Every finding on record at Mountain Ridge Center, Genesis HealthCare

Based on observation, interview, and record review, the facility failed to ensure residents were free from potential exposure to bloodborne pathogens when staff used a resident's insulin pen on two residents (Resident identifiers are #62 and #70). The facility also failed to implement infection control policies for hand hygiene and disinfection of equipment for 2 of 7 residents observed during medication administration (Resident identifiers are #41 and #48). Findings include: Resident #62 and Resident #70 Interview on 5/28/26 at approximately 8:30 a.m. with Resident #62 revealed he/she received someone else's insulin yesterday afternoon. Interview on 5/28/26 at approximately 9:30 a.m. with Staff B (Licensed Practical Nurse (LPN)) revealed that on 5/27/26, he/she used Resident #70's used Novolog (insulin) pen to administer a lunch meal dose of insulin to Resident #62 then put back Resident #70's insulin pen in the medication cart. At approximately 4:00 p.m., Staff B was notified by Staff E (Director of Nursing) that he/she administered insulin to the wrong resident. Resident #70's insulin pen was not removed from the cart or discarded. Staff B stated that he/she administered Resident #70's dinner meal dose of insulin at 4:30 p.m. with the insulin pen that was earlier administered to Resident #62. Staff B then put the insulin pen back in the medication cart. Review on 5/28/26 of Resident #70's May's 2026 Electronic Medication Administration Record (EMAR) revealed an active physician's order for Novolog Penfill Solution Cartridge 100 Unit and was administered on 5/27/26 at 5:09 p.m. Interview on 5/28/26 at approximately 1:00 p.m. with Staff E confirmed that when the medication error was discovered, Resident #70's insulin pen was not removed from use. Review on 5/29/26 of the Novolog manufacturer's instruction revealed: .Warnings and precautions . Never share a Novolog Flex Pen, Novolog Flex Touch, Penfill Cartridge or PenFill Cartridge Device between patients, even if the needle is changed. Patients using Novolog vials must never share needles or syringes with another person. Sharing poses a risk for transmissions of blood-borne pathogens Review on 5/29/26 of the Centers for Disease Control and Prevention (CDC) handout, retrieved from https://www.cdc.gov/injection-safety//1anonly.html, revealed, .Insulin Pens: Recommendation for Safe Use. Protecting your patients from infection is a basic standard of care. Reusing insulin pens and other injection equipment for more than one person can spread infection to your patient. Insulin pens and other injection equipment are mean to be used on one person only. Insulin pens should never be used for more than one person, even when the need is changed. Review on 6/1/26 of the facility's policy, Insulin Pens, revised 5/1/25, revealed .Insulin pens containing multiple doses of insulin are meant for single patients use only and must never be used for more than one person, even when the needle is changed . Resident #48 Observation on 5/26/26 between 8:00 a.m. and 8:30 a.m. with Staff F (LPN) during medication administration revealed that after administering medication to Resident #66, they did not perform hand hygiene before dispensing and administering medication to Resident #48. Interview on 5/26/26 at approximately 8:30 a.m. with Staff F confirmed they did not perform hand hygiene between Resident #66's and Resident #48's medication administration. Review on 5/26/26 of the facility policy titled Hand Hygiene revised 5/1/25, revealed, .1. Perform hand hygiene: 1.1 Before patient/resident (hereinafter patient) care; 1.2 Before an aseptic procedure; 1.3 After any contact with blood or other body fluids, even if gloves are worn; 1.4 After patient care; 1.5 After contact with the patient's environment. Resident #41 Observation on 5/26/26 between 11:40 a.m. and 11:50 a.m. of Staff A (LPN) during medication administration, revealed that after testing Resident #55's blood glucose with the EvenCare G2 meter, they did not clean and disinfect the glucometer before using it to test Resident #41's blood glucose. Interview on 5/26/26 at approximately 11:50 a.m. with Staff A confirmed the above observation. Review on 5/26/26 of the Center for Disease Control and Prevention website Considerations for Blood Glucose Monitoring and Insulin Administration retrieved at: https://www.cdc.gov/injection-safety/hcp/infection-control/index.html revealed, If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared. Review on 5/26/26 of the EvenCareG2 Meter manufacturer instructions revealed, .Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease.The following products are validated for disinfecting the EvenCare G2 meter and lancing device: Dispatch hospital cleaner disinfecting towels with bleach.Clorox Healthcare Bleach Germicidal and Disinfectant Wipes.Medline Micro-Kill Clean Bleach Germicidal Bleach Wipes. Review on 5/26/26 of the facility procedure titled Fingerstick glucose measurement revised on 7/15/25, revealed, .23. Clean and disinfect the blood glucose meter after use with EPA [Environmental Protection Agency}] approved disinfectant, following manufacturer's instructions.

Based on interview and medical record review, the facility failed to act promptly upon the grievances and recommendations of issues of resident care raised at Resident Council Meeting for 2 of 2 months of resident council minutes reviewed. Findings include:Interview on 5/27/26 at approximately 10:00 a.m. during Resident Council Meeting revealed that the group had complained about long call bell wait times over the last 2 months. Residents at this meeting stated they do not feel this concern was addressed and that no one had followed up to inform them of what if any actions had been taken since the initiation of the concerns.Review on 5/27/26 of the facility's Resident Council Meeting minutes revealed the following documented concerns under Nursing:March 19, 2026, minutes: Residents are concerned that call lights aren't consistently responded to timely.April 16, 2026, minutes: Residents are concerned that call lights aren't consistently responded to timely. Previous months grievances reviewed for resolution was marked No.May 21, 2026, minutes: Previous months grievances reviewed for resolution was marked No.Further review revealed that the above minutes were signed by the Staff G (Administrator) as being received and reviewed.Interview on 5/27/26 at 1:47 p.m. with Staff G confirmed the above findings and that the facility had not acted upon the residents' continued concerns.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled according to professional standards on 1 of 3 medication carts observed. Findings include:Review on 5/28/26 of the facility's policy, Insulin Pens, revised 5/1/25, revealed: .Insulin pens will be clearly labeled with the patient's name, physician name, dated used. Observation on 5/28/26 at approximately 9:30 a.m. of the 200's Medication Cart with Staff E (Director of Nursing (DON)) revealed the following: Resident #59's Novolog insulin pen (Insulin Aspart), the pen was not labeled with the patient or physician's name.Resident #70's Novolog insulin pen (Insulin Aspart), the pen was not labeled with the patient or physician's name.Resident #70's Lantus insulin pen (Insulin Glargine), the pen was not labeled with the patient or physician's name. Interview on 5/28/26 at approximately 9:45 a.m. with Staff E confirmed the above findings.

Based on interview and record review, the facility failed to ensure residents remained free of insulin medication errors for 2 of 2 residents reviewed for significant medication error in a final sample of 19 residents. (Resident identifier are #62 and #70.) Findings include:Resident #62Interview on 5/28/26 at approximately 8:30 a.m. with Resident #62 revealed he/she received someone else's insulin yesterday afternoon. Resident #62 stated that a male staff member approached her in the dining room and asked, Are you [first name omitted]?Review on 5/28/26 of Resident #62's provider note dated 5/27/26 revealed that .Nursing discovered that this pt likely received another pt's insulin (with the same first name). This insulin [pronoun omitted] received was rapid acting, whereas the pt typically receives BID (twice a day) 70/30 (long acting) insulin. For this reason, the pt was assessed for signs of acute hypoglycemia .Review on 5/28/26 of Resident #62's active physician orders revealed the following: Novolin 70/30 Flexpen Subcutaneous Suspension Pen-Injector (70-30) 100 Unit/ML (milliliter) (Insulin NPH Isophane (Human)) (long acting insulin), Inject 29 unit subcutaneously one time a day for DM (Diabetes Milletus), schedule for 8:00 a.m.; and Novolin 70/30 Flexpen Subcutaneous Suspension Pen-Injector (70-30) 100 Unit/ML (milliliter) (Insulin NPH Isophane (Human)) (long-acting insulin), Inject 25 unit subcutaneously one time a day for DM (Diabetes Milletus), scheduled for 5:00 p.m.Review on 5/28/26 of Resident #62's May Medication Admin Audit Report revealed that on 5/27/26 at 8:34 a.m., Resident #62 was administered 29 units of Novolin 70/30 (long-acting insulin).Interview on 5/28/26 at approximately 9:30 a.m. with Staff B (Licensed Practical Nurse (LPN)) revealed that on 5/27/26 at approximately 3:30 p.m., he/she used Resident #70's Novolog (insulin) pen to administer 6 units of insulin to Resident #62. Interview revealed that he/she had picked up a shift at the facility for the first time on 5/27/26. Staff B stated that Resident #70 was scheduled to receive a lunch meal dose of insulin. Resident #70 was not in his/her room, so Staff B asked another staff member where Resident #70 was. He/she was told that Resident #70 was attending an activity in the dining room. Staff B brought the insulin pen with him/her and went to the dining room where he/she asked another staff member who Resident #70 was. Staff B approached Resident #62 and asked Resident #62's name, the resident nodded, yes. Staff B proceeded to give Resident #62 the ordered insulin for Resident #70. Review on 5/29/26 of the Novolog manufacturer's instruction revealed: .Warnings and precaution: Hypoglycemia is the most common adverse effect of all insulins, including Novolog. Severe hypoglycemia can cause seizures, may lead to unconsciousness, may be life-threatening or cause death.Review of the facility's policy, Medication Administration General Guidelines, dated 1/26, revealed . 10. Resident are identified before medication is administered using at least two identifiers. 16. Medications supplied for one resident are never administered to another resident .Resident #70Review on 5/28/26 of Resident #70's May Medication Administration Record revealed the following:5/27/26 at 7:30 a.m., Novolog Pen Fill Solution Cartridge 100 Unit/ML (milliliter) (Insulin Aspart), Inject as per sliding scale: If 160-200=4u (unit); 201-250=6u; 251-300-8u; 301-350=10u; subcutaneously before meals for diabetes, revealed that Resident #70's blood sugar was documented as NA (not applicable) and insulin was documented as HD (hold); and 5/27/26 at 11:30 a.m., Novolog Pen Fill Solution Cartridge 100 Unit/ML (milliliter) (Insulin Aspart), Inject as per sliding scale: If 160-200=4u (unit); 201-250=6u; 251-300-8u; 301-350=10u; subcutaneously before meals for diabetes, revealed that Resident #70's blood sugar was documented as 203 and 6 units of insulin was administered. Review further identified that this medication was administered to the wrong person.Interview on 5/28/26 at approximately 12:00 p.m. with Staff B revealed that Resident #70's 7:30 a.m. and 11:30 a.m. blood sugars were not obtained, and insulin was not administered as ordered. Further interview revealed that the provider was not notified that the insulin was not administered as ordered.

Based on observations, interview, and record review, the facility failed to ensure a resident's diet preferences were followed for 1 of 4 residents reviewed for nutrition in a final sample of 19 residents. (Resident identifier is #70.)Findings include:Interview on 5/26/26 at approximately 9:50 a.m. with Resident #70 revealed, I am supposed to be on a vegetarian diet.Review on 5/27/26 of Resident #70's medical record revealed a nutritional assessment, dated 3/3/26, that stated .on a low sodium diet/Vegetarian (per [pronoun omitted] request). Nutritional care plan, created 7/12/24, revealed an intervention to honor food preferences within meal plan.Observation on 5/28/26 at approximately 12:15 p.m. of Resident #70 in the main dining room with chicken salad on their plate for lunch. Resident #70's meal ticket that read, . 2gm [gram] Sodium No salt packet! No pork; requests vegetarian diet.Interview on 5/28/26 at 1:20 p.m. with Staff C (Dietary Manager) stated that Resident #70's preference is for a vegetarian diet but since he/she has an order for a 2gm sodium diet they are only given the 2gm Sodium menu for them to choose their meals from.Interview on 5/28/26 at approximately 2:30 p.m. with Staff D (Regional Dietitian) stated that they facility does have a vegetarian menu, but Staff D had not provided that menu to Resident #70.Review on 5/29/26 of the facility policy titled Dining and Food Preferences, revised 10/2022, revealed, .5. The Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents/patients that do not consume certain food or food groups.

Based on observation, interview, and record review, the facility failed to ensure that insulin was administered per manufacturer's instructions for 1 of 7 residents observed for medication administration (Resident identifier is #55).Findings include: Resident #55 Review on 5/26/26 of Resident #55's physician orders revealed an order for Novolog Insulin (Aspart Insulin) per sliding scale before meals for Diabetes Mellitus. Observation on 5/26/26 at 11:45 a.m. of Resident #55's insulin administration with Staff A (Licensed Practical Nurse (LPN)) revealed when injecting the insulin, with the insulin pen, Staff A held the plunger of the insulin pen for approximately 4 seconds. Interview on 5/26/26 at approximately 11:45 a.m. with Staff A confirmed the above observation. Review on 5/26/26 of Insulin Aspart manufacturer instructions for use revealed .Keep the needle in the skin for at least 6 seconds, and keep the push-button pressed all the way in until the needle has been pulled out from the skin.This will make sure that the full dose has been given.

Based on record review and interview, it was determined that the facility failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in a census of 68 residents. Findings include: Review on 6/19/25 of Mountain Ridge Facility Assessment 2025 revealed staff/personnel required listed staff by shift for the entire facility and did not list staff/personnel required per resident unit. Review on 6/19/25 of personnel files revealed the following staff with light duty restrictions: Staff F (LNA with a 10 pound lifting restriction) and Staff R (LNA with a 10 pound lifting restriction). Interview on 6/19/25 at approximately 1:00 p.m. with Staff A (Administrator) revealed that the facility considered Licensed Nursing Assistant (LNA) that are on light duty as a full duty staff when scheduling. Review on 6/19/25 of 30 days of staffing schedules from 5/20/25 to 6/18/25 revealed the following days with Staff F and/or Staff R working on light duty: On 5/20/25, 5/21/25, 5/26/27, 5/27/25, 5/28/25, 5/29/25, 5/31/25, 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/9/25, 6/11/25, 6/12/25 6/14/25, and 6/18/25. There was one LNA on light duty on the 7:00 a.m. to 3:00 p.m. shift. On 6/15/25 and 6/17/25 7:00 a.m. to 3:00 p.m. there were two LNAs on light duty on the 7:00 a.m. to 3:00 p.m. shift. Interview on 6/19/25 at 7:55 a.m. with Staff I (Anonymous) revealed that the 200 unit works with one LNA at times. The LNAs cannot complete all the require tasks, such as showers, with light duty staff working as a full duty assignment. Interview on 6/19/25 at approximately 8:00 a.m. with Staff O (Anonymous) revealed that on a recent Sunday there were 72 residents and three LNAs working. Two of the LNAs were on light duty with restrictions. Staff O stated, The two other LNA's that were scheduled had restrictions and one LNA cannot physically or mentally take care of 72 residents. Further interview revealed that light duty staff have full assignments frequently and showers are not being given. Interview on 6/20/25 at approximately 11:00 a.m. with Staff A revealed that the facility has approximately 33 residents that are dependent on staff or a two person assist for care. Staff A revealed that on 5/28/25 Staff R (LNA on light duty) was scheduled to work alone on the 200 unit. Interview on 6/19/25 at approximately 7:10 a.m. with Staff L (Anonymous) stated that the staffing at the facility is unsafe. There has been an increase in falls, there are always LNAs that are on light duty scheduled with full assignments. Residents have to wait a long time to be cared for. Interview on 6/19/25 at approximately 7:15 a.m. with Staff K (Anonymous) revealed that he/she felt that there was not enough LNAs to answer call lights and not enough LNAs to assist with resident transfers. Interview on 6/19/25 at approximately 7:20 a.m. with Staff N (Anonymous) revealed that having one LNA assigned to each wing is unsafe. Interview revealed there were 6-7 resident requiring hoyer lifts for transfers (requiring assistance of two LNAs) on the 200 Wing. Residents have to wait in bed until there is someone available to help with their transfers. Residents do not get showers when there are three LNAs scheduled. Interview on 6/19/25 at 7:20 a.m. with Staff D (Anonymous), revealed that the staffing for the whole building is usually two LNAs and one Light Duty aide during the evening and night hours. The building has many two person assist. The facility is also still taking new admissions. Interview on 6/19/25 at approximately 7:30 a.m. with Staff M (Anonymous) revealed that the dining room is frequently shut down due to inadequate staffing. If there are 3 LNAs scheduled, then showers are not getting done. Interview on 6/19/25 at 7:30 a.m. with Staff E (Anonymous) revealed that the 100 Unit has 9 residents that require a hoyer lift and how quickly a resident is transferred depends on the nurse if they can help or not. A good staffing day on the 100 unit is two LNA's and two nurses, but they usually have one LNA and one nurse. Interview on 6/19/25 at 7:40 a.m. with Staff H (Anonymous), revealed that the 100 Unit usually has one LNA and one nurse and that Staff H cannot help with lifting. Interview on 6/19/25 at 7:45 a.m. with Staff G (Anonymous) revealed that he/she needs to go to all three units to ask for help with hoyer lift transfers on the 200 unit. The floor is staffed with one LNA and one light duty. Interview on 6/19/25 at approximately 10:45 a.m. with Staff V (Anonymous) revealed that residents are not getting out of bed frequently due to staffing. Staff V revealed The dining room has been closed this past Saturday, Sunday, yesterday, and today due to inadequate staffing. Interview on 6/19/25 at approximately 11:00 a.m. with Staff Q (Anonymous) revealed that he/she has been at the facility for a few years. Staffing is the worst it has ever been. Residents are not getting to outside specialist appointments, either due to transportation not being scheduled or the appointments not being made. Staff that are here are stressed out. Interview on 6/20/25 at approximately 10:40 a.m. with Staff A (Administrator) revealed that a few weeks ago LNAs arrived at the building to work and refused to punch in due to lack of staff scheduled. The Director of Nursing and Administrator (not clinical) were notified and came in to the building. From approximately 7:00 a.m. until 9:00 a.m. the facility did not have any LNAs in the building. Interview on 6/20/25 at approximately 10:00 a.m. with Staff J (Anonymous) revealed that staffing is horrible and that residents frequently miss meaningful activities due to not being out of bed or dressed. When residents are put back to bed after lunch there is not enough staff to get them back up and they stay in bed for the rest of the day. Interview on 6/19/25 at approximately 7:35 a.m. with Resident #4 had complaints of not enough staff at times and he/she has to wait for care and transfers because he/she requires two people to assist her because he/she uses a mechanical lift for transfers. Observation on 6/19/25 at approximately 7:35 a.m. of Resident #4 revealed he/she was laying in bed fully clothed with a hoyer lift pad placed underneath them. Observation on 6/19/25 at approximately 7:50 a.m. of a resident's room on the 100 Wing revealed three residents sitting in the room. All 3 residents were in Geriatric Chairs with their eyes closed with side tables placed in front of them and clothing protectors on. Interview on 6/19/25 at approximately 7:50 a.m. with Staff E (Anonymous) revealed the three residents in the room were Resident #6, Resident #7 and Resident #8. Staff E revealed that two of the residents (Resident #7 and Resident #8) reside in the room and Resident #6 was brought in the room by staff because the dining room was closed. They do this more often than not to assist the residents with breakfast when the dining room is closed. I put them all together so I can feed them. Review on 6/20/25 of Resident Council Minutes for May 2025 revealed: On 5/22/25, Departmental Requests, Concerns, Suggestions, Compliments, etc., Nursing: . Bells considered good during the day but bad later in day/night shift. Shower Issues. Told can't get showers since there is 1 person on the unit. Report going a long time without a shower Tired of hearing short staffed.

Based on interview and record review, it was determined the facility failed to provide needed care for 2 of 3 residents reviewed for quality of care. (Resident identifiers are #5 and #17 ). Findings include: Resident #5 Review on 6/19/25 of Resident #5's Bowel Movement Size Task Record revealed the following: Resident #5 had a bowel movement on 5/21/25 and 5/31/25. Resident #5 did not have a bowel movement on 5/22/25-5/30/25 (9 days). Resident #5's most recent bowel movement was on 6/12/25. Resident #5 did not have a bowel movement on 6/13/25-6/18/25 (6 days). Review on 6/19/25 of Resident #5's May and June 2025's MAR's (Medication Administration Records) revealed the following physician orders: May 2025 Milk of Magnesia Suspension 400 mg/ml (milliliters) (Magnesium Hydroxide) Give 30 ml by mouth as needed for Constipation give at bedtime if no BM (Bowel Movement) in 3 days, start date 5/15/25. This was not documented as being offered to Resident #5 from 5/25/25-5/30/25. Dulcolax Suppository 10 mg (milligrams) (Bisacodyl) Insert 1 suppository rectally as needed for Constipation, if no result from MOM-Miralax by next shift, start date 4/10/25. This was not documented as being offered to Resident #5 from 5/26/25-5/30/25. June 2025 Milk of Magnesia Suspension 400 mg/ml (milliliters) (Magnesium Hydroxide) Give 30 ml by mouth as needed for Constipation give at bedtime if no BM (Bowel Movement) in 3 days, start date 5/15/25. This was not documented as being offered to Resident #5 from 6/16/25-6/18/25. Dulcolax Suppository 10 mg (milligrams) (Bisacodyl) Insert 1 suppository rectally as needed for Constipation, if no result from MOM-Miralax by next shift, start date 4/10/25. This was not documented as being offered to Resident #5 from 6/17/25-6/18/25. Interview on 6/19/25 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed that on the dates listed above there were no documented interventions offered or given to Resident #5. Resident #17 Interview on 6/19/25 at approximately 11:00 a.m. with Staff Z (Nurse Practitioner) revealed that residents are not going to appointments outside of the facility when he/she refers residents to specialists. Staff Z stated that this is usually because of lack of transportation, or the appointment not being made. Further interview with Staff Z revealed Resident #17 had missed several dermatology referrals/appointments. Review on 6/19/25 of Resident #17's medical record revealed the following physician's orders: Refer to Dermatology, order dated 10/22/24. Further medical record review revealed there was no documentation of Dermatology appointment being scheduled. Further review of physician orders an order for a MRI (Magnetic Resonance Imaging) head and neck, order dated 4/14/25. Review further revealed that there was no documentation of the MRI being scheduled or completed. Review on 6/19/25 of Resident #17's medical record revealed the following provider visit notes for wounds: On 11/22/24 . Patient evaluated for left neck wound. This started as a scratch then subsequently ulcerated and has not healed.Neoplasm of uncertain behavior of skin, Dermatology referral made. Continue wound care to site. On 11/29/24 . Patient evaluated for left neck wound. This started as a scratch then subsequently ulcerated and has not healed. [pronoun omitted] has been referred to Dermatology Outpatient for biopsy/evaluation/treatment. Neoplasm of uncertain behavior of skin, Continue wound care, see Dermatology. On 1/10/25 . [pronoun omitted] has been referred to Dermatology Outpatient for biopsy/evaluation/treatment Neoplasm of uncertain behavior of skin, [pronoun omitted] needs to see Dermatology. Continue wound care. On 1/24/25 . Patient evaluated for left neck wound. This started as a scratch then subsequently ulcerated and has not healed. Ongoing concern for underlying malignancy. An appointment was made with dermatology this week, unfortunately [pronoun omitted] missed [pronoun omitted] appointment. Neoplasm of uncertain behavior of skin, Continue wound care. Dermatology appointment to be rescheduled. On 1/31/25 . Patient evaluated for left neck wound. This started as a scratch then subsequently ulcerated and has not healed. Ongoing concern for underlying malignancy. An appointment was made with dermatology this week, unfortunately [pronoun omitted] missed [pronoun omitted] appointment, it has reportedly been rescheduled for March. Neoplasm of uncertain behavior of skin, Deterioration ongoing. Referral to Derm (Dermatology) appointment reportedly rescheduled. On 2/13/25 . Patient evaluated for left neck wound. This started as a scratch then subsequently ulcerated and has not healed. Ongoing concern for underlying malignancy. [pronoun omitted] has an appointment scheduled in March with dermatology. [pronoun omitted] developed redness, pain, odor, increased swelling and drainage at wound site. Culture obtained and this grew MRSA (Methicillin-resistant Staphylococcus aureus) and Morganella Morganii, . Neoplasm of uncertain behavior of skin, deterioration at site continues. Wound orders updated. Follow up with Dermatology. On 2/21/25 . Patient evaluated for left neck wound. This started as a scratch then subsequently ulcerated and has not healed. Ongoing concern for underlying malignancy. [pronoun omitted] has an appointment scheduled in March with Dermatology. [pronoun omitted] has developed redness, pain, odor, increased swelling and drainage at wound site. Culture obtained and this grew MRSA (Methicillin-resistant Staphylococcus aureus) and Morganella Morganii both sensitive to gentamicin. Infection cleared with gentamicin ointment. Neoplasm of uncertain behavior of skin, [pronoun omitted] needs to see Dermatology for treatment. On 2/28/25 . Patient evaluated for left neck wound. This started as a scratch then subsequently ulcerated and has not healed. Ongoing concern for underlying malignancy. [pronoun omitted] has an appointment scheduled in March with Dermatology. Neoplasm of uncertain behavior of skin, Continue wound care. Dermatology appointment upcoming. On 4/7/25 . Patient evaluated for left neck wound. This started as a scratch then subsequently ulcerated and has not healed. Ongoing concern for underlying malignancy. Several referrals to Dermatology have been requested. [pronoun omitted] had an appointment with Dermatology but this was missed. Thankfully an appointment was made for this week, spouse will transport. Pain has been stable at site, nursing has noted increased drainage and odor. Neoplasm of uncertain behavior of skin, Wound orders updated to include Dakins gauze packing and increased dressing change frequency. Follow up with Dermatology. On 5/9/25 . Patient evaluated for malignant left neck wound. Pathology confirmed squamous cell carcinoma. [pronoun omitted] has been referred to ENT (Ear, Nose, and Throat) Oncology. The wound has continued to deteriorate and there has been persistent signs of disease progression. Unspecified malignant neoplasm of skin of scalp and neck, Disease progression is evident. Wound orders updated. ENT Oncology referral made, appointment was 5/8 but had to be rescheduled due to no transport (transportation) . Review on 6/19/25 of Resident #17's Surgery Consultation Notes, dated 4/28/25 revealed: . presents to surgical consultation with large left neck wound .this wound is from squamous cell carcinoma and has been there are a least several years . No surgical debridement recommended at this time. Interview on 6/20/25 at approximately 9:20 a.m. with Staff B (Director of Nursing) confirmed that there was no documentation of Dermatology being contacted from the initial order dated 10/22/24, and no documentation of the MRI being scheduled or completed.

Based on interview and record review, it was determined the facility failed to provide timely laboratory services to meet the needs of its residents for 1 of 1 resident reviewed for laboratory services. (Resident identifier is #2.) Findings include: Interview on 6/19/25 at 7:55 a.m. with Staff CC (Licensed Practical Nurse) revealed that Resident #2 had a physician's order to obtain a UA (urinalysis) that had not been completed timely. Review on 6/19/25 of Resident #2's physician's orders revealed an order written on 5/6/25, UA with culture and sensitivity one time only for delusions Review on 6/19/25 of Resident #2's May 2025's Treatment Administration Record revealed that the urine had been obtained on 5/7/25. Review on 6/19/25 of Resident#2's medical record revealed that there were no laboratory results for UA on 5/7/25. Review on 6/19/25 of Resident #2's medical record revealed a nursing note, dated 5/13/25 revealed: a urine specimen was collected on 5/13/25 and brought to local laboratory. Interview on 6/19/25 at 11:20 a.m. with Staff Z (Nurse Practitioner) revealed that the urine specimen from 5/7/25 was forgotten in the refrigerator not tested. The specimen needed to be recollected on 5/13/25. Staff Z revealed that specimen obtained are forgotten in the refrigerator all the time and it causes a delay in treatment.

Based on observation, interview, and record review, it was determined that the facility failed to ensure medications were labeled according to professional standards on 2 of 3 medication carts observed. Findings include: Observation on 6/19/25 at approximately 7:15 a.m. of the 200's Medication Cart with Staff T (Licensed Practical Nurse (LPN)) revealed the following: Resident #10's Incruse Ellipta inhaler, opened and not labeled with an open/expiration date Resident #11's Breztri inhaler, opened and not labeled with an open/expiration date Interview on 6/19/25 at approximately 7:15 a.m. with Staff T confirmed the above findings. Observation on 6/19/25 at approximately 7:30 a.m. of the 300's Medication Cart with Staff BB (LPN) revealed the following: Resident #5's Breztri inhaler, opened and not labeled with an open/expiration date Resident #12's 2 Breztri inhalers, opened and not labeled with an open/expiration date Resident #13's Spiriva inhaler, opened and not labeled with an open/expiration date Resident #14's Trelegy inhaler, opened and not labeled with an open/expiration date Resident #15's Incruse Ellipta inhaler, opened and not labeled with an open/expiration date Interview on 6/19/25 at approximately 7:30 a.m. with Staff BB confirmed the above findings. Review on 6/19/25 of the manufacturer's instructions for Incruse Ellipta, Revision Date December 2023 revealed: . Safely throw away Incruse Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0 whichever comes first. Write the date you open the tray on the label on the inhaler. Review on 6/19/25 of the manufacturer's instructions for Breztri Aerosphere inhaler, Revision Date January 2022 revealed: . Throw away your inhaler in household trash when: puff indicator shows 0 or 3 months after your inhaler has been removed from the foil pouch. Review on 6/19/25 of the manufacturer's instructions for Spiriva Respimat inhaler, Revision Date November 2021 revealed: . Three months after insertion of cartridge, throw away the Spiriva Respimat even if it has not been used, or when the inhaler is locked, or when it expires, whichever comes first. Review on 6/19/25 of the manufacturer's instructions for Trelegy Ellipta inhaler, Revision Date 12/2022 revealed: . Write the tray opened and Discard dates on the inhaler label. The Discard date is 6 weeks from the date you open the tray. Review on 6/19/25 of the facility policy titled, 4.1 Storage of Medication, Dated 1/25 revealed: Policy, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep the integrity and to support safe, effective drug administration.

Based on interview and record review, it was determined that the facility failed to maintain weight for 1 of 2 residents reviewed for nutrition in a complaint survey. (Resident identifiers are #16). Findings include:Resident #16 Review on 6/20/25 of the facility provided matrix revealed that Resident #16 had significant weight loss. Review on 6/20/25 of Resident #16's Weight Summary revealed: 5/1/25 Resident #16's weight was 154.6 6/6/25 Resident #16's weight was 144.0 (9.4 pound loss) Review on 6/20/25 of Resident #16's Nutrition Assessments revealed that the last time he/she was seen by the dietician was 2/18/25. Review on 6/20/25 of Resident #16's Physician Regulatory Visit, dated 5/31/25 revealed no mention of recent weight loss, under Past Medical History mentioned weight loss Review on 6/20/25 of Resident #16's documented meal intake titled, Eating Task, Amount eaten (last 30 days) revealed: 5/23 1 meal documented eaten 5/25 2 meals documented eaten 5/26 1 meal documented eaten 5/28 1 meal documented eaten 5/30 1 meal documented eaten 5/31 2 meals documented eaten 6/1 1 meal documented eaten 6/2 1 meal documented eaten 6/3 1 meal documented eaten 6/4 1 meal documented eaten 6/5 no meals documented eaten 6/6 1 meal documented eaten 6/7 1 meal documented eaten 6/9 1 meal documented eaten 6/10 1 meal documented eaten 6/12 1 meal documented eaten 6/15 1 meal documented eaten 6/17 1 meal documented eaten Review on 6/20/25 of Resident #16's care plan for Nutritional Risk, Revision Date 7/11/23 revealed: . Interventions . Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake. Interview on 6/20/25 at approximately 9:30 a.m. with Staff C (Nurse Practice Educator) confirmed that there was no documentation of the dietitian/physician being notified of Resident #16's weight loss or meal intakes.

Based on interview and record review, it was determined that the facility failed to ensure that the facility assessment included specific staffing needs for each resident unit for a census of 68 residents. Findings include: Review on 6/19/25 of Mountain Ridge Facility Assessment 2025 revealed .3. Staff/Personnel required .Combination of RN/LPN: 24 hours Day Shift, 24 Hours evening Shift, 16 Hours night shift (Hours listed for full census) LNA Staff: 52.5 hours Day Shift, 52.5 hours Evening Shift, 22.5 Evening Shift Hours listed for full census) May fluctuate based on census and acuity Further review revealed that the facility assessment did not identify staffing needs per resident unit. Interview with Staff A (Administrator) on 6/20/25 at approximately 11:00 a.m. confirmed the Facility Assessment did not consider the needs of each resident unit.

Based on interview and record review, it was determined that the facility failed to follow professional standards for physician ordered medication parameters for 1 of 8 residents reviewed for unnecessary medications in a final sample of 18 residents (Resident Identifier is #38). Findings include: Standards: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Review on 4/16/25 of Resident #38's medical record revealed the following a physician's orders: Morphine Sulfate Oral Tablet 30 MG (Milligram) (Morphine Sulfate), give 30 mg by mouth every 4 hours as needed for pain (PRN) 7/10 (a pain level of 7 out of 10) or greater, start date 2/17/25 and discontinued 3/20/25.; and Morphine Sulfate Oral Tablet 30 MG (Morphine Sulfate), give 1 tablet by mouth every 4 hours as needed for pain 5/10 (a pain level of 5 out of 10) or greater, start date 3/20/25 and discontinued 4/14/25. Review on 4/16/25 of Resident #38's Medication Administration Record (MAR) for March and April 2025 revealed that Resident #1's as needed (PRN) Morphine Sulfate 30 MG tablet was administered on 3/1 at 6:08 a.m. and 2:39 p.m., 3/4 at 10:59 p.m., 3/5 at 9:42 p.m., 3/12 at 10:12 p.m., 3/14 at 9:41 p.m., 3/16 at 4:28 a.m., 3/18 at 4:18 p.m., 3/19 at 1:55 a.m., 3/25 at 8:32 a.m., 3/30 at 4:05 a.m., 4/2 at 12:50 a.m., 4/3 at 6:33 p.m., 4/8 at 1:46 p.m., 4/12 at 9:24 a.m. with 0 pain level documented. Interview on 4/16/25 at 1:27 p.m. with Staff E (Unit Manager) confirmed that Resident #38 received the above medication and there was 0 pain (no pain) level documented.

Based on interview and record review, it was determined that the facility failed to facilitate the inclusion of the resident and/or representative in quarterly care plan meetings for 2 residents in a final sample of 18 residents. (Resident identifiers are #4 and #54). Findings include: Resident #4 Interview on 4/14/25 at approximately 11:00 a.m. with Resident #4's Durable Power of Attorney (DPOA) revealed that he/she had not been notified or invited and had not attended a care plan meeting in about two years. Review on 4/14/25 of Resident #4's medical record revealed that Resident #4 was admitted to the facility in 2023 and there were no care plan meeting notes after 2023. Interview on 4/14/25 at approximately 1:00 p.m. with Staff A (Director of Social Services) revealed that Resident #4 was on the calendar for care plan meetings on 12/3/24 and 5/28/24 but Staff A had no documentation or recollection of the meetings or of Resident #4's DPOA being invited to the meeting. 47129 Resident #54 Interview on 4/15/25 at 9:10 a.m. with Resident #54's DPOA revealed that Resident #54 was admitted to the facility in January 2024 and had been to one care plan meeting in October 2024. The DPOA would like to be in attendance to know about the goals being set for Resident #54. Review on 4/15/25 of Resident #54's medical record revealed that Resident #54's DPOA was activated. Further review revealed a care plan meeting note, dated 10/21/24, which Resident #54's DPOA was in attendance. Further review revealed that there was no documentation of a care plan meeting for Resident #54 prior to or after 10/21/24. Interview on 4/15/25 at 1:54 p.m. with Staff A confirmed that there was not a care plan meeting for Resident #54 to prior to or after 10/21/24. Review on 4/14/25 of facility policy titled Person-Centered Care Plan, dated 10/24/22, revealed .9. The Center has the responsibility to assist patients to participate by: 9.1 Extending invitations to patient and HCDM (Health Care Decision Maker) sent in advance; 9.3 Facilitating the inclusion of the patient/resident representative(s) to attend .10. Care plan meetings will be documented by the use of the Care Plan Meeting note .

Based on observation, interview, and record review, it was determined that the facility failed to provide sufficient nursing staff for 24 out of 30 days of nursing staff schedules reviewed reviewed between 3/15/25 and 4/15/25. (Resident identifiers are #34, #36, #52, #54, #55, and #278). Findings include: Interview on 4/14/25 at approximately 10:47 a.m. with Resident #278 revealed that he/she waits for staff to get him/her up and dressed. Resident #278 stated that he/she is at the facility for short-term rehabilitation following a back fracture and he/she requires assistance for care. Resident #278 stated that he/she has had an incontinent episode while waiting for his/her call bell to be answered to go to the bathroom. Interview on 4/17/25 with Staff I (Scheduling Coordinator) revealed that the schedule has been consitantly short staffed since they started three weeks ago. 40522 Interview on 4/11/25 with Staff N (Anonymous direct care staff) revealed that the facility does not have enough Licensed Nursing Assistant (LNA) staff to care for the residents on a routine basis. Staff N stated that the facility has ongoing short staffing of LNAs on evening shift. Interview on 4/14/25 at approximately 3:30 p.m. with Staff J (LNA) and Staff K (LNA) revealed they are short staff for at least 3 times a week and that on 7:00 p.m. to 11:00 p.m. shift, there would be one LNA instead of two LNA's working on the 200 unit. Staff J stated that resident's call lights would be answered when they can and at times residents would have to wait for a period of time. Interview on 4/16/25 at approximately 9:08 a.m. with Staff E (Registered Nurse) and L (Registered Nurse) revealed that they are short staff and often works as LNA's or as a direct care nurse on a medication cart to cover shifts which is not there primary role. Staff E and Staff L stated that they cannot do their managerial duties as they are covering shifts as LNA's and direct care nurses. Interview on 4/17/25 at approximately 8:30 a.m. with Staff M (Infection Preventionist) revealed that he/she would cover shift as an LNA on top of his/her primary role as an Infection Preventionist and he/she often missed meetings with the nurse practitioner to discuss resident's on antibiotics and antibiotic sterwardship. Review on 4/17/25 of the facility's matrix revealed that there were 14 residents admitted to the facility for the past 30 days. 47129 Interview on 4/14/25 at 11:18 a.m. with Resident #52 revealed that he/she has been waiting appproximately over an hour for staff to assist him/her back to bed. Resident #52 stated that he/she had asked Staff F (LNA) to assist her back to bed and was told by Staff F that he/she was the only LNA on the 100 unit this morning so he/she would have to wait. Interview on 4/14/25 with Staff F confirmed that Resident #52 had to wait because he/she was assisting another resident. Staff F stated that he/she was the only LNA assigned to the unit due to a staff call out and there was not another LNA assigned to the unit. Staff F also stated that there should be 2 LNA's assigned to 100 unit. Interview on 4/15/25 at approximately 9:00 a.m. with Resident #54's Durable Power of Attorney (DPOA) revealed that Resident #54 had told him/her that Resident #54 would wait up to an hour for care. Resident #54's DPOA stated that Resident #54 liked to stay in bed but he/she can't get up herself so if he/she needed something he/she had to press the call bell. Resident #54's DPOA stated that he/she had spoken to staff and was told a lot of times they only have one LNA on duty so there were long wait times for care. Review on 4/15/25 of the Resident Council Meeting Minutes dated 2/27/25 revealed that there were concerns with very long call bell wait times for getting up. Interview on 4/15/25 at 10:23 a.m. with the Resident Council revealed that all 7 residents in attendance had concerns with call bells being answered timely. 6 out of 7 residents who reside on the 100 and 200 unit stated that it worse on the 3-11 shift. They stated that on most weekends, either a Saturday and/or a Sunday or sometimes both and 2- 3 days during the week, there was one LNA responsible for 28-30 residents on the 100 or 200 halls. One resident stated that it was a rare day when there are more than two LNA's working during the same shift. Interview and observation on 4/15/25 at 10:25 a.m. with Resident #55 (Resident Council President) revealed that staffing was a real problem in the facility. Resident #55 stated that he/she was 20 minutes late to the meeting because there was not enough staff to assist him/her to get out of bed and dressed. Interview on 4/16/25 at 12:01 p.m. with Staff C (LNA) confirmed that Resident #55 was late to the Resident Council Meeting on 4/15/25 because they were short on help. 48515 Resident #55 Interview on 4/14/25 at 10:18 a.m. with Resident #55 revealed that he/she was not able to go to the music activity that started at 10:00 a.m. today because there was not enough staff to get Resident #55 out of bed on time. Resident #55 further revealed that this occurs frequently because there is only one LNA (Licensed Nursing Assistant) for 30 residents in the 200's unit. Interview on 4/14/25 at approximately 1:00 p.m. with Staff C (Licensed Nursing Assistant) revealed that he/she was the only LNA on the 200 unit that morning. Interview on 4/15/25 at approximately 10:00 a.m. with Staff D (Director of Nurses) revealed that there are 8 residents that require mechanical lifts for transfer, 11 residents that require extensive care, and 3 residents that require 2 assist with care on the 200 unit.

Based on observation and interview, it was determined that the facility failed to ensure that expired medications were removed from stock and multi-dose vials were dated when opened in 1 of 1 medication room observed. Findings include: Observation on 4/14/25 at approximately 8:15 a.m. of Medication Room with Staff B (Registered Nurse) revealed the following expired and opened/undated medications and biological: One opened bottle of Tuberculin Purified Protein Derivative (Mantoux) solution with no open date or open expiration date in the vaccine refridgerator; One bottle of opened Afluria, Influenza Vaccine 2024-2025 Formula with no open date or open expiration date in the vaccine refridgerator; Three bags of IV (Intravenous) Vancomycin (antibiotics) 850 mg (milligrams)/267 ml (milliliters) NS (Normal Saline) for Resident #48 with an expiration date of 3/10/25 in the medication room refrigerator; Three bags of IV Zosyn (antibiotic) Intravenous Solution 3-0.375 GM (Grams)/50 ml for Resident #46 with an expiration date of 3/26/25 in the medication room refrigerator. Interview on 4/14/25 at approximately 8:15 a.m. with Staff B confirmed that the above findings had no open date and open expiration date, the Tuberculin and Afluria vaccine vials had been used, and that the IV antibiotics were expired. Review on 4/14/2025 of the manufacturers instructions for Afluria, Influenza Vaccine revealed: 16.2 Storage and handling -Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. Review on 4/14/25 of the manufacturers instructions for Tuberculin Purified Protein Derivative revealed: A vial of Tubersol which has been entered and in use for 30 days should be discarded. Review on 4/14/25 of facility policy titled Medication Storage, dated 1/25 revealed .14. Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal .

Based on interview and record review, it was determined that the facility failed to provide the resident and/or resident representative a timely Notice of Medicare Non-Coverage (NOMNC) for 1 out of 3 residents, and failed to provide the resident and/or representative the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 2 out of 3 residents reviewed for beneficiary notices. (Resident identifiers are #53 and #48). Finding include: Resident #48 Review on 4/15/25 of Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #48's last covered day of Medicare Part A Services was on 4/8/25 with benefit days remaining. Resident #48 remained in the facility. Review on 4/15/25 of Resident #48's NOMNC revealed a last covered day of 4/8/25. Resident #48 was notified on 4/7/25. Interview on 4/15/25 at approximately 1:30 p.m. with Staff H (Business Office Manager) confirmed that Resident #48's NOMNC was not given 48 hours notice. Further interview with Staff H revealed that the SNF ABN was not provided to Resident #48. Resident #53 Review on 4/15/25 of Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #53's last covered day of Medicare Part A Services was on 12/22/24 with benefit days remaining. Resident #53 remained in the facility. Interview on 4/15/25 at approximately 1:30 p.m. with Staff H confirmed that the SNF ABN was not provided to Resident #53.

Based on interview and record review, it was determined that the facility failed to adhere to physician ordered medication parameters for 1 of 3 residents reviewed for pain in a final sample of 22 residents (Resident Identifier #1). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 6/25/24 at approximately 12:48 p.m. of Resident #1's physician orders revealed an order for Oxycodone HCI [Hydrochloride] 5 MG [Milligrams] give 1 tablet by mouth at bedtime for pain management AND give 1 tablet by mouth every 6 hours as needed for pain 5/10 or greater. With a start date of 5/29/24. Review on 6/25/24 of Resident #1's Medication Administration Record (MAR) for June 2024 revealed that Resident #1's as needed (PRN) Oxycodone 5 MG tablet was administered once a day on 6/1, 6/3, 6/5, 6/6, 6/10, 6/17, 6/20, 6/21, 6/23, 6/24, 6/26, and twice a day on 6/8, 6/9, 6/12, 6/14, 6/22 with no pain level documented. Interview on 6/27/24 at approximately 1:00 p.m. with Staff D (Unit Manager) confirmed that Resident #1 received the above medication and there was no pain level documented.

Based on interview and record review, it was determined that the facility failed to ensure residents were offered and/or provided education on the risks and benefits of Pneumococcal immunization for 1 of 5 residents reviewed for immunizations (Resident Identifier #73). Findings include: Review on 6/27/24 of Resident #73's medical record revealed that Resident #73 was admitted to the facility in February 2024. Further review revealed that Resident #73 had no Pneumococcal immunization history in the medical record nor was their education/consent/declination for Pneumococcal vaccine present. Interview on 6/27/24 at approximately 8:45 a.m. with Staff C (Infection Preventionist) confirmed that Resident #73 had not been offered or educated on the risks/benefits of pneumonia vaccines and should have been on admission. Review on 6/27/24 of facility policy titled Pneumococcal Vaccination, revealed: . 1. Upon admission, obtain the pneumococcal vaccination history of all patients .Adults aged greater than or equal to [AGE] years who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine PCV 20 .

Based on interview and record review, it was determined that the facility failed to ensure that all alleged violations were reported immediately or no later than 2 hours after the allegation is made to the State Survey Agency for 1 of 1 resident reviewed for abuse in a final sample of 24 residents (Resident Identifier is #73). Findings include: Interview on 6/6/23 at approximately 8:45 a.m. with Staff A (Anonymous) revealed that Resident #73 was involved in a medication error where they received someone else's Morphine (opioid) and required 3 doses of Narcan(R) (opioid antagonist). Review on 6/6/23 of Resident #73's nurses notes revealed a note dated 5/27/23 that stated Resident #73 received a long acting narcotic and orders received for Narcan(R) 0.4 milligrams per milliliters times 3 doses every 3 hours and to monitor respirations every 15 minutes. Interview on 6/8/23 at approximately 8:59 a.m. with Staff B (Director of Nursing) confirmed that they could not provide confirmation that Resident #73's medication error report, occurring on 5/27/23, was sent to the State Survey Agency or State Long Term Care Ombudsman office.

Based on record review and interview the facility failed to ensure that procedures are implemented to prohibit the neglect of 1 resident dependent on staff for assistance by leaving 1 resident unattended in the bathroom resulting in a fall, and sustaining a right scapula fracture (Resident identifier is #1) Findings include: Review of the facility policy and procedure on 8/16/11, "1.0 NH (Nursing Home) Abuse Prohibition " , revised 8/03/09 indicates under purpose, that the facility staff are doing all that is in their control to prevent occurrences of abuse, neglect ... for all residents. Under section entitled " Definitions " : " Neglect is defined as an act or omission which results or could result in the deprivation of essential services or supports necessary to maintain mental, emotional, or physical health and safety of an incapacitated adult. " Review of Resident #1's medical record on 8/16/11 reveals " Fall Risk Evaluation " form completed on 9/8/10 indicating Resident #1 is considered a high " risk for falls. Review of a nursing assessment for Resident #1 completed on 3/8/11 and 3/11/11 indicating Resident #1 had behaviors of disorganized thinking, difficulty focusing attention, alteration in level of consciousness, and orientation to person and place. Review of Resident #1's care plan dated 3/12/11 indicates; "... risk for falls: impaired mobility, cognitive loss, lack of safety awareness", with the following interventions: " Place call light within reach while in room Remind resident to use call light when attempting to ambulate or transfer Monitor for and assist with toileting needs Fall risk assessment per protocol Bed alarm to remind resident to ring for Nsg (nursing) the need to ambulate Chair alarm to chair / wheelchair to remind resident to ring for the need to ambulate " Resident #1's care plan also reveals a focus area that indicates " ... Risk alteration in functional mobility ... " With the following interventions: " Reinforce precautions: Fall Risk, Skin Risk. Assist resident w/ (with) bed mobility: Mod (moderate) A. (assist) Assist resident w/transfers Min (minimal) A of 1. with gait belt " Review of Resident #1's " Progress Notes " by Staff Q, LPN dated " 4/14/11 8:34 " indicates Resident #sustained an unwitnessed fall at 6:30 am while attempting to transfer self from bathroom and lost balance this note also indicates Resident #1 has a history of unsteady gait, difficulty in walking and some confusion. Review of Radiology report dated 4/14/11 indicates Resident #1's x-ray results post fall reveal Resident #1 sustained a [MEDICAL CONDITION] tip of the right scapula, and had multiple compression fractures of indeterminate age Review of the facility investigation documentation on 8/16/11 reveals a statement signed by Staff C, COTA (Certified Occupational Therapy Aide) on 4/14/11, which revealed Staff C, responded to a bed alarm sounding. Staff C noted Resident #1 was " getting out of bed ". Staff C assisted Resident #1 to the bathroom, and gave Resident #1 the call bell. Staff C noted 3 LNA ' s (Licensed Nursing Assistant) outside Resident #1's door. Staff C informed the 3 LNA's that Resident #1 "was on the toilet with the call bell ". Staff C indicates the LNA's responded okay and Staff C then proceeded to back to another resident that Staff C was previously assisting. Review of statements signed by Staff D, LNA, Staff E, LNA and Staff F, LNA dated 4/14/11, reveals Staff D, E and F heard Resident #1 ' s call bell sounding. Staff D and F statements indicate Staff D and F responded to the call bell sounding and found Resident #1 had fallen. Review of the facility conclusion statement regarding Resident #1 by Staff B dated 4/15/11, indicates on 4/14/11 Resident #1 was assisted to the bathroom by Staff C, who was responding to Resident #1 ' s bed alarm sounding. After seating Resident #1 on the toilet, Staff C gave Resident #1 the call light. Staff C informed other staff members on the unit. During an interview on 8/16/11 with Staff B. Staff B confirmed that Resident #1 is assessed as a high risk for falls. Staff B confirmed it is the facility practice not to leave residents with alarms in place unsupervised in the bathroom.

Based on medical record review, facility document review and interview, the facility failed to ensure that a resident receives adequate supervision to prevent an accident for 1 resident, resulting in a scapula fracture. (Resident identifier is #1) Findings include: Review of Resident #1's medical record on 8/16/11 reveals " Fall Risk Evaluation " form completed on 9/8/10 indicating Resident #1 is considered a " high" risk for falls. Review of a nursing assessment for Resident #1 completed on 3/8/11 and 3/11/11 indicating Resident #1 had behaviors of disorganized thinking, difficulty focusing attention, alteration in level of consciousness, and orientation to person and place. Review of Resident #1's care plan dated 3/12/11 indicates; " ... risk for falls: impaired mobility, cognitive loss, lack of safety awareness", with the following interventions: " Place call light within reach while in room Remind resident to use call light when attempting to ambulate or transfer Monitor for and assist with toileting needs Fall risk assessment per protocol Bed alarm to remind resident to ring for Nsg (nursing) the need to ambulate Chair alarm to chair / wheelchair to remind resident to ring for the need to ambulate " Resident #1's care plan also reveals a focus area that indicates " ... Risk alteration in functional mobility ..." With the following interventions: "Reinforce precautions: Fall Risk, Skin Risk. Assist resident w/ (with) bed mobility: Mod (moderate) A. (assist) Assist resident w/transfers Min (minimal) A of 1. with gait belt " Review of Resident #1's " Progress Notes " by Staff Q, LPN dated "4/14/11 8:34" indicates Resident #sustained an unwitnessed fall at 6:30 am while attempting to transfer self from bathroom and lost balance this note also indicates Resident #1 has a history of unsteady gait, difficulty in walking and some confusion. Review of Radiology report dated 4/14/11 indicates Resident #1's x-ray results post fall reveal Resident #1 sustained a fracture of the distal tip of the right scapula, and had multiple compression fractures of indeterminate age Review of the facility investigation documentation on 8/16/11 reveals a statement signed by Staff C, COTA (Certified Occupational Therapy Aide) on 4/14/11, which revealed Staff C, responded to a bed alarm sounding. Staff C noted Resident #1 was " getting out of bed ". Staff C assisted Resident #1 to the bathroom, and gave Resident #1 the call bell. Staff C noted 3 LNA ' s (Licensed Nursing Assistant) outside Resident #1's door. Staff C informed the 3 LNA's that Resident #1 "was on the toilet with the call bell ". Staff C indicates the LNA's responded okay and Staff C then proceeded to back to another resident that Staff C was previously assisting. Review of statements signed by Staff D, LNA, Staff E, LNA and Staff F, LNA dated 4/14/11, reveals Staff D, E and F heard Resident #1 ' s call bell sounding. Staff D and F statements indicate Staff D and F responded to the call bell sounding and found Resident #1 had fallen. Review of the facility conclusion statement regarding Resident #1 by Staff B dated 4/15/11, indicates on 4/14/11 Resident #1 was assisted to the bathroom by Staff C, who was responding to Resident #1 ' s bed alarm sounding. After seating Resident #1 on the toilet, Staff C gave Resident #1 the call light. Staff C informed other staff members on the unit. During an interview on 8/16/11 with Staff B. Staff B confirmed that Resident #1 is assessed as a high risk for falls. Staff B confirmed it is the facility practice not to leave residents with alarms in place unsupervised in the bathroom.