Every finding on record at NHC Healthcare, Hendersonville

Based on policy review, review of medical records, review of fall investigation documents, hospital record review, and interviews, the facility failed to ensure 1 of 10 (Resident #1) residents were free from accident hazards when staff failed to follow the resident-specific care plan for transfers. On 6/25/2024, 1 staff member transferred Resident #1 without using a lift (a mechanical device to assist caregivers in transferring residents with limited mobility), which resulted in a fall, and right tibia fracture. On 12/12/2024, 2 staff members attempted a stand/pivot transfer, without using a Hoyer lift (a mechanical lift designed to lift, suspend, and transfer a patient using a sling that slides under the patient to provide full body support), which resulted in a fall and a right lower femur fracture, which required surgical intervention. The facility's failure resulted in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) for Resident #1 and placed other residents who required assistance for transfers at risk for Immediate Jeopardy. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/29/2025 at 11:45 AM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ began on 6/25/2024 and continued through 12/16/2024. The facility's corrective actions were completed on 12/17/2024. An acceptable Removal Plan/Allegation of Compliance for the past noncompliance, which removed the immediacy, was provided by the facility on 10/29/2025 and was validated on site. The IJ was cited as past noncompliance for F-689 and the facility is not required to submit a Plan of Correction. The findings include: 1.Review of the facility policy titled, Lifting Machine, Using a Mechanical, dated 7/2017, revealed .the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device .at least at least (2) two certified or licensed personnel are needed to safely move a resident with a mechanical lift .mechanical lifts may be used for tasks that require .lifting a resident from the floor .transferring a resident from bed to chair .lifting limbs .repositioning . Review of the facility policy titled, [Named Facility] Falls Management Process Resource, dated 10/2023, revealed .The Falls Management Program (FMP) is an interdisciplinary quality initiative .The FMP provides personalized and individualized care for patients through educational and quality improvement .FMP includes two primary approaches to the management of falls and injuries .the first is through immediate response .when fall occurs, careful evaluation and investigation, along with immediate intervention during the first 24 hours, can help identify risk, contributing factors, and prevent future incidents .the second approach is long-term management .screening at admission, quarterly, annually and change of condition are key in identifying patients at high risk of a fall .in both approaches, assessment should be used to develop individualized care plan interventions . Review of the facility policy titled, Patient Care Plans, dated 11/2023, revealed .care plan approaches are specific individualized steps partners and patients will take together to assist the patient to achieve the goal .approaches serve as instructions for patient care and provide for continuity of care by all partners .care plans are updated as needed .new problems are handled as they arise and are to be added to the current care plan even if the change in condition is not considered significant enough for complete revision . Review of the facility's undated document titled, Can-Do-Process [information sheet for resident's ADL [Activities of Daily Living] care], revealed .skilled admissions .Therapy Evaluation to establish current LOC [Level of Care] required .Can-Do initiated during first visit and placed in Can-Do Book [Daily Book] at Nursing Station .Forms are updated with changes by nursing/therapy .Non-Skilled Admissions .Fall Coordinator assess patient's fall risk and initiates Can-Do form .Forms are updated with changes by nursing/therapy .LTC [Long Term Care] Patients .The Can-Do will follow the patients as they transition to long term care . 2.Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Spinal Stenosis, Cervical Spine Fusion, History of Falls, and Lumbosacral Disc Disorder. Review of the medical record revealed on 2/1/2024, Resident #1 fell from the bed while reaching for something on her table and sustained bilateral hip fractures, requiring hospitalization and surgery. Resident #1 returned to the facility on 2/9/2024. Review of Resident #1's Care Plan dated 2/7/2024, revealed .perimeter mattress for edge awareness . Review of the facility Can-Do Information Sheet for Resident #1 dated 2/8/2024, revealed .transfer assist .Hoyer lift . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Resident #1 was dependent on staff for all transfers. Review of the Care Plan revised on 5/15/2024, revealed .Increased risk for falls .d/t [due to] recent hospitalization r/t [related to] fall with (B) [bilateral] hip fractures .intervention .assist with transfers/toileting as needed .Activities of Daily Living [ADLs] .Requires staff assist with ADL's .intervention .stand-up lift for transfers . The Care Plan dated 5/15/2024, contradicted the transfer method for the use of a Hoyer lift as was listed on the Can-Do Information Sheet dated 2/8/2024. Review of the Care Plan for Resident #1 dated 6/25/2024, revealed new interventions included .in-service for nursing staff to only use hoyer lift for transfers .counseling with tech [technician] [CNA] assigned to patient . Continued review revealed the care plan was revised on 6/26/2024, 7/1/2024, and 7/3/2024 which included .Increased risk for falls .requires hoyer lift for transfers. Review of the Event Report dated 6/25/2024 at 4:15 PM, revealed Resident #1 was lowered to the floor during a transfer from the wheelchair to the bed by 1 staff member. Review of the facility document titled Immediate QAPI [Quality Assurance Performance Improvement] Meeting-Call to Immediate Action, dated 6/25/2024, revealed the facility identified Resident #1 was transferred with 1 staff member assistance and was lowered to the floor, and documented Resident #1 was care planned for a Hoyer lift transfer as of 2/14/2024. This contradicted Resident #1's care plan, which documented a stand-up lift was to be used. Further review revealed immediate education was provided to CNA L on the transfer requirements for Resident #1 and the facility Can-Do information sheets. Education was also initiated for other CNA's regarding Resident #1's transfer requirements, and facility Can-Do information sheets. The CNA Competency Checklist was reviewed, and the Can-Do information sheet was to be added to the checklist. Random audits were to be conducted for 3 months. Review of the Partner Statement (witness statement) of Incident for Resident #1 dated 6/25/2024, revealed Certified Nursing Assistant (CNA) L documented .I supported all her weight and helped lower (her) to the ground, we were trying to get [her] back in bed . Review of a Nurse Progress note dated 6/25/2024 at 5:58 PM, revealed Registered Nurse (RN) A documented, .Resident was being transferred to bed and slid down to floor assisted by technician. Skin tears noted left arm. Range of motion performed to all extremities without difficulty. No other injuries noted. After dinner resident complained of right knee pain. Son and .[physician] .notified. New orders given for x-ray of right knee. [Mobile X-Ray Company] Radiology notified and stated a technician could not be sent until tomorrow . Review of a Nurse Progress note dated 6/25/2024 at 6:10 PM, revealed .Ice applied to right knee. Will continue to monitor . Review of a Nurse Progress note dated 6/25/2024 at 6:45 PM, revealed .Spoke with Son and POA [Power of Attorney] .related to fall advised.Radiology could not come until tomorrow. Son wants .[Resident #1] .sent to ER [Emergency Room]. Facility on call provider notified . Review of a Nurse Progress note dated 6/25/2024 at 7:10 PM, revealed .Resident left facility .EMS [Emergency Medical Services]. Called report to .ER. Notified .[son] of transfer 3. Review of the (Named) hospital records for Resident #1 dated 6/25/2024, revealed .presents after being gently lowered to the ground during a mishap in transferring into her bed while assisted by a PCT [patient care technician] .complaining of discomfort to her right knee . Further review revealed a small tibial plateau fracture, and orders included an immobilizer and no weight bearing on the right leg. Review of the (Named) hospital Radiology Report dated 6/25/2024, revealed .there is an acute mildly displaced fracture of the lateral tibial plateau [lower leg] fracture where the bone fragments are no longer normally aligned] . Review of a Nurse Progress note dated 6/26/2024 at 3:18 AM, revealed .At approximately 0300 [3:00 AM] on 6/26/24 [2024] resident returned from .[ER], arrived by ambulance via [by] stretcher . Review of the Manager Investigation of Incident for Resident #1 dated 6/26/2024, revealed .resident being transferred to bed from wheelchair, CNA transferred times one assist and patient began to slide from edge of bed with right foot under nightstand. Resident complaining of right knee pain . Review of a quarterly MDS assessment dated [DATE], revealed Resident #1 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Resident #1 was dependent on staff for sit-to-stand and chair/bed-to-chair transfers. 4. Review of the Event Report dated 12/12/2024 at 9:30 PM, revealed Resident #1 was lowered to the floor by 2 CNAs in the shower room during a transfer from the shower chair to the wheelchair. Review of a written statement for Resident #1 dated 12/12/2024, revealed RN B documented .CNA's [CNAs] reported to me.had to lower [Resident #1] to floor. In trying to transfer from shower to the w/c . Resident #1 c/o pain in right knee with slight movement.Red area noted below right knee.On call [physician] notified received new orders. Ice pack applied, Xray called, left message on answering service .Reassess right knee, noted increase swelling and bruising. Review of the Partner Statement of Incident for Resident #1 dated 12/12/2024, revealed CNA K documented .transferring to wheelchair after shower .2 CNA's transferring pt. [patient] Sling moved unable to use [the lift sling had moved and was not positioned correctly under Resident #1 in order to use the Hoyer lift] . Review of the Partner Statement of Incident for Resident #1 dated 12/12/2024, revealed CNA J documented .transfer to wheelchair .sling unable to use . Review of an In-Service Sign In Sheet dated 12/13/2024, revealed CNA J and CNA K received in-servicing on falls training, including Hoyer training, Can-Do training, shower chair seating, and shower bed training. Review of a Supervisory Adverse Action Notice, Written Warning Documentation, for CNA J dated 12/13/2024, revealed supervisor's statement of incident: .Failure to transfer pt per care plan . was signed by CNA J on 12/23/2024. Review of a Supervisory Adverse Action Notice, Written Warning Documentation, for CNA K dated 12/13/2024, revealed supervisor's statement of incident: .Failure to transfer pt per care plan . was signed by CNA K on 12/30/2024. Review of a nurse progress note dated 12/13/2024 at 1:08 AM, revealed .CNA reported that the pt [patient] [Resident #1] was lowered to floor after shower after attempting to transfer from shower chair to w/c [wheelchair]. Pt c/o [complained of] pain in knee. Pt states.[knee].twisted.MD [Medical Doctor] notified. Received order for X-Ray of right knee. Ice pack to knee. Awaiting return call from Xray . Review of an electronic Radiology Order for Resident #1 dated 12/13/2024 at 1:41 AM, revealed .Special Instructions: X-Ray RIGHT KNEE TONIGHT . The order was discontinued on 12/13/2024 at 9:37 AM, .DC [discontinue reason] .[Resident #1] discharged . Review of a nurse progress note for Resident #1 dated 12/13/2024 at 9:39 AM, revealed .resident requested scheduled medication early due to planned loa [leave of absence] outing with family.resident son arrived.and requested that she [Resident #1] be sent to .[hospital] .for evaluation and treatment r/t right leg/ knee pain. 911 called.EMT [Emergency Medical Technician] transport via stretcher. resident transfer assist x [times] 4 [staff assistance] . 5. Review of the (Named) hospital records Computed Tomography (CT) scan of the right knee dated 12/13/2024, revealed .acute, comminuted, impacted fracture of the distal right femur [new break of the lower end of thigh bone into 3 or more pieces and where the bones were forced into each other] . Resident #1 underwent surgical repair of the right femur on 12/13/2024 and returned to the facility on [DATE]. 6. Review of the Manager Investigation of Incident for Resident #1 dated 12/13/2024, revealed .pt [Resident #1] was in SC [shower chair]. Staff felt like the only option was to 2-person lift her to w/c.had to lower pt to the floor where R [right] leg slid under left [leg] in a R hip ext [external] rotation.staff reported.pt was slipping in her chair [shower chair] and had no choice but to attempt t/f [transfer] to prevent pt from sliding to floor. Staff reports attempts to get sling under pt were unsuccessful and 2 person [assistance with transfer] was only option .pt.did report pain at knee with little movement. R knee to ankle.warm to touch. Pt was sent to ER for Xrays and a femur fx [fracture] was noted on R leg distally .intervention: shower bed only . Review of the Nurse Progress note for Resident #1 dated 12/17/2024 at 6:22 PM, revealed .pt returned via ems at 230pm [2:30 PM] from hospital.RLE [right lower extremity] distal femur fx [fracture].brace to RLE in place. Review of the Comprehensive Care Plan revised 12/17/2024, revealed .Increased risk for falls . with a new intervention dated 12/13/2024, .shower bed only for shower room bathing . 7. During an interview on 10/21/2025 at 11:46 AM, CNA J stated .me and [CNA K] were doing her [Resident #1] shower together. After it was done, the sling wasn't under her good enough so we tried to transfer her with 2 people instead and she fell. She did have pain in her leg, the one that ended up being broken . During an interview on 10/21/2025 at 3:30 PM, CNA K stated .we got done giving her [Resident #1] a shower, and the sling wasn't under her well. [CNA J] already tried to reposition it [the lift sling] and it didn't work. We [CNA J and CNA K] decided to 2-person transfer her to her w/c. We were each on one side, and we were facing her, with our arms scooped under [Resident #1's] armpits. We tried to lift her to pivot her to the w/c, but she was heavier than I thought, and we couldn't hold her up, and so we tried to lower her to the floor.we knew she was supposed to be a 2-person Hoyer lift transfer, because that's how we got her up, but the Hoyer lift was in her room, and we just thought we were strong enough to lift her just from the shower chair into her w/c . During a telephone interview on 10/22/2025 at 8:38 AM, CNA L stated, .[Named Resident #1] was calling out for help to go to bed. Her wheelchair was next to the bed, and there was no sling or anything, so I thought she was a stand and pivot transfer. I didn't know her, but I was trying to help her. I'm a big guy, I picked her up and turned her and sat her on the bed. Her butt wasn't on the bed completely, and she started sliding. I lowered her to the floor very gently, she did not fall, but her leg got stuck under the dresser. Later, I found out she was supposed to be a 2 person Hoyer transfer, but there was no sling under her, so I didn't know that . During an interview on 10/22/2025 at 3:30 PM, the DON confirmed on 6/25/2024, 1 staff member transferred Resident #1 without using the care-planned sit-to-stand lift, which resulted in a fall, and right tibia fracture. The DON confirmed on 12/12/2024, 2 staff members attempted a stand/pivot transfer, without using the care-planned Hoyer lift, which resulted in a fall and a right lower femur fracture, which required surgical intervention. The DON confirmed the staff failed to follow Resident #1's care plan related to transfers. 8. Review of the facility document titled Immediate QAPI Meeting-Call to Immediate Action, dated 12/17/2024, revealed the facility identified Resident #1 was lowered to the floor during shower, documenting .Two CNA's were showering the pt [Resident #1] .the patient was noted leaning and having difficulty maintaining position .they attempted, unsuccessfully, to place hoyer sling back under the pt in the shower chair. Pt started slipping from the shower chair and both CNA's lowered the pt to the floor. When the pt was lowered to the floor, her R leg was under her left leg . Further documentation revealed, .conscious decision at the time of the fall was based on safety and comfort, The hoyer was not an option in the moment d/t pt slipping and the CNA's inability to safely utilize the hoyer lift. It was a controlled lowered to the floor vs [versus] a fall . The documentation revealed the QAPI committee identified that another shower device could have been used instead of the chair, interventions included: Anyone using a hoyer lift would be care planned to use a shower bed, in-serviced /educated on hoyer sling placement was initiated, competencies with all new hires and transfer training with therapy, and current employees will need to complete annual competency checks and return demonstration. In-services were initiated 12/17/2024 for transfers per care plan, hoyer sling/sitting, hoyer sling/lying position, timely assessment after lowering a patient to the floor, reduce injury with a fall, timely communication after a fall, and gait belt transfers. The facility's corrective actions for the removal plan were issued to the state surveyors on 10/29/2025. The corrective action plan included the following: 1. Resident #1 returned to the facility on [DATE]. Resident #1's care plan was updated on the use of a shower bed (instead of a shower chair). 2. The facility identified residents who require a Hoyer lift, and care planned these residents to use the shower bed (instead of a shower chair) on shower days, completed on 12/17/2024. 3. Staff in-services and education - initiated 12/17/2024. a. How to safely place Hoyer slings from various positions, sitting and lying. b. How to reduce injury with an interrupted fall. c. How to lower a patient to the floor and body positioning. d. Timely assessments at time of fall. e. Timely notifications with family communication. 4. New Hire orientation to include fall safety and transfer training. Initiated 12/17/2024 and ongoing. 5. Complete competencies with all new hires and transfer training with therapy ongoing. 6. Current employees will complete annual competency checks with return demonstration, and is ongoing. The Removal Plan was validated onsite by the surveyors on 10/29/2025 which included review of the facility education to show each step was completed, staff interviews to confirm completion, review of care plans, review of new hire orientation training, review of new hire competencies and transfer training, and review of current employee annual competency checks.

Based on policy review, medical record review, observations, and interviews, the facility failed to revise resident care plans to include the resident-specific transfer method to prevent falls for 4 of 10 (Resident #3, #4, #5, and #6) residents reviewed for transfers. The findings include: 1. Review of the facility policy titled, Patient Care Plans, dated 5/2025, revealed .care plan approaches are specific individualized steps partners and patients will take together to assist the patient to achieve the goal .approaches serve as instructions for patient care and provide for continuity of care by all partners .care plans are updated as needed .new problems are handled as they arise and are to be added to the current care plan even if the change in condition is not considered significant enough for complete revision . Review of the facility document titled, Can-Do-Process [information sheet for resident's Activities of Daily Living [ADL] care], undated, revealed .skilled admissions .Therapy Evaluation to establish current LOC [Level of Care] required .Can-Do initiated during first visit and placed in Can-Do Book (Daily Book) at Nursing Station .Forms are updated with changes by nursing/therapy .Non-Skilled Admissions .Fall Coordinator assess patient's fall risk and initiates Can-Do form .Forms are updated with changes by nursing/therapy .LTC [Long Term Care] Patients .The Can-Do will follow the patients as they transition to long term care . Forms are updated with changes by nursing/therapy . Review of the facility policy titled, Lifting Machine, Using a Mechanical Hoyer Lift [a total body mechanical lift used by caregivers to transfer individuals with limited mobility], dated 7/2017, revealed .the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device .at least (2) two certified or licensed personnel are needed to safely move a resident with a mechanical lift .mechanical lifts may be used for tasks that require .lifting a resident from the floor .transferring a resident from bed to chair .lifting limbs .repositioning . 2.Review of the facility transfer list for the use of a mechanical lift dated 10/20/2025, revealed Resident #3, Resident #5, and Resident #6 required a Hoyer lift (full-body mechanical lift) for transfers, and Resident #4 required a Stand-Up (sit-to-stand mechanical lift) lift for transfers. 3. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including History of Tibia Fracture, Kidney Disease, Heart Disease, and History of Falling. Review of a Physical Therapy discharge form for Resident #3 dated 3/26/2025, revealed, .chair/bed to chair transfers-CLOF [Current Level of Function]: dependent/total assistance .[Resident #3] currently uses a hoyer to transfer . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Resident #3 was dependent on staff for transfers. Review of the Care Plan dated 10/9/2025, revealed .Resident is at risk for falls r/t [related to] requires assist .hx [history] of falling .substantial assistance with transfers and self-care .Activities of daily living .substantial assistance with transfers and self-care .assist with transfers, bed mobility . Continued review revealed there was an intervention added on 10/21/2025 for .hoyer sling to remain under pt [patient] [Resident #3] while up in chair as pt prefers . Review of the facility's Can-Do Information Sheet for Resident #3 updated 10/20/2025, revealed .Sit to Stand Assist: Hoyer lift 2-person . The facility failed to ensure the Care Plan was revised to include an intervention for method of transfer, including the use of a hoyer lift, as was documented in Physical Therapy notes and on Can-Do Information Sheet. During an interview on 10/20/2025 at 1:26 PM, Certified Nurse Assistant (CNA) H stated, .we use a hoyer lift to get [Resident #3] up, I usually do it by myself .she can hold on . 4. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including History of Knee Replacement, Heart Disease, and Kidney Disease. Review of the facility Can-Do Information Sheet for Resident #4 dated 8/9/2025, revealed .Sit to Stand Assist: STS [sit-to-stand mechanical lift] [a mechanical lift device that allows individuals to stand with transfers from a sitting to standing position for individuals who have partial limited mobility] 2-person . Review of the quarterly MDS assessment dated [DATE], revealed Resident #4 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Resident #4 required Substantial/Maximal Assistance for sit-to-stand and chair/bed-to-chair transfers. Review of the comprehensive Care Plan for Resident #4 dated 8/19/2025, revealed .Resident is at risk for falls r/t requires staff assist .substantial assistance with transfers and self-care .Activities of daily living .substantial assistance with transfers and self-care . The facility failed to ensure the Care Plan was revised to include an intervention for the method of transfer and the use of a sit-to-stand lift, as was documented on the Can-Do Information Sheet. Review of a Physical Therapy discharge form for Resident #4 dated 9/26/2025, revealed, .chair/bed to chair transfers.contact guard assistance .walk 10 feet-CLOF minimal assistance . There was no documentation that Resident #4's care plan or Can-Do information sheet was revised to include the new recommendation of contact guard assistance for transfers. During an interview on 10/21/2025 at 10:35 AM, CNA H stated, .night shift usually gets [Resident #4] up but .is a self-transfer with one person and help to stand and pivot most of the time .some days we use the sit-to-stand lift .[Resident #4] can bear weight and hold on, so it only takes one person to use the lift . 5. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including History of Stroke, Heart Disease, and Fibromyalgia. Review of the facility's Can-Do Information Sheet for Resident #5 dated 1/11/2025, revealed .Transfer Assist: x [times] 2 staff due to weakness and R [right] knee pain/Hoyer lift .Fall Precautions: 2 person transfers or hoyer lift . Review of a Functional Abilities Assessment by Physical Therapy for Resident #5 dated 8/24/2025, revealed .sit-to-stand: dependent .the assistance of 2 or more helpers is required .chair/bed to chair transfers: dependent . Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #5 was dependent on staff for sit-to-stand and chair/bed-to-chair transfers. Review of the Care Plan dated 8/29/2025, revealed a .Resident is at risk for falls.requires staff assist .maximum assistance with transfers and self-care . Continued review revealed .Activities of daily living .maximum assistance with transfers and self-care .assist with transfers, bed mobility . The facility failed to ensure the Care Plan was revised and included an intervention for method of transfer, the use of a 2 person assist or Hoyer lift, as was documented on the Can-Do Information Sheet, and the Physical Therapy Function report. During observation and interview outside of Resident #5's room on 10/21/2025 at 10:27 AM, revealed the door to the resident's room was opened and CNA I was preparing to transport the resident in a wheelchair. Continued observation revealed the Hoyer lift present in the resident's room and no other CNA's or staff were observed entering or exiting the room. CNA I was asked about Resident #5's functional status. CNA I stated, .[Resident #5].can roll in the bed with help, but she can't stand up. She's a Hoyer lift . When asked who transferred Resident #5 from the bed to the wheelchair this morning, CNA I stated, .I did her myself with the Hoyer, it just takes 1 person with her, she grabs onto the bars, there's no issues, like no one needs to hold her legs up or anything . 6. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Kidney Disease, and History of Falling. Review of the facility Can-Do Information Sheet for Resident #6 dated 1/8/2025, revealed .Transfer Assist: 2 person for safety due to bad left knee/use walker .or sliding board [with 1 person assistance] .Fall Precautions: inconsistent transfers/use walker or use 2x staff . Review of a Functional Abilities Assessment by Physical Therapy for Resident #6 dated 10/13/2025, revealed .mobility devices: walker, wheelchair .chair/bed to chair transfers: substantial/maximal assistance . Review of the annual MDS assessment dated [DATE], revealed Resident #6 scored an 8 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Resident #6 required Substantial/Maximal Assistance for sit-to-stand transfers, chair/bed-to-chair transfers, and used a walker and wheelchair for mobility. Review of the Care Plan dated 10/20/2025, revealed .Resident is at risk for falls.requires staff assist .hx of falling .minimum to moderate assistance with transfers and self-care .Activities of daily living .minimum to moderate assistance.assist.with.bed mobility . The facility failed to ensure the Care Plan was revised and included an intervention for method of transfer, including using a 2 person assist and walker, as was documented on the Can-Do Information Sheet. During an interview on 10/21/2025 at 11:19 AM, CNA G stated, .[Resident #6] needs 1 person for transfer, sometimes we will use 2, it depends.she is terrified of falling . 7. During an interview on 10/22/2025 at 3:30 PM, the Director of Nursing (DON) confirmed the care plans for Residents #3, #4, #5, and #6 had not been revised to include the residents' transfer methods, and confirmed the care plans did not match the Can-Do information sheets.

Based on facility documentation, medical record review, observations, and interview, the facility failed to ensure a clean, sanitary environment for 1 of 4 sampled residents (Resident #27) who required enteral feedings. The findings include: Review of the undated facility's document titled, Noncritical Patient Care Equipment-Cleaning Procedure Summary, revealed, .Consistent with cleaning frequency for patient area and as needed . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus with Diabetic [CONDITION(S)], Dependence on [CONDITION(S)], and Dysphagia, Oropharyngeal Phase. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed Resident #27 required a feeding tube. Review of the Comprehensive Care Plan for Resident #27 revealed care plans which included Nutrition/Hydration/Dental, Need for Enteral Support. Review of the Physician Order Report dated 6/7/2022-6/7/2022, for Resident #27 revealed, .5/6/2022 .Tube feeding formula .Nepro [brand of enteral formula] 1.8 @ (at) 55 ML/HR (milliliter/hour) . Observation and interview in Resident # 27's room on 6/6/2022 at 2:10 PM, revealed a feeding pump had dried beige debris on the top and face of the pump. During an interview the Unit Manager/Licensed Practical Nurse (LPN) #5 confirmed the feeding pump had not been cleaned of the dried debris. During an interview on 6/8/2022 at 3:38 PM, the Director of Nursing (DON) confirmed she expected all feeding pumps to be cleaned daily and as needed.

Based on facility policy review, observation, and interview, the facility failed to ensure call lights were within reach for 2 of 31 sampled residents (Resident #55 and #67). The findings include: Review of the undated facility's policy titled, Patient Rights, revealed, .It is the policy of the management to provide a full complement of services as possible and attainable to meet the needs of all patients . Review of the undated facility's policy titled, Call Lights, revealed, .Center will provide each patient with a functioning call light .Be sure the call light is always within easy reach of the patient . Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Resident required supervision to extensive assistance of one person physical assist with Activities of Daily Living (ADL)s. Review of the current Care Plan for Resident #55 revealed, .Resident is at risk for falls .Keep personal items within reach .Orient resident to surroundings, call light, and location of personal items .Activities of Daily Living: Limited ability to perform self-care .Call light within reach when in room . Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #67 had a BIMS score of 6, which indicated severe cognitive impairment. Resident required supervision to extensive assistance of 2 person physical assist with ADLs. Review of the current Care Plan for Resident #67 revealed, .Resident is a risk for falls .Keep personal items within reach .Orient resident to surroundings, call light, and location of personal items .Activities of Daily Living: Limited ability to perform self-care .Call light within reach when in room . Observation and interview in resident's room on 6/6/2022 at 9:39 AM, revealed Resident #55 in bed with her call light between the wall and bed on the floor. Resident stated she did not know where her call light was. During an interview Certified Nursing Assistant (CNA) #2 confirmed the call light was not within reach of the resident. Observation and interview in resident's room on 6/6/2022 at 11:07 AM, revealed Resident #67 in bed with his call light on the floor under his bed. During an interview the Administrator confirmed the call light was not within reach of the resident. During an interview on 6/8/2022 at 3:36 PM, the Director of Nursing (DON) confirmed she expected the call light to be within reach of all residents while in their room.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide a daily activity update in an understandable language which affected 1 of 1 (Resident #33) non English speaking residents sampled. The findings include: Review of the facility's policy titled, Patient's Rights, revision date 2/2022 revealed, .at National Healthcare Corporation [NHC] we support the patient/resident's right to live in an environment which is individualized for them .strive to cultivate and sustain an excellent quality of life for each individual with person-centered care and services . Review of the facility's admission packet policy titled, Patient's Rights, revision date 11/2017 revealed, .NHC .provides free language services to people whose primary language is not English, such as .information written in other languages . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. Review of Resident #33's face sheet revealed her preferred language as Castilian Spanish. Review of the current Care Plan for Resident #33 revealed, .Communication .mostly speaks Spanish . Observation and interview in Resident #33's room on 6/7/2022 at 10:04 AM, Certified Nurse Assistant (CNA) #6, who spoke Spanish, translated for me while doing Resident #33's interview. Observation and interview in Resident #33's room on 6/7/2022 at 4:40 PM, with the Business Office Manager revealed a daily activity note typed in English. During an interview the Business Office Manager who spoke Spanish and who visited Resident #33 daily confirmed the resident could not read the activity note which was typed in English. During an interview on 6/8/2022 at 4:40 PM, the Recreation Director confirmed Resident #33 was not provided a daily activity note typed in Spanish.

Based on facility policy review, medical record review, observation, and interview, the facility failed to have quarterly care plan conference meetings with resident/resident representative for 4 of 31 sampled residents (Residents #33, #42, #58, and #75). The findings include: Review of the facility's policy titled, Documentation Guidelines Section VII: Patient Care Plans updated 10/2021 revealed, .Routine Reviews and Updates: Care plans are updated as needed but are reviewed completely by the interdisciplinary team (IDT) on a quarterly basis within 7 days of the completion of the clinical MDS [minimum data set] assessment . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. Review of the Care Conference notes revealed Resident #33 had one Care Conference dated 9/10/2021. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS dated [DATE], revealed Resident #42 had a BIMS score of 6 which indicated severe cognitive impairment. Review of the medical record revealed Resident #42 had one Care Conference dated 4/15/2021. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Conference notes revealed Resident #58 had one Care Conference dated 2/25/2022. Review of the medical record revealed, Resident #75 was admitted to facility on 10/12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessments for Resident #75 revealed on 1/8/2022, and 2/24/2022, Significant Change in Status Assessments were completed. On 5/17/2022 a Quarterly MDS was completed revealed a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #75's Annual Care Plan on 10/27/2021, revealed care plan conference was held with Resident #75 and her representative was in attendance. Further review revealed the next Quarterly Care Plan meeting to convene 1/25/2022. No other Care Plan conference notes or documentation were found in the residents medical record. Review of Resident #75's Care Plan Conference notes revealed a care plan conference was held on 10/27/2021 with Resident #75 and her representative in attendance. No other Care Plan Conference notes or documentation were found in the residents medical record. Review of Resident #75's Nursing Progress notes revealed no documentation of Care Plan Conference meetings. During an interview on 6/6/2022 at 3:44 PM, Resident #75's stated, Care Plan Meetings .unaware never been to one. My memory is not so good though. During an interview on 6/7/2022 at 2:42 PM, the Social Worker (SW) confirmed the facility had not conducted IDT meetings since the pandemic started. Continued interview she stated the last Care Conference for Resident #33 was 9/10/2021, Resident #42's last Care Conference was 1/8/2021 and Resident #58's last Care Conference was 2/25/2022. During an interview on 6/08/2022 at 3:38 PM, the SW confirmed that care plan meetings should be conducted 72 hours after admission and quarterly following completion of the MDS assessment.

Based on facility policy review, medical record review, observation, and interview the facility failed to perform oral care for 1 of 31 sampled residents (Resident #68). The findings include: Review of facility policy titled, Activities of Daily Living (ADLs), Supporting revised 3/2018 revealed .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .If resident with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate . Review of the medical record revealed Resident #68 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. Continued review revealed Resident #68 had no issues with her teeth or gums. Observation in Resident #68's room on 6/6/2022 at 9:56 AM and 3:44 PM, revealed Resident #68 with dried brown debris on her upper teeth. During an interview on 6/6/2022 at 3:07 PM, the Certified Nurse Aide (CNA) #1 confirmed Resident #68's teeth were not clean. CNA #1 stated Resident #68 had refused oral care earlier when she attempted and did not report it to the nurse. During an interview on 6/8/2022 at 3:07 PM, the Director of Nursing (DON) stated she expected oral care to be done morning and night and if the resident refused care she expected the CNA to tell the nurse. The refusal should be documented and care planned.

Based on facility policy review, medical record review, observation, and interview, the facility failed to administer oxygen (O2) per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility policy titled, Nursing Services, Patient Care Policies revised 2/2022, revealed, .Medications, treatments, and diets are given as ordered and are documented in the medical record . Review of the medical record revealed, Resident #75 was admitted to facility on 10/12/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #75 revealed, a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the Physician's Order Report dated 5/7/2022 to 6/7/2022, revealed, .Oxygen at 1-3 lpm (liters per minute) via NC (nasal cannula) as needed to keep SpO2 (Oxygen Saturation) at 88 % (percent) and above . Review of the current care plan dated 1/20/2022, revealed, .O2 (Oxygen) at 2-3 L/min (liters per minute) via nasal cannula . Observation in Resident #75's room on 6/6/2022 at 9:48 AM and 3:38 PM, revealed resident lying in bed, the call light within reach, and the O2 was humidified set at 4 L per NC. Observation in Resident #75's room on 6/7/2022 at 8:37 AM, revealed resident lying in bed and the call light within reach, 02 per NC 4L. During an interview on 6/7/2022 at 8:41 AM, with Licensed Practical Nurse (LPN) #1 at medication cart on 400 Hall LPN #1 reviewed oxygen orders for Resident #75 and confirmed the resident should be receiving O2 at 1-3 L per minute as needed (PRN) to keep her saturation above 88%. During an interview on 6/7/2022 at 9:05 AM, with LPN #1 in Resident #75's room, she confirmed the residents O2 was set at 4L per minute. LPN #1 stated I didn't look at it today. During an interview on 6/8/2022 at 4:51 PM, the Director of Nursing (DON) confirmed that nurses are expected to review the resident's physician orders for O2 and to verify the settings prior to going into the resident's room.

Based on facility policy review, medical record review, observation and interview, the facility failed to store medications properly for 1 of 31 sampled residents (Resident #1) and in room [ROOM NUMBER] and #312 ; the facility also failed to label Enteral feeding bag for 1 of 4 residents (Resident #42). The Findings include: Review of the facility's policy titled, Medication Storage In The Facility, dated 1/1/2019 revealed .Medications and biologicals are stored safely, securely, and properly .accessible only to licensed nursing personnel .authorized to administer medications .medication supplies are locked when not attended by persons with authorized access .Facility should assure that .labels include the Resident name .rate .date of preparation .initials of person administering . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental status (BIMS) score of 15, which indicated no cognitive impairment. Observation and interview in Resident #1's room on 6/6/2022 at 10:52 AM, revealed Resident #1 applying anti itch cream to her lower right leg. Resident #1 stated the nurses said it was okay for her to use the cream. During an interview on 6/6/2022 at 11:44 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident #1 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/8/2022 at 2:54 PM, Director of Nursing (DON) stated she expected the nurses to look in the residents' rooms and be aware of items that family may have brought from home. Also, to retrieve the item and return to the family and get a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #42 had a BIMS score of 6 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #42 had nutritional approaches for feeding tube in the last 7 days. Observation in Resident #42's room on 6/6/2022 at 9:50 AM, revealed an enteral feeding bag with no name, date, or administration rate. Observation and interview in Resident #42's room on 6/6/2022 at 10:00 AM, Director of Nursing (DON) confirmed the enteral feeding bag should be labeled with resident name, date and rate of administration. Observation in the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] on 6/6/2022 at 9:51 AM, revealed an unopened wound dressing and a medication cup of unidentified ointment on the back of the commode. Observation and interview in the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] on 6/6/2022 at 10:05 AM, Registered Nurse (RN) #1 confirmed the cup of unidentified medication was left unattended and should not have been left in the bathroom.

Based on facility policy review, medical record review, observation, and interview the facility failed to store a [CONDITION(S)]/[CONDITION(S)] (Bi-level Positive Airway/Continuous Positive Airway which help stimulate normal breathing) tubing and facemask for 1 of 5 residents (Resident #135); failed to don gloves while performing a blood glucose finger stick; failed to place a glucometer on a clean surface; and failed to don PPE (personal protective equipment) while in a Droplet Isolation Room for 1 of 7 rooms (room [ROOM NUMBER]) observed. The findings include: Review of the undated facility's policy titled, Transmission-Based Precautions/Isolation Rooms revealed .1. Review the isolation sign on the door for the specific information regarding isolation and instructions before entering the room. If there is no sign on the door, but your information indicates isolation or precautions, please check with Charge Nurse Before entering the room . Review of the facility policy's titled, Blood Sampling-Capillary (Finger Sticks), revised 9/2014, revealed, .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected .Don gloves .Place blood glucose monitoring device on clean field . Review of the medical record revealed Resident #135 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #135 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. Continued review revealed Resident #12 had shortness of breath during exertion and while lying down. Review of the current Care Plan revealed .Respiratory Complications: At Risk For, Will not exhibit complications r/t [related to] aspiration for 120 days from update/last review AND/OR Will not experience any respiratory complications for 120 days from update/last review. [CONDITION(S)] at hs [bedtime] . Review of the current Physician Orders dated 5/23/2022, revealed .Physician Orders: [CONDITION(S)] Auto Ipap [inspiratory positive airway] 14 Epap [expiratory positive airway] 9 PER HOME SETTINGS at HS At Bedtime . Observation in Resident #135's room on 6/6/2022 at 9:42 AM, 11:39 AM, and 3:39 PM, revealed a [CONDITION(S)] machine placed on top of the bedside drawer with the tubing and face mask not covered. During an interview on 6/6/2022 at 3:39 PM, Resident #135 stated he had not been given a bag to place the tubing and mask in when the [CONDITION(S)] machine were not in use. During an interview on 6/6/2022 at 4:02 PM, Licensed Practical Nurse (LPN) #2 confirmed the tubing and mask were to be in a bag when not in use. During an interview on 6/8/2022 at 2:54 PM, the Director of Nursing expected the [CONDITION(S)] machine tubing and face mask to be covered when not in use. Observation and interview on 6/6/2022 at 11:17 AM, revealed Registered Nurse (RN) #1 went in Resident #27's room to perform a blood glucose fingerstick. RN #1 did not wear gloves during the procedure; laid the glucometer on the bedside table without a barrier; punctured the resident's finger with needle; and aspirated blood to apply on test strip. Continued observation revealed she washed her hands after the fingerstick then picked up the uncleaned glucometer and carried it back to the medication cart. Further observation revealed she put gloves on; cleaned the glucometer with a bleach wipe; and then laid it back down on the cart without a barrier to dry. RN #1 confirmed she should have worn gloves during the fingerstick procedure and should have placed the glucometer on a clean barrier during the procedure and after cleaning the glucometer. Observation in room [ROOM NUMBER] on 6/6/2022 at 10:22 AM, revealed a Housekeeper not wearing PPE such as a gown and face mask while cleaning a Droplet Isolation room. During an interview on 6/6/2022 at 10:48 AM, the Housekeeper confirmed she was to wear PPE while in an isolation room. She stated she did not wear PPE because there was not a box of PPE supplies outside of the door. During an interview on 6/8/2022 at 4:40 PM, the Infection Preventionist confirmed she required the staff to wear a face shield and mask while in a Droplet Isolation room.

Based on facility policy review, medical record review, and interview the facility failed to notify the physcian and family upon discovery of open areas on the body of 1 of 3 residents (Resident #1) reviewed for open areas. The findings include: Review of undated facility policy Patient Rights revealed .It is the intention of (named facility) that all treatment decisions and especially end of life treatment decisions be made as a part of the ongoing planning of the patient, persons speaking on behalf of the patient, and the patient's personal physician with minimal institutional intrusion. You have the right to accept or refuse any medication or treatment . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. Review of the care plan dated 6/23/2020 revealed Resident #1 was care planned for skin break down and to be observed by staff for any signs and symptoms of skin irritation. Review of the progress note for nursing dated 7/18/2020 revealed .Pt (patient) has opening on sacrum and R (right) shoulder. Notified wound nurse and applied dressing and cream . During an interview with Licensed Practical Nurse (LPN) #1 on 7/29/2020 at 1:18 PM revealed LPN #1 cared for Resident #1 on July 18th and 19th. Continued interview revealed LPN #1 was alerted by the Certified Nurse Aide (CNA) #1 Resident #1 had red area on her sacrum and right shoulder. Continued interview confirmed LPN #1 did not notify the physician or the assigned family member of the open areas discovered. Continued interview revealed LPN #1 stated .I should have put in the standing orders for wounds . During an interview on 7/29/2020 with the Director of Nursing (DON) at 2:39 PM confirmed it was LPN #1's responsibility to notify the physician, put the standard orders in the computer and call the family.

Based on medical record review and interview the facility failed to complete a Quarterly Minimum Data Set (MDS) for 1 (#1) of 38 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #1 had a Quarterly MDS completed on 3/19/19. Further medical record review revealed no Quarterly MDS was completed in (MONTH) 2019. Interview on 7/9/19 with Registered Nurse (RN) #1, MDS Coordinator at 4:43 PM in her office revealed Resident #1 had not had a Quarterly MDS completed since (MONTH) 2019. When asked when the MDS assessment was due for Resident #1 the MDS Coordinator confirmed, The Quarterly MDS was due on (MONTH) 19, 2019 and I missed it.

Based on facility policy review, medical record review observation and interview, the facility failed to revise/update care plans for 2 (#55 and #237) of 38 residents reviewed. The findings include: Review of the facility policy, Care Plan Development, revised 7/3/08 revealed .Care Plans are updated as needed, but are reviewed completely by the interdisciplinary team on a quarterly basis within 7 days of completion .New problems are handled as they arise, and are to be added to the current care plan even if the change in condition is not considered significant enough for a complete revision . Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed Resident #55 was always incontinent of bladder and bowel. Medical record review of the Admission Observation dated 7/2/19 revealed Resident #55 was admitted with an indwelling catheter. Observation on 7/8/19, 7/9/19, and 7/10/19 in Resident #55's room revealed the resident's catheter bag was in a dignity bag on the side of the bed. Interview with Registered Nurse #5 (RN) on 7/10/19 at 11:50 AM at the nurse station revealed the staff nurses, MDS coordinator and Unit Managers could update the care plans. Continued interview revealed when asked what the date on the care plan was RN #5 responded .7/10/19 . Continued interview revealed when asked when it would be appropriate to update the care plan she replied .If I see a new care order I would update the care plan . Interview with the Director of Nursing (DON) on 7/10/19 at 6:10 PM in the conference room revealed care plans are completed on admission. Continued interview revealed the MDS coordinator completed the comprehensive care plan after the 1st Resident Assessment Instrument (RAI) assessment. Interview with the MDS Coordinator on 7/10/19 at 6:23 PM in her office revealed the care plan was not updated until after an assessment. Continued interview revealed nurses were responsible for updating the care plan when a resident was admitted to the facility. Interview with LPN #6 also known as the Unit Manager on 7/10/19 at 6:30 PM in the conference room confirmed .Normally it (catheter) should be put on admission. I don't know why it was missed . Interview with the DON on 7/10/19 at 6:44 PM in the hall by the conference room when asked to review Resident #55's care plan she confirmed .I will be honest with you, if it's (catheter) not there we forgot to do it . Medical record review revealed Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #237's Admission MDS dated [DATE] revealed the resident had no venous or arterial ulcers. Medical record review of Resident #237's 14 day MDS dated [DATE] revealed the resident had 1 venous and arterial ulcer present. Medical record review of the Physician Orders for Resident #237 revealed .5/1/19 .Right LAT.(Lateral) ANKLE - (SCAB REMOVAL FROM ABRASION) .CLEANSE WITH WOUND WASH &(And) PAT DRY .APPLY SKIN PREP COVER WITH MEDIUM ALLEVYN-DAILY .5/6/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY SANTYL TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING EVERY MON (Monday)/WED (Wednesday)/FRI (Friday) .5/10/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY BIOSTEP TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING DAILY .RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .PRN (As needed) .CLEANSE WITH WOUND WASH & PAT DRY. APPLY SKIN PREP TO PERI-WOUND .APPLY SANTYL TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING AS NEEDED DUE TO ACCIDENTAL REMOVAL/LOOSE/SOILED .6/18/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY ZINC OINTMENT TO PERI-WOUND .APPLY THICK LAYER OF SANTYL TO WOUND BED .LARGE [MEDICATION NAME] .CHANGE DRESSING - EACH SHIFT .Day 7:00 AM .Night 7:00 PM .FLOAT ANKLES/HEELS . Medical Record Review of Resident #237's comprehensive care plan dated 3/29/2019 - 7/10/2019 revealed .alteration in/potential for alteration in skin integrity R/T (related to)[MEDICAL CONDITION] with right sided weakness . Continued review revealed the resident had no wounds to the right lateral ankle. Interview with the DON on 7/11/19 at 11:51 AM in the conference room when asked to look at the care plans for Resident #237, she stated There's nothing in here that addresses the ankle. Continued interview with the DON confirmed Resident #237's care plan was not updated, she stated any nurse receiving orders should update the care plan with what the orders reflect and (named resident) was not.

Based on Medical record review, facility policy review and interview the facility failed to ensure timely physician visits were performed for 1 (#237) of 12 residents reviewed. The findings include: Facility policy review, Medical Services, revised 2/2018, revealed .The physician delegated option does not relieve the physician of the obligation to visit a patient when the patient's medical condition makes that visit necessary or from performing services or procedures prohibited under state law from being delegated .reviews medications, patient program of care, and diagnoses, at regular intervals .supports efforts to assure that patients have indicated laboratory and X-ray or other procedures . Medical record review revealed Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #237's physician visit notes dated 4/1/19 revealed the resident was seen by the physician. Medical record review of Resident #237's physician visit notes dated 5/27/19 revealed the resident was seen by the physician. Interview with the Medical director, also Resident #237's attending physician on 7/9/19 at 5:29 PM in the conference room revealed when asked if he had assessed Resident #237 he confirmed, I never saw the resident.

Based on facility policy review, medical record review and interview, the facility failed to ensure the attending physician visit included an evaluation of the resident's total program of care including medications, treatments and a decision about continued appropriateness for current medical regimen for 1 (#237) of 12 residents reviewed. The findings include: Facility policy review, Medical Services, revised 2/2018, revealed .The physician delegated option does not relieve the physician of the obligation to visit a patient when the patient's medical condition makes that visit necessary or from performing services or procedures prohibited under state law from being delegated .reviews medications, patient program of care, and diagnoses, at regular intervals .supports efforts to assure that patients have indicated laboratory and X-ray or other procedures . Medical record review revealed Resident #237 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Resident #237's physician visit note dated 4/1/19 revealed, .No Ulcer/Rash/Petechia/Purpura/Masses/or other [MEDICAL CONDITION] . Medical record review of Resident #237 Resident Progress Notes by the NP (Nurse Practitioner) dated 4/4/19 revealed, .Ext (Extremities): No [MEDICAL CONDITION] . Medical record review of Resident #237's Resident Progress Notes by the NP dated 4/11/19 revealed, .Skin: No rashes, [MEDICAL CONDITION] or ulcers . Medical record review of Resident#237's Reesident Progress Notes by the NP dated 4/18/19 revealed, .Ext: No [MEDICAL CONDITION] . Medical record review of Resident #237's Resident Progress Notes by the NP dated 4/25/19 revealed, .Skin: see nursing notes . Medical record review of Resident #237's Resident Progress Notes by the PA (Physician's Assistant) dated 4/30/19 revealed, .Skin: warm and dry . Medical record review of Resident #237's physician visit note dated 5/27/19 revealed skin assessment not performed. Medical record review of Resident #237's Resident Progress Notes by the NP dated 6/13/19 revealed, .wound care following skin break down on penis .skin: see wound care notes . Medical record review of Resident #237's Resident Progress Notes by the PA dated 6/21/19 revealed, .Skin: No rashes, [MEDICAL CONDITION] or ulcers . Interview with the Medical director, also Resident #237's attending physician on 7/9/19 at 5:29 PM in the conference room revealed the resident did not have a [DIAGNOSES REDACTED]. Continued interview when asked if Resident's #237's right [MEDICAL CONDITION] could have been prevented he stated, It's hard to tell; possibly if the resident had a Doppler done of the extremity (named resident) could have went to a vascular surgeon for an angioplasty. Further interview when asked if he had assessed Resident #237's wound he confirmed, I never saw the resident. Interview with the Administrator with the Director of Nursing present on 7/10/19 at 7:20 PM in the conference room revealed when asked if Resident #237's attending physician assessed Resident #237's wound during his visit he stated, He signed the orders, I leave the assessments to the nursing department and the Director of Nursing.

Based on facility policy review, medical record review, observation and interview, the facility failed to label and date oxygen and nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) tubing and humidified canisters for 1 (#71) of 20 residents reviewed receiving respiratory treatments. The findings include: Facility policy review, Supplemental Oxygen, dated 1/2005, revealed .the purpose of delivering oxygen by nasal cannula is to: correct [MEDICAL CONDITION] (low oxygen) by increasing available alveolar oxygen .Diminish the [MEDICAL CONDITION] (heart) work load by correcting hypoxemia (low level of oxygen in the blood) .decrease in breathing efforts to maintain adequate oxygenation .infection can occur if equipment is not changed and cleaned properly .change tubing and cannula every 7 days .label each tubing with date, and your initial .change humidifier when empty or at least weekly and date . Facility policy review, Aerosol Therapy, revised 7/2014, revealed .intermittent Aerosol with Medication Administration with medication is used to deliver fine particles of liquid and medication in the [MEDICATION NAME] tree .this means of medication administration is quick and has few systemic side effects .Intermittent aerosol with medication administration is indicated for [MEDICAL CONDITION] such as asthma or [MEDICAL CONDITION] .be sure nebulizer and tubing are labeled with the date and initial .nebulizer can become contaminated resulting in an infection .change nebulizer and tubing every 7 days . Medical record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #71's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident received oxygen therapy. Medical record review of Resident #71's physician orders [REDACTED].oxygen (02) 2 liters per minute via nasal cannula continuous .6/14/19 [MEDICATION NAME] (a medication used to open the airway) solution for nebulization 0.5 milligram (mg) - 3 mg (2.5 mg base)/3 milliliter (ml) 1 inhalation every 6 hours (hr) as needed .[MEDICAL CONDITIONS] . Medical record review of Resident #71's comprehensive care plan dated 6/26/19 revealed .Respiratory complications: at risk for R/T (related to) [MEDICAL CONDITION] 02 dependent .Administer 02 at [MEDICAL CONDITION] (positive air pressure machine to treat sleep apnea) at hour of sleep as ordered neb (nebulizer) treatments as ordered 02 as ordered .administer [MEDICATION NAME][MEDICATION NAME] . Observation on 07/08/19 at 10:56 AM and at 4:22 PM in Resident #71's room revealed the resident receiving 02 via (by) nasal cannula at 2 liters per minute. Continued observation revealed a nebulizer machine (a machine used to deliver aerosol treatments) on the resident's bedside table not in use. Continued observation revealed the oxygen tubing, humidified water bottle and the nebulizer tubing were dated 6/27/19. Interview with the Central Supply Nursing Assistant on 7/8/19 at 4:38 PM in her office revealed she was responsible for changing the residents' oxygen tubing, humidified water bottles and nebulizer tubing. Continued interview revealed oxygen tubing, nebulizer tubing and humidified water were changed weekly. Observation and interview with the Central Supply Nursing Assistant on 7/8/19 at 4:40 PM in Resident #71's room when asked to look at the resident's tubings and humidified water bottle she confirmed the tubings and bottle were dated 6/27/19. Continued interview she stated I thought I changed these Friday (July 5 2019); I did not do (named resident), (named resident) was the last one, (named resident) was in the shower; I meant to go back and change them and I did not. Observation and interview with the Director of Nursing on 7/8/19 at 4:58 PM in the Resident #71's room confirmed the resident's oxygen tubing, nebulizer tubing and humidified water bottle were dated 6/27/19. Continued interview she stated the bottle and tubings were to be changed weekly by the Central Supply Nursing Assistant.

Based on facility policy review, medical record review and interview, the facility failed to obtain physician orders timely for placement of an indwelling catheter for 1 (#55) of 38 residents reviewed. The findings include: Review of the facility policy, Medication Orders, dated 6/2016 revealed .Medications are administered only upon an order from a person lawfully authorized to prescribe . Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the History of Present Illness dated 6/28/19 revealed .had evidence of a acute kidney injury .was found to have acute [MEDICAL CONDITION] by bladder scan .Foley catheter was placed with 1200 ml (milliter) of urine returned . Medical record review of the Physician Orders for Resident #55 dated 7/5/19 revealed .Change Indwelling Catheter every 30 days once a day on the 1st month .Catheter Care Once per shift and document . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #55 required an indwelling catheter. Interview with Licensed Practical Nurse #6 also known as the Unit Manager on 7/11/19 at 11:55 AM in his office revealed .normally the staff nurses would put the orders in on admission . Interview with the Director of Nursing on 7/11/19 at 12:32 PM in the conference room revealed it was a night shift admission and the information did not get relayed appropriately. Continued interview confirmed .any of the nurses could have gotten an order and put it in. It should have been in place .

Based on observation and interview, the facility dietary department failed to maintain and serve hot food at or greater than 135 degrees Fahrenheit (F) for 1 of 6 meal services observed. Findings included: Observation on 7/16/18 at 11:48 AM in the dietary department, with the Registered Dietitian (RD) present, revealed the resident mid-day meal trayline service was in progress. Further observation revealed residents in the main dining room and the 300 hall had been served their meal. Observation of the dietary department trayline revealed the dietary server obtaining food temperatures. Further observation revealed the broccoli was 115 degrees F and the baked pureed fish was 126 degrees F. Further observation revealed the server continued to serve the broccoli after the temperatures were obtained. Interview with the dietary server and the RD on 7/18/18 at 11:55 AM in the dietary department at the trayline confirmed the facility failed to maintain and serve hot food at or greater than 135 degrees F.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 34 residents (Resident #294) reviewed, had clean and groomed finger nails. Findings include: Review of facility policy Fingernails, Cleaning and Trimming, undated, revealed .Designated partner will care for patients nails daily and PRN (as needed) .clean around and under the nails . Medical record review revealed Resident #294 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #294's comprehensive care plan dated 7/12/18 revealed the resident required assistance with activities of daily living. Continued review of the care plan revealed .Check, clean, and trim nails as needed and to keep nails short . Observations of Resident #294 on 7/16/18 at 11:16 AM, 12:47 PM, and 4:41 PM in the residents room revealed the resident's fingernails were long, chipped, and had brown debris under the nails on both hands. Interview with the Director of Nursing (DON) on 7/16/18 at 4:41 PM in Resident #294's room confirmed the resident's nails were uncleaned and ungroomed. The DON looked at Resident #294's nails and stated You're in need of a trim. Further interview with DON revealed resident nail care was to be performed during showers and as needed.

Based on observation and interview, the facility failed to replace and repair the baseboards for 1 of 14 rooms (room [ROOM NUMBER]) on the 400 hall reviewed. Findings include: Observation on 7/16/18 at 9:30 AM, 7/17/18 at 10:36 AM, and 7/18/18 at 8:08 AM, in room [ROOM NUMBER] on the 400 hall revealed the baseboard on the left side entrance to the bathroom was missing. Further observation revealed the baseboard adjacent to the bathroom on the left side was separated from the wall. Observation on 7/18/18 at 5:09 PM, with the Director of Nursing (DON), in room [ROOM NUMBER] revealed the baseboard on the left side entrance to the bathroom was missing. Further observation revealed the baseboard adjacent to the bathroom on the left side was separated from the wall. Interview with the DON on 7/18/18 at 5:44 PM in room [ROOM NUMBER] confirmed the facility failed to replace and repair the baseboards in room [ROOM NUMBER].

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure safety devices were in place and functioning for 3 residents (#105, #25, #68) of 6 residents reviewed for falls. This failure resulted in Harm to 1 resident (#105) who sustained a fall with a femur fracture. The findings included: Review of facility policy, Falls Prevention Program, revised [DATE] revealed The incidence of hip fractures increase with age .Each center has a Falls Committee which monitors falls and utilizes data to systematically address falls which is a subcommittee of the Quality Assurance and Performance Improvement (QAPI) Committee. The Falls Committee takes direction from and reports to the center QAPI (Quality Assurance Performance Improvement) Committee . Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #105 scored 4 on the Brief Interview for Mental Status (BIMS), indicating she was moderately impaired cognitively. Continued MDS review revealed Resident #105 required extensive assistance of 2 people for transfers; extensive assistance of 1 person for dressing, toileting, and grooming; was dependent on 2 people for bathing; and was always incontinent of bowel and bladder. Medical record review of a Falls Investigation dated [DATE] revealed Resident #105 was found on her right side beside the bed. Continued review revealed Resident #105 had a seat belt which was found beside the chair, broken in half. Further review revealed the resident had a contusion to her head and complained of right thigh pain. Medical record review revealed Resident #105 was transported to the hospital where x-rays showed she had suffered a .comminuted intertrochanteric femoral fracture of the right side (unstable hip fracture) . The resident underwent [REDACTED]. Further medical record review revealed Resident #105 was sent out to the hospital on [DATE] and admitted with [DIAGNOSES REDACTED]. Continued medical record review revealed the resident was placed on hospice care on [DATE] and expired on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 12:20 PM in the classroom revealed Resident #105 fell ; complained of leg pain; and hit her head in the fall. Continued interview revealed no one was sure whether she was trying to go to bed or to the bathroom. Further interview revealed the seatbelt Resident #105 was used for pelvic support. Continued interview revealed Resident #105 was [DIAGNOSES REDACTED] and could not stand or walk. Further interview with the DON revealed the zip tie must have come loose from where it was tied to the posts of the wheelchair. Continued interview revealed it is the responsibility of the Certified Nurse Aide (CNA) caring for the resident to check the seat belt and connections before using the wheelchair for a resident. Further interview with the DON confirmed this check was probably not completed if the zip tie broke. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Post Falls Nursing assessment dated [DATE] at 9:30 AM revealed Resident # 25 was found lying on floor mat bedside bed with no injury noted. Medical record review of the Post Falls Nursing assessment dated [DATE] at 6:16 PM revealed staff heard alarms sounding and found Resident #25 sitting on her buttocks by her door in her room and no injury noted. Medical record review of the Post Falls Nursing assessment dated [DATE] at 11:15 AM revealed upon entering room Resident #25 was found sitting on the floor beside the bed without injury. Medical record review of the Post Falls Nursing assessment dated [DATE] revealed .CNA was walking by room and saw patient's feet on the floor. Exiting wheelchair. Entered room and saw patient lying on the floor next to bed .Additional Comments: Alarms were not sounding and staff was educated and reprimanded for safety needs not being met . Continued review revealed the document was signed by Licensed Practical Nurse (LPN) #1. Review of Supervisory Adverse Action Notice dated [DATE] revealed .Supervisor's Statement of Incident: Employee failed to turn alarms back on patient after toileting which resulted in patient falling . Continued review revealed the document was signed by CNA #1 and LPN #1. Review of the Fall Investigation dated [DATE] revealed .Pt (Patient) was toileted by CNA and after pt (patient) was placed back in w/c (wheelchair) the alarms were not turned back on. CNA was written up and all interventions were in place . Medical record review of the care plan updated [DATE] revealed no interventions were initiated after the [DATE], [DATE], [DATE], and the [DATE] falls. Observation on [DATE] at 8:57 AM revealed Resident #25 had a seatbelt in place going across her lower abdomen through the arms of the wheelchair, around the back of and attached to the back frame of the wheelchair on the right and left sides with a zip tie wrapped around several times and secured Observation on [DATE] at 4:57 PM in Resident #25's room revealed a bathroom door alarm on the bathroom door, in the off position. Interview with CNA #1 on [DATE] at 4:54 PM at the door to Resident #25's room revealed when asked about a bathroom door alarm, she explained there was one on the door, but it was never on. We don't turn it on because we have to take her to the bathroom. When asked if she had ever seen the bathroom alarm on she stated No. That's not for these residents. Interview with LPN #1 on [DATE] at 4:58 PM in room 101 revealed the resident had multiple falls in the last couple of months. Continued interview revealed when asked about the bathroom door alarm she stated there was a bathroom door alarm on the bathroom door but it is not on. I'm not sure why it's there. Continued interview revealed she was asked about the fall on [DATE]. The LPN explained a CNA had recently toileted the resident and after transferring the resident back to the wheelchair, the Aide had forgot to put the alarm back on. Continued interview revealed the resident then fell out of her wheelchair. Continued interview with the LPN revealed it had been determined the fall was due to the alarm not being turned back on. The LPN confirmed the facility failed to prevent the resident's fall. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Falls Investigation dated [DATE], revealed Resident #68 was found sitting on the floor near the head of the bed. His call light was on but his alarms were not in place. Resident #68 stated he was trying to go get his nurse. The resident did not sustain any injuries as a result of the fall. Review of the falls investigation revealed a Supervisory Adverse Action Notice dated [DATE] stating the patient alarms were not in place at the time of the fall and were set in place after the resident was placed in bed. Interview with the DON on [DATE] at 4:30 PM in the classroom, confirmed the report stated the resident's alarms were not in place at the time of the fall and confirmed the staff would not have been alerted to the resident's fall.

Intakes: TN 765 Based on review of the facility's investigation of the incident, medical record review and interview, it was determined the facility failed to provide two person assistance for transfer and bed mobility to prevent accidents for 1 of 5 (Resident #1) sampled residents. The failure to provide two person assistance for Resident #1 resulted in actual harm when resident fell from the bed and sustained a displaced oblique fracture through the left proximal fibula and a suspected nondisplaced chip fracture through the posterior lateral tibia. The findings included: Review of the facility's investigation revealed an "Employee Statement of Incident" completed by Certified Nursing Assistant (CNA) #1, dated 9/5/13 documented, "...I was turning the patient (Resident #1) towards me (right side) to pull her gown down a little after I had transferred her to the bed. When I turned her over towards me all of her weight shifted on to me. I was unable to get the patient back into the bed with it moving. The patient fell on to me and slipped past me onto the floor in between the night stand and the bed..." A statement by Nurse #1 documented, "Incident 9/5/13... CNA (#1) interviewed following pt (patient) incident. CNA (#1) stated as she was turning pt and repositioning gown and removing sling (Hoyer lift sling) the pt started to slide with the mattress overlay. Siderail was in the down position on the side CNA (#1) was working. CNA (#1) attempted to reposition pt back onto bed, but was unable. CNA (#1) stated the bed was locked, but the bed gaveway. I (Nurse #1) also checked bed following incident and lock was engaged..." Medical record review for Resident #1 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] for Section G Functional Status documented Resident #1 required extensive assistance of 2 + (plus) persons physical assist for bed mobility and total dependence of 2 + persons physical assist for transfer. A Nursing Summary Report dated 9/4/13 documented, "...ADL (activities of daily living) STATUS: Bed Mobility: Self Performance - Total dependence Bed Mobility: Support Provided - Two + persons physical assist Transfers: Self Performance - Total dependence Transfers: Support provided - Two + persons physical assist..." Review of a hospital emergency room "Final Report" dated 9/5/13 documented, "...Fall... Associated Diagnoses... Head injury... Hematoma of scalp... Contusion of the upper arm... Contusion of the knee... Closed fracture of the fibula... History of Present Illness: The patient presents following fell during transfer to bed at nursing home... Radiology results... 1. Displaced oblique fracture through the LEFT proximal fibula. 2. Suspected additional nondisplaced chip fracture through the posterior lateral tibia..." During a telephone interview in the Social Service's office on 11/20/13 at 11:35 AM, CNA #1 stated, "...I don't want to speak about this. I gave my statement (CNA #1's statement of the incident) and that's what happened. I'm not answering any questions." Then CNA #1 hung up on the surveyor. During a telephone interview in the Social Service's office on 11/20/13 at 12:00 PM, Nurse #8 stated, "...I heard (CNA #1's name) yelling for me and (CNA #2's name) yelling down the hall for me. I saw (Resident #1's name) in (on) the floor... (CNA #1) told me when she went to adjust her the mattress slid and patient ended in the floor..." During a telephone interview in the state office on 11/21/13 at 11:20 AM, CNA #2 stated, "...I was in the hall taking linens when she (CNA #1) called me into the room. The patient was facedown in (on) the floor. She (CNA #1) had just put the patient (Resident #1) to bed. The lift was in the room... She (Resident #1) was a two person assist, two CNAs or a CNA and nurse to transfer, change or reposition the patient. The failure of the facility to provide two person assistance for Resident #1 resulted in actual harm when resident fell from the bed and sustained a displaced oblique fracture through the left proximal fibula and a suspected nondisplaced chip fracture through the posterior lateral tibia.

Based on medical record review, observation and interview, it was determined the facility failed to ensure that a resident at risk for falls had interventions implemented after each fall to prevent further falls for 1 of 10 (Resident #17) sampled residents identified with falls. Resident #17 was assessed at risk for falls. Resident #17 sustained multiple falls between 3/5/10 and 2/22/11 and the facility failed to implement new interventions after each fall. Resident #17 sustained a fall on 2/22/11 that resulted in actual harm when Resident #17 required medical intervention, hospitalization and surgical intervention for Left Proximal Ulnar Fracture. The findings included: Medical record review for Resident #17 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], assessed Resident #17 with a summary cognitive score of 99 which indicated Resident #17 was unable to complete the interview and had a short term memory problem and had moderately impaired cognitive skills. Review of the Post Falls Nursing Assessments documented the following: a. 3/5/10, fell in room, no injury, intervention was walking assessment. b. 3/13/10, fell in room, skin tear to elbow, intervention was toileting program. c. 3/27/10, fell in room, no injury, no new intervention. d. 8/26/10, fell in bathroom, no injury, no new intervention. e. 12/28/10, fell in room, intervention was use socks with non-skid tread. f. 1/08/11, fell in room, no injury, intervention was remind to use wheelchair (w/c) or cane to ambulate and if he can't locate them to have staff assist. g. 1/24/11, fell in room, no injury, intervention was clear walking pathways. h. 2/08/11, fell in room, no injury, intervention was safe shoes and (&) slippers, seat sensor chair alarm, alarmed black floor mat. i. 2/12/11, fell in room, no injury, no new intervention. j. 2/13/11, fell in room, red area to back, Depakote & Zyprexa started. Intervention was Restorative walking program. Review of the therapy progress note dated 2/14/11, documented..." Not approp (appropriate) @ (at) this time..." There were no additional interventions put in place at that time to prevent falls. k. 2/16/11, fell in corridor,no new intervention. l. 2/18/11, fell in corridor, no injury, no new intervention. m. 2/22/11, fell in room, no new intervention. Intervention for falls on 3/13/10, 3/27/10 and 8/26/10 was toileting. Intervention for falls on 12/28/10, 2/8/11 and 2/16/11 was non-skid shoes or slippers. Intervention for falls on 2/8/11 and 2/12/11 was chair alarm. There were no new interventions put in place for falls on 3/27/10, 8/26/10, 2/12/11, 2/16/11, 2/18/11 and 2/22/11. Review of the care plan for Resident #17 initiated on 6/10/10 through update on 2/26/11 documented Resident #17 at risk for falls. The care plan for falls for Resident #17 documented the following: 6/10/10- "... to assist me as needed with safe transfers, be alert to increased confusion or change in my mental status, assist me to toilet as I indicate, place my call light within my reach, place my personal items and water within easy reach, report any falls, accidents, or injuries to the charge nurse and/or physician, make sure my alarms are working and turned on..." 2/8/11, "...seat sensor chair alarm, bed against the wall..." Review of the nurse's notes for Resident #17 documented the following: a. 2/23/11 at 8:00 PM, "...noted with edema to L (left) elbow/forearm and N.O. (new order) received to obtain x-ray of area..." b. 2/24/11 at 3:30 AM, "...MD (medical doctor) informed of x-ray results..." c. 2/28/11 at 7:00 PM, "...pt (patient) went to appt (appointment) with (named) doctor... ortho (orthopedics)... N.P. (nurse practitioner) informed nurse that pt will be admitted for surgery..." Review of a physician's history and physical note dated 2/28/11, documented "...on February 23, the patient fell while attempting to access his wheelchair... he sustained a comminuted fracture of the left olecranon..." Review of a physician's discharge summary from (named) hospital dated 3/3/11 documented, "...underwent open reduction internal fixation of the left proximal ulna olecranon for a left proximal ulnar fracture..." During an interview in the 300 hall nurses station on 4/27/11 at 4:55 PM, the Director of Nursing (DON) was asked what he remembered about Resident #17's falls. The DON stated, "...one fall was a night fall so no non-slip socks on at night... hard to tell what was happening with a dementia patient..." The DON was asked how the staff recognized that Resident #17 had an injury after the fall on 2/22/11. The DON stated, "...he (Resident#17) had pain in his left elbow with putting his left arm through his shirt sleeve and was sent to the doctor..." During an interview in the 300 hall nurses station on 4/27/11 at 5:05 PM, Nurse #5 was asked if Resident #17 was able to understand when he was reminded to lock his wheelchair or put on non-skid sock. Nurse #5 stated, "...he's not able to do that cognitively." Nurse #5 was asked why no new interventions were implemented after Resident #17's falls. Nurse #5 stated, "...he will push mats away and unplug alarms... we've tried to find interventions he'd allow... urinalysis done on 1/10/11 and showed no growth... tried bathroom door alarm without success... he fell on [DATE] at 5:55 AM... the 23rd is when edema was noted and we notified the doctor and got x-rays... several laboratory tests were done during January and February 2011 and all were within normal limits..." The facility was unable to provide documentation of new interventions put in place after the falls on 2/16/11 and 2/18/11. Resident #17 sustained falls on 3/5/10, 3/13/10, 3/27/10, 8/26/10, 12/28/10, 1/8/11, 1/24/11, 2/8/11, 2/12/11, 2/13/11, 2/16/11, 2/18/11 and 2/22/11 with no new interventions implemented on 3/27/10, 8/26/10, 2/12/11, 2/16/11, 2/18/11 and 2/22/11. Resident #17 sustained an injury after a fall on 2/22/11 at 5:55 AM, that resulted in actual harm when Resident #17 fractured his left Proximal Ulna and was not treated until 2/28/11. He required surgical intervention on 3/1/11 and remained in the hospital until 3/3/11.