Every finding on record at North Woods Nursing Center

Based on interview and record review, the facility failed to implement an effective and current system of surveillance for staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, resulting in the potential for an outbreak to go undetected.Findings:During an interview on 04/08/2026 at 11:37 AM, Director of Nursing (DON) reported that Infection Control Preventionist (ICP) A was off on 4/8/26 and she would review the Infection Control Program in her place. DON reported that when a facility employee called off the employee answering the phone would complete the Call off Notice form. DON confirmed that it did not need to be a licensed nurse to complete the form. Once that form was completed it was sent to Human Resources to review/document. If the call-off was illness related the Call off Notice was reviewed by ICP A.DON reported that the Employee Surveillance Log included all facility staff and was to include the symptoms and the onset date, the date last worked, and the unit worked further stating that that information is the requirement. DON reported that if the symptoms were vague, ICP A would call the staff member to obtain additional details.Review of the CDC (Centers for Disease Control and Prevention) Long-Term Care (LTC) Respiratory and Acute Gastroenteritis Surveillance Line List templates revealed, Information gathered on the worksheet should be used to build a case definition, determine the duration of outbreak illness, support monitoring for and rapid identification of new cases, and assist with implementation of infection control measures by identifying units where cases are occurring. The Line List (Surveillance Log) should contain, all healthcare personnel (e.g., nurses, physicians and other providers, therapists, food services, environmental services) whether employed, contracted, consulting or volunteer.For each staff member listed, indicate the floor, unit or location where that staff member had been primarily working at the time of illness onset. Symptoms and Symptom onset date: Record the date (month/day) each person developed or reported signs/symptoms.and Symptom Resolution Date.Review of the 2026 Infection Control Binder revealed the tabs for March and April contained only the staff Call off Notice forms.On 04/08/2026 at 1:24 PM, an email was sent to the Nursing Home Administrator (NHA) which included, For the employee surveillance log I am not seeing documentation of the date they last worked, the department they are from, the unit they worked, etc. Is there any additional documentation you can find?During an interview on 04/08/2026 at 2:28 PM, DON provided a copy of the March Infection Control Map which was a printout of the facility floor plan. DON reported there was no April Infection Control Map. The Infection Control Map was located in ICP A's office (not in the infection control binder.) The map was color coordinated as follows blue-gastrointestinal symptoms, green-influenza, pink-congestion/body aches, orange-RSV, and yellow-unknown. DON reported the Infection Control Map was utilized to track the location the employee last worked. However, it did not contain any dates of symptom onset/resident exposure or the correlated staff member.During an interview on 04/08/2026 at 2:28 PM, DON confirmed that the Infection Control Maps were located in ICP A's office, the staff Call off Notice forms were located in the Infection Control Binders, and the line list was printed off from the facility charting system. Confirming all required employee surveillance documentation was not accessible in one location.Review of the March staff Call off Notice forms and the March Employee Surveillance Log revealed:Licensed Practical Nurse (LPN) U called off 3/1/26 for nausea and diarrhea and called off 3/2/26 for confirmed Flu. LPN U was not listed on the Employee Surveillance Log. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included.Certified Nursing Assistant (CNA) V called off 3/3/26 for fever/chills. CNA V was not on the Employee Surveillance Log. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included.Dietary Aide (DA) W called off on 3/3/26 for vomiting and loose watery diarrhea. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included.CNA Q called off 3/7/26 for vomiting. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included.CNA X called off 3/9/26 for fever/chills, congestion, body aches, and sinuses and called off 3/16/26 for sore throat and body aches. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included.Housekeeper Y called off on 3/13/26 for nausea and fever/chills and called off 3/16/26 for fever/chills, body aches, and headache. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included.CNA Z called off 3/11/26 for fever/chills and sore throat, on 3/12/26 with no symptoms included, on 3/14/26 for positive for RSV, and on 3/16/26 for RSV. They were not added to the line list until 3/17/26 (created date). The date of symptom onset and the unit/department they last worked was not included.CNA AA called off 3/16/26 for fever/chills and vomiting. CNA AA was not listed on the Employee Surveillance Log. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included.Activity Aide (AA) BB called off on 3/18/26 for fever/chills and vomiting. The date of symptom onset and the date they last worked was not included.CNA CC called off on 3/22/26 for vomiting. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included.RN DD called off on 3/23/26 for congestion and cough. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included. The Employee Surveillance Log listed the onset date as 3/24/26.CNA EE called off on 3/25/26 for puked. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included. They were not added to the Employee Surveillance Log until 4/7/26.DA FF called off on 3/27/26 for congestion and cough. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included. They were not added to the Employee Surveillance Log until 4/7/26.CNA V called off on 3/29/26 for vomiting. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included. They were not added to the Employee Surveillance Log until 4/7/26.Review of the March Infection Control Map revealed there was no highlighted area of RSV/orange highlight despite CNA Z calling off 3/11/26 for fever/chills and sore throat, on 3/12/26 with no symptoms included, on 3/14/26 for positive for RSV, and on 3/16/26 for RSV. There were areas highlighted in yellow (unknown) but no way to determine the correlating staff member or the illness.Review of the April staff Call off Notice forms and the March Employee Surveillance Log revealed:CNA II called off on 4/1/26 for nausea and sick. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included. They were not added to the Employee Surveillance Log until 4/7/26.CNA EE was sent home on 4/426 for vomiting. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included. They were not added to the Employee Surveillance Log until 4/7/26.DA JJ called off on 4/4/26 for vomiting. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included. They were not added to the Employee Surveillance Log until 4/7/26.CNA GG called off on 4/4/26 for nausea. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included. They were not added to the Employee Surveillance Log until 4/7/26.CNA HH called off on 4/7/26 for vomiting. The date of symptom onset, the date they last worked, and the unit/department they last worked was not included. They were not on the Employee Surveillance Log.During an interview on 04/08/2026 at 2:29 PM, Regional Clinical Nurse (RCN) R confirmed that the Employee Surveillance Log did not include the unit the staff member last worked. RCN R reported that going forward that information would be added to the comment section on the Employee Surveillance Log. RNC R confirmed that the March Infection Control Map did not specify the dates the unit(s) were exposed to different infection types and did not adequately depict the unit the staff members last worked.Review of the Facility Assessment last completed/updated 3/9/26 revealed, .Evaluation of Infection Prevention and Control Program .IFC surveillance will identify trends, types of infections for all residents and staff. When patterns persist education maybe provided to staff to assist with minimizing any further exposure. We also use information from our QIO. The QIO offer trainings and education on various topics related to Infection prevention .Review of the facility policy Infection Prevention and Control Plan last updated March 2024 revealed, Policy: It is the policy of this facility to implement the Infection Prevention and Control Program utilizing a systematic, coordinated and continuous approach guided by OSHA regulations, and pertinent state, federal and local regulations pertaining to infection control.2. Surveillance includes HAIs among staff and residents.a. Continuously collect and screen data to identify potential outbreaks.d. The Infection Prevention Manager assumes direct accountability for the surveillance, aggregation and analysis of the data.4.Monitoring and evaluation of key performance aspects of infection control through preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted.f. Employee health trends.

Based on observation and record review, the facility failed to ensure call lights were within reach for one of three residents reviewed (Resident #60) for accommodation of needs. Findings:Resident #60 (R60)Review of an admission Record revealed R60 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses of dementia, high blood pressure and type 2 diabetes. During an observation on 4/06/26 at12:03 PM, R60s call light was draped over the shade of the small lamp that sat on the table near the foot of the bed, out of reach of the resident. During an observation on 4/06/26 at 1:03 PM, staff had just delivered a lunch tray to R60 in her room. After staff left the room, the call light laid over the small lamp shade at the foot of the bed, out of reach of the resident. During observation on 04/07/26 at 8:10 AM and again at 2:20 PM, R60 laid in bed and the call light was draped over the shade of the lamp that sat on the table at the foot of the bed, out of reach of the resident. During observation on 04/08/26 at 8:24 AM, R60 laid in bed and the call light was draped over the shade of the lamp that sat on the table at the foot of the bed, out of reach of the resident. Review of a Care Plan for R60 revealed .resident is able to utilize the call light for assistance.

Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders and nursing professional standards of practice of 4 residents (Resident #1, #5, #47, and #57) out of 15 residents reviewed for medication administration.Findings: Resident #1 (R1)Review of an admission Record reflected R1 admitted to the facility with diagnoses that included atrial fibrillation, high blood pressure and biventricular heart failure. Review of R1's March 2026 Medication Administration Record (MAR) reflected licensed nurses administered Midodrine HCl Oral Tablet 10 MG (milligrams) (Midodrine HCl) Give 1 tablet by mouth three times a day for Hypotension (low blood pressure) Hold is (sic) SBP (systolic blood pressure) > (greater than) 120 outside of prescribed parameters 7 times (three times on 3/16/26, once on 3/26/26, once on 3/28/26, once on 3/29/26, and once on 3/30/26). Review of an order on R1's April 2026 MAR reflected Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 1 tablet by mouth three times a day for Hypotension Hold is (sic) SBP (systolic blood pressure) > (greater than) 120 - D/C Date- 4/06/2026 revealed a licensed nurse administered the medication outside of parameters on 4/4/2026 with a blood pressure (BP) of 124/57. Review of a physician order found on R1's April 2026 MAR reflected Midodrine HCL Oral Tablet 10 MG (milligrams) (Midodrine HCL) give 0.5 (half) tablet by mouth three times a day for hypotension Hold is (sic) SBP (systolic blood pressure) greater than 120. The medication is documented as given on 4/6/26 at 10:00 AM with a BP of 126/60. Resident #5 (R5) Review of an admission Record reflected R5 admitted to the facility with a diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Review of the April 2026 Medication Administration Record (MAR) reflected an order for Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 18 unit subcutaneously every morning and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY (E11.42) During an observation of Medication Administration on 4/7/2026 at 7:32 AM, Registered Nurse (RN) J prepared the prescribed Insulin Glargine for R5. RN J did not prime the needle prior to injecting the resident with the medication and did not hold the pen injection against the skin for 10 seconds to ensure full delivery of the prescribed dose of medication. When asked, RN J said she was not sure if she was supposed to prime the needle and did not know she was to hold the injector next to the resident's skin for 10 seconds. During an interview on 04/08/2026 at 9:24 AM, the DON reported that she expected staff to hold the medication if the blood pressure is outside the prescribed parameters. The DON also reported that she expected nurses to prime the needle of any injection insulin and to hold the needle in place for a count according to policy. Review of a policy Medication Administration by Various Routes revised December 2024 reflected It is the policy of this facility to administer medication in agreement with standards of practice as well as in accordance with applicable state and federal law. 13' General Preparation: . e. take vitals as indicated if the medication is contingent upon the results. Review of a Lantus SoloStar Step-by-Step Guide_Lantus (insulin glargine injection) 100 Units_mL.pdf reflected Step 3. Perform a Safety Test, dial a test dose of 2 units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Never use the pen if no insulin comes out after a second needle. Step 5. Inject your Dose, . Use your thumb to press the injection button all the way down. When the number in the dose window returns to 0 (zero) as you inject, slowly count to 10 before removing. (Counting to 10 will make sure you get your full insulin dose.) . Resident #47 (R47) Review of an admission Record revealed R47 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain. Review of R47's Order Summary dated 5/28/25 revealed, Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Controlled Drug Give 1 tablet by mouth every 12 hours. To be administered at 6:00 AM and 6:00 PM. Review of R47's Controlled Drug Receipt/Record/Disposition Form revealed a tablet of Norco was not dispensed for the 6:00 PM dose on 4/4/26. Review of R47's April Medication Administration Record revealed the 4/4/26 6:00 PM dose of Norco was documented as administered. Review of R47's Electronic Medical Record revealed no documentation for the withholding and/or incorrect documentation of the Norco administration. Resident #57 (R57) Review of an admission Record revealed R57 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain. Review of R57's Order Summary dated 2/10/25 revealed, Norco Oral Tablet 7.5-325 MG (Hydrocodone/Acetaminophen) Give 1 tablet by mouth four times a day. To be administered at 5:00 AM, 12:00 PM, 5:00 PM, and 11:00 PM. Review of R57's April Medication Administration Record revealed that on 4/2/26 the 5:00 AM dose of Norco was not documented as administered (left blank). Review of R57's Electronic Medical Record revealed no documentation for the withholding of the Norco. During an interview on 04/08/2026 at 2:29 PM, Regional Clinical Nurse (RCN) R confirmed the medication errors for R47 and R57 and reported that the nurse that made the medication errors was an agency nurse. Review of the facility policy, Medication Administration by the Various Routes last revised December 2024 revealed, .6. All current medications, dosage schedules and treatment records will be noted on the residents Electronic Medication Administration Record (eMAR).n. If a dose of medication is withheld or refused, the nurse will note that on the eMAR.

Based on observation, interview, and record review, the facility failed to implement the facility policy for pressure injury prevention and management for 3 residents (Resident #32, #50, and #55) out of 5 reviewed for pressure injuries.Findings:Resident #32 (R32)Review of an admission Record revealed R32 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: muscle wasting and atrophy. Further review of the record revealed that R32 had a responsible party (guardian/decision maker).Review of R32's Skin assessment dated [DATE] revealed, Open area to right buttocks scar tissue measuring 0.3cm x 0.2cm. Area opened while providing personal care. Clinical coordinator notified, treatment ordered.Review of a handwritten entry in the Physician Communication book dated 3/31/26 revealed, open area to right buttocks. There was a handwritten line through the entry and noted was printed. There was no date or initials documented to reflect when the entry was reviewed or by whom.Review of R32's Electronic Medical Record (EMR) revealed no documentation that RP S was notified or that R32's practitioner was notified via in person or telephone of the newly identified pressure injury. Additionally, there was no comprehensive wound assessment completed (description of the pressure injury location, dimensions, description of wound bed, exudate type, exudate amount, presence of odor, wound edges, peri-wound assessment, tunneling/undermining, and pain.)During an interview on 04/07/2026 at 10:23 AM, Responsible Party (RP) S reported that she was not aware of any recent skin breakdown or newly implemented treatments.Review of R32's Order Summary dated 3/31/25 revealed, wound care - Cleanse open area to right buttocks, pat dry, apply collagen, and cover with foam dressing. Change every three days and prn (as needed) until resolved. Monitor dressing integrity every shift.During an observation and interview on 04/08/2026 at 11:12 AM, R32's skin was observed with Clinical Care Coordinator (CCC) B. CCC B pointed out an area of thin fragile intact skin (scar tissue) where R32's pressure injury had been located. CCC B reported that the nurse that had identified the pressure injury implemented a treatment order at the time using the facility's wound care guide.Review of R32's Treatment Administration Record revealed the wound care order was transcribed for the assessment of the dressing integrity every shift but was not transcribed to reflect the dates the dressing was to be changed.Review of R32's EMR revealed no documentation of the dates R32's dressing was changed.Review of R32's Health Care Provider Visit note dated 4/3/26 revealed no documentation that the provider was made aware of or assessed R32's pressure injury.Review of R32's Order Audit Report for the pressure injury treatment revealed that on 4/5/26 R32's treatment was discontinued for Reason: resolved.Review of R32's EMR revealed there had not been an additional Skin Assessment since 3/31/26 and there had been no Wound Measurement assessments. There was no documentation that a licensed nurse had reassessed the pressure injury and observed it as resolved.During an interview on 4/8/26 at 10:25 AM, Director of Nursing (DON) reported that CCC B was responsible for the oversight of R32's pressure Injury. CCC B reported that she assessed her buttocks on Sunday (4/5/26) and there were no open areas identified on R32's buttocks. DON communicated to CCC B that the assessment of the resolution of R32's pressure injury should have been documented at that time. CCC B reported that staff should have notified RP S and the physician of R32's pressure injury at the time it was discovered and reported that the physician communication book was not a sufficient method to communicate pressure injury concerns.Resident #50 (R50)Review of an admission Record revealed R50 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of buttocks stage 2.Review of the facility policy Skin at Risk Assessment Documentation, Staging & Treatment revealed, .9. Re-assess and measure a pressure ulcer a minimum of weekly.Review of R50's Wound Measurement assessment revealed the last assessment was completed on 3/30/26.Review of R50's EMR revealed no documentation that a comprehensive wound assessment had been conducted on 4/6/26.During an interview via email on 04/08/2026 at 1:49 PM, Nursing Home Administrator (NHA) confirmed R50's Wound Measurement had not been completed and stated the CCC is completing wound measurement currently.Resident #55 (R55)Review of an admission Record revealed R55 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral palsy and muscle wasting and atrophy.Review of R55's Order Summary dated 2/24/26 revealed, MASD (moisture associated skin damage) to bilateral buttock - wash, pat dry and apply zinc ointment to affected areas q (every) shift and PRN.Review of R55's April Treatment Administration Record revealed that on 4/1/26 the treatment was not completed.Review of R55's EMR revealed no documentation for the rationale of the missed treatment.During an interview on 04/08/2026 at 2:29 PM, Regional Clinical Nurse (RCN) R confirmed R55's treatment had not been documented as completed in the EMR on 4/1/26 and reported the agency nurse believed another nurse had completed the treatment.Review of the facility policy Skin at Risk Assessment Documentation, Staging & Treatment last revised January 2020 revealed, Policy: It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity and intervene as indicated utilizing the admission assessment, plan of care, and Minimum Data Set as formal assessment tools. It is the policy of this facility to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred. Weekly measurements and narrative assessments are conducted on existing pressure injuries. Purpose: To provide prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. To limit the development of avoidable pressure ulcers and provide evidenced based guidance on effective strategies to promote pressure ulcer healing.Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open / ruptured blister. This stage should not be used to describe moisture associated skin damage, including incontinence associated dermatitis, intertriginous dermatitis, medical adhesive related skin injury, or traumatic wounds (skin tears, burns, or abrasions).8. Individualize the resident goals and interventions as documented on the plan of care. 9. Re-assess and measure a pressure ulcer a minimum of weekly .10. Document the appearance of the wound with considerations to the physical characteristics as applicable to the resident; a. Location b. Stage c. Size d. Color e. Peri-wound condition f. Wound edges g. Sinus tracts or tunneling h. Exudate i. Odor.Review of the facility policy, Change in Resident Condition Physician/Family Notification last revised January 2026 revealed, Policy: It is the policy of this facility to inform the resident; consult with the residents health care practitioner, and notify the residents authroized (sic) representative according to the minimum guidelines established in this procedure and more frequently at the discretion of the licensed nurse or member of the interdisciplinary team. 1. The health care practitioner will be promptly notified when.c. A resident assessment indicated the need to alter the treatment significantly i.e.commence a new treatment. 2. The resident, or authorized representative will be notified when. c. There is a significant change in the physical, mental or psychosocial status. 3. Immediate attempts at notification will occure (sic) with all medical emergencies, in other instances notification will occure as soon as possible and as soon as prudent given the time of day and nature of event. 5. Objective observations of changes in a resident's condition, including emotional changes as a means for analyzing and determining care required and the need for further medical evaluation and treatment shall be recorded in the resident's record.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, For patients experiencing acute or chronic illnesses, diseases, or trauma, patients' family members and surrogate decision makers become active partners in decision making and care .When possible, patients and family caregivers want to participate in shared decision making about treatment options and ongoing symptom management. Incorporating a patient's and family's cultural beliefs, values, and communication patterns is essential to provide individualized patient/family-centered care. When developing a plan of care, consider all resources available to patients. The family plays a key role .Engaging the family or designated surrogate is a fundamental skill of patient-centered care [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for residents. Findings include: On 04/07/2026 at 10:12AM, observed the drain line for the ice machine in the Nourishment room, had a whitish gel-like substance coming out of the drain line. Dietary Manager (DM) D, present at time of observation, stated that maintenance department was responsible for the cleaning and maintenance of the ice machines. On 04/07/2026 at 3:04PM, Maintenance Supervisor (MS) C observed the gel-like substance coming out of the drain line. MS C noted that this had happened before after the ice machine had been cleaned and believes it might be the cleaning product interacting with minerals in the well water. On 04/07/2026 at 3:05PM, observed in the Nourishment room, a piece of coving (1 foot long) missing from wall, floor juncture next to the ice machine and paint bubbling on wall behind the ice machine. MS C confirmed condition of the surfaces in vicinity of the ice machine. On 04/07/2026 at 3:07PM, observed in the Housekeeping/Mechanical closet on main hall, paint chipping (12-inch by 10-inch section) on the wall, about 3 feet off the floor, next to the mop sink in the housekeeping room. MS C confirmed there is chipping paint on the wall.

Based on observation, interview, and record review, the facility failed to safely transport residents in wheelchairs for 2 residents (Resident #7 and #5) out of 15 residents reviewed for accidents and hazards.Findings:Resident #7 (R7)Review of an admission Record revealed R7 was an [AGE] year-old female, admitted to the facility on [DATE].During an observation on 04/06/2026 at 11:00 AM, Certified Nursing Assistant (CNA) Q was observed propelling R7 in her wheelchair without foot pedals from room [ROOM NUMBER] to the nurses' station.Resident #5 (R5)Review of an admission Record revealed R5 was a [AGE] year-old male, admitted to the facility on [DATE].During an observation on 04/08/2026 at 8:13 AM, CNA L was observed propelling R5 in his wheelchair into his room, his left foot was behind the foot pedal. During an observation on 04/07/2026 at 4:45 PM, while exiting the building with 2 other healthcare surveyors, a facility staff member was observed propelling a resident in her wheelchair down the 100 unit with her feet behind the foot pedals.During an interview on 04/08/2026 at 12:39 PM, Nursing Home Administrator (NHA) reported the facility staff were to push residents in their wheelchairs with foot pedals on and with their feet on the foot pedals. NHA reported pushing residents without their feet on foot pedals was not safe practice.A copy of the facility's policy for wheelchair safety/foot pedals was requested on 4/8/26 at 12:32 PM via email. A copy was not received prior to survey exit.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Another area of fall risk includes wheelchair-related falls involving older adults or patients with disabilities. Patients who use wheelchairs can experience falls .Transporting patients without proper application or engagement of safety features .may lead to patient ejection. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

Based on observation, interview, and record review the facility failed to change and store oxygen tubing per physician orders and facility policy for three of five residents residents (Resident #42 , Resident #52, and Resident #73) reviewed for oxygen storage.Findings: Resident #42 (R42) Review of an admission Record revealed R42 was a [AGE] year-old female, last admitted to the facility on [DATE] following a four day hospitalization after a fall and was found to be positive for RSV (respiratory syncytial virus). During an observation on 04/06/26 at 10:41 AM, R42 laid in bed resting with her eyes closed. A disposable nebulizer (a machine that converts liquid medicine into fine inhalable mist to treat respiratory conditions) mouthpiece and tubing, dated 03/23/26, laid on the mattress next to R42's pillow. Clear liquid sat in the disposable medication cup. Review of a physician order reflected an order for the breathing treatment .albuterol sulfate inhalation nebulization solution 1.25 mg(milligrams)/3ml (milliliters), inhale 3ml orally every 6 hours as needed for dyspnea (difficulty breathing). Start date 03/23/226. Review of the facility policy Small Volume Nebulizer Treatment and Care, last reviewed June 2022, revealed .tubing and nebulizer delivery systems are changed weekly and as needed. According to this policy, R42's nebulizer delivery mouthpiece and tubing was to have been changed on 03/30/26. Review of an Electronic Medication Administration Record (Emar) dated 03/31/26 to 04/06/26 revealed R42 received a nebulizer breathing treatment with the disposable mouthpiece and tubing that was to have been changed on 03/30/26. Resident #52 (R52) Review of an admission Record reflected R52 admitted to the facility with diagnoses that included chronic heart failure, chronic obstructive pulmonary disease (COPD) and permanent atrial fibrillation. Review of the form CMS 802 - MDS (Minimum Data Set) Resident Matrix printed on 4/6/2026 reflected R52 admitted to the facility on [DATE] and triggered for excessive weight loss and pulmonary infection. Review of a Care Plan initiated on 3/16/2026 reflected R52 has potential for acute condition change with cardiopulmonary, metabolic or infectious complications, atrial fibrillation, CHF (congestive heart failure), COPD and CKD (chronic kidney disease). Interventions included Check oxygen saturation levels (SAO2%) and capillary refill prn (as needed), initiate O2 as ordered. Review of Interdisciplinary Documentation dated 4/1/2026 indicated R52 was diagnosed with pneumonia and prescribed an antibiotic based on the results of a chest xray and recent shortness of breath. During an observation on 04/06/2026 at 10:45 AM, Oxygen tubing for R52 was lying on the bed, not contained in a clean plastic bag, oxygen concentrator running. Resident #73 (R73) Review of an admission Record reflects R73 admitted to the facility with diagnoses that included chronic systolic (congestive) heart failure, atrial fibrillation and anxiety. Review of a Care Plan initiated on 3/31/2026 reflected R73 had the potential for acute condition change with cardiopulmonary, metabolic or infectious complications related to chronic systolic heart failure, abdominal aortic aneurysm, and paroxysmal a fib (atrial fibrillation). Interventions included Check oxygen saturation levels SAO2% and capillary refill prn, initiate O2 as ordered. Review of the April 2026 Medication Administration Record and Treatment Administration Record (MAR/TAR) reflects an order for Oxygen at 2 liters PRN (as needed) to maintain an oxygen saturation of > (greater than) 87% every shift. Further review of the entire MAR/TAR did not reveal orders for storage of oxygen tubing or to change oxygen tubing every week. During an observation on 04/06/2026 at 11:37 AM, oxygen tubing that was not in use for R73 was wrapped around a portable oxygen tank. The oxygen tubing was not dated and was not secured in a clean bag. During an interview on 04/08/2026 9:14 AM, the DON reported that she expects oxygen tubing that is not in use is to be secured in a clean bag with the date written on the tubing. The DON reported that oxygen tubing is dated and changed weekly. Review of a policy Oxygen Use; Storage & Handling of Concentrators & Compressed Gas Cylinders revised November 2010 reflected .Concentrator Use, . 6. Change the cannula and humidifier bottle weekly and prn (as needed). 7. Date the cannula and humidifier bottle when changed.Safety, Cleaning & Maintenance of the Concentrator: .4. A receptacle should be available to attach to the concentrator to store the oxygen tubing when not in use. Oxygen Cylinders . 9. Attach the dated oxygen device to the cylinder (Change devices weekly and prn) .13. A receptacle should be available to attach to the E tank to store the oxygen tubing when not in use.

Based on observation, interview, and record review, the facility failed to follow infection control practices when providing peri-care for two residents (Resident #46 and Resident #2) of four reviewed for infection control, and when preparing medications for administration to residents. Findings: Resident #46 (R46) Review of an Admission Record revealed R46 was a [AGE] year old male, last admitted to the facility on [DATE], with pertinent diagnoses of profound intellectual disabilities, seizure disorder, muscle wasting, dependent on tube feeding for hydration and nutrition, and dependent on total assistance from staff for all care needs. During an observation on 03/04/25 at 10:19 AM, CNA's (certified nurse aides) N and O provided peri care to R46 and the following was noted: (a) R46 was incontinent of urine and two wash clothes were used to clean the residents genitalia and then placed on the residents over bed table, (b) after peri-care was completed CNA N did not remove the contaminated gloves and touched the broda chair, gait belt, R46s clothing, the foot rest on the broda chair, and bed linens, (c) with the same contaminated gloves on. CNA N closed the top of the tube feed and positioned R46's abdominal binder over the tube feed port, and (d) the over bed table was not sanitized after the two contaminated wash clothes were removed. Resident #2 (R2) Review of an Admission Record revealed R2 was a [AGE] year old female with pertinent diagnoses of spastic quadriplegic (affecting all four extremities) cerebral palsy, severe intellectual disabilities, and a history of urinary tract infections. R2 depended completely on staff to attend to her care needs. During an observation on 03/05/25 at 8:37 AM, CNA I and CNA J provided peri care to R2 and the following was noted: (a) R2 had some stool present, (b) CNA J used a wash cloth to remove the stool, wiping R2's bottom three separate times with the same wash cloth, (c) the wash cloth had visible stool on it, (d) CNA J did not remove the gloves worn to remove the stool and hold the contaminated wash cloth, (e) with the same gloves on, CNA J opened a cupboard in R2's room, removed a small bottle of baby powder, dispensed baby powder onto R2's skin, and returned the bottle of baby powder to the cupboard, (f) CNA I handed CNA J a single use unopened packet of remedy protect zinc oxide, CNA J received the packet with the same gloves used to provide peri care to R2 and placed the packet in the front pocket of her scrubs, (g) CNA J then opened another cupboard in R2's room with the contaminated gloves on, (h) CNA J removed the contaminated gloves and performed hand hygiene, and (i) CNA J removed the contaminated packet of remedy protect zinc oxide from her scrub pocket with a bare hand, showed the surveyor the packet, and stated that it will get used later on another resident because the packet cannot be left in the room. During an observation on 03/06/25 at 8:05 AM, Registered Nurse (RN) M did not perform hand hygiene, removed a medication card from the controlled substance locked drawer, popped out a pill into her bare hand, and then placed the pill in a medication cup that contained other pills. RN M repeated the process with a second medication card and pill without performing hand hygiene. RN M took the medication cup to the resident residing in bed 116-1 and administered them to the resident. During an interview on 03/06/25 at 8:16 AM, RN M indicated that she was not aware that dispensing pills into her bare hand was not an acceptable practice at this facility. During an interview on 03/06/25 at 8:43 AM, the Director of Nursing stated that dispensing pills into a bare hand and placing that medication in a cup with the intention of administering the pills to a resident, was not the facilities practice nor a standard of practice.

Based on interview and record review, the facility failed to obtain and document vital signs prior to medication administration for 2 of 6 residents (Resident #6 and #51) reviewed for professional standards of practice. Findings: Resident #6 (R6) Review of an Admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Review of R6's Order Summary dated 9/11/24 revealed, Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro)-Inject 5 unit subcutaneously with meals for DM (diabetes mellitus) hold if BS <110 (blood sugars less than 110). Blood sugars were to be obtained prior to the insulin administration to ensure R6's blood sugar was not less than 110. This was to be completed prior to the 8:00 AM, 12:00 PM, and 5:00 PM insulin administration. Review of R6's Blood Sugar Summary revealed: *On 01/14/2025 at 9:59 AM R6's blood sugar was 182. There was no blood sugar assessment completed prior to the 8:00 AM lispro administration. Indicating R6's blood sugar was not assessed prior to the administration of lispro insulin. *On 01/22/2025 at 11:59 AM R6's blood sugar was 166. There was no blood sugar assessment completed prior to the 8:00 AM lispro administration. *On 02/24/2025 at 10:35 AM R6's blood sugar was 172. There was no blood sugar assessment completed prior to the 8:00 AM lispro administration. Review of R6's January Medication Administration Record revealed *On 01/14/2025 R6's insulin was documented as administered at 8:00 AM with a blood sugar of 182 and was documented as administered at 12:00 PM with a blood sugar of 182. *On 01/22/2025 R6's insulin was documented as administered at 8:00 AM with a blood sugar of 166 and was documented as administered at 12:00 PM with a blood sugar of 166. Review of R6's February Medication Administration Record *On 01/22/2025 R6's insulin was documented as administered at 8:00 AM with a blood sugar of 172 and was documented as administered at 12:00 PM with a blood sugar of 172. Review of R6's Electronic Medical Record revealed no documentation for the lack of the blood sugar assessments with the administration of lispro. During an interview on 03/06/2025 at 9:10 AM, Director of Nursing (DON) reported that she spoke with the nurse that administered the lispro insulin on 01/14/2025 and 01/22/2025 and it was reported to her that R6 had refused the morning lispro but instead of documenting the refusal on the Medication Administration Record, the nurse put in the 12:00 PM blood sugar assessment and documented the morning lispro as administered. DON was unable to provide a rationale for the lack of blood sugar assessment for R6 on 02/24/2025. Resident #51 (R51) Review of an Admission Record revealed R51 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R51's Order Summary dated 12/21/24 revealed, Bisoprolol Fumarate Oral Tablet 10 MG (Bisoprolol Fumarate)-Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold if HR (heart rate) < (less than) 60, or SBP (systolic blood pressure) < 90 AND Give 0.5 tablet by mouth in the evening related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if HR<60 or SBP <90. To be administered at 8:00 AM and 4:00 PM. Review of R51's Blood Pressure Summary revealed: *On 01/04/2025 at 08:34 AM R51's blood pressure was 116/65. R51's blood pressure was not reassessed until 11:41 PM. *On 01/14/2025 at 07:43 AM R51's blood pressure was 162/70. R51's blood pressure was not reassessed until 8:30 PM. *On 01/22/2025 at 07:43 AM R51's blood pressure was 126/70. R51's blood pressure was not reassessed until 01/23/2025. Review of R51's January Medication Administration Record revealed: *On 01/04/2025 R51's antihypertensive medication was documented as administered at 8:00 AM with a blood pressure of 116/65 and was documented as administered at 4:00 PM with a blood pressure of 116/65. (Indicating R51's blood pressure was not assessed prior to the administration of the Bisoprolol Fumarate at 4:00 PM.) *On 01/14/2025 R51's antihypertensive medication was documented as administered at 8:00 AM with a blood pressure of 162/70 and was documented as administered at 4:00 PM with a blood pressure of 162/70. *On 01/22/2025 R51's antihypertensive medication was documented as administered at 8:00 AM with a blood pressure of 126/70 and was documented as administered at 4:00 PM with a blood pressure of 126/70. Review of R51's Blood Pressure Summary revealed: *On 02/03/2025 at 08:07 AM R51's blood pressure was 142/75. R51's blood pressure was not reassessed until 02/04/2025 at 12:30 AM. *On 02/04/2025 at 12:30 AM R51's blood pressure was 138/65. R51's blood pressure was not reassessed until 02/04/2025 12:43 PM. *On 02/18/2025 at 07:55 AM R51's blood pressure was 122/64. R51's blood pressure was not reassessed until 02/19/2025 at 12:57 AM. Review of R51's February Medication Administration Record revealed: *On 02/03/2025 R51's antihypertensive medication was documented as administered at 8:00 AM with a blood pressure of 142/75 and was documented as administered at 4:00 PM with a blood pressure of 142/75. *On 02/04/2025 R51's antihypertensive medication was documented as administered at 8:00 AM with a blood pressure of 138/65. R51's blood pressure result was from approximately 7.5 hours prior. *On 02/18/2025 R51's antihypertensive medication was documented as administered at 8:00 AM with a blood pressure of 122/64 and was documented as administered at 4:00 PM with a blood pressure of 122/64. Review of R51's Electronic Medical Record revealed no documentation for the lack of the blood pressure assessments prior to the administration of Bisoprolol Fumarate. During an interview on 03/06/2025 at 10:30 AM, Nursing Home Administrator (NHA) reported she had confirmed with DON that there was no additional or supporting documentation for the lack of R51's blood pressure assessments. During an interview on 03/05/25 at 07:50 AM, Registered Nurse (RN) M reported that both the CNAs (Certified Nursing Assistants) and licensed nurses can obtain vital signs. If the CNA doesn't get the vitals prior to the medication administration she will grab her own if there are ordered parameters. RN M reported that the electronic medical record prompts the licensed nurse to input the vital signs. RN M reported that the vital sign assessments are to be made prior to medication administration. Review of the facility policy Medication Administration by the Various Routes dated December 2024 revealed, .13. General Preparation .e. Take vital signs as indicated if the medication administration is contingent upon the results .

This citation pertains to intake M100147294. Based on interviews and record review, the facility failed to ensure facility staff responded to (reported), and investigated, a witnessed staff to resident physical and verbal abuse timely for one resident (R4) of four residents reviewed for abuse, resulting in the staff member working several more shifts exposing (R4) and other vulnerable residents to further possible abuse. Findings include: Review of a Face Sheet revealed R4 admitted to the facility on [DATE] with pertinent diagnoses of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, claustrophobia, and Alzheimer's. Review of a facility investigation reflected the following information: (a) On 9/23/24 at 7:10 PM, a housekeeping staff member (HK O) reported to the Director of Nursing (DON), who is also the facility abuse coordinator, that she witnessed abuse on 9/12/24, (11 days after witnessing the incident of abuse) and (b) the incident involved Registered Nurse (RN) N holding R4's wrists down in the wheelchair and RN N told R4 I don't work in an insane asylum, I work in a nursing home. On 9/23/24 the facility reported an allegation of abuse to the State Agency when a nurse engaged in abusive behavior towards R4 on 9/12/24. Review of the work schedule revealed RN N worked 9/16, 9/20, 9/21, and 9/22 from 6:00 PM to 6:30 AM, prior to the facility suspending him pending an investigation into allegations of abuse. The facility suspended RN N pending investigation on 9/23/24. In an interview on 9/30/24 at 3:20 PM, Activities Aide (AA) G reported she worked the evening of 9/12/24 when around 8:00 PM she witnessed RN N behind R4 grabbing her arms, holding them down and telling the resident not to hit. AA G stated that RN N said he was going to call the DON to tell her about the situation and that is why AA G did not report the incident of abuse. In an interview on 10/1/24 at 8:07 AM, Housekeeping Manager (HKM) H reported that on 9/16/24 a housekeeper who worked on 9/12/24 (HK O) informed her that she witnessed RN N restrain R4's arms, let R4 loose and then restrain R4 again. HK O also reported to HKM H she heard RN N tell R4 I don't work in a f*ck*ng mental institution, why am I dealing with this stuff!. HK O did not tell anyone at the time of the incident because she was new and was unsure what to do. HK O reported to HKM H that the incident was weighing her down, so she called HKM H at work on 9/16/24. HKM H said she reported this incident right way to the DON/Abuse Coordinator. Review of the Facility Investigation Interview with the perpetrator RN N revealed the DON asked the RN N on 9/17/24 when she was made aware of RN N holding R4's hands down. RN N stated the resident was upset and I was just trying to get her away from there, I didn't hurt her. He denied stating that he said he didn't work in a f*ck*ng insane asylum and said that and that he was trying to work on his stress and anxiety levels. He doesn't know why anyone would say that. Resident was verified as being upset and having behaviors that night. There were no other comments made to indicate that RN N had acted any other way than preventing [name of resident (R4)] from hurting herself or others. On 9/23/24 the (DON) interviewed RN N at (approximately) 7:20 PM about the same incident and made RN N aware that there is now an allegation of abuse related to that same night. (DON) asked him about him yelling at a resident that you do not work in a mental hospital. RN N denied it and asked why people would say that. He stated I'm not lying. Ask (LPN J) she will vouge (sic) for me. (LPN J) was right there. She knows exactly what happened. (DON) suspended RN N pending investigation. Review of a Witness Statement dated 9/27/24, CNA Q stated upon returning from my break there was distress going on over her (R4) trying to return to her old room. Myself and activities removed her from area into her room where we had been able to calm her down, toilet and prepare for evening did not have anymore issues with her thru out rest of night. I did witness her arms being restricted from hitting nurse. (sic) In an interview on 9/30/24 at 3:39 PM, the DON/Abuse Coordinator reported that HKM H informed her on 9/17/24 that housekeeper (HK O) reported she observed RN N holding down the arms of R4 on 9/12/24. The DON/Abuse Coordinator did not report the allegation of abuse to the State Agency on 9/17/23. The DON reported that it seemed reasonable if the resident was striking out to hold R4 so other residents didn't get hit. The DON realized the situation was more of a concern when another housekeeper came to her on 9/23/24 and reported different information, and she said she felt he was aggressive. The DON reported she called RN N again on 9/23/24 to talk about the incident again and to inform him that another staff member expressed concerns he was aggressive. RN N is not to return to work due to the lying and the verbal altercation. She said she cannot prove he was physically aggressive but can for sure say he was verbally abusive.

This citation pertains to intake M100147294. Based on interview and record review, the facility failed to provide an advanced written notification of a room change and obtain consent for 1 (R4) of 1 resident reviewed, resulting in the potential of a nonconsensual room change and emotional distress for the resident. Findings include: Review of a Face Sheet revealed R4 admitted to the facility on [DATE] with pertinent diagnoses of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, claustrophobia, and Alzheimer's. Review of an Interdisciplinary progress note dated 9/11/24 (Wednesday) at 6:44 PM for R4 revealed the resident was upset when staff tried to redirect her from entering another resident's room (room [ROOM NUMBER]). R4 became verbally and physically aggressive with staff, declined to let go of the door handle, was shouting at staff and attempting to hit and kick staff. After multiple attempts of redirecting, staff was able to move the resident who was tearful and continued to shout at staff. After approximately 10 minutes, R4 was calm and resting in wheelchair near the nurse's station. R4s nurse gave the resident an Ativan 20 minutes prior to the incident. Review of the Census Report revealed R4 resided in room [ROOM NUMBER] since her admission on 10/27/22 and had a recent room change to room [ROOM NUMBER] on 9/11/24. There was no documentation in the Electronic Medical Record (EMR) indicating why she had a room change or documentation showing the Power of Attorney (POA) was informed or consented to a room change. Review of an undated typed Witness Statement revealed HK O reported I witnessed (R4) become upset on 9/12/24 about a room in the 100 hall that used to be hers. She asked me to open the door, and I told her I could not as it wasn't hers anymore. She became upset and I told the nurse. In an interview on 10/1/24 at 11:00 AM, Certified Nursing Assistant (CNA) L reported since R4 had a room change, she keeps trying to go to her old room and gets very upset and agitated when she cannot go back to that room. In an interview on 10/1/24 at 11:43 AM, Licensed Practical Nurse (LPN) J reported she worked the night of 9/12/24 when R4 was upset she had a room change and could not go to her old room. In an interview on 10/1/24 at approximately 1:00 PM, Social Worker (SW) P reported she did inform R4's POA of the room change but could not find any documentation that they were informed. SW P reported she usually documents consent in the progress notes. She is aware R4 was having a hard time accepting the room change and kept going back to her old room but finally adjusted to her new room. SW P reported the faciltiy moved R4 from the room because the residents were not compatible with one another. SW P could not say who was in the room first but felt it was for their safety. When asked if there were any altercations between the two residents, SW P could not say there were any. SW P reported R4's roommate was more [NAME] and proper than R4 was, and they just didn't get along. Review of the electronic medical record for R4 revealed no documentation there were any concerns with her roommate.

This citation pertains to intake M100147294. Based on interviews and record review, the facility failed to protect the resident's right to be free from staff to resident verbal and physical abuse for one (R4) of 4 residents reviewed for abuse. Findings include: Review of a Face Sheet revealed R4 admitted to the facility on [DATE] with pertinent diagnoses of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, claustrophobia, and Alzheimer's. Review of a facility investigation reflected the following information: (a) On 9/23/24 at 7:10 PM, a housekeeping staff member (HK O) reported to the Director of Nursing (DON), who is also the facility abuse coordinator, that she witnessed abuse on 9/12/24, (11 days after witnessing the incident of abuse) and (b) the incident involved Registered Nurse (RN) N holding R4's wrists down in the wheelchair and RN N told R4 I don't work in an insane asylum, I work in a nursing home. On 9/23/24 an allegation of abuse was reported to the State Agency when a nurse engaged in abusive behavior towards R4. RN N was then suspended pending investigation on 9/23/24. Review of the work schedule revealed RN N worked 9/16, 9/20, 9/21, and 9/22 from 6:00 PM to 6:30 AM before being suspended pending an investigation into allegations of abuse. In an interview on 9/30/24 at 3:20 PM, Activities Aide (AA) G reported she worked the evening of 9/12/24 when around 8:00 PM she heard R4 yell and scream at the top of her lungs No I don't want to! AA G then stepped out of the office and witnessed R4 at the nurses' station holding on to the wheels of her wheelchair to keep it from moving. RN N was behind R4 grabbing her arms and holding them down. He told the resident not to hit. AA G approached R4 and asked if she wanted to go with her, and R4 agreed. AA G took R4 back to her room and the resident was still upset. In an interview on 10/1/24 at 8:07 AM, Housekeeping Manager (HKM) H reported that on 9/16/24 she was informed by HK O (who was working on 9/12/24) that she witnessed RN N restrain R4's arms, let R4 loose and then restrain R4 again. HK O also reported to HKM H she heard RN N tell R4 I don't work in a f*ck*ng mental institution, why am I dealing with this stuff!. In an interview on 9/30/24 at 3:39 PM, the DON/Abuse Coordinator reported that HKM H informed her on 9/17/24 that housekeeper (HK O) reported RN N was observed holding down the arms of R4. The DON/Abuse Coordinator also reported that on 9/23/24 another housekeeper (HK K) reported to her that RN N was aggressive towards R4. The DON/Abuse Coordinator was able to figure out the incident reported by HK K occurred on 9/12/24 due to an interview with Licensed Practical Nurse (LPN J). Review of an Interdisciplinary progress note dated 9/11/24 (Wednesday) at 6:44 PM for R4 revealed the resident was upset when staff tried to redirect her from entering another resident's room (room [ROOM NUMBER]). R4 became verbally and physically aggressive with staff, declined to let go of the door handle, was shouting at staff and attempting to hit and kick staff. After multiple attempts of redirecting, staff was able to move [the resident] to a common area. R4 was tearful and continued to shout at staff. After approximately 10 minutes R4 was calm and resting in wheelchair near the nurses station. R4's nurse gave the resident an Ativan 20 minutes prior to the incident. Review of R4's medical record revealed no progress notes or documentation on 9/12/24 regarding R4 having behaviors. Review of a Skin assessment dated [DATE] for R4 revealed she had scattered bruising to BUE (bilateral upper extremities) from recent behavioral episode where she became physically aggressive. STCP (short term care plan) initiated to monitor bruising. (R4) denies pain. Previous skin assessments do not show any bruising. Review of a Skin assessment dated [DATE] for R4 revealed Scattered bruising to BUE continues to improve. On 10/1/24 at 8:40 AM, an attempt to contact HK O for interview was made but HK O was not available and messages could not be left due to a voicemail response stating the mailbox was full. Review of an undated typed Witness Statement revealed HK O reported I witnessed (R4) become upset about a room in the 100 hall that used to be hers. She asked me to open the door, and I told her I could not as it wasn't hers anymore. She became upset and I told the nurse. The nurse (RN N) took her to the nurse's station, and she became more angry and started to yell and flinging her arms. (RN N) put her arms to her chest. (R4) got her arms free and started to reach for her wheelchair and (RN N) proceeded to retrain (sic) her arms again. He yelled I don't work in a f*ck*ng mental hospital; I work in a g*d d*mn nursing home. I don't get paid enough for this sh*t. In an interview on 10/1/24 at 11:00 AM, Certified Nursing Assistant (CNA) L reported she saw the tail end of the incident between RN N and R4 on 9/12/24. CNA L indicated she heard a commotion, walked towards the nursing station and saw the back of RN N leaning over R4 while she was sitting in her wheelchair. R4 was screaming and crying. The RN N then grabbed R4's wrists and crossed them over the front of R4's body. CNA L reported she approached the nurse with another CNA and told the nurse to take a break and walk away. R4 told CNA L that she hated RN N, and RN N hurt her wrists. In an interview on 10/1/24 at 11:23 AM, HK K reported she was down the hall near the soiled utility room and heard R4 screaming at the top of her lungs and she froze because it scared her. She saw RN N put his arms around R4's chair and restrain her arms in her chair. R4 was screaming, Get the h*ll off of me, you're hurting me at the top of her lungs. R4 tried to wheel away by putting her arms on the wheels of her wheelchair when RN N took her arm off the wheels and threw her arms on her stomach forcefully and told her she could not move. RN N was screaming in R4's face at this time but could not recall all he said but remembered he said, I don't have to quit. At that time an Activity Aide and a CNA came down and took R4 to her room and I overheard RN N say I don't work at a f*ck*ng mental institution; I work at a nursing home, and I don't get paid enough to deal with this sh*t. In an interview on 10/1/24 at 11:43 AM, Licensed Practical Nurse (LPN) J reported she worked the night of 9/12/24 when R4 was upset she had a room change and could not go to her old room. RN N yelled that we are not going to have this type of behavior, grabbed R4's arms and held them to the chair and then wheeled her towards her room. R4 was not screaming at that time but did tell him she didn't want to go. RN N then swore and said this is not an insane asylum. That was all LPN J heard. LPN J reported she did not think it was appropriate for him to hold the residents' arms down and to swear at her. Review of an Investigation Statement revealed the DON asked RN N on 9/17/24 about him holding R4's hands down when he stated the resident was upset and he was just trying to get her away from there and denied hurting her or stating he didn't work in a f*ck*ng insane asylum. He did say he was trying to work on his stress and anxiety levels and didn't understand why anyone would say this about him. On 9/23/24 at 7:20 PM, the DON interviewed RN N again regarding the events that night. She informed him of the allegation of abuse and suspended him this day. The timeline of events according to the DON/Abuse Coordinator was as follows: On 9/12/24 the incident of abuse between RN N and R4 occurred. On 9/13/24 skin assessments show scattered bruising on BUE. On 9/16/24, the Housekeeping Manager (HKM) H was told of the incident from HK O. On 9/17/24 HKM H informed the DON of the incident. On 9/17/24 the DON/Abuse Coordinator provided an all-staff education. That is when the DON/Abuse Coordinator was informed that RN N was more aggressive than originally thought. The facility did not report the allegation of abuse to the State Agency until 9/23/24. Review of a policy titled Abuse/Suspected Abuse; Crime Investigation & Reporting last reviewed 2/2023 revealed: It is the policy of this facility to encourage and support all residents, covered individuals, and families, to report any suspected acts involving resident mistreatment, neglect, exploitation, abuse, crimes, misappropriation of resident property or injuries of unknown source. Allegations of abuse and crime are thoroughly investigated and properly reported in accordance with Federal Regulation including the Elder Justice Act. Purpose: Residents have the right to be free from verbal, sexual, physical, psychological abuse, corporal punishment, involuntary seclusion, and crimes. 2. Any person(s) witnessing or having knowledge of potential or actual abuse or crime must immediately report the incident to the Administrator and / or designee. In the case of a resident or family member, such a report can be made to the charge nurse or person assigned to receive complaints, who is responsible to follow through with reporting procedures. 3. When allegations of resident (S483.5) mistreatment, abuse, crime, neglect, exploitation, misappropriation, or injuries of unknown source are reported, the administrator and designees will investigate the allegation with the assistance of appropriate personnel. 8. In accordance with S483.12(b)(c) the facility will report all alleged violations to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigations. The facility will reference The State Licensing and Regulatory Affairs ([NAME]) guidelines to make reporting determinations. 9. Reports are submitted online into the MI-FRI system: (1) Immediately but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. (2) No later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; and does not result in serious bodily injury. 11. Elder Justice Act Reporting Requirements: a. The facility will report any reasonable suspicion of a crime against any individual who is a resident of or receiving care from this facility. b. A report will be filed with at least one local law enforcement agency within two (2) hours of forming a suspicion if there is serious bodily injury and within twenty-four (24) hours of forming a suspicion if no serious bodily injury has occurred.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 4 of 11 residents (Resident #10, #11, #35, and #30), reviewed for the provision of nursing services, resulting in lack of vital sign and blood sugar assessments prior to medication administration, medications improperly administered, and management of controlled substances. Findings: Resident #10 (R10) Review of an Admission Record revealed R10 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R10's Order Summary revealed, Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 0.5 tablet by mouth one time a day for Hold for BP (blood pressure) less than 110/60, HR (heart rate) less than 60 dated 6/24/23. Review of R10's February Medication Administration Record revealed the following: *On 2/7/24 R10's blood pressure was 110/55 and the losartan was administered. *On 2/8/24 R10's blood pressure was 126/56 and the losartan was administered. *On 2/10/24 R10's blood pressure was 124/58 and the losartan was administered. *On 2/22/24 R10's blood pressure was 112/57 and the losartan was administered. *On 2/26/24 R10's blood pressure was 114/53 and the losartan was administered. Review of R10's March Medication Administration Record revealed the following: *On 3/11/24 R10's blood pressure was 110/58 and the losartan was administered. *On 3/13/24 R10's blood pressure was 98/65 and the losartan was administered. *On 3/22/24 R10's blood pressure was 108/60 and the losartan was administered. *On 3/24/24 R10's blood pressure was 116/57 and the losartan was administered. Resident #11 (R11) Review of an Admission Record revealed R11 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure. Review of R11's Order Summary revealed, Carvedilol Oral Tablet 3.125 MG (Carvedilol) Give 1 tablet by mouth two times a day .Hold for BP (blood pressure) less than 110/60 dated 3/6/24. To be administered at 8:00 AM and 4:00 PM. Review of R11's March Medication Administration Record and Blood Pressure Summary revealed the following: *On 3/7/24 at 12:04 PM R11's blood pressure was 102/57. Both the 8:00 AM and 4:00 PM doses of carvedilol were administered. *On 3/10/24 R11's blood pressure was assessed 1 time at 5:04 PM. The 8:00 AM dose of carvedilol was administered without a blood pressure assessment ensuring the provider ordered parameters were followed. *On 3/15/24 at 3:04 PM R11's blood pressure was 105/56 and the 4:00 PM dose of carvedilol was administered. *On 3/16/24 at 9:38 AM R11's blood pressure was 127/57 and the 8:00 AM dose of carvedilol was administered. *On 3/17/24 at 9:16 AM R11's blood pressure was 128/58 and the 8:00 AM dose of carvedilol was administered. *On 3/20/24 R11's blood pressure was assessed 1 time at 7:25 AM. The 4:00 PM dose of carvedilol was administered without a blood pressure assessment ensuring the provider ordered parameters were followed. *On 3/24/24 5:13 PM R11's blood pressure was 120/57 and the 4:00 PM dose of carvedilol was administered. Resident #35 (R35) Review of an Admission Record revealed R35 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R35's Order Summary revealed, Cardizem CD Oral Capsule Extended Release 24 Hour 120 MG (Diltiazem HCl Coated Beads) Give 1 capsule by mouth one time a day .Hold for SBP<110 (systolic top number blood pressure less than 110) or DBP<60 (diastolic bottom number blood pressure less than 60) dated 12/22/23. Review of R35's March Medication Administration Record and Blood Pressure Summary revealed: *On 3/2/24 at 9:22 AM R35's blood pressure was 111/56 and the Cardizem was administered. *On 3/3/24 at 10:05 AM R35's blood pressure was 104/55 and the Cardizem was administered. *On 3/4/24 at 8:44 AM and 9:51 AM R35's blood pressure was 133/59 and the Cardizem was administered. *On 3/8/24 at 8:59 AM R35's blood pressure was 103/58 and the Cardizem was administered. *On 3/12/24 at 9:51 AM and 10:00 AM R35's blood pressure was 108/53 and the Cardizem was administered. *On 3/14/24 at 8:42 AM R35's blood pressure was 123/58 and the Cardizem was administered. During an interview on 03/27/24 at 07:51 AM, Registered Nurse (RN) G reported that if blood pressure or heart rate parameters are ordered, they are to be followed. RN G reported that if the order is written to hold if less than 110/60 that implies to hold the medication if the systolic blood pressure was less than 110 and to hold if the diastolic blood pressure was less than 60. During an interview on 03/27/24 at 09:22 AM, Clinical Care Coordinator (CCC) B and CCC C reported that the licensed nurses should be following the provider ordered parameters and administering the medications within the ordered parameters. CCC A and CCC B confirmed/clarified that the parameters ordered as Hold for BP less than 110/60 would require to hold the medication if the systolic blood pressure was less than 110 and to hold the medication if the diastolic blood pressure was less than 60. They confirmed/clarified that it would be one or the other and would not require both the systolic blood pressure and diastolic blood pressure to be outside of the parameters. Resident #30 (R30) Review of an Admission Record revealed R30 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle wasting and pain. Review of R30's Order Summary revealed, Gabapentin Capsule 100 MG Give 1 capsule by mouth three times a day dated 10/31/20. Review of R30's Controlled Drug Receipt/Record/Disposition Form revealed that on 3/22/24 R30 received 4 doses of gabapentin instead of the ordered 3 doses. 2 doses were documented as administered at 11:50 AM by Licensed Practical Nurse (LPN) H. Review of R30 Electronic Health Record revealed no documentation of an order for an additional dose and/or an increased dose of gabapentin on 3/22/24. During an interview on 03/26/24 at 2:00 PM, Clinical Support Nurse (CSN) A reported that confirmed the medication error and reported that LPN H could not provide a rationale as to why an additional dose of gabapentin was administered on 3/22/24 and reported that LPN H had not wasted a gabapentin capsule with a nurse witness. During an interview on 3/27/24 at 10:21 AM, CSN A confirmed the medication errors for R10, R11, R30, and R35. CSN A reported that the order in the Electronic Health Record was modified to prompt the licensed nursing staff to obtain and review the residents blood pressures prior to the administration of the antihypertensive medications. CSN A reported that the facility nursing staff would receive education on medication administration as it relates to ordered parameters and professional standards of practice. Review of the facility policy Medication Administration by the Various Routes last revised March 2022 revealed, .e. Take vital signs as indicated if the medication administration is contingent upon the results .n. If a dose of medication is withheld or refused, the nurse will note that on the eMAR (Electronic Medication Administration Record . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, (Nurses) are responsible for documenting any preassessment data required of certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of warfarin, before giving the medication. After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered. Inaccurate documentation, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about patient care. For example, errors in documentation about insulin often result in negative patient outcomes. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 609). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to ensure that pre-admission screening/annual resident review (PASARR) level I and level II's were completed on admission and at the annual review for 1 of 1 resident (Resident #28) reviewed for PASARR screening/assessment. Findings included: The facility provided a copy of the PASARR Screening policy dated 11/2008, with a last revised date of 5/2015 for review. The policy reflected, d. When a level II evaluation is indicated for Annual Resident Review (ARR), the nursing facility will notify the local CMHSP (Community Mental Health Services Program) of the need for a level II evaluation at least 30 days prior to the due date of the ARR by sending them a new DCH-3877 (PASARR level I evaluation) .The facility assumes responsibility for verifying that required PAS and ARR processes are completed and documented in the resident's record . R28 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R28 was admitted to the facility on [DATE] with diagnosis of (but not limited to) Parkinson's Disease (movement disorder of the nervous system), arthritis, psychotic disorder (out of touch with reality), hallucinations, and a mood disorder. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which represented R28 was cognitively intact. R28 had a guardian for all medical and financial decision making. R28 required extensive staff assistance of 1-2 with all activities of daily living. Several attempts were made to interview R28 during the onsite survey on 3/25/24 at 3:30 PM, R28 was sleeping in her bed, on 3/26/24 at 10:30 AM, 1:30 PM, and 3:35 PM, R28 was sleeping in bed and 3/27/24 at 9:50 AM, R28 was sleeping in her bed. On 3/26/24 at approximately 12:25 PM, R28 was seated in a chair in the hall but declined to be interviewed at that time. The facility provided a copy of R28's PASARR level 1 that was completed on 2/20/23 for review. The form reflected, If any answer to items 1-6 in Section II is Yes, send one copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 (PASARR level II assessment) if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy of the patient or legal guardian . The form reflected 4 of the 6 questions were answered yes and a level II was indicated. Social Worker (SW) E provided a copy of an email that was dated 2/19/24 at 1:44 PM that reflected, I'm looking for the OBRA (PASARR level 1 and II) determination for (name of R28) .She's due for her annual, but in looking/auditing I don't see the determination from last year. The MDS assessments were reviewed and reflected an admission assessment was completed on 2/27/23 and the annual assessment was completed on 2/13/24. According to the policy the facility will notify CMHSP 30 days prior to the due date of the annual assessment. The email request should have been sent on or before 1/13/23 for the 2/13/24 assessment. During an interview on 3/27/24 at 10:00 AM, SW E stated that when R28 was first admitted on [DATE] she notified CMHSP of the need for a level II assessment. SW E stated that R28 went out to the hospital from 3/1/23-3/6/23 and again 3/22/23-3/30/23 and some how didn't get the level II assessment done. SW E stated she emailed them in February (see email dated 2/19/24 above) and let them know that she didn't have the admission one and now needed the annual review as well. SW E stated that they still haven't come as of this interview, and she would follow up with them with another email.

Based on observation, interview and record review, the facility failed to address the root causes of multiple falls and implement meaningful interventions for 1 (Resident #60) of 3 residents reviewed for falls, resulting in repeated falls. Findings include: Resident #60 (R60) Review of a Face Sheet revealed R60 admitted to the facility on [DATE] with pertinent diagnoses of cognitive communication deficit, a fractured femur and generalized muscle weakness, muscle wasting and atrophy. On 1/2/24 she is diagnosed with a wedge compression fracture on T11-T12 vertebra. During an observation on 3/25/24 at 10:17 AM, R60 is in the hallway sitting in her wheelchair and most of her face has black and blue bruising with red eyes. The resident reported she thinks she fell and landed but was not sure exactly how she got there. She thought it happened in the main drag and was nonsensical. In an interview on 3/25/24 at 1:00 PM, Family Member (FM) K reported R60 fell in the beginning of January and fractured her vertebrae, then fell again on 2/14/24 and landed on her bottom. FM K reported she is getting medications that may be interfering with her judgement and will just get up when she wants to without realizing she should ask for help. Review of an incident report dated 1/2/24 at 1:43 PM for R60 revealed she had an unwitnessed fall and was found on the floor parallel with the bathroom door. She was attempting to get up and moved her wheelchair and fell landing on her back. She was transported to the hospital. Root cause: she is on medications that may contribute to dizziness, lethargy, and postural hypotension. She is also self-determined and has been observed attempting to rise independently. Upon attempting to stand independently her wheelchair rolled back and contributed to her loss of balance resulting in her on the floor. Anti rollback locks to her wheelchair were implemented. In an interview on 3/27/24 at 9:35 AM, Clinical Care Coordinator (CCC) /Registered Nurse (RN) B and CCC/RN C reported R60 had a fall on 1/2/24 when she attempted to go to the bathroom and did have a fracture. They implemented anti rollbacks on the wheelchair because she did not lock her wheelchair when she tried to get up. When asked if she was able to get up to ambulate alone, they reported no and that the resident has always been in her wheelchair for mobility. When asked the rationale for the anti-tipping device on the wheelchair for a resident who is not supposed to be getting up, they said it is to help the wheelchair lock in place when she does try to get up but did not address the toileting needs of a resident who has mixed incontinence and is not cognitively intact. Review of an Incident Reported dated 2/14/24 for R60 revealed she had an unwitnessed fall at 1:50 PM and was found on the floor in her bathroom on her stomach lying perpendicular with the toilet with her TSLO brace (a brace that limits movement in your spine from the thoracic area to your sacrum) on (as a result from the previous fall). She was last toileted at 11:00 AM and last observed at 1:30 PM sitting in her wheelchair in her room. Patient stated she had to go to the bathroom. Root cause: R60 was attempting to take herself to the bathroom and walked from her room to the bathroom without assistance or assistive devices. She went to the Emergency Department and was diagnosed with a urinary tract infection. No intervention documented. In an interview on 3/27/24 at 9:35 AM, CCC B and CCC C was questioned about the incident on 2/14/24 and reported R60 walked to the bathroom. When questioned about when the last time the resident was toileted, they reported their standard practice is to toilet the residents every 2 hours and the documentation on the task list only indicates staff toileted the residents on their shift and do not document every time they toilet the residents. R60 did have a UTI with yeast in her urine at this time, but the colony count was not enough to treat the infection and she was asymptomatic. Review of an Incident Report dated 2/16/24 at 12:15 AM for R60 revealed the resident had an unwitnessed fall when staff heard someone yelling and found the resident on the floor next to her bed. The resident stated she was getting up to go home. Root cause: medications, weakness, and lack of awareness. Staff reported they checked on her 10 minutes before the fall and offer her toileting. No documentation that the resident was incontinent or was toileted. No intervention documented. In an interview on 3/27/24 at 9:35 AM, CCC B and CCC C was questioned about the incident on 2/16/24 for R60 when the resident was trying to get up from her bed to go home. They implemented a perimeter mattress. She was on an antibiotic for her UTI and Physical Therapy picked her up after this. The Care Plan shows a perimeter mattress was initiated on 12/7/23 under an ADL (activities of Daily Living) Care Plan. Review of an Incident Report dated 3/6/24 at 8:15 AM for R60 revealed the resident had an unwitnessed fall when the Nurse heard a yell in the hallway and the housekeeper reported the resident fell . The resident reported she was trying to go to the bathroom. She was last seen 10 minutes prior to the fall. The nurse saw R60 in the bathroom, face down with the left side of her face on the floor. The residents' right arm was bleeding from a skin tear and could not move because of the pain. She was sent to the hospital. Root cause: she attempted to independently ambulate without staff or assistive devices and had a loss of balance resulting in her on the floor. She has self-determined behaviors and does not recognize her own functional limitations. She also had a recent diagnosis of COVID 19. She has impaired cognition AEB (as evidenced by) her MOCA (Montreal Cognitive Assessment for dementia) of 8 indicating severe cognitive impairment.) She returned from the hospital with a subcutaneous contusion and small hematoma of the right upper thigh. Intervention: Care Plan was updated to include a door open alert alarm to bathroom door to notify staff when the resident is attempting to self-transfer. Review of a Hospital Record dated 3/6/24 for R60 revealed Patient does have a history of dementia. Patient does have a TLSO brace for previous fall. Diagnostic test results show 1. Progressive height loss of the T11 vertebral body compared to 1/2/24, now moderate to severe. In an interview on 3/27/24 at 9:35 AM, CCC B and CCC C was questioned about the incident on 3/6/23 for R60 when the facility implemented a door alarm alert on the bathroom door because staff would catch the resident trying to go to the bathroom a lot and does not always let staff know when she has to go. The resident will tell staff she does not have to go and then try to go herself. CCC B reported R60 was last toileted 10 minutes prior but did not have the exact time. This is conflicting what the report states that the CNA had just been there a few minutes prior to check on her and offer her assistance with toileting or anything else she may need, and she stated she was good. When questioned about the rationale of the door alarm on the bathroom door, they reported it would let the staff know when she is trying to open the door, indicating she needed to use the bathroom. Review of an Incident Report dated 3/23/34 at 9:20 PM for R60 revealed she had an unwitnessed fall when the nurse heard yelling down the hall and went to the residents' room and saw her on the floor on her left side and complained of left side pain. Her nose started to bleed shortly after the fall. Her forehead and her lips were extremely inflamed. She was then sent to the hospital. New intervention of Call don't fall signs in easily visualized areas in her room for intervention, also updated in care plan. Conclusion: The resident did not understand she fell and stated I didn't fall recently. Maybe a week or more ago. And I fell at home. Root cause: she attempted to transfer herself independently to bed. The care plan was updated to place signs in easily visualized areas to aid in reminder to use call light when transferring. No indication the resident was educated, understood, or acknowledged this intervention. In an interview on 3/27/24 at 9:35 AM, CCC B and CCC C was questioned about the incident on 3/23/24, R60 was up in her wheelchair when she declined to go to bed after the staff asked her. When asked when staff asked her if she wanted to go to bed last, CCC B reported it was about an hour before the incident. This investigation was not completed yet as of the day of this survey because CCC B was still trying to get staff interviews, but they implemented putting signage in her room to remind her to use her call light for assistance. When questioned if R60 can read and understand the signage, they did not know. Review of the Nursing Progress Notes dated 3/27/24 at 6:41 AM for R60 (during this survey) revealed she had an unobserved fall and was found laying on the floor with her feet by the bed and she was angled towards the bedroom door. Bilateral knees have redness, and the resident denies discomfort. Care plan reviewed and updated. In an interview on 3/27/24 at 9:35 AM, CCC B and CCC C reported today R60 tried to get out of bed because she was incontinent and found her on the floor with her belly down. Staff heard the crash and R60 yelling. When questioned if the resident had a toileting schedule, the answer was no. Today they are going to start implementing a toileting schedule and talk to PT to do a thorough assessment of her room to keep her safe from injury. Review of a Bowel and Bladder Evaluation Worksheet for R60 dated 12/7/23 to 12/11/23 revealed the resident was assessed on an hourly basis and was continent and incontinent at different times during a 24 hour period. Review of the Care Plan for R60 revealed it does not address falls in an organized way or have the dates the interventions post falls were implemented. No dementia or cognitive communication deficit addressed. Record of frequency of bowel movements. Assist with toileting before and after meals, at bedtime and as needed. Wears incontinence products, check and change before and after meals, at bedtime and as needed, assist when verbal or non-verbal indicators communicate toileting needs. Fall Risk Management under the ADL Care Plan initiated 12/7/23 and last revised 3/23/24 with a list of interventions not indicating what date they were implemented.

Based on interview and record review, the facility failed to accurately monitor and prevent a significant weight loss for one (Resident #17) of two residents reviewed for nutrition and hydration. This deficient practice resulted in the potential for unmet nutritional needs and unnecessary weight loss. Findings include: Resident #17 (R17) Review of R17 electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including dementia and diverticulitis (inflammation of pouches in the digestive track). R17's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicative of moderate cognitive impairment. Review of the weight history revealed R17 weighed 207.4 lbs. (pounds) on 9/24/23 and weighed 185.0 lbs. on 10/24/23, for a total weight loss of 22.4 lbs. This resulted in a 10.8% weight loss within a 30-day period. On 1/12/24, R17 weighed 178.6 lbs., which represented an additional 6.4 lb. weight loss. This equated to a 13.9% or 28.8 lb. weight loss in an approximate 110-day period. Review of Dietary Progress notes and Nutritional Assessments written by Dietary Manager (DM) F revealed the following: 1. 11/17/23: [R17] noted to have weight loss of 12# (pounds)/6.2% in last 30 days . 2. 1/11/24: [R17] has a decrease in his weight of 8# in the last week . 3. 12/27/24: [R17] continues to have a weight loss in the last 6 months .Weight is 181# and this is down 12%/25#'s in the last 3 months. [R17] stated on admit (admission) his normal weight was between 192# and 200# . 4. 2/1/24: [R17] continues to have weight loss over 10% in the last 6 months . Continue plan of care. 5. 3/8/24: [R17] continues to have significant weight loss [in the] last 6 months . No change in plan of care. On 3/26/24 at 12:54PM, an interview was conducted with Registered Dietitian (RD) I. RD I indicated the protocol for weight loss consultation is to wait for a referral from the dietary or nursing department via a communication form. When asked if a referral had been made for R17, RD I replied, It doesn't look like I have seen him. If I was consulted, I would have put it in a progress note. RD I stated she didn't have an expectation about consultation because the root cause of R17's weight loss was unknown to her. When asked if a consultation may have assisted in gaining insight into the cause of R17's weight loss, RD I replied, Yes. On 3/26/24 at 2:56PM, an interview was conducted with DM F. DM F was asked the protocol for interdisciplinary communication regarding resident weight loss. DM F stated, I always try to give them a supplement or snack first . If things aren't working, I would notify the dietitian. When asked why the RD was not consulted despite R17's continued weight loss, DM F stated, I don't have a good reason. Review of R17's Plan of Care identified a focus that read, [R17] has potential for nutritional concerns . with an intervention initiated on 9/26/24 that read, Registered Dietitian evaluation prn (as needed). On 3/27/24 at 8:44AM, an interview was conducted with Clinical Support Nurse A. Clinical Support Nurse A indicated a RD should be consulted when a weight loss triggers in the MDS and continues to be a pattern. Clinical Support Nurse A acknowledged that R17 should have received a RD consultation due to significant weight loss. Review of R17's Weight Summary revealed the following weight fluctuations: 1. 9/24/23: 207.4 lbs. 2. 9/25/23: 203.0 lbs. (4.4 lb. weight loss in 1 day) 3. 10/18/23: 196.0 lbs. 4. 10/20/23: 188.0 lbs. (8.0 lb. weight loss in 2 days) 5. 12/9/23: 189.0 lbs. 6. 12/11/23: 182.5 lbs. (6.5 lb. weight loss in 2 days) 7. 1/12/24: 178.6 lbs. 8. 1/16/24: 189.5 lbs. (10.9 lb. weight gain in 4 days) 9. 1/26/24: 189.0 lbs. 10. 1/27/24: 182.5 lbs. (6.5 lb. weight loss in 1 day) On 3/27/24 at 9:13 AM, a follow-up interview was conducted with Clinical Support Nurse A. Clinical Support Nurse A indicated a former RD who is no longer employed at the facility was likely told to complete a consultation for R17 in December and it, didn't happen. Clinical Support Nurse A stated re-weighs are expected when weights differ by 3 lbs. on a day-to-day basis and had no explanation as to why this hadn't occurred for R17. Review of R17's EMR revealed the following order, initiated 12/28/23: Snack acceptance in morning and afternoon. Review of R17's snack intake record between 2/26/24 and 3/26/24 indicated Not Applicable for 23 of 86 snack opportunities. On 3/27/24 at 10:32AM, an interview was conducted with Clinical Care Coordinator (CCC), C. CCC C was asked why Not Applicable would be charted for snack acceptance R17's EMR. CCC, C replied, They [Certified Nursing Assistants (CNAs)] should never chart a snack as, 'Not applicable' unless the resident is not physically in the facility .We've had a lot of education on this during shift-to-shifts [team meetings] and apparently, they're [CNAs] not following through. Review of facility policy titled, Weight Management, effective April 2015 read, in part: It is the policy of this facility that resident's weight will be monitored by the IDT (interdisciplinary team) in coordination with the nutritional plan of care . in the event of a patterned or significant unplanned weight loss/gain the IDT team is responsible for assessing and implementing individualized interventions . Review of R17's EMR revealed no communication to nursing staff, a registered dietician, or a physician regarding significant weight loss.

Based on observation, interview and record review, the facility failed to implement an effective and current system of surveillance of staff illnesses and failed to ensure appropriate hand hygiene (washing with soap and water) was employed for residents in contact precautions while under investigation for an unknown gastrointestinal illness, resulting in the potential for cross contamination and spread of disease-causing pathogens amongst residents and staff. Findings: Review of the facility GI (gastrointestinal) Outbreak timeline revealed, on 1/21/23 3 residents residing on the same wing were noted to develop GI related symptoms including nausea, vomiting and loose stools. This occurred following a single case on 1/18/23 with matching symptomology on the same wing. On 1/22/2023 3 more residents developed these symptoms and on 1/23/2023 one more resident also developed these symptoms. Awaiting results at this time. All cases at this time are Probable. Following contact tracing it was noted that a staff member was patient 0 .Staff GI timeline-on 1/17/2023-Staff member developed a fever with nausea, vomiting and loose stools during her shift and was sent home .1/23/2023-Staff member called in with complaints of nausea, vomiting, and loose stools. Staff member worked last on 1/20/2023 and had worked in house keeping on 100 hall .Discussed the outbreak status of GI symptoms with HCP (Healthcare Provider) and residents and also received orders to obtain stool samples to test for yersinia, shigella, salmonella, fecal leukocytes with C&S (culture and sensitivity) and norovirus on those with continued loose stools. Increased cleaning initiated. House keeping switched from normal disinfectant to bleach water until results from tests are obtained . Confirming norovirus was identified as probable and transmission-based precautions for norovirus were implemented. (Norovirus is a very contagious virus that causes vomiting and diarrhea. People of all ages can get infected and sick with norovirus .Norovirus spreads easily and is extremely contagious. Cdc.gov/norovirus/about/index.html.) During an interview on 02/09/2023 at 10:42 AM. Infection Control Preventionist (ICP) C reported that there was an ongoing GI Outbreak that was identified. ICP C reported that residents with nausea, vomiting, and/or diarrhea were being placed in isolation to rule out Norovirus and other gastrointestinal infections. Symptomatic residents had a stool specimen sent to the laboratory and treated as though they were positive for norovirus until 24 hours after last symptom. ICP C reported that she was tracking the GI Outbreak using the Infection Control Resident Surveillance log which included symptoms, unit, onset date, and resolution date. ICP C reported that the outbreak originated with a staff member on 1/18/23. ICP C reported that when staff members called off work a Call-In Slip was filled out by the staff member taking the call, submitted it to Human Resources Manager (HRM) B, and HR B would give it to ICP C for review. ICP C reported staff call offs were reviewed daily and staff with symptoms of a gastrointestinal illness were not permitted to return to work until after 24 hours symptom free. ICP C reported she did not track employee illness on an infection control surveillance log. ICP C reported she was working on putting an employee line list (surveillance tool) together and would continue tracking employee illnesses in the future. During an interview on 02/08/2023 at 12:32 PM, Dietary Manager (DM) R reported that when the dietary staff call off work the staff member taking the call completes the Call-In Slip and submits it to HR B. DM R was not responsible for tracking the employee illness. During an interview on 02/08/2023 at 12:43 PM, Housekeeping Manager (HM) S reported that when the housekeeping staff call off work the staff member taking the call completes the Call-In Slip and submits it to HR B. HM S was not responsible for tracking the employee illness. During an interview on 02/08/2023 at 12:48 PM, HR B reported that employees Call-In Slips were given to HR B for attendance tracking and review and forwarded to ICP C for infection control surveillance. During an interview on 02/09/2023 at 7:53 AM, Registered Nurse (RN) O reported that the facility was having a GI outbreak with both residents and staff. RN O reported a new resident was identified with GI symptoms and placed in isolation that morning and staff GI illness was ongoing. Review of the Nursing Daily Schedule and the Call-In Slip revealed Certified Nursing Assistant (CNA) F called off work on 1/20/23 for vomiting, diarrhea, and low-grade fever. The Nursing Daily Schedule revealed CNA F worked 1/21/23. There was no documentation to reflect that CNA F had been symptom free of a GI illness for 24 hours prior to returning to work (following the GI Outbreak identified on 1/18/23.) Review of the Nursing Daily Schedule and the Call-In Slip revealed CNA E called off work on 1/26/23 for vomiting and diarrhea. The Nursing Daily Schedule revealed CNA E worked 1/27/23. There was no documentation to reflect that CNA E had been symptom free of a GI illness for 24 hours prior to returning to work. Review of the Nursing Daily Schedule and the Call-In Slip revealed CNA H called off work on 1/22/23 for diarrhea. The Nursing Daily Schedule revealed CNA H worked 1/23/23. There was no documentation to reflect that CNA H had been symptom free of a GI illness for 24 hours prior to returning to work. Review of the Nursing Daily Schedule dated 1/19/23 revealed Licensed Practical Nurse (LPN) M called off work. Review of the Nursing Daily Schedule dated 1/27/23 revealed CNA N and CNA F called off work. Review of the Nursing Daily Schedule dated 1/30/23 revealed CNA V called off work. During an interview on 02/09/2023 at 1:06 PM, Nursing Home Administrator (NHA) reported that there were no Call-In Slips for the staff and dates listed above. Confirming employee illness was not being tracked during an ongoing facility wide GI Outbreak. 29073 During an observation on 2/8/2023 at 8:54 AM, a tower of Personal Protective Equipment (PPE) and signage was posted on the door of room [ROOM NUMBER] indicating a resident in the room was on Contact Precautions and See Nurse before entering room. The signage did not specify which resident of two living in the room was in contact precautions. During an interview on 2/8/2023 at 8:56 AM, Certified Nurse Aides (CNA's T and U) reported that a resident in room [ROOM NUMBER] was in contact precautions due to having signs of a gastrointestinal illness. Neither CNA was able to specify what the appropriate method of hand hygiene was. Both CNAs said they would use alcohol-based hand rub (ABHR) unless they knew that a resident had C. Diff (clostridium Diffcile, a bacterial infection). During an observation on 02/09/2023 at 7:28 AM, Certified Nursing Assistant (CNA) Q exited room [ROOM NUMBER] (isolation room for probable norovirus) without washing her hands with soap and water and instead used the alcohol-based hand sanitizer (ABHS). The signage on the door did not indicate that handwashing with soap and water was required after providing care. Review of an undated document provided to the surveyor by the DON on 2/9/2023 reflected the correct policy and signage and conditions for contact precautions and specified Contact precautions should be initiated when someone is experiencing: 1. C-diff; 2. Diarrhea is defined as: 6 watery stools in the past 36 hours, 3 unformed stools in 24 hours for 2 days, 8 unformed stools over 48 hours, bowel movements that are unusual for the resident; there is no other recognized etiology for the diarrhea; 3. Persistent vomiting; 4. Norovirus; 5. VRE/MRSA (Vancomycin-resistant Enterococci/Methicillin-resistant Staphylococcus aureus) that is not contained; 6. Scabies; 7. Salmonella. The signage on the document indicated Soap and water required upon exit, however, the graphic included on the sign had a bottle labeled ABHR and could contribute to confusion. The section of the document related to Staff Initiation indicated 10. Educate Staff they must wash hands with soap and water after entering contact precaution area. During an interview on 2/9/2023 at 11:37 AM, the Director of Nursing (DON) reported that signage for residents in contact precautions for symptoms of gastroenteritis (nausea, vomiting, diarrhea) was not printed correctly and does not clearly indicate staff should wash their hands with soap and water. Review of the CDC guidelines for Norovirus revealed, Overall, studies suggest that proper hand washing with soap and running water for at least 20 seconds is the most effective way to reduce norovirus contamination on the hands, whereas hand sanitizers might serve as an effective adjunct in between proper handwashings but should not be considered a substitute for soap and water handwashing . Appropriate hand hygiene is likely the single most important method to prevent norovirus infection and control transmission. Reducing any norovirus present on hands is best accomplished by thorough handwashing with running water and plain or antiseptic soap. Washing with plain soap and water reduces the number of microbes on hands via mechanical removal of loosely adherent microorganisms .Isolation of both exposed and unexposed well persons might be useful during outbreaks in long-term--care facilities to help break the cycle of transmission and prevent additional cases. In health-care facilities, ill patients may be cohorted together in a unit or part thereof, with dedicated nursing staff providing care for infected persons. Updated Norovirus Outbreak Management and Disease Prevention Guidelines (cdc.gov) Review of the facility policy Infection Prevention and Control Plan effective March 2020 revealed, Policy: It is the policy of this facility to implement the Infection Prevention and Control Program utilizing a systematic, coordinated and continuous approach guided by OSHA regulations, and pertinent state, federal and local regulations pertaining to infection control .Procedure: 1. The infection control committee incorporates the following on an ongoing basis: a. Surveillance, prevention and control of infections throughout the facility . 2. Surveillance includes HAIs among staff and residents. Infections are monitored when a treatment plan is ordered by a Health Care Practitioner. a. Continuously collect and screen data to identify potential outbreaks .c. A collaborative corrective action plan is formulated when surveillance and / or evaluation detects an area of concern or opportunity for improvement. d. The Infection Prevention Manager assumes direct accountability for the surveillance, aggregation and analysis of the data .4. Monitoring and evaluation of key performance aspects of infection control surveillance, prevention and management include .f. Employee health trends 10. Confirmed infections are evaluated to assure proper implementation of blood and body fluid barriers. 12. Activities involved in program development and oversight include but are not limited to .c. Monitoring and documentation of infections, including tracking and analyzing outbreaks of infection as well as implementing and documenting actions to resolve related concerns. 13. The facility performs monitoring to allow the infection control process to renew itself through new information. Monitoring is achieved through .e. Process surveillance including .f. Hand Hygiene g. Appropriate use of PPE .

Based on interview and record review, the facility failed to ensure Certified Nurse Aides (CNA's) completed an annual clinical skills evaluation and received an annual performance evaluation resulting in the potential for physical and psychosocial harm and diminished quality of care for residents living at the facility. Findings: Review of a facility policy Continuing Education Hours last revised 1/2022 reflected It is the policy of this facility to provide regular in-service education for facility staff. The policy specified 1. The Facility will perform an annual performance review and clinical skill evaluation of each Certified Nursing Assistant at least once every 12 months. 2. Individual or group education will be based on these reviews and the in-service education will: a. Be sufficient to provide for the continuing competence of the nurse aides and be no less than 12 hours per year; b Address areas of weakness as determined in the nurse aides' performance reviews and may address the special needs of residents as determined by staff; and c. Address the care of the cognitively impaired/dementia residents. Review of a log Annual Clinical Skills Checklist provided to the survey team on 2/8/2023 reflected that 24 of 38 CNA's had not had an annual skills evaluation. Review of a log for Annual Performance Review provided to the survey team on 2/8/2023 reflected that 35 of 46 CNA's had not been given an annual performance review. During an interview on 2/9/2023 at 12:07 PM, the Nursing Home Administrator (NHA) confirmed that annual skills evaluations and performance evaluations were not up to date for CNAs at the facility.

This citation refers to MI 142, MI 840, and the annual recertification survey. Based on interview and record review, the facility failed to maintain complete and accurate medical records for all residents having a COVID rapid test, and for an additional five of 24 (R21, R8, R6, R52, and R202) sampled residents, the facility failed to maintain a complete medical record, resulting in facility staff and providers to not have a clear picture of how to meet the needs and or current condition. Findings include: Record reviews throughout the survey revealed no current rapid COVID testing results in the Electronic Medical Record (EMR). During an interview on 11/23/21 at 11:15 AM, the Nursing Home Administrator (NHA) stated that staff use resident rosters to record when rapid COVID testing is done, including date, time, and results. During a comprehensive infection control interview on 11/23/21 at 3:30 PM, the Director of Nursing (DON), Clinical Care Coordinator (CCC) M, and Clinical Support G agreed that the rapid COVID testing done by the facility was documented on a resident roster and not in the individual resident records located in the EMR. R21 According to the Minimum Data Set (MDS) assessment, dated 11/8/21, R21 admitted to the facility with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This same assessment indicated that R21 required extensive assist of two staff members for moving in bed, transferring, dressing, and hygiene needs. Staff assessed R21 as moderately cognitively impaired. During the initial tour on 11/17/21 beginning at 11:00 AM, R21 was observed resting in bed with eyes closed. That same day at 12:33 PM R21 was sitting in the wheelchair in his room, mood was pleasant but R21 indicated some agitation with interview questions. Housekeepers present at time of this interaction reported R21 always required two staff members due to R21 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission Assessment, dated 11/2/21, indicated R21 had a wound on the left lower leg that was treated with a wound vac. Review of progress notes beginning 11/2/21 through 11/23/21 revealed on 11/20/21 staff changed a dressing on R21's left great toe. There were no wound measurements or description of the wound. On 11/22/21 staff documented that R21's orders were received for a left great toe ulcer, and read, cover with Vaseline gauze, place a 4x4 over the Vaseline gauze and apply tape to hold in place; change this once daily. There was no description of the ulcer nor how it occurred. During an interview on 11/23/21 at 12:01 PM, CCC's I and M revealed that R21 developed a skin tear when his foot fell off the wheelchair pedal on his way to the wound clinic on Friday (four days prior). It was reported that the wound clinic had evaluated the wound immediately following the event. When asked if the event was documented in R21's record, CCC M indicated that the wound had been measured by the facility and the measurements had not yet been documented in the EMR. CCC I reviewed progress notes and stated that the staff must have forgotten to document the event. R8 According to the Minimum Data Set (MDS) Assessment, dated 11/16/21, R8 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This same assessment indicated that R8 required set up or limited assistance with activities of daily living. Staff assessed R8 as severely cognitively impaired. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Electronic Medical Record, R8 elected hospice benefits beginning 11/10/21. Review of R8's progress notes beginning 11/5/21 through 11/20/21 revealed no notation that R8 was evaluated or admitted to Hospice. On 11/20/21 a progress note revealed that Hospice was notified of R8's clinical status and that facility staff were awaiting a call back. Review of R8's care plan revealed no indication R8 was receiving Hospice services. During an email communication on 11/30/21 at 9:32 AM the Nursing Home Administrator (NHA) clarified that hospice documentation was located in a binder at the nurse's station. At 1:09 PM that same day, the Nursing Home Administrator (NHA) clarified via email that R8 was on hospice services and that the facility had not yet completed a care plan for hospice. It was reported that the staff had since updated R8's care plan to reflect this care need. There was no documentation in the EMR indicating R8 was evaluated, admitted , or received any Hospice services between 11/10/21 and 11/20/21. Resident #52 A review of Resident #52's Admission Record, dated 11/30/21, revealed Resident #52 was a [AGE] year-old resident admitted to the facility on [DATE]. Resident #52's Admission Record also revealed Resident #52 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #52's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 12/16/20, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed Resident #52 was cognitively intact. Incident #1 A review of the facility's Facility Reported Incident (FRI) Incident Summary, dated 1/12/21, revealed on 1/5/21, Registered Nurse (RN) I and certified nursing assistant (CNA) J were transferring Resident #52 to the toilet using a sit-to-stand (a type of mechanical lift that assists a resident to stand up). Upon lowering [name of Resident #52] onto the toilet her L. (left) knee hyper extended (moved at an angle beyond the knee's normal range of motion) and a pop noise was heard. L. ankle appeared to lean to the left. Bilateral (both) feet were planted firmly on sit to stand and knees were in proper alignment upon lifting [name of Resident #52] to a standing position. The FRI Incident Summary further revealed Resident #52 had non-skid foot wear on, the proper loops on the sling to the sit-to-stand mechanical lift were used, and no injuries were noted at the time of the incident. The FRI Incident Summary also revealed Resident #52 was assisted off the toilet with a full mechanical lift (a lift that uses a sling to lift the resident up without the resident putting weight on their legs), placed in a wheelchair, and x-rays were ordered of Resident #52's left knee and ankle. In addition, The FRI Incident Summary revealed after Resident #52's x-ray results came back for a fracture to the left ankle, Resident #52 was transferred to the hospital emergency room for further evaluation and treatment. A review of Resident #52's hospital emergency room provider notes, dated 1/6/21, revealed, Resident #52 stated the previous night (1/5/21) while she was being assisted to the toilet with a sit-to-stand mechanical lift, she heard a pop and she thought her left ankle twisted and her knee hyperextended. Resident #52's hospital emergency room provider notes also revealed Resident #52 told the emergency room physician that her knee hyperextends often. A review of Resident #52's hospital emergency room provider notes, dated 1/6/21, revealed Resident #52 had an x-ray of the left foot and ankle and it was discovered Resident #52 had an impacted fracture (a fracture where the broken ends of the bone are jammed together) in the medial malleolus (the bump that protrudes on the inner side of the ankle)and a suspected compression fracture (a fracture caused by the bone structure collapsing, for example in individuals with [CONDITION(S)] or other bone disease) in the lateral aspects of the distal tibia (the area near the ankle). Resident #52's hospital emergency room provider notes further revealed a well-padded splint with posterior OCL (a hard plaster splint roll on the back of the ankle and extending from the calf to the middle/end of the bottom of the foot- used to stabilize the ankle joint) was applied to Resident #52's left leg using an ACE wrap to secure it in place. A review of Resident #52's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #52's progress notes, dated 1/5/21 to 1/12/21, revealed the following: - Interdisciplinary Documentation, dated 1/7/21, revealed, Resident arrived back to facility at 2245 (10:45 PM) on 1/6/21 via ambulance . Dx (diagnosis) closed fx (fracture) of distal end of left tibia. Left ankle has been splinted and wrapped by hospital. Skin otherwise intact aside from existing wound to left heal already being treated . - Orders- Administration Note, dated 1/7/21 at 8:32 PM, revealed, left extremity in a cast. However, other documentation (see above) revealed Resident #52 had a splint, not a cast. - Interdisciplinary Documentation, dated 1/8/21, revealed, the nurse spoke to Resident #52's mother, after obtaining Resident #52's permission to do so, regarding allegation [name of Resident #52] has made and that we had submitted report to the state. However, this progress note does not mention what the allegation was. A further review of Resident #52's medical record failed to reveal what the allegation mentioned in the Interdisciplinary note, dated 1/8/21, was. A review of the facility's investigation documentation (Supervisor Investigation) into the incident on 1/5/21, undated, revealed on 1/8/21 Resident #52 alleged that the staff must not have had my feet placed right, otherwise if they did, I wouldn't have broken my ankle. I've done this a million times and never had this happen. However, the facility's investigation documentation was not a part of Resident #52's medical record. During an interview via phone on 11/30/21 at 11:05 AM, Resident #52 stated after she returned from the hospital on 1/6/21, she had a half cast- the back was hard it was molded around her leg- it was covered in fabric, and then ACE bandaged on to her leg. She stated it went from the back of her knee all the way down to her toes. Resident #52 stated the back of the splint was like a cast material, they put padding under my foot along the cast material then ace-wrapped the whole thing, it was open in the front. Incident #2 A review of the facility's Facility Reported Incident (FRI) Incident Summary, dated 2/5/21, revealed on 1/28/21 Resident #52 attended her scheduled appointment at [name of physician (PHY) K]'s office. [Name of PHY K] removed the splint and assessed [name of Resident #52]'s foot. Upon assessment he removed a treatment and noted black necrosis (dead skin). [Name of PHY K] began debridement of this area and reported difficulty controlling [name of Resident #52]'s bleeding to which he sent [name of Resident #52] to the ER (emergency room ) via ambulance . [Name of Resident #52] on 1/31/21 called this facility and reported to [name of RN L] that they f-ed her foot up. It is unclear what is [name of Resident #52]'s concern or who they she is referring are . A review of Resident #52's progress notes, dated 1/21/21 to 2/1/21 revealed the following: - Orders- Administration Note, dated 1/29/21 at 8:46 AM, revealed, hospital. - Orders- Administration Note, dated 1/29/21 at 2:41 PM, revealed, LOA (leave of absence). - Orders- Administration Note, dated 1/29/21 at 2:23 PM, revealed, LOA. - Orders- Administration Note, dated 1/30/21 at 8:36 AM, revealed, hospital. A further review of Resident #52's medical record failed to reveal any documentation that Resident #52 had gone to PHY K's office and a wound had been debrided (the removal of damaged tissue from a wound usually done by cutting it out with a scalpel). In addition, a review of Resident #52's medical record failed to reveal the reason for the hospitalization noted in the Administration Notes for 1/29/21 and 1/30/21. In addition, Resident #52's medical record failed to reveal whether the LOA noted in Resident #52's Administration Notes on 1/29/21 was a leave of absence because of hospitalization or for other reasons. On 11/30/21 at 11:01 AM, the surveyor requested from the Nursing Home Administrator (NHA) via e-mail Resident #52's consultation notes from Resident #52's visit to the orthopedic specialist on 1/28/21 and any other documents that the facility might have regarding the visit and subsequent hospitalization (per the facility's FRI Summary noted above). During an interview via phone on 11/30/21 at 11:05 AM, Resident #52 stated she went to her orthopedic specialist appointment on 1/28/21. She stated the doctor x-rayed her foot/ankle and when the nurse started to unwrap the ACE bandage and remove the splint, she had a wound on her left heel that would not stop bleeding. The doctor had to come in and hold pressure, it would not stop bleeding, She stated because the doctor could not stop the bleeding, he sent her to the ER by ambulance. During an interview on 11/30/21 at 12:25 PM, the Director of Nursing (DON) stated she received my request for Resident #52's consultation notes and any other documents that the facility might have regarding the visit and subsequent hospitalization from the NHA. During an interview on 11/30/21 at 12:58 PM, the NHA stated they did not have any orthopedic consultation notes from Resident #52's appointment on 1/28/21 because she did not return to the facility after her appointment. During a second interview on 11/30/21 at 03:30 PM, the DON stated the facility did not receive any orthopedic consultation notes because Resident #52 did not return to the facility after her appointment and went to the emergency room (hospital) instead. During a third interview on 11/30/21 at 04:11 PM, the DON stated the information they had mentioned in their FRI Summary related to Resident #52's orthopedic appointment and subsequent hospitalization was only verbal communication with the orthopedic specialist's office and they did not document the conversation in Resident #52's medical record. Resident 6 A review of R6's Admission Record revealed, resident was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's Order Summary Report dated 11/19/21 at 3:42 PM reflected that staff Refer to Preferred Treatment Option for Advanced Directives Active 11/16/20. Review of R6's computerized medical record Resident Preferred Treatment Option dated 6/23/21 revealed, This resident/DPOA/Guardian has chosen the option of status 4 (circled below): . Status 4: The resident is to be hospitalized for any treatments that exceed the nursing home's capabilities and that are necessary to extend the life or maintain comfort. Such treatments are to include resuscitation and surgical intervention. Also noted that The resident is not capable of making decisions and has no legal representation (Status 4) During an interview on 11/23/21 at 1:13 PM, Social Services Director (SSD) F revealed the resident had a guardianship hearing a couple months back, prior to the hearing resident was a DNR, then when she needed a guardian, R6 was deemed a full code. During an interview with 11/23/21 at 1:19 PM, the DON revealed that the code status sheets (Resident Preferred Treatment Option ) for all residents were at the front desk nurses station in a book. The DON stated (Name of R6) new status is in the code status book and that she was changed from DNR to full code when she was deemed incompetent and needed to have a guardian in place. Walked with DON to nurses station to review residents code status. Review of R6's code status/ Resident Preferred Treatment Option located in the book at front nurses station reflected, as of 11/5/21 R6's Resident Preferred Treatment Option was Status 2. Status 2: The resident is not to be hospitalized , but is to be treated in the nursing home and is to receive all interventions necessary to promote comfort and to treat illness. Such interventions are limited by their availability in the nursing home, but include diagnostic tests, hydration through tube feedings, IV fluids if available, and IM or IV antibiotics. Such treatments are not to include resuscitation. During the interview on 11/23/21 at approximately 1:25 PM, DON revealed that (Name of R6's) Resident Preferred Treatment Option in the code status book it just needs to be uploaded to residents record. Noted that the new status is not in the residents uploaded medical record, but states that staff are supposed to go to the book first when something happens. DON further revealed that the person who use to scan everything into the record no longer works here and stated that it is challenge. Resident 202 A review of R202's Admission Record revealed, resident was readmitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/17/21 at 1:47 PM, Resident stated they had been out to the hospital about four times in last month. R202 stated that they had [CONDITION(S)], asthma, pneumonia, and COVID are all underlying issues as to why she has gone including she had carbon monoxide poisoning from my sleep apnea. And stated, If these people had not stormed into action, I would not be here today. Review of R202's MDS revealed that the resident was discharged four times from the nursing home from September- November 23, 2021: 09/30/2021 Discharge Return Anticipated /End of PPS Part A Stay M D S 3.0, 10/31/2021 Discharge Return Anticipated M D S 3.0 11/08/2021 Discharge Return Anticipated M D S 3.0 11/14/2021 Discharge Return Anticipated M D S 3.0. Review of R202's medical record on 11/23/21 at 4:40 PM, reflected the 11/8/21 & 11/14/21 Transfer/discharge forms/packets were not in the residents medical record. During an interview on 11/23/21 at 4:51 PM, Social Services Director (SSD) F was asked to provide all Transfer/discharge forms/packets for R202. SSD F stated that the resident had went to hospital every time for respiratory issues. SSD F revealed that they were probably in the stack to be scanned in. On 11/24/21 at 9:48 AM, SSD F provided an email with R202's last 3 Transfer/discharge packets dated 10/31/21, 11/8/21 and 11/14/21. They had not been scanned into R202's medical record.

Part 1 Based on observations, interviews, and record reviews, the facility failed to maintain infection control standards by inappropriate use and disposal of Personal Protective Equipment (PPE) and failed to implement appropriate surveillance and/or screening of staff and visitors when entering the facility, potentially affecting all 49 residents in the facility. This deficient practice resulted in improper Personal Protective Equipment (PPE) usage, inadequate visitor and staff screening for COVID 19, and the potential for the spread of infection and illness. Findings include: During the initial tour of the facility beginning on 11/17/21 at 11:09 AM, Staff member (SM) BB was observed exiting a resident room and entered the hallway wearing a mask, disposable gown, and gloves. SM BB leaned against the handrail briefly and then re-entered the room while removing the gown and gloves. Another staff member obtained a trash can from an unseen location in the room so that SM BB could dispose of the used Personal Protective Equipment (PPE). During an interview on 11/18/21 at 1:56 PM, the Director of Nursing (DON) indicated that staff should not wear dirty (used) gowns or PPE in the hallway. Review of facility policy, COVID19 Response and Testing Guidance, revised 10/20, read, Gowns Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Visitor Screening and entry During an observation beginning on 11/17/21 at 11:00 AM, staff were noted to have remote access to open the locked front door. Observations revealed staff were opening the front door by remote for people to enter the facility and staff did not always check the screening log (located in the entryway) to ensure those people entering did not need additional screening and/or testing prior to entering resident areas. Review of facility visitor screening logs revealed the following: 1. On a COVID Screening Questions document, dated 11/16/21, one visitor did not document a temperature and another visitor did not answer the screening question Any N/V/D (nausea/vomiting/diarrhea) or headache (Insert NO or identify which). This same form had two columns under Result of Screen, Cleared and Referred to I.P.M for additional analysis. There were no initials for these two visitors indicating staff had reviewed the screening results and acted on the missing information. 2. On a Visitor COVID Screening document, dated 11/17/21, a visitor answered Y (yes) to travel in last 14 days. Staff did not document any follow-up to this positive screening question. On 11/23/21 at 3:30 PM, Clinical Care Coordinator (CCC) M and Clinical Support G revealed the process for visitor entry into the building. The front door is locked, and staff have access to a remote that unlocks the door allowing visitors into the building. If the visitor is not a routine visitor, staff review the facility policy and expectations for visitors while in facility. It was revealed that the only restriction to visitation at this time was if a visitor could not pass a screening question. When the above documents were reviewed with this staff, it was revealed that CCC M had determined the screening process for visitors could be improved. Staff COVID 19 Screening During an observation on 11/18/21 beginning at 1:56 PM, staff arrived through a back door of the facility. Registered Nurse (RN) Z entered the back door at this time. RN Z reported that staff screen themselves into the building and document the results in the logs located in the back entrance breezeway. RN Z stated that the Clinical Care Coordinators reviewed the log for accuracy. Review of staff COVID Screening Questions Log revealed the following: On 11/4/21, Certified Nursing Assistant (CNA) V signed in and marked the questionnaire yes for symptoms of a cough, sore throat, shortness of breath, nausea, and vomiting. The Results of Screen column was blank, and staff provided no additional documentation. That same day CNA W signed in and marked the questionnaire yes for symptoms of a cough, sore throat. The Results of Screen column was initialed with CNA W's initials and no additional documentation was provided. On 11/5/21 CNA V signed in and marked the questionnaire yes for symptoms of a cough, sore throat, shortness of breath, nausea and headache. The Results of Screen column was blank, and staff provided no additional documentation. On 11/9/21 Therapist Y signed in and marked the questionnaire yes for symptom of a cough. The Results of Screen column was blank, and staff provided no additional documentation. On 11/10/21, Therapist Y signed in and marked the questionnaire yes for symptom of a cough. The Results of Screen column was blank, and staff provided no additional documentation. On 11/23/21 at 3:30 PM, Clinical Care Coordinator (CCC) M and Clinical Support G revealed the process for staff entry to the building. Staff screen through the back door. Staff screen, self-test, and document the results. A nurse is supposed to review the log. It was reported that staff are encouraged to not enter the building if they are having any symptoms. Staff are to call, and someone will go to the parking lot to test them for COVID. On 11/24/21 at 9:15 AM during an interview, Therapist Y, stated that the screening process is to clear yourself and that staff had not been signing that they clear themselves. During an interview that same day at 10:15 AM, CCC M stated that they had identified some concerns with the screening logs and entry process and that they were currently working on a resolution. Review of facility policy Infection Prevention and Control Plan, effective March 2020, revealed, The Infection Prevention Manager assumes direct accountability for the surveillance, aggregation and analysis of the data . e. Surveillance data may prompt auditing of specific procedures and /or a thorough infection control assessment. Part II. Based on observation interview and record review, the facility failed to follow infection control practices as evidenced by: A. Failing to test and demonstrate adequate disinfectant (Quaternary ammonium) chemicals used for the disinfection of Covid quarantine and Covid positive resident areas,. B. Failing to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria pathogen in the facility water system, in accordance with QSO 17-30 Hospitals/CAHs/NH, Revised 7-6-2018, and failed to Develop and implement a water management program that considers the ASHRAE 188 (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the CDC (Centers for Disease Control) tool kit. The failure to develop a comprehensive Water Management Plan has the potential to allow for the proliferation and transmission of the bacteria in the circulating water of the building and the spread of Legionella infections. This deficient practice has the potential to result in the spread of pathogens and infections among all 49 residents. Findings include: A. On 11/17/21 at 2:30 PM, an interview was conducted with Housekeeping supervisor D related to the procedures used to clean and disinfect resident rooms and areas potentially exposed to Covid 19 virus. Observations were made with Staff D in the presence of the chemical disinfectant dispenser, located in a housekeeping closet. This dispenser was attached to the wall and connected to the mop sink faucet with a container of Neutral Disinfectant Cleaner. Staff D explained the dispenser was automatic and the housekeepers' buckets were filled through this process. When asked if Staff D was aware of the final concentration of the disinfectant that was targeted to be dispensed. Staff D stated she did not know. When asked if the facility had any type of test kit to ensure the proper targeted concentration of disinfectant was met, Staff D again stated they did not. A review of the Vendor's reference sheet Neutral Disinfectant Cleaner, the vendor identified a concentration of 660 ppm (parts per million) as the minimum concentration for a sanitization dilution. The facility's policy and procedure titled Environmental and reusable Patient care equipment cleaning and sanitization , dated with the latest revision of March 2021 was reviewed. The policy did not address the specific chemical being used by the facility for cleaning Covid exposed environmental surfaces and failed to address the testing or assurance mechanism to ensure that the proper concentration of the disinfectant was met. B. On 11/17/21 at 12:30 PM, an interview with the Administrator and Maintenance Director/ Staff B was conducted to review the facility's WMP for the control of Legionella in the water supply system. The facility presented a notebook titled Water Management Plan as the facility's WMP. However, the contents of the book included copies of the QSO Memo, The CDC Tool Kit, a copy of ASHRAE 188, and a policy directing the facility to develop a comprehensive WMP. During the interview, it was learned the facility staff were unaware of any components of a water management plan or any controls or interventions to prevent the transmission of the disease. The following components were absent from the facility WMP : A. The designation of a water management team consisting of facility and non-facility staff who are integral in assessing and responding to Legionella risk. B. A comprehensive description of the facility water system in both a narrative and graphic representation identifying integral components of the plumbing system to facilitate a risk analysis relative to the growth and spread of Legionella. C. A quantitative inventory and assessment of plumbing fixtures and the identification of high risk fixtures/locations. D. Identification of control measures where and how control of the bacteria can be accomplished. E. Identification of critical limits related to the risk areas, control measures and which can be utilized to control the growth and spread of Legionella including identification of interventions/procedures to follow when critical limits are not met. E. An evaluation process to determine how the plan is being implemented related to the critical limits and control points.

Based on observation, interview and record review, the facility failed to prevent neglect for 1 of 4 residents (Resident #1), resulting in Resident #1 sustaining fractures during a transfer. Findings include: A review of the facility's Identification of Abuse Policy and Procedure, revised 3/19, revealed, Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A review of Resident #1's Admission Record, dated 5/13/21 , revealed Resident #1 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, Resident 1's Admission Record revealed Resident #1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/23/21, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12 which revealed Resident #1 was cognitively intact. In addition, Resident #1's MDS revealed Resident #1 needed extensive physical assistance (resident involved in activity, staff provide weight-bearing support) of 2 (or more) persons for transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and was independent after set up with ambulation around the facility. A review of Resident #1's progress notes, dated 4/22/21 to 5/10/21, revealed the following: - Interdisciplinary Documentation, dated 5/3/21, revealed, [Name of Resident #1] readmitted to facility for LTC (long-term care) from hospital r/t (related to) left hip ORIF (open reduction-internal fixation- a type of surgery to repair broken bones), via EMS (emergency medical services- a.k.a. the ambulance) stretcher. [Name of Resident #1] is currently NWB (non-weight bearing) with no ROM (range of motion) at this time to LLE (left lower extremity- leg); transfer via mechanical lift. LLE immobilizer (a type of brace) in place. Sling to LUE (left upper extremity- arm) in place . Returned to facility with L/R (left/right) hearing aide; upper/lower dentures. Very HOH (hard of hearing). Noted pain to LLE and LUE but denied pain medication at this time. - Interdisciplinary Documentation, dated 4/30/21, revealed, 4/29/21 1631: CNA (certified nursing assistant) reports that [name of Resident #1] is reporting pain. Assessment completed. [Name of Resident #1] reports pain in Left knee. No visible abnormalities; pain with palpation. Administered PRN (as needed) Tylenol at 1642 (4:42 PM). Offered ice and [name of Resident #1] declined. At 1745 (5:45 PM), [name of Resident #1] reported discomfort, but had improved. Ice offered and she declined. At 1933 (7:33 PM), [name of Resident #1] continued to complain of discomfort. On-call [physician] notified and new orders from [name of physician service] for xray. Transfer status updated to full mechanical lift. Transferred [name of Resident #1] to bed using full mechanical lift. [Name of Resident #1] was informed of plan of care and in agreement. - Interdisciplinary Documentation, dated 4/30/21, revealed, EMS here at 0725 (7:25 AM) to pick resident up for transport. She will be going to [name of hospital]. - Interdisciplinary Documentation, dated 4/30/21, revealed, Residents (Resident #1) X ray report of Left knee reveals a complete [MEDICATION(S)] fx (an angled fracture) involving the left distal femur (away from center of body- towards knee) . Midnight nurse called on call nurse to report and also called administrator and [name of Physician (PHYS) Q]. Received new orders to transfer to ER (emergency room ) for Eval (evaluation) and treatment. A review of facility's investigation report, dated 5/7/21, revealed, [Name of Resident #1] complained of pain in her left leg at bedtime. [Name of Registered Nurse (RN) B] assessed the area and contacted [name of PHYS Q] on 4/29/21 @ (at) 7:53pm. [Name of RN B] obtained new orders to obtain an x-ray. 4/30/21 @ 639am Resident Xray report of Left knee revealed a complete [MEDICATION(S)] fracture involving the left distal femur. [Name of Resident #1] was transferred to [name of hospital] ER for evaluation and treatment. Investigation Summary Root Cause Analysis: [ Name of Resident #1] has been assessed to have osteopenia (reduced bone mass) on 4/30/21 x-ray with previous surgical intervention with left knee arthroplasty. [Name of Resident #1] stood and was weight bearing to pivot for a transfer (where the resident turns on the balls of their feet or takes small steps and gradually turns) from the bed to the wheelchair using a pivot disk (a device that the resident stands on and it turns the resident without the resident having to take steps). [Name of CNA A] assisted [name of Resident #1] with a one person assist despite the facilities preference of having two staff member present. Following the transfer, she reported pain to her left knee and was assessed to have a mildly angulated distal femoral shaft fracture, just proximal (near) to the femoral arthroplasty component (joint replacement part- e.g. hip or knee) noted on x-ray in the facility. It is reasonable to conclude this injury is a result of position change at the knee level with increased weight bearing causing a periprostatic femoral fracture (a fracture caused by a high energy force- e.g. a direct blow or sudden twisting). Subsequently it was noted upon further assessment at the ER she also has a left non-displaced (broken, but not out of place) humoral head fracture after further review with [name of athletic trainer R] who spoke on behalf of [name of orthopedic surgeon S]. It is explained that there is an acute (new) fracture to her left shoulder, and he noted that she is predisposed related to osteopenia and overall poor bone health. A review of Resident #1's hospital physician notes, dated 4/30/21, revealed Resident #1 had a questionable nondisplaced fracture of the left shoulder, a fracture of the left knee, and a mildly angulated fracture of the left femur that required surgery. They also revealed Resident #1 had [CONDITION(S)] (a medical condition in which the bones become brittle and fragile) and this is patient's (Resident #1's) second fragility fracture in 9 months. A review of Resident #1's left knee x-ray, dated 4/29/21, revealed Resident #1 had a complete [MEDICATION(S)] fracture involving left distal femur with no callus (bony healing tissue around a fracture) and mild posterior displacement (bone broken and out of alignment with the broken part behind the non-broken) . Diffuse osseous demineralization (bone breakdown) is noted . Conclusion: left knee fracture as described above. During an interview on 5/12/21 at 11:00 AM, Resident #1 was observed lying in bed with her left arm in a sling. She stated she did not remember how she broke her left shoulder. Resident #1 stated when her leg went out and she broke her left leg she thinks two people helped her to transfer from her bed to the wheelchair, but she was unsure and it could have been one person. Resident #1 also stated, I warned them to watch that leg. It has a way of turning out. They did not listen. Resident #1 stated she felt her leg break. She was adamant that she did not fall when her leg broke/gave out. However, Resident #1 stated she does not remember when her shoulder and/or her leg broke. She was not sure if it was days, weeks, or months ago. During an observation on 5/12/21 at 11:10 AM, CNA C and CNA Dwere observed transferring Resident #1 from her bed to her wheelchair with a mechanical lift. A brace going from the ankle to above the knee with flexible area over knee was observed on Resident #1's left leg. During an interview on 5/12/21 at 11:55 AM, CNA A stated she was familiar with Resident #1, but did not take care of her often. CNA A stated on 4/29/21 saw Resident #1's call light was on prior to dinner, around 4:30 PM, and she went into her room to answer it. CNA A stated at the time she was helping another aide with her call lights and was not directly assigned to Resident #1 for care. She stated she provided incontinence care to Resident #1 and then transferred her from her bed to her wheelchair after she had changed her. CNA A stated she transferred Resident #1 with a gait belt, used a pivot disc, had Resident #1 put her weight on the pivot disc, and pivoted her into the wheelchair. CNA A stated she had both of her hands on Resident #1's gait belt (one on each side of her) when she transferred her. She stated Resident #1 did not complain of any pain when she transferred her to the wheelchair. CNA A stated Resident #1 started to cry and said her knee hurt about a minute after she put her in the wheelchair. She stated she told the nurse Resident #1 was crying and complaining her knee hurt. During an interview on 5/12/21 at 11:55 AM, CNA A stated, I transferred her (Resident #1) with one assist. I did not know she was a two person assist. She stated she did not look at Resident #1's care plan to see what her transfer status was before she transferred her. CNA A further stated, It's (Resident #1's care plan) kept in the closet. I did not look at it until after the nurse updated it to a hoyer lift for transfers. She did that after she (Resident #1) complained of knee pain. I found out later that she was a max (maximum) assist of 2 [ persons] with transfers before she changed the care plan. But I don't know that for sure because I did not see the care plan before she changed it. A review of Resident #1's Care Plan History report, dated 5/12/21, Resident #1 was a 2x assist (two person assist) with transfer using pivot disc from 1/4/21 to 4/29/21. Resident #1's Care Plan History report revealed Resident #1 was changed to a full mechanical lift for transfers on 4/29/21 by RN B. A review of CNA A's interview, typed and undated, revealed CNA A stated she did not review Resident #1's care plan prior to transferring her. She stated she normally reviews residents' care plans before transferring residents. CNA A was asked why she did not review Resident #1's care plan prior to transferring her. She stated, I don't know. She was asked if she had transferred Resident #1 in the past and she stated she had. She also stated she had not reviewed Resident #1's care plan when she transferred her in the past, but repeated that it was her normal practice to review the residents' care plans prior to transferring residents. During an interview on 5/12/21 at 2:00 PM, RN B stated she was familiar with Resident #1. She stated at around 4:20 PM or 4:30 PM on 4/29/21 her medication cart was in the hallway outside of Resident #1's room. She stated CNA A went into Resident #1's room to get her ready for dinner. A few minutes later, CNA A came out of Resident #1's room and said, You need to look at [name of Resident #1]. She's crying. She said her leg was hurting. RN B stated, I could hear her crying through the open door. RN B stated she went into Resident #1's room and Resident #1 was sitting in her wheelchair next to the bed. She stated she asked her what was wrong and Resident #1 stated her left knee hurt. RN B said she then asked Resident #1 to point to the exact spot where it hurt and Resident #1 did a circular motion around her left knee. RN B stated, I went to touch it and she flinched. She said it was painful to touch. RN B said she was able to pull Resident #1's pant leg up and was able to assess her knee. There was no bruising, redness, swelling. RN B then asked Resident #1 to move and wiggle her leg. She stated Resident #1 could move it very little. However, that was not unusual for her because RN B usually does not see Resident #1 moving her legs a lot (Resident #1 is mostly in bed when RN B gives her medications). RN B stated she asked CNA A if anything had happened when she transferred Resident #1 to her wheelchair and CNA A said the transfer had gone smooth and they had used the pivot disc. CNA A also told her that Resident #1 started complaining of pain when she got her in the wheelchair. RN B stated she asked Resident #1 if she wanted something for pain and she said she did. RN B stated she gave Resident #1 Tylenol (acetaminophen) 500 mg (milligrams). She stated she also offered Resident #1 some ice and she declined. RN B stated about an hour later, she checked on Resident #1 again. Resident #1 told her-her knee was still hurting. RN B offered her some ice again, but Resident #1 declined it. She asked Resident #1 if her pain was better and Resident #1 stated it was. During an interview on 5/12/21 at 2:00 PM, RN B stated Resident #1 usually likes to go back to bed after dinner. But on 4/29/21 after dinner, Resident #1 was anxious to go back to bed. Resident #1 told her she did not want to get up to go to bed because she did not want to put any weight on her left leg. At that point, around 7:30 PM, RN B told another CNA (CNA I) that they were going to use a mechanical lift to put Resident #1 back to bed. She stated she then called the on-call nurse manager and told her that Resident #1 was having knee pain. RN B stated she told the on-call nurse manager she was going to have to call the physician and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN B stated she then changed Resident #1's care plan from a two person assist to a mechanical lift for transfers after she spoke with the on-call nurse manager. RN B stated CNA I and her then put Resident #1 back into bed using the mechanical lift. RN B stated she asked Resident #1, after they had placed her back into bed how her pain was. Resident #1 stated her pain had not changed and it wasn't getting better. RN B then called the physician and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/12/21 at 2:00 PM, RN B stated CNA A was the only aide in the room at the time of the transfer. She stated CNA A did not specifically say she did the transfer alone, but she kept saying when I transferred her and used I a lot when talking about the transfer. RN B stated Resident #1 was a two person transfer with the pivot disc prior to the incident. RN B stated prior to this incident, Resident #1 did not really have any pain. She was pretty consistent. RN B further stated she has only covered Resident #1's hall for a few hours when the nurse leaves early, but she has not taken care of her for a full shift since she returned from the hospital. She stated she's not sure how often Resident #1 is getting pain medication now. A review of CNA I's interview, typed an undated, revealed she had worked the afternoon shift (2:00 PM to 10:30 PM) on 4/29/21. She stated Resident #1 did not have any complaints of pain prior to the transfer on 4/29/21. She stated after the transfer, Resident #1 complained of left leg pain. She stated at 7:30 PM, Resident #1 asked for pain medication and CNA I notified the nurse. CNA I stated after this, Resident #1 did not have any more complaints of discomfort or pain. CNA I stated Resident #1 [at some point] asked to go to bed and CNA I and the nurse used the mechanical lift to transfer her to bed. She stated when they transferred Resident #1 to bed, she had no complaints of pain or discomfort or displayed any physical signs or symptoms of pain or discomfort. During an interview on 5/12/21 at 2:30 PM, CNA D stated on 4/29/21 she and CNA L went into Resident #1's room after lunch, around 1:00 PM or 1:30 PM. She stated Resident #1 was two person pivot assist with a gait belt at that time. CNA Dstated they transferred Resident #1 from the wheelchair to the bed. She stated the transfer went smoothly. CNA D stated Resident #1 did not complain of pain. She stated she knew Resident #1 was a two person assist with transfers because she checked the care plan before she transferred her. CNA D stated she always checks the care plan before doing anything with a resident (e.g. transfers, care, toileting) because the care plan could change since the last time she looked at it. During an interview on 5/12/21 at 2:35 PM, Activities Aide (AA) G stated she had seen Resident #1 up in the hallway ambulating. She stated she was not sure if it was the day of the incident (4/29/21) or the day before. AA G stated she had said, Hi and Resident #1 had said, Hi back. She stated at the time, she (AA G) was helping to pass the lunch trays. AA G further stated Resident #1 did not complain of any pain to her at the time. In addition, AA G stated she has seen Resident #1 since the incident (on 4/29/21). She stated she will ask Resident #1 how her leg is doing and she'll say ok. AA G stated she will ask Resident #1 if her leg hurts and she'll say not really. A review of AA G's interview, typed and undated, revealed on 4/29/21 she saw Resident #1 ambulating independently in her wheelchair in the hallway around 11:45 AM. They exchanged Hello's. Resident #1 was not showing any signs of pain or discomfort. A review of CNA O's interview, typed and undated, revealed on 4/30/21 at 6:10 AM, she went into Resident #1's room. Resident #1 complained she was cold. As CNA O was pulling up her blanket to cover her, Resident #1 said ow my leg. During an interview on 5/13/21 at 8:20 AM, the Director of Health Care Services (DHCS) stated Resident #1's shoulder fracture could not be determined to be a result of CNA A transferring her by herself. She stated she had called the orthopedic surgeon and he referred her to an athletic trainer because he could not determine if Resident #1's shoulder injury was a fracture or not. The DHCS stated the athletic trainer stated Resident #1 did have a shoulder fracture, but he could not tell if it was a new fracture, a pre-existing fracture, if it had been caused by a fall, or if it had been a spontaneous fracture due to her osteopenia. The DHCS stated the athletic trainer said he doubted it could have been caused by the transfer that occurred on 4/29/21, but it was possible. During an interview on 5/13/21 at 11:20 AM, CNA K stated she normally takes care of Resident #1 and she knows her well. She stated she worked the Day shift on 4/29/21 (6:00 AM to 2:30 PM). She stated Resident #1 was doing her laps independently in her wheelchair in the hallway before she left for the day. She stated during her shift Resident #1 did not complain of any pain. CNA K stated since Resident #1 had returned from the hospital, she needs help ambulating in her wheelchair. She stated before Resident #1 went to the hospital, she could get around independently. CNA K stated Resident #1 had not really complained of pain before the incident on 4/29/21. She stated she has not really heard Resident #1 complaining of pain since she returned from the hospital. CNA K stated, She may have complained the first day after she came back, but I haven't heard her complain about it. Usually she can tell us if she has pain. They usually can keep it under control. During an interview on 5/13/21 at 11:30 AM, RN M stated she had worked on 4/29/21, but did not take care of Resident #1. She stated RN B did tell her that night that during a transfer, Resident #1 started complaining of leg pain. RN B told her that CNA A had transferred Resident #1. She asked what she should do. RN M stated she told her if the Tylenol was not working, she should get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/13/21 at 11:30 AM, RN M stated on 4/29/21 she asked CNA A if she used another person to transfer Resident #1 prior to her complaining of pain and she said no, she did it herself. During an interview on 5/13/21 at 11:30 AM, RN M stated she worked the day shift on 4/30/21. She received a report that Resident #1 had a knee fracture from RN J. RN M stated RN J had called the physician and he said to send her out. RN M stated, I got the papers together to send her out. RN M stated Resident #1 was up in her wheelchair that morning. She stated she had the aides get Resident #1 back to bed, so it would be easier for EMS to transfer her onto the stretcher. RN M stated she asked Resident #1 if she had any pain and if she needed something. Resident #1 stated she wanted something. RN M stated she got her some Tylenol and Resident #1 took it. When EMS arrived, RN M gave them report, they transferred Resident #1 to the stretcher with four people (2 holding on to her upper body and two holding on her her lower body to stabilize her), and EMS took her to the hospital. She stated Resident #1 complained of left knee pain during the transfer to the stretcher. During an interview on 5/13/21 at 12:35 PM, CNA L stated she worked Day shift (6:00 AM to 2:30 PM) on 4/29/21. She stated she and CNA D laid Resident #1 down between 1:00 PM and 1:30 PM. They did a 2-person pivot transfer from her wheelchair to her bed. CNA D stated they did not have any problems with the transfer and Resident #1 did not complain of pain. She stated she did not hear Resident #1 complaining of pain on 4/29/21 during her shift. CNA D stated Resident #1 did not normally complain of pain prior to her going to the hospital on 4/30/21. CNA D stated Resident #1 was able to independently wheel herself in her wheelchair before the incident on 4/29/21. She stated since her return from the hospital she's only seen Resident #1 in her wheelchair in her room. She has not seen Resident #1 in the hallway. During an interview on 5/13/21 at 12:50 PM, Occupational Therapist- Registered (OTR) E stated Resident #1 used a pivot disk to transfer before the incident on 4/29/21. She stated the pivot disc is a disc that's flat like a pizza pan, it has grippy pads on the top and bottom. She stated it has a circular disc part that turns and one that stays still that are connected. She stated as the resident stands on the disc, they are turned so they can transfer. OTR E indicated the pivot disc moves like a turntable where one disc is stationary and the other one (the one the resident stands on) moves. It is for people who can't take steps to pivot turn. She stated with the pivot disc, one person or two people could be used to assist the resident. She stated, It just depends on how much assistance the person (resident) needs to transfer. OTR E stated the aide will have the resident put their feet on the pivot disc. The aide would then put their foot on the pivot disc to keep it from moving while they stand the resident up. After the resident is standing, the aide should remove their foot from the pivot disc so it can rotate the resident in the direction they need to go. If the aide leaves their foot on the pivot disc while the resident is standing and trying to turn, the disc will not move because of the grippy material on the bottom of the disc. She stated if this happens, the resident could twist their legs, knees, and/or ankles while their feet remained in place. During an interview on 5/13/21 at 12:50 PM, OTR E stated prior to the incident, Resident #1 could ambulate independently in the wheelchair before she fractured her leg. However now, she needs assistance to wheel around in her wheelchair because of immobilizer on her left leg and it rests up on a foot pedal. She stated Resident #1 cannot bend her left leg with the immobilizer on to ambulate herself in the wheelchair. OTR E stated it would be difficult for Resident #1 to ambulate the wheelchair on her own with only one leg. However, they are working with Resident #1 in therapy so she can become independent again ambulating in her wheelchair. A review of Resident #1's April 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] = no pain to 10= worst possible pain imaginable) prior to the incident on 4/29/21. However, after the incident on 4/29/21, Resident #1's pain level was 5, 8,9, and 10 prior to transfer to the hospital on 4/30/21. A review of Resident #1's April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . After the incident, Resident #1 received acetaminophen 500 mg three times between 4:42 PM (on 4/29/21) and 6:58 AM (on 4/30/21) for pain rated as a 5, 8 and 10. Therefore, Resident #1's April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's May 2021 MAR, dated 5/4/21 to 5/13/21, revealed Resident #1's pain level was assessed every shift (three times a day) and ranged from 0 to 10, In addition, Resident #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] = 3 to 10). Therefore, Resident #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's current long-term care plan, dated 5/3/21 and revised 5/7/21, revealed, Resident #1 was non-ambulatory for ambulation (dated 5/7/21) and required a mechanical lift for transfers (revised 5/10/21) because of non-weight bearing LUE (left upper extremities) in sling at all times and non-weight bearing to LLE in hinged knee brace locked in extension at all times. Resident #1's current long-term care plan revealed Resident #1 had a decline in ambulatory function and transfer assistance since 4/29/21. A review of CNA A's separation notice, dated 5/6/21, revealed CNA A was notified via telephone she was separated from employment effective immediately on 5/6/21 at 3:06 PM due to her violation of the plan of care and it resulting in an injury.

Based on interview and record review, the facility failed to implement the care plan prior to a bed-to-wheelchair transfer for 1 of 4 residents (Resident #1), resulting in a major injury that required surgical intervention. Findings include: A review of Resident #1's Admission Record, dated 5/13/21 , revealed Resident #1 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, Resident 1's Admission Record revealed Resident #1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/23/21, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12 which revealed Resident #1 was cognitively intact. In addition, Resident #1's MDS revealed Resident #1 needed extensive physical assistance (resident involved in activity, staff provide weight-bearing support) of 2 (or more) persons for transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and was independent after set up with ambulation around the facility. A review of Resident #1's progress notes, dated 4/22/21 to 5/10/21, revealed the following: - Interdisciplinary Documentation, dated 5/3/21, revealed, [Name of Resident #1] readmitted to facility for LTC (long-term care) from hospital r/t (related to) left hip ORIF (open reduction-internal fixation- a type of surgery to repair broken bones), via EMS (emergency medical services- a.k.a. the ambulance) stretcher. [Name of Resident #1] is currently NWB (non-weight bearing) with no ROM (range of motion) at this time to LLE (left lower extremity- leg); transfer via mechanical lift. LLE immobilizer (a type of brace) in place. Sling to LUE (left upper extremity- arm) in place . Returned to facility with L/R (left/right) hearing aide; upper/lower dentures. Very HOH (hard of hearing). Noted pain to LLE and LUE but denied pain medication at this time. - Interdisciplinary Documentation, dated 4/30/21, revealed, 4/29/21 1631: CNA (certified nursing assistant) reports that [name of Resident #1] is reporting pain. Assessment completed. [Name of Resident #1] reports pain in Left knee. No visible abnormalities; pain with palpation. Administered PRN (as needed) Tylenol at 1642 (4:42 PM). Offered ice and [name of Resident #1] declined. At 1745 (5:45 PM), [name of Resident #1] reported discomfort, but had improved. Ice offered and she declined. At 1933 (7:33 PM), [name of Resident #1] continued to complain of discomfort. On-call [physician] notified and new orders from [name of physician service] for xray. Transfer status updated to full mechanical lift. Transferred [name of Resident #1] to bed using full mechanical lift. [Name of Resident #1] was informed of plan of care and in agreement. - Interdisciplinary Documentation, dated 4/30/21, revealed, EMS here at 0725 (7:25 AM) to pick resident up for transport. She will be going to [name of hospital]. - Interdisciplinary Documentation, dated 4/30/21, revealed, Residents (Resident #1) X ray report of Left knee reveals a complete [MEDICATION(S)] fx (an angled fracture) involving the left distal femur (away from center of body- towards knee) . Midnight nurse called on call nurse to report and also called administrator and [name of Physician (PHYS) Q]. Received new orders to transfer to ER (emergency room ) for Eval (evaluation) and treatment. A review of facility's investigation report, dated 5/7/21, revealed, [Name of Resident #1] complained of pain in her left leg at bedtime. [Name of Registered Nurse (RN) B] assessed the area and contacted [name of PHYS Q] on 4/29/21 @ (at) 7:53pm. [Name of RN B] obtained new orders to obtain an x-ray. 4/30/21 @ 639am Resident Xray report of Left knee revealed a complete [MEDICATION(S)] fracture involving the left distal femur. [Name of Resident #1] was transferred to [name of hospital] ER for evaluation and treatment. Investigation Summary Root Cause Analysis: [ Name of Resident #1] has been assessed to have osteopenia (reduced bone mass) on 4/30/21 x-ray with previous surgical intervention with left knee arthroplasty. [Name of Resident #1] stood and was weight bearing to pivot for a transfer (where the resident turns on the balls of their feet or takes small steps and gradually turns) from the bed to the wheelchair using a pivot disk (a device that the resident stands on and it turns the resident without the resident having to take steps). [Name of CNA A] assisted [name of Resident #1] with a one person assist despite the facilities preference of having two staff member present. Following the transfer, she reported pain to her left knee and was assessed to have a mildly angulated distal femoral shaft fracture, just proximal (near) to the femoral arthroplasty component (joint replacement part- e.g. hip or knee) noted on x-ray in the facility. It is reasonable to conclude this injury is a result of position change at the knee level with increased weight bearing causing a periprostatic femoral fracture (a fracture caused by a high energy force- e.g. a direct blow or sudden twisting). Subsequently it was noted upon further assessment at the ER she also has a left non-displaced (broken, but not out of place) humoral head fracture after further review with [name of athletic trainer R] who spoke on behalf of [name of orthopedic surgeon S]. It is explained that there is an acute (new) fracture to her left shoulder, and he noted that she is predisposed related to osteopenia and overall poor bone health. A review of Resident #1's hospital physician notes, dated 4/30/21, revealed Resident #1 had a questionable nondisplaced fracture of the left shoulder, a fracture of the left knee, and a mildly angulated fracture of the left femur that required surgery. They also revealed Resident #1 had [CONDITION(S)] (a medical condition in which the bones become brittle and fragile) and this is patient's (Resident #1's) second fragility fracture in 9 months. A review of Resident #1's left knee x-ray, dated 4/29/21, revealed Resident #1 had a complete [MEDICATION(S)] fracture involving left distal femur with no callus (bony healing tissue around a fracture) and mild posterior displacement (bone broken and out of alignment with the broken part behind the non-broken) . Diffuse osseous demineralization (bone breakdown) is noted . Conclusion: left knee fracture as described above. During an interview on 5/12/21 at 11:00 AM, Resident #1 was observed lying in bed with her left arm in a sling. She stated she did not remember how she broke her left shoulder. Resident #1 stated when her leg went out and she broke her left leg she thinks two people helped her to transfer from her bed to the wheelchair, but she was unsure and it could have been one person. Resident #1 also stated, I warned them to watch that leg. It has a way of turning out. They did not listen. Resident #1 stated she felt her leg break. She was adamant that she did not fall when her leg broke/gave out. However, Resident #1 stated she does not remember when her shoulder and/or her leg broke. She was not sure if it was days, weeks, or months ago. During an observation on 5/12/21 at 11:10 AM, CNA C and CNA Dwere observed transferring Resident #1 from her bed to her wheelchair with a mechanical lift. A brace going from the ankle to above the knee with flexible area over knee was observed on Resident #1's left leg. During an interview on 5/12/21 at 11:55 AM, CNA A stated she was familiar with Resident #1, but did not take care of her often. CNA A stated on 4/29/21 saw Resident #1's call light was on prior to dinner, around 4:30 PM, and she went into her room to answer it. CNA A stated at the time she was helping another aide with her call lights and was not directly assigned to Resident #1 for care. She stated she provided incontinence care to Resident #1 and then transferred her from her bed to her wheelchair after she had changed her. CNA A stated she transferred Resident #1 with a gait belt, used a pivot disc, had Resident #1 put her weight on the pivot disc, and pivoted her into the wheelchair. CNA A stated she had both of her hands on Resident #1's gait belt (one on each side of her) when she transferred her. She stated Resident #1 did not complain of any pain when she transferred her to the wheelchair. CNA A stated Resident #1 started to cry and said her knee hurt about a minute after she put her in the wheelchair. She stated she told the nurse Resident #1 was crying and complaining her knee hurt. During an interview on 5/12/21 at 11:55 AM, CNA A stated, I transferred her (Resident #1) with one assist. I did not know she was a two person assist. She stated she did not look at Resident #1's care plan to see what her transfer status was before she transferred her. CNA A further stated, It's (Resident #1's care plan) kept in the closet. I did not look at it until after the nurse updated it to a hoyer lift for transfers. She did that after she (Resident #1) complained of knee pain. I found out later that she was a max (maximum) assist of 2 [ persons] with transfers before she changed the care plan. But I don't know that for sure because I did not see the care plan before she changed it. A review of Resident #1's Care Plan History report, dated 5/12/21, Resident #1 was a 2x assist (two person assist) with transfer using pivot disc from 1/4/21 to 4/29/21. Resident #1's Care Plan History report revealed Resident #1 was changed to a full mechanical lift for transfers on 4/29/21 by RN B. A review of CNA A's interview, typed and undated, revealed CNA A stated she did not review Resident #1's care plan prior to transferring her. She stated she normally reviews residents' care plans before transferring residents. CNA A was asked why she did not review Resident #1's care plan prior to transferring her. She stated, I don't know. She was asked if she had transferred Resident #1 in the past and she stated she had. She also stated she had not reviewed Resident #1's care plan when she transferred her in the past, but repeated that it was her normal practice to review the residents' care plans prior to transferring residents. During an interview on 5/12/21 at 2:00 PM, RN B stated she was familiar with Resident #1. She stated at around 4:20 PM or 4:30 PM on 4/29/21 her medication cart was in the hallway outside of Resident #1's room. She stated CNA A went into Resident #1's room to get her ready for dinner. A few minutes later, CNA A came out of Resident #1's room and said, You need to look at [name of Resident #1]. She's crying. She said her leg was hurting. RN B stated, I could hear her crying through the open door. RN B stated she went into Resident #1's room and Resident #1 was sitting in her wheelchair next to the bed. She stated she asked her what was wrong and Resident #1 stated her left knee hurt. RN B said she then asked Resident #1 to point to the exact spot where it hurt and Resident #1 did a circular motion around her left knee. RN B stated, I went to touch it and she flinched. She said it was painful to touch. RN B said she was able to pull Resident #1's pant leg up and was able to assess her knee. There was no bruising, redness, swelling. RN B then asked Resident #1 to move and wiggle her leg. She stated Resident #1 could move it very little. However, that was not unusual for her because RN B usually does not see Resident #1 moving her legs a lot (Resident #1 is mostly in bed when RN B gives her medications). RN B stated she asked CNA A if anything had happened when she transferred Resident #1 to her wheelchair and CNA A said the transfer had gone smooth and they had used the pivot disc. CNA A also told her that Resident #1 started complaining of pain when she got her in the wheelchair. RN B stated she asked Resident #1 if she wanted something for pain and she said she did. RN B stated she gave Resident #1 Tylenol (acetaminophen) 500 mg (milligrams). She stated she also offered Resident #1 some ice and she declined. RN B stated about an hour later, she checked on Resident #1 again. Resident #1 told her-her knee was still hurting. RN B offered her some ice again, but Resident #1 declined it. She asked Resident #1 if her pain was better and Resident #1 stated it was. During an interview on 5/12/21 at 2:00 PM, RN B stated Resident #1 usually likes to go back to bed after dinner. But on 4/29/21 after dinner, Resident #1 was anxious to go back to bed. Resident #1 told her she did not want to get up to go to bed because she did not want to put any weight on her left leg. At that point, around 7:30 PM, RN B told another CNA (CNA I) that they were going to use a mechanical lift to put Resident #1 back to bed. She stated she then called the on-call nurse manager and told her that Resident #1 was having knee pain. RN B stated she told the on-call nurse manager she was going to have to call the physician and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN B stated she then changed Resident #1's care plan from a two person assist to a mechanical lift for transfers after she spoke with the on-call nurse manager. RN B stated CNA I and her then put Resident #1 back into bed using the mechanical lift. RN B stated she asked Resident #1, after they had placed her back into bed how her pain was. Resident #1 stated her pain had not changed and it wasn't getting better. RN B then called the physician and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/12/21 at 2:00 PM, RN B stated CNA A was the only aide in the room at the time of the transfer. She stated CNA A did not specifically say she did the transfer alone, but she kept saying when I transferred her and used I a lot when talking about the transfer. RN B stated Resident #1 was a two person transfer with the pivot disc prior to the incident. RN B stated prior to this incident, Resident #1 did not really have any pain. She was pretty consistent. RN B further stated she has only covered Resident #1's hall for a few hours when the nurse leaves early, but she has not taken care of her for a full shift since she returned from the hospital. She stated she's not sure how often Resident #1 is getting pain medication now. A review of CNA I's interview, typed an undated, revealed she had worked the afternoon shift (2:00 PM to 10:30 PM) on 4/29/21. She stated Resident #1 did not have any complaints of pain prior to the transfer on 4/29/21. She stated after the transfer, Resident #1 complained of left leg pain. She stated at 7:30 PM, Resident #1 asked for pain medication and CNA I notified the nurse. CNA I stated after this, Resident #1 did not have any more complaints of discomfort or pain. CNA I stated Resident #1 [at some point] asked to go to bed and CNA I and the nurse used the mechanical lift to transfer her to bed. She stated when they transferred Resident #1 to bed, she had no complaints of pain or discomfort or displayed any physical signs or symptoms of pain or discomfort. During an interview on 5/12/21 at 2:30 PM, CNA D stated on 4/29/21 she and CNA L went into Resident #1's room after lunch, around 1:00 PM or 1:30 PM. She stated Resident #1 was two person pivot assist with a gait belt at that time. CNA Dstated they transferred Resident #1 from the wheelchair to the bed. She stated the transfer went smoothly. CNA D stated Resident #1 did not complain of pain. She stated she knew Resident #1 was a two person assist with transfers because she checked the care plan before she transferred her. CNA D stated she always checks the care plan before doing anything with a resident (e.g. transfers, care, toileting) because the care plan could change since the last time she looked at it. During an interview on 5/12/21 at 2:35 PM, Activities Aide (AA) G stated she had seen Resident #1 up in the hallway ambulating. She stated she was not sure if it was the day of the incident (4/29/21) or the day before. AA G stated she had said, Hi and Resident #1 had said, Hi back. She stated at the time, she (AA G) was helping to pass the lunch trays. AA G further stated Resident #1 did not complain of any pain to her at the time. A review of AA G's interview, typed and undated, revealed on 4/29/21 she saw Resident #1 ambulating independently in her wheelchair in the hallway around 11:45 AM. They exchanged Hello's. Resident #1 was not showing any signs of pain or discomfort. A review of CNA O's interview, typed and undated, revealed on 4/30/21 at 6:10 AM, she went into Resident #1's room. Resident #1 complained she was cold. As CNA O was pulling up her blanket to cover her, Resident #1 said ow my leg. During an interview on 5/13/21 at 11:20 AM, CNA K stated she normally takes care of Resident #1 and she knows her well. She stated she worked the Day shift on 4/29/21 (6:00 AM to 2:30 PM). She stated Resident #1 was doing her laps independently in her wheelchair in the hallway before she left for the day. She stated during her shift Resident #1 did not complain of any pain. CNA K stated since Resident #1 had returned from the hospital, she needs help ambulating in her wheelchair. She stated before Resident #1 went to the hospital, she could get around independently. During an interview on 5/13/21 at 11:30 AM, RN M stated on 4/29/21 she asked CNA A if she used another person to transfer Resident #1 prior to her complaining of pain and she said no, she did it herself. During an interview on 5/13/21 at 12:35 PM, CNA L stated she worked Day shift (6:00 AM to 2:30 PM) on 4/29/21. She stated she and CNA D laid Resident #1 down between 1:00 PM and 1:30 PM. They did a 2-person pivot transfer from her wheelchair to her bed. CNA D stated they did not have any problems with the transfer and Resident #1 did not complain of pain. She stated she did not hear Resident #1 complaining of pain on 4/29/21 during her shift. CNA D stated Resident #1 did not normally complain of pain prior to her going to the hospital on 4/30/21. CNA D stated Resident #1 was able to independently wheel herself in her wheelchair before the incident on 4/29/21. She stated since her return from the hospital she's only seen Resident #1 in her wheelchair in her room. She has not seen Resident #1 in the hallway. During an interview on 5/13/21 at 12:50 PM, OTR E stated prior to the incident, Resident #1 could ambulate independently in the wheelchair before she fractured her leg. However now, she needs assistance to wheel around in her wheelchair because of immobilizer on her left leg and it rests up on a foot pedal. She stated Resident #1 cannot bend her left leg with the immobilizer on to ambulate herself in the wheelchair. OTR E stated it would be difficult for Resident #1 to ambulate the wheelchair on her own with only one leg. However, they are working with Resident #1 in therapy so she can become independent again ambulating in her wheelchair. A review of Resident #1's April 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] = no pain to 10= worst possible pain imaginable) prior to the incident on 4/29/21. However, after the incident on 4/29/21, Resident #1's pain level was 5, 8,9, and 10 prior to transfer to the hospital on 4/30/21. A review of Resident #1's April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . After the incident, Resident #1 received acetaminophen 500 mg three times between 4:42 PM (on 4/29/21) and 6:58 AM (on 4/30/21) for pain rated as a 5, 8 and 10. Therefore, Resident #1's April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's May 2021 MAR, dated 5/4/21 to 5/13/21, revealed Resident #1's pain level was assessed every shift (three times a day) and ranged from 0 to 10, In addition, Resident #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] = 3 to 10). Therefore, Resident #1's May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's current long-term care plan, dated 5/3/21 and revised 5/7/21, revealed, Resident #1 was non-ambulatory for ambulation (dated 5/7/21) and required a mechanical lift for transfers (revised 5/10/21) because of non-weight bearing LUE (left upper extremities) in sling at all times and non-weight bearing to LLE in hinged knee brace locked in extension at all times. Resident #1's current long-term care plan revealed Resident #1 had a decline in ambulatory function and transfer assistance since 4/29/21. A review of CNA A's separation notice, dated 5/6/21, revealed CNA A was notified via telephone she was separated from employment effective immediately on 5/6/21 at 3:06 PM due to her violation of the plan of care and it resulting in an injury.

Based on interview and record review, the facility failed to provide adequate supervision and assistance for 1 of 4 residents (Resident #1), resulting in major injuries (fractures) requiring surgical intervention. Findings include: A review of Resident #1's Admission Record, dated 5/13/21 , revealed Resident #1 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, Resident 1's Admission Record revealed Resident #1 had multiple diagnoses that included a displaced fracture of the left femur (leg bone), a nondisplaced fracture of the upper left humerus (arm bone), [CONDITION(S)] in both eyes, [CONDITION(S)] in both eyes, [CONDITION(S)] (an eye disease that causes blindness) in both eyes, bone density and structural disorders, arthritis, and muscle wasting and atrophy. A review of Resident #1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/23/21, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 12 which revealed Resident #1 was cognitively intact. In addition, Resident #1's MDS revealed Resident #1 needed extensive physical assistance (resident involved in activity, staff provide weight-bearing support) of 2 (or more) persons for transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and was independent after set up with ambulation around the facility. A review of Resident #1's progress notes, dated 4/22/21 to 5/10/21, revealed the following: - Interdisciplinary Documentation, dated 5/3/21, revealed, [Name of Resident #1] readmitted to facility for LTC (long-term care) from hospital r/t (related to) left hip ORIF (open reduction-internal fixation- a type of surgery to repair broken bones), via EMS (emergency medical services- a.k.a. the ambulance) stretcher. [Name of Resident #1] is currently NWB (non-weight bearing) with no ROM (range of motion) at this time to LLE (left lower extremity- leg); transfer via mechanical lift. LLE immobilizer (a type of brace) in place. Sling to LUE (left upper extremity- arm) in place . Returned to facility with L/R (left/right) hearing aide; upper/lower dentures. Very HOH (hard of hearing). Noted pain to LLE and LUE but denied pain medication at this time. - Interdisciplinary Documentation, dated 4/30/21, revealed, 4/29/21 1631: CNA (certified nursing assistant) reports that [name of Resident #1] is reporting pain. Assessment completed. [Name of Resident #1] reports pain in Left knee. No visible abnormalities; pain with palpation. Administered PRN (as needed) Tylenol at 1642 (4:42 PM). Offered ice and [name of Resident #1] declined. At 1745 (5:45 PM), [name of Resident #1] reported discomfort, but had improved. Ice offered and she declined. At 1933 (7:33 PM), [name of Resident #1] continued to complain of discomfort. On-call [physician] notified and new orders from [name of physician service] for xray. Transfer status updated to full mechanical lift. Transferred [name of Resident #1] to bed using full mechanical lift. [Name of Resident #1] was informed of plan of care and in agreement. - Interdisciplinary Documentation, dated 4/30/21, revealed, EMS here at 0725 (7:25 AM) to pick resident up for transport. She will be going to [name of hospital]. - Interdisciplinary Documentation, dated 4/30/21, revealed, Residents (Resident #1) X ray report of Left knee reveals a complete [MEDICATION(S)] fx (an angled fracture) involving the left distal femur (away from center of body- towards knee) . Midnight nurse called on call nurse to report and also called administrator and [name of Physician (PHYS) Q]. Received new orders to transfer to ER (emergency room ) for Eval (evaluation) and treatment. A review of facility's investigation report, dated 5/7/21, revealed, [Name of Resident #1] complained of pain in her left leg at bedtime. [Name of Registered Nurse (RN) B] assessed the area and contacted [name of PHYS Q] on 4/29/21 @ (at) 7:53pm. [Name of RN B] obtained new orders to obtain an x-ray. 4/30/21 @ 639am Resident Xray report of Left knee revealed a complete [MEDICATION(S)] fracture involving the left distal femur. [Name of Resident #1] was transferred to [name of hospital] ER for evaluation and treatment. Investigation Summary Root Cause Analysis: [ Name of Resident #1] has been assessed to have osteopenia (reduced bone mass) on 4/30/21 x-ray with previous surgical intervention with left knee arthroplasty. [Name of Resident #1] stood and was weight bearing to pivot for a transfer (where the resident turns on the balls of their feet or takes small steps and gradually turns) from the bed to the wheelchair using a pivot disk (a device that the resident stands on and it turns the resident without the resident having to take steps). [Name of CNA A] assisted [name of Resident #1] with a one person assist despite the facilities preference of having two staff member present. Following the transfer, she reported pain to her left knee and was assessed to have a mildly angulated distal femoral shaft fracture, just proximal (near) to the femoral arthroplasty component (joint replacement part- e.g. hip or knee) noted on x-ray in the facility. It is reasonable to conclude this injury is a result of position change at the knee level with increased weight bearing causing a periprostatic femoral fracture (a fracture caused by a high energy force- e.g. a direct blow or sudden twisting). Subsequently it was noted upon further assessment at the ER she also has a left non-displaced (broken, but not out of place) humoral head fracture after further review with [name of athletic trainer R] who spoke on behalf of [name of orthopedic surgeon S]. It is explained that there is an acute (new) fracture to her left shoulder, and he noted that she is predisposed related to osteopenia and overall poor bone health. A review of Resident #1's hospital physician notes, dated 4/30/21, revealed Resident #1 had a questionable nondisplaced fracture of the left shoulder, a fracture of the left knee, and a mildly angulated fracture of the left femur that required surgery. They also revealed Resident #1 had [CONDITION(S)] (a medical condition in which the bones become brittle and fragile) and this is patient's (Resident #1's) second fragility fracture in 9 months. A review of Resident #1's left knee x-ray, dated 4/29/21, revealed Resident #1 had a complete [MEDICATION(S)] fracture involving left distal femur with no callus (bony healing tissue around a fracture) and mild posterior displacement (bone broken and out of alignment with the broken part behind the non-broken) . Diffuse osseous demineralization (bone breakdown) is noted . Conclusion: left knee fracture as described above. During an interview on 5/12/21 at 11:00 AM, Resident #1 was observed lying in bed with her left arm in a sling. She stated she did not remember how she broke her left shoulder. Resident #1 stated when her leg went out and she broke her left leg she thinks two people helped her to transfer from her bed to the wheelchair, but she was unsure and it could have been one person. Resident #1 also stated, I warned them to watch that leg. It has a way of turning out. They did not listen. Resident #1 stated she felt her leg break. She was adamant that she did not fall when her leg broke/gave out. However, Resident #1 stated she does not remember when her shoulder and/or her leg broke. She was not sure if it was days, weeks, or months ago. During an observation on 5/12/21 at 11:10 AM, CNA C and CNA Dwere observed transferring Resident #1 from her bed to her wheelchair with a mechanical lift. A brace going from the ankle to above the knee with flexible area over knee was observed on Resident #1's left leg. During an interview on 5/12/21 at 11:55 AM, CNA A stated she was familiar with Resident #1, but did not take care of her often. CNA A stated on 4/29/21 saw Resident #1's call light was on prior to dinner, around 4:30 PM, and she went into her room to answer it. CNA A stated at the time she was helping another aide with her call lights and was not directly assigned to Resident #1 for care. She stated she provided incontinence care to Resident #1 and then transferred her from her bed to her wheelchair after she had changed her. CNA A stated she transferred Resident #1 with a gait belt, used a pivot disc, had Resident #1 put her weight on the pivot disc, and pivoted her into the wheelchair. CNA A stated she had both of her hands on Resident #1's gait belt (one on each side of her) when she transferred her. She stated Resident #1 did not complain of any pain when she transferred her to the wheelchair. CNA A stated Resident #1 started to cry and said her knee hurt about a minute after she put her in the wheelchair. She stated she told the nurse Resident #1 was crying and complaining her knee hurt. During an interview on 5/12/21 at 11:55 AM, CNA A stated, I transferred her (Resident #1) with one assist. I did not know she was a two person assist. She stated she did not look at Resident #1's care plan to see what her transfer status was before she transferred her. CNA A further stated, It's (Resident #1's care plan) kept in the closet. I did not look at it until after the nurse updated it to a hoyer lift for transfers. She did that after she (Resident #1) complained of knee pain. I found out later that she was a max (maximum) assist of 2 [ persons] with transfers before she changed the care plan. But I don't know that for sure because I did not see the care plan before she changed it. A review of Resident #1's Care Plan History report, dated 5/12/21, Resident #1 was a 2x assist (two person assist) with transfer using pivot disc from 1/4/21 to 4/29/21. Resident #1's Care Plan History report revealed Resident #1 was changed to a full mechanical lift for transfers on 4/29/21 by RN B. A review of CNA A's interview, typed and undated, revealed CNA A stated she did not review Resident #1's care plan prior to transferring her. She stated she normally reviews residents' care plans before transferring residents. CNA A was asked why she did not review Resident #1's care plan prior to transferring her. She stated, I don't know. She was asked if she had transferred Resident #1 in the past and she stated she had. She also stated she had not reviewed Resident #1's care plan when she transferred her in the past, but repeated that it was her normal practice to review the residents' care plans prior to transferring residents. During an interview on 5/12/21 at 2:00 PM, RN B stated she was familiar with Resident #1. She stated at around 4:20 PM or 4:30 PM on 4/29/21 her medication cart was in the hallway outside of Resident #1's room. She stated CNA A went into Resident #1's room to get her ready for dinner. A few minutes later, CNA A came out of Resident #1's room and said, You need to look at [name of Resident #1]. She's crying. She said her leg was hurting. RN B stated, I could hear her crying through the open door. RN B stated she went into Resident #1's room and Resident #1 was sitting in her wheelchair next to the bed. She stated she asked her what was wrong and Resident #1 stated her left knee hurt. RN B said she then asked Resident #1 to point to the exact spot where it hurt and Resident #1 did a circular motion around her left knee. RN B stated, I went to touch it and she flinched. She said it was painful to touch. RN B said she was able to pull Resident #1's pant leg up and was able to assess her knee. There was no bruising, redness, swelling. RN B then asked Resident #1 to move and wiggle her leg. She stated Resident #1 could move it very little. However, that was not unusual for her because RN B usually does not see Resident #1 moving her legs a lot (Resident #1 is mostly in bed when RN B gives her medications). RN B stated she asked CNA A if anything had happened when she transferred Resident #1 to her wheelchair and CNA A said the transfer had gone smooth and they had used the pivot disc. CNA A also told her that Resident #1 started complaining of pain when she got her in the wheelchair. RN B stated she asked Resident #1 if she wanted something for pain and she said she did. RN B stated she gave Resident #1 Tylenol (acetaminophen) 500 mg (milligrams). She stated she also offered Resident #1 some ice and she declined. RN B stated about an hour later, she checked on Resident #1 again. Resident #1 told her-her knee was still hurting. RN B offered her some ice again, but Resident #1 declined it. She asked Resident #1 if her pain was better and Resident #1 stated it was. During an interview on 5/12/21 at 2:00 PM, RN B stated Resident #1 usually likes to go back to bed after dinner. But on 4/29/21 after dinner, Resident #1 was anxious to go back to bed. Resident #1 told her she did not want to get up to go to bed because she did not want to put any weight on her left leg. At that point, around 7:30 PM, RN B told another CNA (CNA I) that they were going to use a mechanical lift to put Resident #1 back to bed. She stated she then called the on-call nurse manager and told her that Resident #1 was having knee pain. RN B stated she told the on-call nurse manager she was going to have to call the physician and get an order for an x-ray and the on-call nurse manager agreed. RN B stated she then changed Resident #1's care plan from a two person assist to a mechanical lift for transfers after she spoke with the on-call nurse manager. RN B stated CNA I and her then put Resident #1 back into bed using the mechanical lift. RN B stated she asked Resident #1, after they had placed her back into bed how her pain was. Resident #1 stated her pain had not changed and it wasn't getting better. RN B then called the physician and got an order for an x-ray. She stated the x-ray technician showed up after 10:00 PM- during shift report- and she saw him go into Resident #1's room while she was giving report to the night shift nurse. During an interview on 5/12/21 at 2:00 PM, RN B stated CNA A was the only aide in the room at the time of the transfer. She stated CNA A did not specifically say she did the transfer alone, but she kept saying when I transferred her and used I a lot when talking about the transfer. RN B stated Resident #1 was a two person transfer with the pivot disc prior to the incident. RN B stated prior to this incident, Resident #1 did not really have any pain. She was pretty consistent. RN B further stated she has only covered Resident #1's hall for a few hours when the nurse leaves early, but she has not taken care of her for a full shift since she returned from the hospital. She stated she's not sure how often Resident #1 is getting pain medication now. A review of CNA I's interview, typed an undated, revealed she had worked the afternoon shift (2:00 PM to 10:30 PM) on 4/29/21. She stated Resident #1 did not have any complaints of pain prior to the transfer on 4/29/21. She stated after the transfer, Resident #1 complained of left leg pain. She stated at 7:30 PM, Resident #1 asked for pain medication and CNA I notified the nurse. CNA I stated after this, Resident #1 did not have any more complaints of discomfort or pain. CNA I stated Resident #1 [at some point] asked to go to bed and CNA I and the nurse used the mechanical lift to transfer her to bed. She stated when they transferred Resident #1 to bed, she had no complaints of pain or discomfort or displayed any physical signs or symptoms of pain or discomfort. During an interview on 5/12/21 at 2:30 PM, CNA D stated on 4/29/21 she and CNA L went into Resident #1's room after lunch, around 1:00 PM or 1:30 PM. She stated Resident #1 was two person pivot assist with a gait belt at that time. CNA Dstated they transferred Resident #1 from the wheelchair to the bed. She stated the transfer went smoothly. CNA D stated Resident #1 did not complain of pain. She stated she knew Resident #1 was a two person assist with transfers because she checked the care plan before she transferred her. CNA D stated she always checks the care plan before doing anything with a resident (e.g. transfers, care, toileting) because the care plan could change since the last time she looked at it. During an interview on 5/12/21 at 2:35 PM, Activities Aide (AA) G stated she had seen Resident #1 up in the hallway ambulating. She stated she was not sure if it was the day of the incident (4/29/21) or the day before. AA G stated she had said, Hi and Resident #1 had said, Hi back. She stated at the time, she (AA G) was helping to pass the lunch trays. AA G further stated Resident #1 did not complain of any pain to her at the time. In addition, AA G stated she has seen Resident #1 since the incident (on 4/29/21). She stated she will ask Resident #1 how her leg is doing and she'll say ok. AA G stated she will ask Resident #1 if her leg hurts and she'll say not really. A review of AA G's interview, typed and undated, revealed on 4/29/21 she saw Resident #1 ambulating independently in her wheelchair in the hallway around 11:45 AM. They exchanged Hello's. Resident #1 was not showing any signs of pain or discomfort. A review of CNA O's interview, typed and undated, revealed on 4/30/21 at 6:10 AM, she went into Resident #1's room. Resident #1 complained she was cold. As CNA O was pulling up her blanket to cover her, Resident #1 said ow my leg. During an interview on 5/13/21 at 8:20 AM, the Director of Health Care Services (DHCS) stated Resident #1's shoulder fracture could not be determined to be a result of CNA A transferring her by herself. She stated she had called the orthopedic surgeon and he referred her to an athletic trainer because he could not determine if Resident #1's shoulder injury was a fracture or not. The DHCS stated the athletic trainer stated Resident #1 did have a shoulder fracture, but he could not tell if it was a new fracture, a pre-existing fracture, if it had been caused by a fall, or if it had been a spontaneous fracture due to her osteopenia. The DHCS stated the athletic trainer said he doubted it could have been caused by the transfer that occurred on 4/29/21, but it was possible. During an interview on 5/13/21 at 11:20 AM, CNA K stated she normally takes care of Resident #1 and she knows her well. She stated she worked the Day shift on 4/29/21 (6:00 AM to 2:30 PM). She stated Resident #1 was doing her laps independently in her wheelchair in the hallway before she left for the day. She stated during her shift Resident #1 did not complain of any pain. CNA K stated since Resident #1 had returned from the hospital, she needs help ambulating in her wheelchair. She stated before Resident #1 went to the hospital, she could get around independently. CNA K stated Resident #1 had not really complained of pain before the incident on 4/29/21. She stated she has not really heard Resident #1 complaining of pain since she returned from the hospital. CNA K stated, She may have complained the first day after she came back, but I haven't heard her complain about it. Usually she can tell us if she has pain. They usually can keep it under control. During an interview on 5/13/21 at 11:30 AM, RN M stated she had worked on 4/29/21, but did not take care of Resident #1. She stated RN B did tell her that night that during a transfer, Resident #1 started complaining of leg pain. RN B told her that CNA A had transferred Resident #1. She asked what she should do. RN M stated she told her if the Tylenol was not working, she should get an order for an x-ray. RN Mstated because she did not see Resident #1 before she heard she was complaining of left leg or knee pain, she does not know if Resident #1 had pain before CNA A transferred her. During an interview on 5/13/21 at 11:30 AM, RN M stated on 4/29/21 she asked CNA A if she used another person to transfer Resident #1 prior to her complaining of pain and she said no, she did it herself. During an interview on 5/13/21 at 11:30 AM, RN M stated she worked the day shift on 4/30/21. She received a report that Resident #1 had a knee fracture from RN J. RN M stated RN J had called the physician and he said to send her out. RN M stated, I got the papers together to send her out. RN M stated Resident #1 was up in her wheelchair that morning. She stated she had the aides get Resident #1 back to bed, so it would be easier for EMS to transfer her onto the stretcher. RN M stated she asked Resident #1 if she had any pain and if she needed something. Resident #1 stated she wanted something. RN M stated she got her some Tylenol and Resident #1 took it. When EMS arrived, RN M gave them report, they transferred Resident #1 to the stretcher with four people (2 holding on to her upper body and two holding on her her lower body to stabilize her), and EMS took her to the hospital. She stated Resident #1 complained of left knee pain during the transfer to the stretcher. During an interview on 5/13/21 at 12:35 PM, CNA L stated she worked Day shift (6:00 AM to 2:30 PM) on 4/29/21. She stated she and CNA D laid Resident #1 down between 1:00 PM and 1:30 PM. They did a 2-person pivot transfer from her wheelchair to her bed. CNA D stated they did not have any problems with the transfer and Resident #1 did not complain of pain. She stated she did not hear Resident #1 complaining of pain on 4/29/21 during her shift. CNA D stated Resident #1 did not normally complain of pain prior to her going to the hospital on 4/30/21. CNA D stated Resident #1 was able to independently wheel herself in her wheelchair before the incident on 4/29/21. She stated since her return from the hospital she's only seen Resident #1 in her wheelchair in her room. She has not seen Resident #1 in the hallway. During an interview on 5/13/21 at 12:50 PM, Occupational Therapist- Registered (OTR) E stated Resident #1 used a pivot disk to transfer before the incident on 4/29/21. She stated the pivot disc is a disc that's flat like a pizza pan, it has grippy pads on the top and bottom. She stated it has a circular disc part that turns and one that stays still that are connected. She stated as the resident stands on the disc, they are turned so they can transfer. OTR E indicated the pivot disc moves like a turntable where one disc is stationary and the other one (the one the resident stands on) moves. It is for people who can't take steps to pivot turn. She stated with the pivot disc, one person or two people could be used to assist the resident. She stated, It just depends on how much assistance the person (resident) needs to transfer. OTR E stated the aide will have the resident put their feet on the pivot disc. The aide would then put their foot on the pivot disc to keep it from moving while they stand the resident up. After the resident is standing, the aide should remove their foot from the pivot disc so it can rotate the resident in the direction they need to go. If the aide leaves their foot on the pivot disc while the resident is standing and trying to turn, the disc will not move because of the grippy material on the bottom of the disc. She stated if this happens, the resident could twist their legs, knees, and/or ankles while their feet remained in place. During an interview on 5/13/21 at 12:50 PM, OTR E stated prior to the incident, Resident #1 could ambulate independently in the wheelchair before she fractured her leg. However now, she needs assistance to wheel around in her wheelchair because of immobilizer on her left leg and it rests up on a foot pedal. She stated Resident #1 cannot bend her left leg with the immobilizer on to ambulate herself in the wheelchair. OTR E stated it would be difficult for Resident #1 to ambulate the wheelchair on her own with only one leg. However, they are working with Resident #1 in therapy so she can become independent again ambulating in her wheelchair. A review of Resident #1's April 2021 Medication Administration Record (MAR) revealed Resident #1's pain level was assessed every shift (three times a day) and as needed. Resident #1's April 2021 MAR also revealed Resident #1's pain level was consistently 0 with the isolated 2, 3, 5, or 8 (0= no pain to 10= worst possible pain imaginable) prior to the incident on 4/29/21. However, after the incident on 4/29/21, Resident #1's pain level was 5, 8,9, and 10 prior to transfer to the hospital on 4/30/21. A review of Resident #1's April 2021 MAR revealed Resident #1 was only on as needed (prn) acetaminophen for pain prior to the incident on 4/29/21. Resident #1's April 2021 MAR also revealed Resident #1 received acetaminophen 500 mg every 6 hours as needed three times between 4/1/21 and 4/29/21 (on 4/6/21, 4/7/21, and 4/21/21). After the incident, Resident #1 received acetaminophen 500 mg three times between 4:42 PM (on 4/29/21) and 6:58 AM (on 4/30/21) for pain rated as a 5, 8 and 10. Therefore, Resident #1's April 2021 MAR entries demonstrated Resident #1 had significantly increased pain after the incident on 4/29/21. A review of Resident #1's May 2021 MAR revealed Resident #1 was on as needed [MEDICATION(S)] (a narcotic) ([MEDICATION(S)]-acetaminophen) 5-325 mg (5 mg [MEDICATION(S)] and 325 mg acetaminophen) every 12 hours from 5/4/21 to 5/6/20. Resident #1's May 2021 MAR revealed Resident #1 received 5 doses of [MEDICATION(S)] between 7:49 AM (on 5/4/21) and 4:11 PM (on 5/6/21) for pain ranging from 6 to 10. A review of Resident #1's May 2021 MAR revealed Resident #1 received acetaminophen 500 mg every 4 hours as needed 13 times between 5/7/21 and 5/13/21 for pain ranging from 4 to 9 with the majority of the pain at 6 or greater. A review of Resident #1's May 2021 MAR, dated 5/4/21 to 5/13/21, revealed Resident #1's pain level was assessed every shift (three times a day) and ranged from 0 to 10, In addition, Resident #1's May 2021 MAR revealed Resident #1 had complaints of pain at a minimum of once or twice daily with the majority of these pain levels at 6 or greater (range= 3 to 10). Therefore, Resident #1's May 2021 MAR entries demonstrated Resident #1 had significantly increased pain after the incident on 4/29/21 and surgery on 4/30/21. A review of Resident #1's current long-term care plan, dated 5/3/21 and revised 5/7/21, revealed, Resident #1 was non-ambulatory for ambulation (dated 5/7/21) and required a mechanical lift for transfers (revised 5/10/21) because of non-weight bearing LUE (left upper extremities) in sling at all times and non-weight bearing to LLE in hinged knee brace locked in extension at all times. Resident #1's current long-term care plan revealed Resident #1 had a decline in ambulatory function and transfer assistance since 4/29/21. A review of CNA A's separation notice, dated 5/6/21, revealed CNA A was notified via telephone she was separated from employment effective immediately on 5/6/21 at 3:06 PM due to her violation of the plan of care and it resulting in an injury.

This citation pertains to MI# 621, MI# 036 Based on observation, interview and record review, the facility failed to prevent incidences of elopement for 2 (#101 and 102) of 4 residents reviewed for accident hazards from a total sample of 8 residents , resulting in immediate jeopardy for Residents #101 and 102. Resident #101 has a [DIAGNOSES REDACTED]. Resident #102 has a [DIAGNOSES REDACTED]. These two elopements from the facility placed Resident #101 and Resident #102 at high risk for serious harm or death. The Administrator, Director of Nursing (DON) and corporate clinical consultant were notified on 5/16/14 at 2:20 PM of the immediate jeopardy that began on 4/8/14 at 10:30 AM due to the facility's knowledge of Resident #101's elopement attempts and failed to develop, add, or modify interventions to care plans and or provide increased/adequate supervision to prevent several elopement attempts of Resident #101. Resident #102 eloped on 5/8/14, time unknown; about 6:09 PM facility staff could not account for Resident #102 and elopement alert called. Resident #102 was found at 6:20 near the wood's line. On 5/16/14 at 5:30 PM, the surveyor confirmed that the facility implemented the following interventions related to reassessments to residents #101 and 102; review of all environmental gadgets on residents and exit door to prevent egress; and training of facility staff to remove the immediate jeopardy. The immediate jeopardy was removed but not corrected and the deficient practice remained for more than potential risk for elopement at a pattern for the 21 residents who were identified for exit seeking behaviors. The facility will report to their Quality Assurance Improvement Program to sustain these corrections. The immediate jeopardy was removed on 5/16/14 at 5:30 PM. The facility remained out of compliance at no actual harm with the potential for more than minimal harm that is not immediate jeopardy at a pattern due to the facility front door needing maintenance work and sustained compliance has not been verified by the state agency. Findings include: Record review of Facility 'Wandering Resident Elopement Prevention' policy dated 5/2012, revealed it is the policy of the facility to assess residents and plan their care to limit injuries for foreseeable accidents related to wandering and exit seeking behaviors which has the potential to lead to elopement. Definitions: Wandering- Aimless or purposeful motor activity that causes a social problem such as becoming lost, leaving a safe environment, or intruding in an inappropriate place. Elopement- The resident's leaving of the facility without staff observation or knowledge of the departure. Assessment and identification of wandering residents: A) the history of behaviors, including wandering and exit seeking, will be obtained prior to or upon admission. E) Each resident's level of supervision and elopement prevention interventions will be modified according to these assessments. The plan of care will be updated accordingly. Section 2. A.) iv- Tracking of wandering behaviors to assist with identification of specific individualized effective approaches. Record review of Resident #101's 'Incident report' dated 4/8/14 revealed that the resident was observed outside the facility in a wheelchair propelling toward the front door from the south edge of the building. The incident report noted that Resident #101 had a Brief Interview of Mental status (BIMs) score of 6, indicating severe cognitive impairment with an extensive history of exit seeking behaviors and had an exit seeking transmitting device to her right ankle. The incident report did not identify any witnesses or exact time that the resident exited the facility or how long the resident was out doors. Record review of Resident #101's Minimum Data Set ((MDS) dated [DATE] revealed an [AGE] year old female with Brief Interview of Mental status (BIMs) score of 6, indicating severe cognitive impairment with noted behaviors of wandering and medical [DIAGNOSES REDACTED].#101 required assistance with transfers, ambulation, and toilet use and bed mobility. Record review of Resident #101's admission Minimum Data Set ((MDS) dated [DATE] revealed that there were no noted behaviors of wandering identified on the MDS section F assessment although the CAA ( Care Area Assessments) dated 9/2/13 for falls noted the resident had dementia, some concerns with safety related to re-orientation and reminders and a wander guard was initiated. The CAA referred to the 'Exit Seeking/Wandering Assessment' for details. Record review of Resident #101's 'Exit Seeking/Wandering Assessment' revealed a score of 11; meaning 11 or more are high risk to wander. A High risk- initiated interdisciplinary care plan included considerations for exit seeking armband, photography, visual observation and alarm. An assessment dated [DATE] revealed a score of 11 (high risk), and assessments dated 11/27/13 and 2/24/14 revealed scores of 19. The facility identified Resident #101 to be independently ambulatory/ or independent in wheelchair mobility, a history of wandering on admission, wanders aimlessly within the facility with attempts to exit seek during the past 3 months and a medical [DIAGNOSES REDACTED]. The record review of physician progress notes [REDACTED].#101 was seen at the request of the nurse for increased confusion over several days. Record review of Resident #101's medical record nursing notes dated 12/9/13 revealed that the behavior tracking was started on the resident since she was exit seeking. Record review of nursing notes dated 1/14/14, 1/20/14 and 1/21/14 revealed that the Resident #101 was self-propelling throughout the facility and going in and out of other resident rooms. On 1/21/14 the nurse noted that the resident stated, "I want to go home". Nursing notes dated 2/18/14 revealed that Resident #101 expressed anxiety and needed to leave, but unable to state where she wanted to go. Nurse's notes dated 3/4/14 revealed Resident #101 had impaired cognition, independently wheeled herself in facility, assisted with supervision at times when wandered throughout the facility in her wheelchair, exit seeking at times and an exit seeking device applied to her wheelchair. Resident #101's nursing note dated 3/9/14 at 9:00 AM revealed the resident had increased confusion and anxiety, appeared wide eyed and not easily re-oriented. The resident requested staff "to let her out" frantically looking for an unlocked door. Resident #101's nursing note dated 4/5/14 at 9:35 PM revealed the resident was seen propelling self in wheelchair, asking staff and other residents what to do and where to go. Resident was in and out of resident rooms and was re-directed by staff several times. Resident attempted to go outside using the side door, alarm was activated and staff re-directed. Resident was noted to state that she wanted to go home. The record review of facility's 'Care Plan/Comprehensive Interdisciplinary' policy dated 1/1994 (the only care plan policy per RN MDS "D" could find) described a comprehensive care plan will be developed for each resident.......The care plan must include measurable objectives and timetables to meet a resident's medical, nursing and psycho social needs as identified in the comprehensive assessment. The policy identified that care plans will periodically be reviewed and revised by the interdisciplinary team after each resident assessment, assessment review, or significant change in condition. The care plan will be otherwise updated as warranted by changes in condition. Record review of Resident #101's 'Altered Mobility' care plan dated 9/6/13 revealed under "'safety: Exit seeking alarm band protection device applied, follow guidelines for placement and function on the treatment administration record". Hand written on the care plan with date 4/21/14 (13 days post elopement on 4/8/14) an ID bracelet was applied to Resident #101's left wrist. Record review of 'Fall and Injury' care plan dated 9/6/13 revealed the history of exit seeking and mobility independence apply interventions as indicated and reassess PRN (as needed). There were no added interventions or increased visual/supervision after Resident #101's attempt to go outside using the side door, alarm was activated and staff re-directed Resident #101 back to the hallway. Resident was noted to state that she wanted to go home. In an interview on 5/15/14 at 11:15 AM with Licensed Practical Nurse (LPN) "E" revealed that Resident #101 checked the exit doors every day, checked all the doors. LPN "E" explained that a fire test was conducted the day on 4/8/14 when Resident #101 exited the doors. There were fire alarms that sounded, the fire doors were closed and residents were placed in their rooms. That same day a second fire alarm sounded but it was a test not to respond. LPN "E" stated that she knew Resident #101 was in her wheelchair in her room during the first fire drill and a during the resident count immediately after the first fire drill. LPN "E" stated that Resident #101 is fast and quick propelling herself in her wheelchair wherever she went throughout the facility. LPN "E" stated that Resident #101 had read to her the sign on the 200 hall side door stating, "She (Resident #101) has told me If I hold this for 15 seconds the door will open". LPN "E" stated that Resident #101 would set off the alarms and staff had to get her. The state surveyor asked LPN "E" if Resident #101 set off door alarms; LPN "E" stated, "Yes. There's no pattern, after meals usually breakfast. She's always looking for something to do". LPN "E" added that Resident #101's daughter explained to her a big reason Resident #101 was at the facility was because Resident #101 would leave the house. One time the resident left the house at 4:00 AM, knocked on the window and the family did not know how long she was outside. LPN "E" stated that there was no wander guard safety device on the 200 hall exit door that will alarm when a resident with a wander guard safety transmitter exits. An interview on 5/15/14 at 1:37 PM with Certified Nurse assistant (CNA) "F" revealed on 4/8/14 Resident #101 was in her wheelchair, propelled self throughout facility. CNA "F" stated that she picked up hall trays and Resident #101 went back and forth on the 200 hall. CNA "F" stated that Resident #101 sat at the door looking out and read the signs on the door that printed, 'Push on door hold 15 seconds, door will open'. CNA "F" stated that Resident #101 had exit seeking behaviors since admission. CNA "F" stated, " I saw Resident #101 pushed the door and held down the door bar. She (Resident #101) knew how to hold the bar down and the door will open; I've seen her do it ". An interview on 5/15/14 at 1:50 PM with Certified Nurse Assistant (CNA) "G" revealed that Resident #101 always wanted to go outside and went to the doors to exit. CNA "G" stated that Resident #101 sat by the door, looked outside and correctly read the door signs to her, 'Press, hold for 15 second and door will release'. Observation and interview on 5/15/14 at 10:20 AM with the maintenance supervisor "H" of the 200 hall side door revealed that on 4/8/14 the door had a Radio Shack door alarm in place that was tested by the state surveyor, noted to sound for only 90 seconds and then shut off. The door had a mag lock located at the top of the door and a sign across the door at wheelchair height that stated, 'Hold down to release in 15 seconds'. There was no wander guard safety device noted to the exit door on the 200 hall. An interview on 4/15/14 at 10:30 AM with the Activity Director "J" revealed that he stood at the nursing station when visitors left, visitors returned and stated, "I don't know if it's OK, but someone is outside in a wheelchair by herself ". The Activity Director "J" stated that he went outdoors and found Resident #101 by herself propelling her wheelchair in the parking lot and was located in the second handicap parking slot in front of the building. Activity Director "J" stated that Resident #101 was in her wheelchair, faced west, propelled along and wore a sweater and shoes or slippers. The Activity Director "J" stated that no one heard door alarms go off that he knew of, but did not know why. Record review of the weather history for the area on 4/8/14 on www.wunderground.comhistoryairport/KMOP/2014/4/8/DailyHistory.html web site revealed on 4/8/14 at 10:15 AM the outdoor temperature to be 45.7 degrees with wind-chill of 42 degrees. An interview on 5/15/14 at 9:25 AM with Resident #101's responsible party/POA (power of attorney) revealed that when Resident #101 lived at home with her spouse, the resident played with the locks, figured them out and walked out. The POA stated that she told the facility when the resident was admitted Resident #101 exited from home and the facility placed an alarm to the wheelchair. The POA stated that Resident #101 played with the 200 hall door and read the sign that the door can be opened in 15 seconds. The POA stated that during each of her visits the resident took her to each exit doors and read the signs out loud to her. An interview on 5/16/14 at 8:30 AM with Resident #101 revealed that she recalled going outside in her wheelchair, it was cold that morning, but did not know where she went to but just around. Resident #101 stated, "Yes, I can read the signs on the doors, they say to hold them down to open". Resident #101 recalled the man with the beard (activity director has a beard) brought her back the facility. Resident #101's elopement on 4/8/14 was preventable that had the potential for her to fall from her wheelchair, the wheelchair to be caught or hit by a car who may not see her or suffer from hypothermia causing life threatening injury and harm. (# }/ ( ) This citation pertains to M 036 According to a facility face sheet dated 5/13/14 at 9:53 a.m., Resident #102 was an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A Minimum Data Set (MDS) for Resident #102 dated 3/10/14, indicated that Resident #102 had a "Staff Assessment for Mental Status" because Resident #102 was unable to complete the "Brief Interview for Mental Status". The "Staff Assessment for Mental Status" for Resident #102 was scored as a "3" indicated Resident #102 was "severely impaired, never/rarely made decisions". This MDS dated [DATE] for Resident #102 also reflected that Resident #102 had signs and symptoms of delirium. Resident #102 exhibited inattention and disorganized thinking that was continually present, fluctuates, comes and goes, changes in severity. This MDS Assessment for Resident #102 dated 3/10/14 also reflected under "Wandering - Presence and Frequency":... 3 - behavior of this type occurred daily". Resident #102 had a facility document titled " Wandering/Exit Seeking Risk Assessment Scale " completed on 3/15/14 (no time noted) that reflected a score of "22" that indicated Resident #102 was a " high risk to wander". Resident #102 had a facility document titled, "Fall Potential Assessment" completed on 3/15/14 (no time noted) that reflected a score of "12". The higher the score, the greater the risk for falls is what the document reflected for Resident #102. Review of a facility document, a care plan (no title) for Resident #102 dated 7/10/13 (no time noted) reflected, "(Name of Resident #102) is at risk for falls for injury related to her exit seeking and wandering behaviors. She (Resident #102) is independent throughout the facility. (Resident #102 name) looks as though she could be a visitor. (Name of Resident #102) has a slow and steady gait. Contributing [DIAGNOSES REDACTED]. (Name of Resident #102) is also at risk for bruising and bleeding related to her daily use of Plavix (a blood thinner). Interventions were: "with history of exit seeking and mobility independence apply interventions as indicated and reassess as needed". Review of Resident #102 's ADL (Activity Daily Living) care plan dated 7/10/13 had the following interventions: "Safety: exit seeking alarm band protection device applied; follow guidelines for placement and function on the Treatment and Administration Record. ID bracelet to left wrist". There was no intervention noted to Resident #102 's care plans or care guide regarding the need to monitor or supervise Resident #102 related to her exit seeking or wandering behaviors. According to facility document titled, "Behavior tracking log", for April and May 2014, Resident #102 was monitored for the following specific behaviors: " refusing care, exit seeking, verbally agitated with staff, worried expression, wandering, pacing, and tearfulness". On 4/15/14 at 10:00 a.m., Resident #102 refused care, was exit seeking, had a worried expression, and wandered/paced with an "unknown precipitating event". The interventions used for Resident #102 ' s behavior on 4/15/14 at 10:00 a.m. was to approach calmly, listen empathically to resident's concerns, attempt to re approach, and offer distraction such as an activity or snack. According to facility documents titled, " Behavior tracking log " for 5/2014, Resident #102 was monitored for the following specific behaviors: " exit seeking, expressing feelings of sadness and verbalizations of needing to get out, needing to leave". There were no notations of exhibited behaviors noted on the 5/2014 Behavior Tracking Log for Resident #102. Review of a facility document titled, " Exit Seeking " dated 5/8/14 at 10:53 p.m., " Resident #102, was observed by staff pacing and unable to be easily redirected. Staff tried coaxing her into the dining room for hot cocoa prior to the meal. She (Resident #102) was pacing and exit seeking at dinner time. Certified Nurses Aid (CNA) "S" informed Registered Nurse (RN) "M" at approximately 6:09 p.m. that staff was unable to locate resident (Resident #102). Elopement procedures initiated immediately. Resident (Resident #102) observed at approximately 6:20 p.m. on the west side of facility by Dietary Aid (DA) "N". (Name of Resident #102) was assisted into the facility by DA "N", Laundry staff "R" and CNA "U" without difficulty. (Name of Resident #102) is alert and orient (sic) to herself with cognitive impairment AEB a [DIAGNOSES REDACTED]. She (Resident #102) has a BIMS (Brief Interview for Mental Status) score of 99 which indicated the inability to complete interview. (Name of Resident #102) has a history of exit seeking. She (Resident #102) ambulates independently throughout facility. An exit seeking transmitter is in place to her (Resident #102) right ankle. Device (exit seeking transmitter) was tested and is working properly. (Name of Resident #102) also wears a name band to her left wrist which is in place. (Name of Resident #102) told DA "N" that she was going to the market, but she got lost. Immediate actions taken: VS 98.2 (temperature), 68 (heart rate), 18 (respirations). (Name of Resident #102) denies pain. LSCTA (lung sounds clear to auscultation) no cough or shortness of breath noted. SpO2 (pulse oximetry, level of oxygen in the blood) was 98% on room air. Apical heart rate was 68 beats per minute regular rhythm auscultated (heard with stethoscope). Bowel sounds active all four quads (quadrants). Abdomen is soft, non-distended. Range of motion is within normal limits. Bilateral upper extremities and bilateral lower extremities strength are strong. No abnormalities noted. Skin assessment complete. Skin is warm, dry and intact. No redness, bruising, or swelling noted. There is no change in level of consciousness or functional ability. Care plan (of Resident #102) reviewed, no changes. 15 minute visual checks initiated for 72 hours, 72 hour charting initiated, new order noted to obtain urinalysis and vital signs every shift for 72 hours. Son (name of son) notified. Administrator notified. (Name of physician) aware. Notes: (Name of Resident #102) is an [AGE] year old female admitted to our facility on 7/1/11. She (Resident #102) is unable to make her own medical decisions. Her guard is her son (name of Son). She (Resident #102) is independent in ambulation throughout out the facility without any assistive devices. She (Resident #102) has a history of wandering while living at home prior to admission. She had an exit seeking transmitter placed on her right ankle that was tested and functioned daily according to facility practice. Expiration date (of exit seeking transmitter) 6/2014. (Name of Resident #102) also has a name band placed on her left wrist that includes facility address and phone number ". According to the facility document titled, " Exit Seeking " dated 5/8/14 at 10:53 p.m., Notes on Resident #102 revised 5/12/12 at 11:34 a.m. reflected: " 5/9/14 (no time noted), On 5/8/14 (Name of Resident #102) spent the afternoon outside for a supervised activity from 2:30 p.m. to 3:30 p.m.. She (Resident #102) was visiting with a facility friend in her room until 4:30 p.m.. At this time, (name of facility staff) Housekeeper "T" was working on 200 Hall and (name of Resident #102) asked her to open the door to the outside. Per Evening Manager, Human Resources Staff (HR) "Q", (name of resident) was pacing and challenging to redirect during dinner. Staff tried to coax her into the dining room with a favorite beverage, hot cocoa. When (name of Resident #102) did come into the dining room, she would not stay seated for any extended period of time before she got up to pace again. When the resident (Resident #102) exited the facility on 5/8/14, it is unknown if the wandering system (exit seeking transmitter) on the front door triggered the door to lock by the exit seeking transmitter placed on the resident's (Resident #102 ' s) right ankle. (Name of CNA) "S" was working the east end of 100 Hall with a resident approximately 5:45 p.m. when he heard the front door alarm. He responded to the alarm and saw a family member exit the building and get into their SUV (vehicle). There was no one else outside and no other residents within the vicinity of the door. He (CNA) "K" reset the alarm (to the exit seeking device on the door). CNA "K" indicated that there were several visitors throughout the dinner hour. (Name of RN) RN "M" was caring for a resident on the west end of the 100 Hall at approximately 6:00 p.m. when she heard the front door alarm. She (RN "M" ) was unable to leave the resident due to safety reasons. (Name of RN "M" ) indicated that the door had alarmed a few times earlier during the shift and at around 4:30 p.m.. There was no reason for the alarms to be sounding and she (RN "M" ) had to reset it. At approximately 6:09 p.m. (name of CNA) told (name of RN "M" ) that she (CNA "S" ) was unable to locate (name of Resident #102). (Name of RN "M" ), called an elopement drill at 6:10 p.m. Staff responded immediately by searching both the interior and exterior of the facility. (Name of DA "N") and (name of Laundry staff "R") located (name of Resident #102) at approximately 6:20 p.m. outside the building on the west side of the (facility) property. (Name of Resident #102) indicated to (Name of DA "N" ) and (name of Laundry staff "R" ) that she (Resident #102) was going to the market. (Name of Resident #102) was not visibly upset. She (Resident #102) was willing to be escorted back into the building without difficulty. Actions taken: Resident (#102) was assessed for injury. She (Resident #102) was placed on 15 minute checks for 72 hours. Urinalysis with culture and sensitivity were ordered. All residents with exit seeking transmitters were checked for placement and to ensure that they (exit seeking transmitters) were working correctly by nursing. Maintenance personnel was called in to check door alarms and to ensure that all exit seeking transmitters worked within 6 feet of the doors. The front door was placed on continual secure lock with staff providing visitors with access in and out of the facility. Preventative Maintenance logs indicate that the door alarms are being checked twice daily 5 out of 7 days and this practice will continue. In addition, maintenance personnel will perform random door alarms checks twice daily through the weekend. The door alarm service technician (the exit seeking alarm) was called in to inspect the function of the door alarm system. Elopement drills will continue weekly at random times of the day and shift. Although the facility had all their maintenance process and safety checks in place, this may have been a spontaneous manufacturer default with the electrical system of the wandering exit seeking system of the front door. A quote was received today (5/9/14) for a new door alarm, enunciator panel audible and visual alerts". Review of a facility document titled, " Interdisciplinary Notes " dated 3/15/14 at 2:20 p.m. for Resident #102 had nursing noted, " Resident (Resident #102) continues to wander aimlessly throughout facility with exit seeking behaviors ". Review of a facility document titled, " Interdisciplinary Notes " dated 5/8/14 at 8:00 p.m. for Resident #102 had nursing noted, " Resident alert and responsive. Resident observed by staff with increased agitation at time exit seeking. Staff unable to local resident. Elopement drill initiated. Resident observed outside assisted by Housekeeping "R" and DA "N" assisted back into building without difficulty. Resident has [DIAGNOSES REDACTED]. (Name of Resident #102) has a history of exit seeking. Exit seeking transmitter to right ankle. Transmitter functioning tested and functioning properly. Resident has name band to left wrist which is present. (Name of Resident #102) ambulates independently throughout facility. ... " An interview on 5/15/14 at 10:40 a.m. with Evening Supervisor and HR staff "Q" was conducted. HR "Q" was asked what occurred the night that Resident #102 eloped from the facility (5/8/14). HR "Q" stated that a facility elopement drill was called (5/8/14) at approximately 6:00 p.m. HR "Q" was asked which door Resident #102 eloped from and HR "Q" replied, "It was believed the front door of the facility". HR "Q" was asked if any alarms were going off when Resident #102 's eloped and she confirmed that no alarms sounded during Resident #102's elopement. HR "Q" revealed that Resident #102 was found at about 10 minutes at the corporate end (of the facility), across the yard, in the woods". HR "Q" was asked what the weather was at approximately 6:00 p.m. on 5/8/14 and HR " Q " stated, " It was warm and the Resident had a white fleece jacket on". HR "Q" stated that DA "N" and Laundry Staff "R" found Resident #102. Resident #102 was escorted back to the facility, given water and examined by nursing staff. HR "Q" stated that Resident #102 did not have any injury and did not complain of pain. HR "Q" stated that the front door was monitored and Maintenance staff was called. HR "Q" stated that the nurse called the Administrator "A". HR "Q" confirmed that Resident #102 had her exit transmitter bracelet on her right ankle. HR "Q" added that when Resident #102 was returned to the facility through the front door, the exit transmitter bracelet alarmed. An interview and observation with Maintenance Staff "I" on 5/15/14 at approximately 11:00 a.m. reflected that there is a 5-6 foot reading range on the exit seeking transmitters. Maintenance Staff "I" stated that exit seeking transmitter antennas are located at the facility front entrance and at the facility interior business hall doors only. During this interview, Resident #102 was noted at the facility entrance door, peered out the door at surveyors and Maintenance Staff "I". An observation of the area in the woods where Resident #102 was located on 5/8/14 at approximately 6:25 p.m. was noted to be about 30 feet into a densely wood area outside the facility grounds. This wooded area was noted to have tripping hazards such as branches and downed tree trunks that Resident #102 traversed to get approximately 30 feet into the woods. (Resident #102 is on medications that would easily make her bruised and bleed if she got injured ). Maintenance Staff "I" was asked how far from where Resident #102 was found on 5/8/14 at approximately 6:25 p.m. to the 55 mile an hour road M115 running in front of the facility and woods. Maintenance Staff "I" stated, "120 feet from where Resident #102 was found in the woods to the road M115. It was approximately 180 yards from the facility front entrance to the area in the woods that Resident #102 was found". Maintenance Staff "I" confirmed when nursing staff checked Resident #102' s exit seeking device transmitter, it was operational when Resident #102 returned to the facility. Maintenance Staff "I" confirmed that he did not check Resident #102 's exit seeking device transmitter at the front exit. Maintenance Staff "I" stated another exit seeking device transmitter was used to test the antenna of the exit seeking system at the facility's front entrance. Another interview with Maintenance Staff "I" on 5/14/14 at 11:40 a.m. revealed that the exit seeking antennas were checked once daily until the elopement on 5/8/14 when the frequency of the exit seeking antennas at the front door and at the business office hallway was checked twice a day. Maintenance Staff "I" stated that if there were any malfunctions, the facility called the exit transmitter device company to come. Maintenance Staff "I" stated that in 5 years, the exit transmitter device company has come maybe twice to service because of malfunctions. Maintenance Staff "I" confirmed that the only maintenance done on the exit transmitter antennas was a rechargeable battery change every two years. Maintenance Staff "I" stated that when the exit seeking transmitter company came for the service call on 5/9/14, the facility Maintenance Staff was told to change the rechargeable battery in the exit seeking antenna once a year. The company changed the rechargeable battery during the 5/9/14 service call. Maintenance Staff "I" confirmed that the exit seeking device antennas are factory set and do not require any changes to be done by the facility staff. Maintenance Staff "I" stated that no exit seeking device/antenna company maintenance is done, just trouble shooting. During review of a facility document and interview with Director of Nursing (DON) "B" on 5/15/14 at 2:25 p.m., DON "B" was asked why Resident #102's exit seeking transmitter device, check function every evening (if no positive result; replace transmitter) in the afternoon was discontinued on 5/9/14. On 5/15/14 at 2:30 p.m., DON "B" stated that the discontinuation of the checking of the exit seeking transmitter device every evening was a user error. It was explained the order was placed in the computer order system but the user did not specify whether the order needed to go to the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). DON "B" confirmed that Resident #102 did not have a function check of her exit seeking transmitter device every evening from 5/9/14 to 5/15/14 (after her elopement on 5/8/14) until this Surveyor brought this to the attention of the DON "A". An interview on 5/15/14 at 3:45 p.m. with RN "M" was conducted. RN "M" confirmed she was working on 5/8/14 and caring for Resident #102. RN "M" revealed the last time

This citation pertains to MI# 206 Based on observation, interview and record review the facility failed to prevent an accident in 1 (#1) of 4 total sampled residents, resulting in Resident #1 who had a history of [REDACTED]. Findings include: Record review of facility reported incident dated 3/17/14 at 6:30 PM revealed that Resident #1 was observed on her left side on the floor in the hallway in front of her wheelchair. Resident #1 was noted to exhibit signs and symptoms of pain with facial grimacing and vocalized pain by stating, "Ouch" and guarding her left hip. Resident #1 was unable to accurately or reliably recall and state the events surrounding the unwitnessed fall related to her severe dementia with long and short term memory deficits. A recent change in condition with cognitive decline noted Resident #1's Brief Interview of Mental status (BIMs) score was 99 related to her cognitive impairments. Resident #1 recently had a change of condition assessment on 3/10/14 related to her decline in Activities of Daily Living (ADLs), ambulation and cognition. The facility identified on the incident report that Resident #1 required extensive assistance with wheelchair mobility, toileting and dressing. Record review of Resident #1's radiology report dated 3/17/14 revealed a garden classification 1, acute femoral neck fracture. Record review of Resident #1's significant change Minimum Data Set ((MDS) dated [DATE] revealed an [AGE] year old female with cognitive impairment. Record review of cognitive CAA (Care Area Assessment) dated 3/10/14 noted Resident #1 had a [DIAGNOSES REDACTED]. Resident #1 had a history of walking/wandering throughout the facility looking for a chair or bed. Resident #1 had periods when she was easily distracted, had difficulty focusing on a single subject...her responses can be nonsensical and at other times she may not respond at all. A further decline in her cognition can be expected and is unavoidable related to the progression of her dementia. Resident #1 had Depakote, lorazepam and celexa medications prescribed. Record review of Resident #1's Communication CAA (Care Area Assessment) dated 3/10/14 noted Resident #1 had impaired cognition; her BIMs (Brief Interview of Mental status) score was 99 and had difficulty conveying her needs. She had supporting [DIAGNOSES REDACTED]. Record review of Resident #1's Fall CAA (Care Area Assessment) dated 3/10/14 noted Resident #1had history of falls. Contributing factors include her impaired cognition, impulsivity, wandering and exit seeking behaviors, poor endurance, impaired balance, shuffling unsteady gait with history of buckling at the knees and unexpectedly attempting to sit, incontinence, chronic pain, history of agitation and use of fall potential contributing medications. Record review of Resident #1's 'Physician Determination of Decision Making Capability' form signed by two physicians dated 9/24/13 and 10/16/13 certified that Resident #1 was not capable of understanding the Bill of Rights and participate in medical treatment decisions. Record review of facility 'Fall Potential Assessment' policy dated 6/2009 revealed: It is the policy of the facility to prevent avoidable falls through identification of risk and implementation of corresponding interventions. Purpose is to ensure the residents have appropriate intervention for the prevention of falls based on a risk-benefit analysis. If any resident has had any falls within the last 30 days, or if the score of the assessment is above 10, the resident will be considered at risk for falls. Record review of Resident #1's 'Fall Potential Assessment' forms with varied dates revealed: dated assessment 8/6/13 revealed a score of 20, and that the resident was observed on the floor and that a laser alarm was added to the bed. assessment dated [DATE] revealed a fall score of 20, and that Resident #1 was observed sitting on the floor in the admission director's office next to a chair. Quarterly fall assessment note dated 10/2/13 with score of 20, revealed that Resident #1 had 4 falls in the past quarter with no injury and continued at risk for falls related to her impaired cognition resulting in an inability to use call-light appropriately, to verbalize needs or ask for assistance. Quarterly fall assessment dated [DATE] with score of 18, revealed that the resident had one fall in that quarter. Fall assessment dated [DATE] with score of 21, revealed Resident #1 was observed on floor in room with unsteady gait without physical support, remains independent but also uses a laser alarm to alert staff ....Fall assessment dated [DATE] with score of 23, revealed Resident #1 was observed on floor on buttocks next to her bed in her room. No injury noted, resident continues at risk for falls related to her impaired cognition, impaired balance with declining use of walker, incontinence and use of fall potential contributing medications. Resident #1 has laser alarm to FOB (foot of bed) to alert staff when she is rising. Care plans reviewed and therapy evaluation related to unsteady gait were requested. Resident tends to lean forward during ambulation with fast, shuffling gait. Record review of Resident #1's quarterly 'Fall Potential Assessment' with fall score of 23 on 3/10/14 and a note dated 3/15/14 revealed that Resident had 2 falls this quarter without injury. Resident continues at risk for falls related to her impaired cognition with impulsiveness, behavioral episodes with history of striking out at staff, impaired balance, unsteady shuffling gait, transfers without asking for assistance, poor endurance, incontinence with history of toileting in inappropriate places, chronic pain, difficulty conveying needs and use of medications that contribute to potential falls. Resident has a low bed with laser alarm, bedside floor mat and auto lock brakes to wheelchair for safety. Record review of Resident #1's 'Fall Potential Assessment' form note dated 3/18/14 revealed that Resident #1 was observed on floor and was in a wheelchair prior to the fall. Transferred to ER (emergency room ) for hip fracture on 3/17/14. Record review of Resident #1's potential risk for falls or injury care plan dated 3/15/14 identified her impaired cognition, impulsivity, wandering and exit seeking, poor endurance, impaired balance, attempts to transfer and ambulate without asking for assistance, shuffling unsteady gait with history of buckling knees and unexpected attempts to sit, SOB (shortness of breath) with exertion, inability to use call light appropriately, incontinence......potential fall contributing medications. Interventions included wheelchair for locomotion and to follow during ambulation. Record review of Resident #1's ADL (Activity of Daily Living) and mobility care plan dated 3/15/14 listed her impaired cognition, impaired balance, unsteady gait, poor endurance, chronic pain, agitation, buckling at the knees........A further ADL decline can be expected and is unavoidable related to the progression of her dementia. Interventions for locomotion as independent in wheelchair. Safety interventions included auto lock brakes, floor mat to bedside and laser alarm to foot of bed and transfer with one assist. No safety devices/alarms were noted to wheelchair. Record review of Resident #1's interdisciplinary notes dated 3/5/14 revealed that nursing staff noted a decline with ambulation and ADL's with further decline expected and unavoidable related to progression of disease in Resident #1 and noted a significant change of status MDS assessment would be completed on 3/10/14. Nurse noted that the resident's spouse was aware of decline and that he noticed resident getting weaker. Record review of Resident #1's interdisciplinary notes dated 3/17/14 at 9:30 AM revealed Resident noted with increased weakness with ambulation, complaint of lower back pain, rubbing back with temperature of 99.0 dysuria (painful urination) signs/symptoms with urination. UA (urinalysis) dip positive for abnormal. UA obtained (for lab). An interview on 3/25/14 at 2:10 PM with Certified Nurse assistant "E" revealed that on 3/17/14 at 6:30 PM Resident #1 was care planned as independent in wheelchair and that staff were attempting to walk the resident to and from dining room, stating that staff walk with her and follow with a wheelchair, but that it was not working well and that Resident #1 was using a wheelchair. CNA "E" stated that she was in another resident's room when she came out she heard a moaning sound and looked into another resident's room , then looked down the hall and Resident #1 was on the floor in front of her wheelchair, trying to grab the handrail trying to pull herself up, moaning and crying out like she was hurting. CNA "E" stated that there were no alarms to the wheelchair and that Resident #1 was impulsive. CNA "E" stated that she was upset that no one had told her that Resident #1 was back from dinner and that Resident #1 was one (resident) that you want to take care of first. CNA "E" stated that she did not trust Resident #1 up in a wheelchair. An interview on 3/25/14 at 2:20 PM with Registered Nurse (RN) "D" revealed that there was no alarm to Resident #1's wheelchair and that night (3/17/14) Resident #1 was a two person assist due to her knees buckling and could not walk. Staff attempted to walk Resident #1 to the dining room, but could not so they used a wheelchair, that's why she was in the wheelchair. RN "D" stated that someone brought Resident #1 back from dining room and left her in the hallway, Resident #1 attempted to get up and walk, no one witnessed the fall. RN "D" was aware of Resident #1 having a positive urine dip done that morning (3/17/14) and that urinalysis results came back later that evening with positive urinary tract infection. Record review of Resident #1's interdisciplinary notes dated 3/17/14 at 1:50 PM written by the physical therapy coordinator "G" revealed that Resident #1 had a quarterly (therapy) screen completed with triggers in declines in ambulation, transfers and balance. Resident #1 was discharged on 2/10/14 from physical therapy services for these matters. Resident not appropriate at this time for therapy. Resident screened for changes. This therapist and another screened resident #1. Resident was able to stabilize self without assist. Resident able to ambulate without assist; however, requires consistent verbal cues and encouragement. Resident resistive to ambulation and prefers to lie in bed. Resident ambulated with shuffle gait and very slow speed. Resident requires excess tine to ambulate to meals. An interview on 3/26/14 at 8:20 AM with physical therapy coordinator "G" revealed that the therapy department had screened Resident #1 on 3/17/14 for ambulation and that the therapy department did not give the resident a walker or wheelchair to use. Staff "G" stated that staff knows that any resident that ambulates, if not safe, fatigued or weak, that staff use a wheelchair to get resident to meals. Staff "G" stated that if therapy would have put Resident #1 in a wheelchair, therapy would have done an assessment for safety measures. Examples given included fall alarms, pummel cushion, appropriate size wheelchair, auto lock brakes and made sure resident is safe in wheelchair. Staff "G" stated that nursing placed Resident #1 in wheelchair, not therapy. Nursing used a wheelchair to take resident to dinner, brought her back to the unit and left her. Facility is attempting to go alarm free, but alarms are available in nursing care areas. Staff "G" stated that she would have recommended a PSA (personal safety alarm). Staff "G" stated that she had 3-4 referrals from nursing in the last 2 months and that therapy services had spoken with staff on how to safely ambulate the resident with 2 staff people and slowly to take her time. Staff "G" stated that therapy did not evaluate Resident #1 for independent wheelchair use. An interview on 3/26/14 at 9:40 AM with Registered nurse/100 Hall unit coordinator and MDS staff "F" revealed that Resident #1 was not safe to ambulate with staff, so nursing staff started using a wheelchair to take the resident to meals....The wheelchair was new to Resident #1 and had been used for a week prior to the fall. Staff "F" stated that she re-wrote Resident #1's care plans on 3/15/14 making the resident independent in wheelchair. Staff "F" stated that there was no wheelchair assessment and none was done by physical therapy. Staff "F" stated that Resident #1 propelled using her feet and that she (STAFF "F") made the decision to use a wheelchair and chose a wheelchair with auto lock brakes due to cognition and that was her wheelchair nursing assessment. Staff "F" stated that the laser bed alarm was used to notify staff when Resident #1 was moving. Record review of facility 'Alarm' list dated 3/25/14 revealed that 7 residents on the list had laser alarms to bed, and 6 of the 7 had wheelchair alarms, all except Resident #1 who had only a laser alarm to bed and no wheelchair alarm. Observation on 3/25/14 at 8:10 AM of Resident #1 while up in wheelchair in the assisted dining room for breakfast revealed that the resident had no fall alarms in place to wheelchair post fall with fracture. In an interview on 3/26/14 at 12:10 PM with facility Registered Nurse Clinical Support Corporate consultant "C" revealed that Resident #1 had declined over the past 2 months and had started to use a wheelchair on 3/3/14, and the wheelchair was care planned on 3/14/14. Consultant "C" revealed that there was no wheelchair assessment by physical therapy and that there was a communication issue between the unit coordinator and therapy, that no one talked to therapy about the resident's fluctuation in ability or that she used a wheelchair to go to meals. Based on interview and record review, it was noted that Resident #1 was not properly assessed for wheelchair use and that the unwitnessed fall which occurred 3/17/14 was preventable which resulted in fracture with hospitalization . ( ) ( )

This citation pertains to MI# 212 Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistive devices to prevent accidents in 1 (#101) of 4 sampled residents from a total sample of 4 residents resulting in resident #101 who had a history of [REDACTED]. Findings include: Record review of the facility incident report dated 5/25/11 at 5:40 AM revealed: Resident (#101) observed lying on right side against wall in front of bathroom. Resident assessment revealed resident was alert and responsive. Complained of pain of right hip and right shoulder pain. Skin tear to right elbow of 4 centimeter (cm) x 4 cm with flap intact was noted. Range of motion was not completed due to resident #101 was noted to scream out in pain. The right leg was noted to appear shorted and turned outward. It was noted resident #101 did not remember hitting her head. Record review of resident #101's nurse notes dated 5/25/11 at 6:30 AM revealed that the nurse was called to resident #101's room at 5:40 AM, resident observed lying on floor on right side. Resident #101 stated that she was trying to do as much as possible for herself and slipped when she was walking to bathroom. Resident #101 was noted to complain of pain to right hip, right elbow and right shoulder. A skin tear was noted to right elbow of 4 cm x 4 cm, and facility staff were unable to perform range of motion on right hip without resident #101 screaming out in pain. Resident #101's right leg appeared to be turned outward and shorter. Emergency services were called Record review of resident #101's Minimum Data Set ((MDS) dated [DATE] revealed resident #101 was an [AGE] year old female with summary score for cognitive patterns of 11 (Moderately impaired-decisions poor, cues/supervision required). Functional impairment of upper extremity was noted. Record review of resident #101's preadmission screening (PAS) dated 3/24/11 revealed a [DIAGNOSES REDACTED]. Record review of the physician progress notes [REDACTED]. A [DIAGNOSES REDACTED]. Record review of resident #101's psychiatric care plan dated 3/30/11 revealed resident #101 had both short and long term memory loss and required cues and supervision for safety and decision making. Record review of resident #101's fall potential assessment dated [DATE] revealed a score of 24 (10 or greater indicates a high risk for falls). Initial review note dated 3/30/11 stated, 'At risk for falls related to decreased mobility, decreased functional ability, history of falls at home, poor standing tolerance, and pain to knees'. Record review of resident #101's fall care plan dated 4/7/11 revealed resident #101 was at risk for falls or injuries related to her increased weakness, decreased mobility and functional ability, incontinence, polypharmacy, and a history of falls at home. Review of the approaches implemented by the facility did not mention safety alarms/devices. Record review of hospital physician emergency records dated 5/25/11 at 6:30 AM revealed resident #101 was seen for fall at nursing home and had memory impairment at baseline. Review of hospital history and physical dated 5/25/11 revealed resident #101 was noted to be awake, but confused, disoriented and demented. During an observation on 6/15/11 at 8:40 AM of resident #101 revealed an elderly female lying in bed in her room with the bed elevated approximately 3 feet from the floor, there was no safety alarm in place. The resident made eye contact and spoke with this surveyor. An interview on 6/15/11 at 9:15 AM with resident #101 in room #204, revealed that resident #101 remembered falling, that she was braced up against the wall, and that she hit her shoulder and hip. Resident #101 stated that she thought she was going to the bathroom. Resident #101 indicated the door located at the foot of her bed as the bathroom. The resident stated, "I did it myself. I got up and walked and slipped. No one helped me". An interview on 6/16/11 at 2:15 PM with the certified nurse assistant (CNA) #6, who cared for the resident on 5/25/11 at 5:40 AM on the 200 hallway, revealed that she was in the employee bathroom when the incident occurred. CNA #6 stated that resident #101 did not have safety alarms/devices at the time of the fall. An interview on 6/16/11 at 1:53 PM with the CNA #5 who first found the resident on the floor revealed that she heard a noise and went to see what it was. CNA #5 found resident #101 on the floor leaning against the wall near the bathroom door. CNA #5 revealed that resident #101 did not have safety alarms at the time of the fall. An interview on 6/15/11 at 12:20 PM with the registered nurse (RN)#4, clinical coordinator for the 200 hallway, revealed that resident #101 was independent in her room with transfers from bed to wheelchair, and wheelchair to toilet. But, she was not independent with ambulation. RN #4 reported that resident #101 had no alarms because she had not attempted to get out of bed, and when she's out of bed, she was either with therapy or at meals. RN #4 stated that she was not aware of the dementia diagnosis. The RN #4 was shown the physician progress notes [REDACTED]. An interview on 6/15/11 at 10:30 AM with director of health care services #2 revealed that the fall/fall prevention policy was part of facility accident/incident reports policy dated 1/11 that she pulled from the facility computer and that there were no other policy related to falls/alarms. The director stated, "We don't put alarms on every resident, if we assess and feel they are at risk then we will place an alarm. (Resident #101) is alert, lets her needs be known. She has not gotten out of bed before; there was no need for an alarm..... " Record review of the accident/incident reports policy dated 1/11 revealed there to be no mention of a falls assessment, or when it is to be performed. There was no mention of resident assessment for safety alarms/devices, when to apply alarms/devices, or how to maintain the safety devices. Record review of the nursing station Policy and Procedure binder on 6/15/11 revealed a 'Personal Alarms' policy and procedure (undated, on facility letterhead) revealed the policy was to assure the safety of residents, who for varied reasons, are unable to stand or ambulate safely, a personal alarm is used to alert the staff when ever the resident rises from the sitting position in chair or lying position in bed. The purpose is to provide a safe environment for the resident and to alert staff to who may require assistance with standing or ambulating. An interview on 6/15/11 at 1:00 PM with physical therapy assistant (PTA) #8 revealed that she did work with the resident. PTA #8, reviewed the therapy notes with the state surveyor and stated that resident #101 was made independent with wheelchair transfers to bed or toilet approximately the first week of 5/11. The next step/goal in therapy for the next week was independence with rolling walker in room. PTA #8 stated that she had a talk with resident #101 about goals for independence. PTA #8 stated that she was aware of resident #101's dementia [DIAGNOSES REDACTED]. Observation on 6/16/11 at 9:50 AM of resident #101 sitting in her wheelchair while in therapy revealed resident #101 needed cueing to perform the exercises from the PTA #8 on which leg to move. Further observation revealed there was no safety device implemented to the wheelchair to assist in the prevention of further falls. Observations on 6/15/and 6/16/11 of sampled residents #102, #103, and #104 revealed that the residents had either a pressure alarm or a clip alarm attached while in wheelchairs and beds. The sampled residents were observed with a paper 3 inch by 4 inch peach colored cut out of an airplane attached to the back of their wheelchairs. An interview on 6/15/11 at 10:55 AM with CNA #3 indicated that the peach colored airplanes provided a visual aide to identify the residents with alarms and fall risk to all staff members. Resident #101 did not have a peach colored airplane on her wheelchair to indicate fall risk. #