S)], anasarca and hypertension. The intervention directed staff to administer the diuretic as ordered. During an interview on 1/18/22 at 10:05 AM, the Assistant Director of Nursing (ADON) stated Resident #26 should have a daily weight if the order was to give diuretic medication if 5 pound weight change. If the resident was weighed it would have been put in the Electronic Health Record. If the order reads to administer the medication with a 5 pound weight gain I would expect staff to weigh daily. During an interview on 1/18/22 at 11:18 AM, the Director of Nursing (DON) stated she would expect staff to follow the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/18/22 at 1:20 PM, the DON stated they do not have a policy regarding Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on resident observation, staff interview, and facility policy review, the facility failed to implement appropriate Infection Control procedures with hand hygiene and disinfection of mechanical lifting equipment prior to usage, and after usage for 1 out of 2 residents (Resident #14). The facility reported a census of 27 residents. Findings Include: The 11/30/21 Admission Minimum Data Set (MDS) for Resident #14 documented the resident required extensive assistance of two staff for transferring. The 11/30/21 Care Plan for Resident #14 listed an intervention to transfer the resident with a sit to stand lift and assist of two. On 1/12/22 at 8:42 AM, observed Staff F, Certified Nursing Assistant (CNA) and Staff G, CNA assist Resident #14 with catheter care, self-care, activities of daily living (ADL's) and transfer to his wheelchair. Staff F brought the sit to stand to the resident's room and left outside of the room in the hallway initially. Resident #14's catheter bag leaked on to the bed, his socks and pants. Staff F and Staff G then removed the catheter bag from it's covering, along with the resident's pants, and placed a clean barrier under resident legs. Staff F briefly left resident room, came back and obtained a wash basin from cabinet under sink, filled basin with water and completed catheter care without changing gloves. After completing catheter care, Staff F proceeded to dry the resident and the catheter without hand hygiene or change of gloves On 1/12/22 at 9:03 AM, Staff G, CNA performed hand hygiene prior to getting the sit to stand lift, but failed to don gloves or disinfect the lift prior to the transfer of Resident #14. On 1/12/22 at 9:11 AM, Staff G moved the sit to stand lift back to hallway without disinfecting the lift after utilized in the transfer of Resident #14. 1/12/22 at 9:19 AM, Staff F CNA moved the sit to stand from hallway outside of Resident #14's room down the hall to outside of room [ROOM NUMBER] without completing disinfection of the device. On 1/12/22 at 9:21 AM, Staff F and Staff G used alcohol based rub, donned gloves and put gowns on outside room [ROOM NUMBER] (Contact precautions requirements on door). Staff G then took the sit to stand lift into room [ROOM NUMBER] without completing disinfection On 1/13/22 at 10:40 AM, Staff G stated proper hand hygiene includes washing hands with soap and water for 20 seconds or using alcohol based hand rub, then putting on gloves. Staff G stated gloves should be changed after touching resident, or railings. Staff G stated that before and after using a sit to stand lift the device should be wiped down with bleach wipes that are located in a bag on the equipment. On 1/13/22 at 10:50 AM, Staff F stated proper hand hygiene includes changing gloves if they get dirty and if working closely with a resident such as completing pericare. Staff F stated that equipment needs to be sanitized if there is anything on the lift, and anytime it is used. Staff F stated the sit to stand lift should be sanitized after utilized in a room where the resident is sick. On 1/13/22 at 1:35 PM, the Director of Nursing (DON) stated she expected hand hygiene to be completed: before resident care, when gloves are soiled, and after resident care. The DON stated that all equipment should be wiped down after each use with bleach wipes in the bag attached to the equipment. On 1/18/22 at 2:25 PM per facility Infection Prevention and Control Program policy effective date of 8/1/17 documented as follows: The primary purposes of the facility Infection Prevention and Control Policies and Procedures are to establish guidelines to follow to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The policy directed staff to: Ensure that reusable patient care equipment is cleaned and reprocessed appropriately before use on another resident

Based on observation and staff interviews, the facility failed to have the Daily Staff Posting in a prominent area for resident and visitors to review for 1 of 3 days observed. The facility reported a census of 27 residents. Findings include: During an observation on 1/10/22 at 11:55 AM, the facility had Staffing posted outside administrators door states 1/8/22. During an observation on 1/10/22 at 4:00 PM, the Staff Posting outside the administrators office remained the one from 1/8/22. During an observation on 1/11/22 at 8:24 AM, Daily Staff Posting outside administrators office still states 1/8/22. During an observation on 1/11/22 at 10:46 AM, the Daily Staff Posting was updated to 1/11/22. During an interview on 1/18/22 at 09:57 AM, the Assistant Director of Nursing (ADON) stated the night shift is responsible for updating the Staff Posting and it should be posted every night for the next day. The ADON reported Daily staffing should be posted every day. During an interview on 1/18/22 11:22 AM, the Director of Nursing (DON) stated she would expect the staff to post the Staffing daily and third shift is responsible for it.

Based on staff record review, and staff interviews the facility failed to provide documentation of COVID 19 vaccination declination forms for 5 of 5 staff, and 1 of 1 residents (Resident #127). The facility reports a resident census of 27. Findings Include: On 1/13/22 record review revealed five unvaccinated staff (Administrator, E, H, I, and J ) employed. Five out of the five staff submitted religious exemption requests, none of these requests indicated management approval. Further review shoed the Declinations Forms completed for 4 of 5 (not completed for E) on 1/13/2022, during the time the survey conducted. On 1/13/22 the Administrator stated that she received education via a COVID 19 Management Meeting held on 11/16/21. The Administrator presented a copy of her electric calendar with scheduled meeting, no meeting agenda presented. On 1/13/21 Staff E, Assistant Director of Nursing stated that she discussed the COVID 19 vaccination with a previous Director of Nursing in August 2021. Review of records failed to find documentation available. Resident #127 is the only unvaccinated resident in the facility and no Declination Form signed presented by the facility when requested. Later in the day on 1/13/22 after request made, a Declination Form dated 1/13/22 was presented. Resident #127 noted in quarantine per Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, staff interview, physician interview, Power of Attorney (POA) interview, professional drug reference, emergency services record review, and social media postings, the facility failed to provide comprehensive cardiac assessments for a resident with a recent history of heart surgery; failed to transcribe and clarify cardiac medication orders; and failed to notify the cardiologist of acute cardiac change of condition for 1 of 12 residents reviewed for assessment and intervention (Resident #3). Resident #3 complained of indigestion over a span of several days, reached out to 911 on [DATE], and on [DATE] the resident found unresponsive and CPR (cardiopulmonary resuscitation) started. The resident transferred to the hospital where he later was pronounced deceased . The failures identified on [DATE] as an immediate jeopardy situation. The facility reported a census of 30 residents. Findings include: The [DATE] Minimum Data Set (MDS) Assessment Tool revealed Resident #3 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident scored 13 out of 15 points possible on the Brief Interview of Mental Status (BIMS) cognitive assessment, without symptoms of [CONDITION(S)], had verbal behaviors directed at others from 1 to 3 days of the 7 days that preceded the assessment, and required extensive assistance of at least 1 staff for transfers to and from bed and chair, ambulation, dressing, bathing, toileting and personal hygiene. A History and Physical dated [DATE] transcribed by the resident's cardiologist described the resident had a [CONDITION(S)] (heart attack) on [DATE] that required angioplasty with stent placement, and had significantly diminished ability for his heart to pump and circulate blood effectively. The Hospital Discharge and Facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (a strong antiarrhythmic heart medication) 200 milligrams (mg) oral once daily. b. [MEDICATION(S)]-clavulanate ,d+[DATE] mg tablet (an antibiotic) oral 2 times daily for 2 days. c. [MEDICATION(S)] 5 mg oral twice daily. d. [MEDICATION(S)] (vitamin C) 500 mg oral 3 times daily. e. [MEDICATION(S)] (a statin used to lower cholesterol) 80 mg oral daily. f. [MEDICATION(S)] (a blood thinning medication) 75 mg oral daily g. [MEDICATION(S)] (an antibiotic) 100 mg oral every 12 hours for 5 days. h. [MEDICATION(S)] (a diuretic) 80 mg oral twice daily. i. [MEDICATION(S)] 0.1 percent ointment (antibiotic ointment) applied to affected area on left lower leg twice daily. j. [MEDICATION(S)] insulin 8 units injected subcutaneously daily. k. [MEDICATION(S)] (an ACE inhibitor anti-hypertension medication) 20 mg oral daily. l. [MEDICATION(S)] Extended Release (ER) (a diabetic medication) 1000 mg oral twice daily. m. [MEDICATION(S)] (beta blocker medication used for hypertension and to prevent heart attacks) 25 mg 24 hour tablet oral twice daily. n. [MEDICATION(S)] ER (an electrolyte replacement supplement) 20 miliequivalents oral twice daily. o. [MEDICATION(S)] (a diuretic and anti-hypertension medication) 25 mg oral daily. p. [MEDICATION(S)] (a bronchodilator medication used open airways) 2.5 mg in 3 milliliters (ml) solution administered via nebulizer every 4 to 6 hours as needed for wheezing. Other Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note Summary of the resident's cardiologist appointment on [DATE] directed staff to continue the same medications, and return office appointment in 3 to 6 months or sooner as needed. Further directives on the visit summary listed today's orders, that included a 12 lead electrocardiogram completed at the appointment, [MEDICATION(S)] 100 mg tablet without further description of the amount or frequency, and [MEDICATION(S)] 50 mg 24 hour tablet, also without frequency. The last page of the summary described medications stopped today, and listed [MEDICATION(S)] 200 mg oral daily and [MEDICATION(S)] 24 hour tablet oral twice daily. There was a hand written notation by the [MEDICATION(S)] by Staff G, Registered Nurse (RN) and Assistant Director of Nursing (ADON) that stated was already discontinued, continue with 50 mg daily. Staff G, RN transcribed a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pages 112 through 115 of the facility's Drug Reference Nursing 2018 Drug Handbook, published by Wolters Kluwer, cautions that [MEDICATION(S)] had a Black Box warning the medication only to be used for patients with life-threatening ventricular fibrillation (a fatal cardiac arrhythmia) or recurrent unstable ventricular tachycardia unresponsive to other medications (an arrhythmia when the heart ventricle beats at a fast rate and requires immediate treatment), and patient's should not stop taking the medication without consulting the prescriber. An altered mood due to getting agitated at times problem initiated on the Nursing Care Plan on [DATE] directed staff: a. Attempt to redirect resident's behavior If resistive to cares leave alone and try again in a few minutes. b. Encourage resident to vent feelings and concerns. c. Medicate as ordered, monitor and record response. d. Refer to qualified professional as needed. e. Reward verbally all positive behavior and compliance. A verbal behavioral symptoms directed towards others problem initiated on the Nursing Care Plan on [DATE] directed staff: a. Avoid over-stimulation. b. Avoid power struggles with the resident. c. Convey an attitude of acceptance towards the resident. d. Explore with the resident, previous effective and ineffective coping mechanisms. Allow resident to call his family. e. If resident has delusions do not try to reason with or confront him, offer reassurance. f. Maintain a calm environment and approach to the resident. g. Praise resident when behavior is appropriate. h. Refocus conversation when resident becomes verbally abusive. Vital sign assessment related to COVID-19 screening, recorded on the March Medication Administration Record (MAR), the temperature recorded in Fahrenheit and blood pressure not assessed, revealed: Temperature Pulse Respiration Oxygen Saturation [DATE] Day shift 97.3 74 18 94 percent Evening shift 97.2 76 18 95 percent [DATE] Day shift 97.6 72 16 96 percent Evening shift 98.7 65 18 97 percent [DATE] Day shift 98.2 64 16 96 percent Evening shift 96.8 83 18 94 percent [DATE] Day shift 97.5 76 16 96 percent Evening shift 97.3 64 18 96 percent [DATE] Day shift 97.6 68 16 96 percent Evening shift 97.8 79 18 95 percent [DATE] Day shift 98 80 18 96 percent Evening shift 97 81 20 92 percent The only blood Pressure (BP) assessments recorded in the resident's record revealed: a. On [DATE] at 3:40 p.m. 118 over 73. b. On [DATE] at 4:42 a.m. 126 over 68. c. On [DATE] at 1:13 p.m. 122 over 72. d. On [DATE] at 9:56 p.m. 110 over 66. e. On [DATE] at 12:30 a.m. 116 over 62. f. On [DATE] at 12:43 p.m. 110 over 68. g. On [DATE] at 4:58 p.m. 144 over 92. h. On [DATE] at 12:05 p.m. 138 over 80. i. On [DATE] at 8:27 p.m. 88 over 57. A Nurse's Progress Note transcribed by Staff K, Agency Licensed Practical Nurse (LPN) at 8:20 p.m. on [DATE] stated around 5:00 p.m., resident in bed, screaming for help continuously, she went to the room, the resident stated he slipped and fell on the floor, laid there for an hour, crawled back into bed because staff refused to help him and he broke his leg. The resident resisted Staff K's attempts to assess his leg for injury and told her to call the police. When asked why she needed to call the police, the resident stated it was because she wouldn't help him. Staff K documented a police officer came to the facility, stated he received a call and he spoke to the resident. Staff K notified the director of nursing (DON) and the resident's power of attorney (POA) of the events, asked the POA to speak to the resident to gain the resident's cooperation in order for the nurse to assess the resident, and the resident then allowed Staff K to assess his leg and she found no signs of injury. The written transcript of a 911 call to the County Emergency Dispatch Center revealed a call received from the resident at 5:49 p.m. on [DATE], the caller stated he had a possible broken leg, he fell and needed help, stated they knew he fell but were not helping him. The Dispatch Center attempted to make contact with the facility by phone at 5:51 p.m. and 5:56 p.m., unable to make contact with facility and dispatched the [NAME] police to see if medical support was needed. The written transcript of a 911 call to the County Emergency Dispatch Center revealed a call received from the resident at 5:11 p.m. on [DATE], the resident was asked for help and no one helped him. The Dispatch Center called the facility twice between 5:11 p.m. and ,d+[DATE] p.m., let the phone ring and ring and ring without answer. [NAME] police were dispatched to the facility. The audible recordings of the resident's 911 calls on [DATE] at 5:49 p.m. and [DATE] at 5:11 p.m. revealed an obvious decline in the resident's condition on [DATE], with shortness of breath and weakness evident by the resident's voice, and the resident's great difficulty expressing himself and what he needed help with. Screenshots of the resident's posts to his social media account revealed the following: a. On [DATE] at 12:13 p.m. - Can't eat .can't poop .can't throw up . help me please. b. On [DATE] at 12:31 p.m. - Can't eat, poop or breath. Help me. A contact responded do you need to go to the hospital at 12:31 p.m. c. On [DATE] at 1:02 p.m. - Called 911 twice, no emergency room in [NAME]. Called private ambulance service twice, help please. d. On [DATE] between 1:02 p.m. and 1:17 p.m., a contact responded Is there a nurse there who can help you? I called the care center, did someone come check with you? [DATE] at 1:19 p.m. -A contact posted What have you got?, the resident responded Don't know. Trying to get to [NAME]. No emergency room here. An order transcribed by Staff C, RN at 2:00 a.m. on [DATE] directed staff to administer [MEDICATION(S)] (an antacid medication) [DATE] mg per 5 ml, 20 ml administered oral 1 time daily as needed for indigestion until [DATE]. There was no documentation at the time in the resident's record of an assessment of the resident or need for the order. The Medication Administration Record (MAR) revealed [MEDICATION(S)] was administered to the resident: a. On [DATE] at 1:12 p.m. by Staff K, agency LPN. b. On [DATE] at 12:30 a.m. by Staff J, agency RN. c. On [DATE] at 11:07 p.m. by Staff C, RN. Nurse's Progress Notes transcribed at times related to the [MEDICATION(S)] administration revealed: a. On [DATE] at 12:03 p.m., Staff K wrote Resistant with care this shift, on the phone after breakfast yelling, screaming and cursing at whomever was on the phone. This nurse went into room to answer call light, resident asked how long does it take to answer a call light? This nurse reminded the resident we are in the middle of breakfast and certain people have to be assisted and staff are getting to call lights as quick as possible. Asked what he needed, resident wanted breakfast tray off bedside table and lights turned off. When nurse went into room to administer the [CONDITION(S)] skin test, explained what the test was and how it was done, the resident refused the test and asked where his COVID-19 vaccine was as it was scheduled for 3 days prior. Nurse explained they awaited a call from the clinic to schedule a date for the vaccine for him and the resident not satisfied with the answer. A notation on the MAR described the [MEDICATION(S)] was effective. There was no documentation of any assessment of the resident's overall physical condition at any time on [DATE]. b. On [DATE] at 12:50 a.m., Staff J, Agency RN, stated [MEDICATION(S)] administered for resident complaints of indigestion. c. On [DATE] at 4:33 a.m., Staff J wrote Resident got up during the night and stated I think I am having a heart attack I need [MEDICATION(S)] resident received [MEDICATION(S)] and sleep through the night no complain of pain. Staff J noted at 4:45 a.m. on [DATE] that [MEDICATION(S)] was effective. There was no documentation of any assessment of the resident's overall physical condition, or further assessment of the resident's statement he thought he was having a heart attack at any time on [DATE], and the physician was not notified of the statement or repeated [MEDICATION(S)] administrations. d. On Friday, [DATE] at 11:07 p.m., Staff C, RN noted [MEDICATION(S)] administered, followed by an entry at 11:16 p.m. Resident continues to report heartburn. He has been given medication, per standing orders, for 3 days. Physician notified, per standing order, if discomfort is not resolved. e. On Saturday [DATE] at 1:24 a.m., Staff C noted [MEDICATION(S)] was effective. Staff C documented resident continues to complain of heartburn. He has taken [MEDICATION(S)] per standing orders. It relieves at the time and heartburn returns on a form dated [DATE] and used for physician notification via facsimile (fax). There was no documentation or acknowledgement on the form that it was received or reviewed by the physician. There was no documentation of any assessment of the resident's overall physical condition at any time on [DATE] or early hours of [DATE]. Other pertinent Nurse's progress note documentation between [DATE] and [DATE] revealed: a. At 5:30 p.m. on [DATE], by Staff K, Agency LPN, stated Incontinent care provided by Certified Nursing Assistant (CNA), resident on phone not even 15 minutes later saying the nurse will not help me, I've been soiled for 2 hours. She said she will not help me because she does not like me. Family called facility asking for care to be provided. Staff went into room to address resident needs, states he needs Tylenol; given by med nurse per request. Law enforcement at facility said someone called stating they needed assistance, 2 CNA's went into room, resident said he did not need care at that time but wanted to know how to get someone to help him. Encouraged to use call light if he needed something. There was no documentation of any assessment of the resident's overall physical condition at any time on [DATE], and the physician was not notified that police were dispatched to the facility on behalf of the resident. b. On [DATE] at 9:43 p.m., Staff K, Agency LPN recorded At approximately 8:00 p.m., blood sugar 152 (within normal range), resident not talkative or as responsive as usual, asked other nurse to lay eyes on resident, Staff J, RN went to the resident's room, stated oxygen saturation level was low and resident needed oxygen. Oxygen concentrator and nasal cannula taken to room and applied at 2 liters per minute. At approximately 8:20 p.m. while RN obtained vital signs, the resident's blood pressure (BP) dropped, this nurse checked code status and called 911. As this nurse walked down hall towards room at approximately 8:30 p.m., RN yelled out the resident was unresponsive, this nurse took the crash cart to the room where RN provided chest compressions (cardiopulmonary resuscitation CPR), this nurse assisted with CPR until ambulance arrived. c. On [DATE] at 9:49 p.m., Staff J, agency RN, recorded this nurse check on resident at 8:10 p.m., resident lying in bed with eyes open, BP 104 over 58 (normal low range), pulse 57 (normal 60 to 80), oxygen saturation 89 percent (normal 97 to 100 percent). Oxygen applied at 8:15 p.m., at 8:20 p.m. BP 88 over 57 (low), oxygen saturation 88 percent, oxygen increased to 6 liters per minute, at 8:30 p.m. resident unresponsive, CPR started. d. On [DATE] at 10:45 p.m., Staff K noted the resident's POA notified the facility the resident passed away. The ambulance report dated [DATE] described personnel were dispatched at 8:37 p.m. with all 5 crew-members at facility at 8:46 p.m., CPR in progress by facility staff. Ambulance staff took over CPR, attached a monitor with defibrillator that revealed ventricular fibrillation, followed established protocols and continued CPR, transported the resident and arrived at hospital emergency room (ER) at 9:44 p.m. The Hospital ER record revealed the resident arrived by ambulance in full cardiac arrest with CPR in process on [DATE] at 9:45 p.m., the heart monitor showed asystole (no heart rhythm), assessed for viable signs of life, all were negative and the resident pronounced dead at 9:51 p.m. by the ER physician. The undated facility's Physician Notification Policy directed staff to notify the physician of a resident's change in condition that included: a. Significant change in resident condition which is life threatening. b. A significant change in resident condition which has potential for clinical complication. c. A change in condition which requires a significant alteration in treatment. d. Any change in condition which may be life-threatening should be called and not faxed to the physician immediately. Staff interviews revealed: a. On [DATE] at 10:02 a.m. Staff G, ADON, stated she saw the order to discontinue the [MEDICATION(S)] on page 6 of the progress note, did not see the other pages of the note, did not call the cardiologist office to verify the order, wrote the order to discontinue [MEDICATION(S)] and sent it to the medical director for signature and did not send it to the cardiologist. b. On [DATE] at 11:15 a.m., the resident's cardiologist stated the resident had heart conditions that required the [MEDICATION(S)] medication, seen at the office on [DATE], the resident was to continue the medication regimen that included [MEDICATION(S)] and it should not have been discontinued, the facility had not contacted their office to question the orders or asked if the medication could have been discontinued. In another interview on [DATE] at 1:54 p.m., the cardiologist stated it was difficult to say with any certainty, but the [MEDICATION(S)] discontinuation could have contributed to the resident's death. c. On [DATE] at 11:47 a.m., the Advanced Practice Nurse Practitioner (ARNP) at the resident's cardiologist office stated she assessed the resident at the [DATE] appointment, ordered his medication regimen continued that included [MEDICATION(S)], and the medication should not have been discontinued. d. On [DATE] at 1:06 p.m., Staff L, CNA, stated they were in a different resident's room on [DATE] when a coworker (Staff O, CNA) said the police had just been in the building because of calls about the resident, they went to the resident's room, the resident stated he trusted the 2 of them, stated the nurse on duty said she wouldn't help him because he had an attitude and described the nurse on duty (Staff K) who said it. The resident asked this employee how do I fix my attitude? and the employee didn't know what to say. The employee stated they had the impression that it was said that day/had recently occurred, assured the resident they would help him and encouraged him to use his call light if he needed anything. The employee stated the resident would yell at staff, but it really wasn't at them, it was a condition, such as if he wanted chocolate milk and received regular milk, he would yell about that. e. On [DATE] at 2:21 p.m., Staff O, CNA, stated police came into the facility on [DATE], spoke to the nurse (Staff K) who said there was a resident that calls 911 in his room down that hall (directed the officer), the officer said he didn't need to see him and left the building. The employee stated it never came out as to why the resident called 911, thought there was probably staff that didn't like him due to how he acted, but this employee never had any problems with him and they got along well. f. On [DATE] at 3:04 p.m., Staff N, CNA, stated the resident used his call light a lot and thought it was downplayed, other staff comments he's on his light all the time and what he wanted wasn't that important. Employees were told that he called 911 because he didn't feel like he was getting the help he needed, but thought it depended on who the staff on duty was. There were staff on both day and evening shifts that didn't want to deal with the resident or go into his room, management was aware of that and heard the administrator was fired because of the resident. The employee stated the resident was always on his call light and that annoyed the nurse, Staff K. g. On [DATE] at 1:38 p.m., Staff M, CNA, stated the resident would get agitated fast, would say he wasn't getting the help he needed and at some point he thought a CNA needed to stay in the room with him. The employee said they never felt unsafe around the resident, he just said mean things once in a while. On the day the resident passed, he acted nice, sweet, wasn't acting like there was anything unusual, the employee thought maybe he had some medication changes that caused it. h. On [DATE] at 2:18 p.m., Staff B, RN, stated the resident could be explosive, he wanted to be left alone if he was on the phone. The employee thought the resident called 911 to get out of the facility, he claimed he fell and hurt his leg but there were no obvious injuries. If the resident said he thought he was going to die or complained of chest pain, that was definitely an immediate need for assessment of the resident and determination of needs, call the physician if there were concerns and send the resident to the hospital when needed. i. On [DATE] at 11:24 a.m., Staff E, LPN, stated the resident would be nice 1 day, and not the next, he screamed so loud he was heard at the opposite end of the building, staff were scared that he would become physical, the employee thought the resident needed a psychiatric consult. Staff had notified the Director of Nursing (DON) with concerns about the resident's actions and the response was to take a 2nd staff member to the room when care was provided. The resident complained of leg pain with dressing changes, had not complained of chest pain or shortness of breath, he said his stomach hurt and refused to eat, the employee offered warm packs for his stomach but the resident wanted to be left alone. j. On [DATE] at 1:03 p.m., Staff H, RN, stated 1 time when she cared for the resident he yelled at her and said she talked too loud, she apologized and the resident was okay with her then and she hadn't had any problems when she worked with him. If a resident complained of heartburn or indigestion, she would check their vital signs, skin, respiratory effort, assess for diaphoresis, nausea or vomiting, or any [CONDITION(S)] of pain symptoms and would notify the physician. If it was 1:00 a.m. and [MEDICATION(S)] resolved the issue, she would fax the physician about the event, wouldn't give the medication without an assessment and would always notify the physician. k. On [DATE] at 7:55 p.m., Staff C, RN, stated the resident had complaints of indigestion and there was a standing order for staff to administer [MEDICATION(S)]. Staff C stated she had worked as a nurse on a psychiatric unit, she felt the resident probably had some psychiatric issues so she had the aides check on him every 15 minutes, just like staff did in psychiatric units, and they never had problems with the resident on the night shift, but knew staff on other shifts did. During another interview on [DATE] at 1:27 a.m., Staff C stated the resident complained of indigestion one night, she wrote the order for the [MEDICATION(S)] from the physician's standing orders and administered it (2:00 a.m. on [DATE]), it seemed to help at the time, but he continued to have indigestion, the [MEDICATION(S)] would help but only for a while, they could only give the medication for 3 days, so she wrote a fax to the physician when the order expired to let him know that. l. On [DATE] at 9:06 a.m., Staff K, Agency LPN, stated the resident complained of heartburn, took [MEDICATION(S)] and it helped but she didn't have to administer it to him. The resident complained of leg pain, Tylenol worked to relieve it, he wasn't short of breath. The 1st time he called 911 he said he fell and broke his leg, a police officer came into the facility and spoke to him. A few days later he called 911 again, police came but didn't talk to him, the resident said he didn't know how to get help and she told him to use his call light. On [DATE], she had seen the resident 4 times before he arrested, at the beginning of the shift his vital signs weren't unusual, he took his medication but didn't eat supper, had no complaints of pain. She took his blood sugar around 8:00 p.m., within normal range, normally he was very verbal, but he wasn't responding like he normally did, had the other nurse on duty Staff J, RN, look at the resident, and that's when everything started to crash. CPR was initiated and she called for an ambulance. During another interview on [DATE] at 3:18 p.m., Staff K stated on [DATE] the resident had leg pain or a headache earlier in the shift, the other nurse gave him Tylenol for it, he didn't tell her he had pain, he wanted help but couldn't say what he wanted help with. He didn't have indigestion or stomach upset, she didn't have to call the physician about him and she never gave him [MEDICATION(S)]. On [DATE] at 4:01 p.m., when asked what type of assessment was completed when she administered [MEDICATION(S)] to the resident, Staff J, Agency RN, stated all residents were assessed every shift because of COVID. Staff J stated the resident asked for [MEDICATION(S)] and she administered it, he didn't complain of anything like nausea or chest pain. During another interview on [DATE] at 7:17 a.m., Staff J stated the resident asked for [MEDICATION(S)] and she gave it, she would have remembered if he had chest pain or other symptoms that concerned her. When asked about her documentation, the resident said he felt like he was having a heart attack, Staff J stated she didn't remember writing that, and when asked about the assessment completed when the [MEDICATION(S)] was administered, she said all residents were assessed every shift and all documented in Point Click Care (PCC, the facility's electronic medical record system). On [DATE] at 4:10 p.m., the DON stated she'd had several conversations with the resident's POA about his 911 calls, she hadn't spoken with the resident about the calls or why he called 911, but read his chart, staff said in the notes he called 911 because he wanted to get cleaned up and know how to get help. Staff reported they had problems with him, the resident called a nurse brain-dead, refused medications and treatments and ordered staff out of his room. Some staff felt nervous to go in his room alone so she told them to go in pairs. The administrator told her that someone called the facility and said to check on the resident, she and the administrator spoke with the POA about the resident's social media account and the POA said they would turn it off. The DON stated if a resident complained of indigestion, the nurse should assess the resident, document the assessment in PCC, in this resident's situation, staff should have called the physician and sent him to the hospital. On [DATE] at 4:06 p.m., Staff AA, [NAME] police officer, stated 911 dispatch notified him on [DATE] that a resident at the care center had fallen and needed help, the call center had tried to call the facility but couldn't get an answer and asked that he go to the center to check on the matter. He was able to get into the facility, staff directed him to the resident's room where he was in bed, the resident said he didn't need anything, the officer spoke to the nursing staff about the call and they assured the officer they would take care of the resident. On [DATE] at 2:59 p.m., Staff BB, [NAME] police officer, stated on [DATE], dispatch notified him that a resident at the care center called for help, dispatch tried to call the care center and couldn't get an answer on the phone and dispatched him to the facility to see what was going on. He got into the facility and at first didn't see any staff, but then saw a staff member who helped him locate the nurse. When he told the nurse a resident there had called 911, the nurse said she knew who it was, said the resident was down a hall and pointed in the direction, staff were headed to the room, the nurse said they would take care of the resident and didn't need further assist from him so he left. During an interview with the resident's POA, she stated the resident had a cell phone, frequently called and told the POA he'd activated his call light and staff hadn't responded, at times they remained on the phone with the resident until someone responded and it was more than 15 minutes, sometimes the POA called the facility to ask staff to provide assistance, 1 time she called and Staff K, LPN, stated his light hasn't been on that long, other times no one answered the phone with multiple calls placed. The POA reported the resident had problems with Staff K, they didn't get along very well. On [DATE], the resident kept calling the POA and family members, said he was dying, the POA called facility staff who assured them he was fine. The resident really struggled with the isolation he was in because of COVID, he wanted a shower so badly but couldn't have one until out of isolation, scheduled for [DATE]. Between [DATE] and [DATE], the resident complained of pain in his stomach and it hurt to swallow, couldn't swallow his pills or it hurt to swallow them and couldn't eat because his stomach hurt so bad. The POA tried to encourage the resident, the last time they talked to him on [DATE] they told him to hang in there, just a few more days and he would be out of isolation and get the shower he wanted so badly and the resident said I don't think I can make it that long. The POA stated on the morning of [DATE], they received a phone call from the Administrator and Nursing Director, they were on speaker phone, the Administrator asked them to disable his social media account and said the resident's cell phone caused problems and they might have to come and get it from the resident. On [DATE] at 3:34 p.m., the facility's Medical Director physician stated it was hard to say whether staff should have notified him about the resident's complaints of indigestion, it would have depended on if he had other symptoms and what their assessment indicated, but they should have assessed the resident, and he should have been notified if he'd had indigestion several days in a row, or without resolve from the [MEDICATION(S)]. The physician expressed his concern about the competence of the facility's current nursing staff that didn't assess the resident. The incident detailed above resulted in determination of an Immediate Jeopardy (IJ) for the facility and notified of such on [DATE] at 2: [TRUNCATED]

Based on record review and staff interviews, the facility failed to provide adequate supervision to prevent accidents for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 59 residents. Findings include: According to documentation in the medical record, Resident #1 entered the facility on 8/17/16 following a hospitalization due to multiple falls at home. Resident #1 discharged to home on 9/14/16 and re-entered the facility on 10/3/16, again due to a history of falls. According to record review Resident #1 had other [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment tool dated 10/17/16 indicted Resident #1 displayed severe cognitive impairment and required staff assistance with bed mobility, ambulation (walking), dressing and personal hygiene and supervision for bathing. The MDS dated [DATE] revealed the resident experienced moderate cognitive impairment and indicated Resident #3 required extensive staff assistance with bathing. The plan of care dated 10/11/16 identified Resident #1 as at risk for falls related to a history of falls and impaired mobility with a goal for Resident #1 to transfer/ambulate with one (staff) assist while minimizing the risk for falls. The plan of care directed staff to: 1. Keep the resident's personal items and frequently used items within reach. 2. Assist the resident to transfer with one staff assist, walker and gaitbelt. 3. Participate in the Walk to Dine program Documentation in the nurse's notes revealed the following: a. On 10/16/16 (no time documented), staff continually educated Resident #1 to use the call light and wait for help to get up. b. On 10/16/16 at 9:15 a.m. revealed staff witnessed Resident #1 transfer without the walker and stumble on his/her moccasin, which then fell off. Staff responded and eased the Resident #1 to the floor without injury. c. On 10/18/16, the physician saw Resident #1 and changes were made to Resident #1's medication regimen. d. On 10/30/16 at 7:00 a.m., Staff walked into Resident #1's room and found Resident #1 in the center of the room without his/her walker. Resident #1 then lost footing and fell to his/her left side. The resident reported he/she hit his/her head. Staff assessed Resident #1 and reinforced the resident needed to use the call light to obtain assistance with ambulation and use his/her walker at all times. Resident #1 responded, I don't need any help. e. On 10/30/16 at 9:51 a.m., Resident #1 continued to be non-compliant with waiting for staff for transfers and stated, I'm fine, I don't need help from anyone. f. On 10/30/16 at 9:32 p.m., Resident #1 was still non-compliant with assistance to walk in hallways or bedroom. Staff found the resident walking in their room without a walker multiple times today, and reminded the resident and family that he/she needs to ask for help when wanting to stand up. g. On 10/31/16 at 2:00 a.m., staff observed Resident #1 ambulating to the bathroom without the walker. The resident had not activated the call light to summon staff assistance. Staff documented when the resident is found ambulating he/she is reminded by staff to ask for assistance to prevent additional falls. Resident #1 voiced understanding but stated, I do just fine. h. On 11/2/16 at 3:18 p.m., indicated the resident was moved to a different room and activities resumed per usual. e. On 11/3/16 at 1:00 a.m., staff was summoned to Resident #1's room, and found the resident on the floor on his/her back next to the roommate's bed. The resident's walker was by his/her night stand and staff noted he/she had not activated the call light. Staff noted the resident sustained [REDACTED]. The resident also sustained 2 skin tears to the left elbow that measured 0.5 cm x 0.6 cm and 1.2 cm x 0.2 cm. Staff assessed Resident #1 and notified the physician and family. The physician gave an order to transfer Resident #1 to the emergency room . The Hospital Discharge Summary dated 11/9/16 at 12:28 p.m. documented Resident #1 was admitted to the hospital after a fall in which he/she sustained head trauma and a subdural hemorrhage, subarachnoid hemorrhage, and brain contusion. During an interview on 12/13/16 at 10:38 a.m. Staff A, LPN stated Resident #1 was non-compliant and staff were directed to keep a closer eye on him/her. She added that other departments (in addition to nursing) also would notify nursing staff if they observed Resident #1 up without staff assistance. Staff A stated the family had provided different foot wear for Resident #1. Staff reported the facility was trying to get away from using alarms, so a personal alarm was not attempted as a fall intervention for the resident. During an interview on 12/12/16 around 2:30 p.m., the Director of Nursing stated the family was asked to provide new/different footwear for Resident #1 and the physician was contacted for a medication review. During an interview on 12/13/16 at 9:33 a.m. the Administrator and Director of Nursing (DON) stated (personal) alarms were used sparingly, and it was felt Resident #1 would not have been complaint with and alarm and likely would have thrown it at staff. Neither the Administrator nor the DON identified any other interventions considered or attempted to increase supervision or the frequency of monitoring. This, despite the fact Resident #1 frequently did not use the call light to call for assistance and ambulate without the walker or staff assistance.

Based on clinical record review, resident and staff interviews, the facility failed to plan for and direct nursing services to ensure Resident #1 received adequate supervision against hazards. Resident #1 fell and fractured his/her right leg after staff left him/her unattended in the bathroom. The facility reported a census of 57 residents with four residents reviewed for falls. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 scored 13 out of 15 on the BIMS (Brief Interview for Mental Status) indicating the resident had intact cognitive skills, required extensive assistance of two staff to transfer and ambulate. The MDS assessment documented the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had no falls since admission on 4/11/2011, or the prior assessment. The care plan dated 7/22/2011, directed staff to keep call light within reach, provide bed and chair alarms, transfer and ambulate with the assistance of one and a walker with wheel chair to follow as needed, and provide a low bed with mat beside. Problem: Resident at risk for falling related to history of falls, [DIAGNOSES REDACTED]. Resident #1 also had a care plan for not threatening, screaming, or cursing at others with directives for staff to set expectations and limits for the resident. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. The resident had a stroke and then had a seizure and broke their right ankle. A physician progress notes [REDACTED]. Nurse notes dated 7/24/2011 at 3:40 p.m., documented Staff B called Staff D to the resident's room. Staff D found the resident face down on the floor, partially out of the bathroom. The resident complained of pain in the right ankle, denied hitting his/her head but staff observed the resident's glasses bent and a mark on the resident's right cheek. The resident transferred to the emergency room via ambulance and returned the following day with a cast to their right lower leg. The hospital Emergency Department (ED) Physician Note documented on 7/24/2011, the resident presented to the emergency room with chief complaint: fall. The history revealed the resident reported falling at the nursing home, tripped on the walker and landed on their face and re-injured the right leg. The resident had a prior fracture and internal fixation of the right bimalleolar (ankle) earlier this year. According to the ED note, the x-ray imaging showed right tib-fib spiral fracture of right distal tibia (lower leg bones). The resident received morphine to address his/her pain needs. During interview on 8/8/2011 at 11:30 a.m., the resident reported he/she had been walking up and down the hall quite a bit with therapy and felt pretty good. The next day Staff B assisted the resident to the bathroom, and the resident asked Staff B to get a sandwich and said "If you don't get me a sandwich, I'm going to". Staff B told the resident to stay seated on the toilet and left to get the sandwich. The resident decided to transfer to the wheel chair that sat in the bathroom doorway, took one step and fell . The resident reported he/she broke the rules and had been good otherwise, and knew he/she had osteoporosis. During interview on 8/8/2011 at 12:05 p.m., Staff B, CNA (certified nurse aide) reported the resident wanted a sandwich and to go to the bathroom. Staff B ambulated the resident to the toilet and the resident demanded a sandwich when she got back in the wheel chair. Staff B told the resident he/she could not leave but the resident insisted. Staff B went to the kitchen, got the sandwich and returned within a couple of minutes and found the resident lying face down on the floor. The resident attempted to get up unassisted one other night in early May when he/she had increased confusion. Staff added the alarms and low bed for safety. Staff B received a write-up following the incident. Staff B educated new hires to never leave a resident with alarms unattended on the toilet or in their wheel chairs. The facility posted signs by the time clock and in the daily charting books as well that reminded staff of the policy. Staff B knew the policy, and trained new hires of the facility's procedure. During interview on 8/8/2011 at 2:40 p.m., the DON (Director of Nursing) reported the resident transferred and ambulated independently initially, but after a fall in April and after experiencing a couple of seizures staff applied alarms. The resident improved and did well ambulating with therapy, and staff considered removing the alarms within a month or so. The resident had demanding behaviors and told Staff B to get a sandwich or he/she would get it, and Staff B left the resident on the toilet unattended while getting the sandwich. During interview on 8/8/2011 at 3:20 p.m., the Administrator said they educated all staff during a staff in-service. They reminded staff of the alarms and supervision policy. The resident was fairly alert and knew what they wanted, had been working with therapy and gaining confidence. During interview on 8/8/2011 at 2:50 p.m., Staff D reported on 7/24/2011, Staff B yelled for assistance and observed the resident on the floor, face down, conscious and alert and complained of right ankle pain. Staff D initiated the alarms after the resident fractured the ankle the first time and had a cast. The resident had no weight bearing orders and had attempted to get up out of bed. All residents with alarms require supervision. During interview on 8/8/2011 at 1:35 p.m., Staff C, RN (Registered Nurse) reported the resident had demanding behaviors, had fallen prior and fractured the right leg and staff added the alarms. The resident also had seizures in the past. The resident had been compliant with no attempts to get up unassisted. Prior to the first fracture, the resident ambulated and transferred independently. A facility document titled RTC Expectations dated 9/27/07, #18 indicated the following: Alarm residents will not be left in wheelchair or in bathroom unattended.