Every finding on record at Nspire Healthcare Kendall

Based on observation, record review and interviews the facility failed to properly store medications in two out of two medication rooms as evidenced by an expired emergency kit in the North medication room and a thermometer reading of 52 degrees Fahrenheit in the South medication room. The findings include:Observation on 06/02/2026 at 9:41 AM in the North Medication Room revealed an expired emergency drug kit with an expiration date of 12/25. Photo evidence.Interview on 06/02/2026 at 9:45 AM Staff A, Unit Manager stated: The unit managers are in charge of checking for any expired medications and supplies in the medication room.Observation on 06/02/2026 at 9:51 AM in the South Medication Room, revealed the refrigerator temperature log last signed on 06/02/2026 documented a temperature of 38 degrees Fahrenheit. Further observation revealed the refrigerator contained insulin and the thermometer in the refrigerator indicated a temperature of 52 degrees Fahrenheit. Photo evidence.During an interview on 06/02/2026 at 09:55 AM, the Director of Nursing (DON) stated: We defrosted all the refrigerators overnight because the freezers had ice in it. We placed the refrigerators back on this morning. The thermometer still has not regulated.On 06/02/2026 at 12:15 PM during a second observation the South Medication Room thermometer indicated a registered temperature of 52 degrees Fahrenheit. Photo evidence. Review of the facility's policy titled Medication Storage 06/01/2025 states 6. Refrigerated Products: a. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. b. Temperatures are maintained at 36-46 degrees F. Charts are kept on each refrigerator, and temperature levels are recorded daily by the charge nurse or other designee. c. In the event that a refrigerator is malfunctioning, the person discovering the malfunction must promptly report such finding to Maintenance Department for emergency repair. 8. The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. On 06/02/2026 at 12:34 PM the Pharmacist stated: I am not sure how an expired kit got in the refrigerator. I check the emergency kits monthly and I told the facility to order new kits when they told me state was in the building On 06/03/2026 at 1:16 PM, the DON revealed the nurses are required to check the refrigerator thermometer daily and document the temperature on the monitoring log. The refrigerator was replaced, and the thermometer was also replaced after it was determined that the thermometer was faulty.

Based on observations, interviews, and record review, it was determined that the facility did not consistently store, prepare, distribute, and serve food in a sanitary manner within the kitchen and nourishment rooms. This was evidenced by the presence of undated, unlabeled, and expired food items and dietary staff not wearing required hair restraints, including beard guards, during food preparation. There were 117 residents residing in the facility at the time of the survey The findings included: During a tour on 06/01/2026 at 9:53 AM, with the Corporate Kitchen Manager and the facility's Kitchen Manager an opened container of apple juice was noted in a reach-in refrigerator with an open date of 04/10/2026; there was also a clear plastic type pitcher with contents identified as coffee which had no preparation or discard date with a printed sticker indicating: SUN/[NAME]/[NAME]. Additionally, an undated bag of bread was observed in the dry storage area. Observation on 06/02/2026 at 9:46 AM in the North Nourishment Room refrigerator revealed packets of unlabeled packaged apple slices in the refrigerator. Photo evidence. Observation on 06/02/2026 at 10:22 AM in the South Nourishment Room revealed an uncovered unlabeled, undated plastic cup containing loose unidentified white granulated type substance stored on top of the ice machine. Photo evidence. Review of the facility's Use and Storage of Food Brought in by Family or Visitors policy, implemented 06/01/2025 and reviewed 11/06/2025, revealed prepared food items brought into the facility must be labeled with contents and date, refrigerated when appropriate, and discarded if not consumed within three days. On 06/02/2026 at 10:28 AM, Staff D, a Registered Nurse, acknowledged the concerns identified and stated that all food items in the nourishment refrigerators should be labeled and dated. Additionally, Staff D noted that the cup placed on top of the ice machine was inappropriate and should not have been there. On 06/02/2026 at 11:24 AM, an observation in the kitchen revealed three dietary staff members (Staff B Dietary Aid Porter, Staff C Dietary Aid Porter, and Staff E Dietary Aid Porter) were engaged in food preparation activities without wearing beard guards.Review of the facility's Dietary Sanitation and Hygiene Policy, implemented 06/01/2025 and reviewed 11/05/2025, revealed hair restraints, including beard restraints, shall be worn at all times in food preparation and service areas to prevent food contamination.During an interview on 06/02/2026 at 11:27 AM, Staff C, Dietary Aid [NAME] confirmed that he was not wearing a beard guard and revealed all staff with beards are required to wear a beard guard every time staff enter the kitchen.On 06/02/2026 at 11:29 AM, the Kitchen Manager explained the beard guards had not arrived, and employees used medical procedure masks because they found them more comfortable. The Kitchen Manager also revealed that the facility's policy permitted the use of a hairnet if beard guards were unavailable.On 06/02/2026 at 11:29 AM, the Kitchen Manager stated that the beard guards had not arrived and that employees chose to use medical procedure masks because they found them more comfortable. The Kitchen Manager further explained that the facility's policy allowed employees to use a hairnet when beard guards were unavailable. During an interview conducted on 06/04/2026 at 2:30 PM concerning expired and undated items, Staff E, Dietary Aid Porter, stated that upon receipt of supplies, expiration dates are verified and stock is rotated by positioning older products at the front and newer items behind.

Based on observation, record review, and interview, the facility failed to demonstrate or implement effective plan of actions to correct identified quality deficiency in the problem area related to repeated deficient practice for F761- Label/Store Drugs and Biologicals as evidenced by an expired emergency kit and thermometer reading 52 degrees Fahrenheit found in medication rooms during observations on a recertification survey ending [DATE]. There were 117 residents in the facility at the time of survey. Record review of the facility's survey history revealed, during a recertification conducted on [DATE], through [DATE], the facility was cited F761- Label/Store Drugs and Biologicals as the facility failed to ensure proper storage of medications. Review of the facility's policy and procedures titled Quality Assurance and Performance Improvement (QAPI) Plan undated states: Nspire of Kendall's QAPI program encompasses all areas that impact quality of care, quality of life, resident choice and care transition with participation from all disciplines. We will utilize available data from state and national organizations and internal metrics to set strategic goals and monitor and continuously improve outcomes on behalf of those we serve. During an interview on [DATE] at 4:12 PM the Administrator/Quality Assurance (QA) stated: The QAPI committee conducts monthly meetings. specifically on the last week of the month. The QAPI members include the Director of Nursing Administrator, Medial Director, Unit Managers, Social Worker, Department Heads, one Certified Nursing Assistant, Rehab Director, Life Safety/Maintenance, Activities Director, Dietitian, Dietary Director, and Minimum Data Set Coordinators. We base our QAPI programs on feedback, monitoring, and data system reports such as falls, grievance logs, weight loss, survey results, and hospital readmissions. Examples of our focused projects are decreasing falls and decreasing medication errors. On the first day of survey, we started a Performance Improvement Plan (PIP) focusing on medication storage, expiration dates, falls, ensuring emergency narcotic kit is not expired. We started re-education on all these issues as well as the goals. We also started working on the proper use of thermometers that will affect refrigerator temperature. The last QAPI meeting we had was the last week of [DATE]. We focused on falls, return to hospital, and dietary programs. We also discussed hospital rates, and any ongoing programs that was not brought to compliance. and reviewed our QI pharmacy reports which included our pharmacy recommendations.

Based on observations, record review and interviews the facility failed to implement quality of care and service related to a trial for removal of restraints for one resident (Resident #47) out of eight sampled residents as evidenced by; a trial removal of restraints was initiated without a physician's order. There were 110 residents residing in the facility at the time of the recertification survey. The findings included: Record review of the matrix revealed Resident #47 used restraints. On 11/19/24 at 8:48 AM Resident t#47 was observed in bed with eyes closed; the mattress appeared concave. A belt with fastener was observed on a wheelchair next to bed. Record review of a demographic sheet for Resident #47 revealed an admitted [DATE] with diagnosis that included: Cerebral Infarction. Record review of Resident #47's physicians' orders revealed an order dated 5/22/24 with directions: Soft [fastener brand] belt while in wheelchair when in wheelchair to maintain seating position and minimize risk of falling out of chair release at mealtimes and during personal care every shift for safety and 8/8/24 directions: check [fastener brand] safety belt every shift and as needed for skin integrity and patient comfort. Review of an assessment document titled, Restraint-physical (quarterly/annual evaluation) dated 9/26/24 documented the Physician was aware after trial was completed. Record review of a Quarterly Minimum Data Set (MDS) with reference date 9/25/24 section C (Cognitive status) revealed cognitive impairment, section E (Behaviors) revealed no potential indicators of psychosis, no rejection of care, section GG (functional status) revealed dependent for Activity of Daily Living and section P (restraints) revealed none coded. Record review of a Care Plan started on 9/25/24 revealed Resident #47 was at risk for further falls related to gait balance problems, history of falls, confusion, poor communication, comprehension, psychoactive drug use and unaware of safety needs with a goal to be free of minor injury throughout the next review date. The interventions included: scoop mattress on bed, soft [brand] safety belt when in wheelchair, place bed close to wall, frequent rounds, follow facility fall protocol. During an interview on 11/21/24 at 10:15 AM, the MDS coordinator stated, the Quarterly dated 9/25/24 was not coded for restraints because we did a trial taking the [brand fastener] belt off to see if [Resident#47] risk for fall had changed. During the trial [Resident#47] remained close to the nursing station with 1:1 supervision. The goal was to see how [Resident#47] would do without the [brand] belt. There is documentation on 9/24/24. There was no stop date for the order of Soft [brand] belt while in the wheelchair. The MDS coordinator was asked if the restraints should have been coded based on the current order dated 5/22/24 for [ fastener brand] belt; The MDS coordinator replied, Restraints did not need to be coded because I observed [Resident#47] without the [brand] belt while in the wheelchair seven days prior to the MDS being completed. On 11/21/24 at 2:43 PM the Nurse Consultant revealed there was no order given for a trial removal of the restraint because it was an interdisciplinary team decision. On 11/21/24 at 5:01 PM The Assistant Director of Nursing (ADON) stated, According to CMS (Centers for Medicare and Medicaid Services) guidelines we are required to attempt to reduce restraints. The doctor should have been notified. [Resident #47] has worn a restraint for a long time. The care plan does not reflect that a trial was done. There was an IDT (Inter Disciplinary Team) meeting held after the completion of the trial and the doctor was present to discuss the trial results. A copy of the facility's policy related to restraints and quality of care. On 11/21/24 at 6:00 PM The ADON came to conference room and stated, we don't have a specific policy for quality of care.

Based on observations, record review, and interviews the facility failed to provide a safe environment for one resident (Resident #46) out of eight residents sampled as evidenced by an observation of four shaving razors on Resident#46 nightstand. The findings included: Observation on 11/18/24 at 9:20 AM Resident #46 was in bed awake, alert; four disposable shaving razors were in a cup on the nightstand. (photo evidence) Resident#46 stated, I shave myself and the staff give me the razors. On 11/18/24 at 9:23 AM, Staff B, Registered Nurse (RN) was asked what the facility's policy and procedure for shaving residents is and if residents are permitted to keep shaving razors in their room. Staff B, RN replied, Residents are not able to keep razors in their rooms. When residents need to be shaved, the Certified Nursing assistants (CNA) gives the residents the razors and when done, places the used razor inside the sharps container. When I do rounds, I check to make sure the residents are safe. If there is a razor in the room, I remove it. On 11/18/24 at 9:26 AM Staff B, RN, was informed of shaving razors observed in Resident #46's room. Staff B, RN removed the razors and placed them into the sharps container located in resident's room and educated resident about safety. Record review of Resident #46's demographic face sheet revealed the resident was admitted on [DATE] with diagnosis that included: Angina Pectoris. Review of a Quarterly Minimum Data Set (MDS) with reference dated 11/7/24 Section C (Cognitive) revealed a Brief Interview for Mental Status score of 14 indicating no cognitive impairment. Section E (Behavior) revealed no potential indicators of psychosis, no wandering, no rejection of care. Section GG (functional status) revealed Resident #46 was independent with personal hygiene which included shaving. Record review of a Care Plan that started on 11/7/24 revealed Resident #46 was a hoarder and hoards items on his bed and in bathroom/throughout his side of the room with a goal of having fewer episodes of hoarding items by the next review date. Interventions included: Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. During an interview on 11/21/24 at 10:50 AM, the Director of Nursing (DON) was asked about resident's safety related to shaving razors. The DON stated: Whenever a resident needs to be shaved the CNAs and nurse are responsible for providing the shaving razors and disposing them into the sharps container. No residents are allowed to keep shaving razors in the room for safety of the residents and staff. Record review of the facility's policy titled, Safety Precautions Nursing Services effective date 11/30/2014 no revision date Policy: Safety precautions for the nursing units shall be followed by all personnel involved in the provision of nursing care. Procedure: 1. Follow established policies and procedures for discarding used needles, syringes, and all sharps. Do not bend, break or recap needles. Discard needles only in specified impenetrable storage container. Do not overfill storage, change when necessary.

Based on observation, record review and interviews, the facility failed to administer oxygen as prescribed for one resident (Resident #83) out of eight sampled residents, as evidenced by observations of Resident #83 without oxygen in progress. The findings Included: During an Observation on 11/19/24 at 9:31 AM Resident #83 was lying in bed with eyes closed; the there was a nasal cannula on top of a pillow next to the resident and the oxygen concentrator at bedside was running at 2 liters per minute (L/min). On 11/19/24 at 9:31 AM am an interview was held with Resident#83's daughter and who revealed the resident#83 doesn't require continuous oxygen. On 11/20/24 at 2:48 PM Resident #83 observed in the dining room area participating in activities with no oxygen in progress. Record review of Resident #83's demographic face sheet revealed an admitted [DATE] and Readmission of 10/31/2024 with diagnosis that included: Heart Failure, Cerebrovascular Disease, unspecified/Pleural Effusion. Review of Resident #83's Physician Orders revealed an order for: Oxygen at a rate of two Liters per minute (L/min) every shift. Review of a Care Plan initiated on 7/30/24 Revised on 11/20/2024 revealed Resident #83 had altered respiratory status/difficulty breathing: with a goal to have no signs or symptoms of poor oxygen absorption through the review date. The interventions included: Oxygen setting: Humidified O2 via nasal cannula at 2 L/min continuously. Record review of a Quarterly Minimum Data Set (MDS) revealed in Section C (cognitive status) documented a Brief Interview for Mental Status score of 7 out of 15 indicating moderate cognitive impairment. On 11/21/24 at 4:03 PM Staff D, Registered Nurse (RN) stated, [Resident #83] was discharged and left with oxygen at 2 L/min via nasal cannula. I have observed this resident (#83) removing the nasal cannula because she is confused. The times I observed [Resident#83] without the nasal cannula in place, I immediately replaced it. I didn't report this because the resident remained in stable condition. The oxygen was ordered for continuous for [Resident#83]. A Nursing Note dated 11/21/24 at 3:30 PM revealed Resident #83 was discharged home, left stable, O2 saturation was 97%. The documentation did not include that resident left with O2 via nasal cannula in progress. On 11/21/24 at 4:12 PM Staff C, Certified Nursing Assistant revealed that upon initial rounds Resident #83 was in bed with eyes closed and no oxygen was in progress. Also stated, I don't know if [Resident#83] was to wear her oxygen at all times. On 11/21/24 at 4:51 PM the Assistant Director of Nursing stated, If there is an order for continuous oxygen there is a concentrator in the room and the tubing is changed weekly. If the resident is not using the oxygen it is maintained in a plastic bag in the room. A doctor might give an order to wean a resident off oxygen. If there is an order for continuous oxygen the resident should not be without it except during personal care. The oxygen care plan should match the order. When a resident is observed removing the nasal cannula the nurse should notify the doctor and it should be documented, and they should test the oxygen saturation. The floor nurse is responsible for making staff members aware which residents require oxygen continuously. Record review of a policy, titled, Oxygen therapy effective date 11/30/24 revised on 8/28/17 indicated: Start O2 flow rate at the prescribed liter flow or appropriate flow for administration device. Place delivery device on resident.

Based on observations, record review and interviews the facility failed to properly store medications for four residents (Resident #53, Resident #313, Resident #314, and Resident #315) and one medication cart out of three sampled medication carts as evidenced by pills, eye drops, ointments and nasal sprays at the bedside of residents and an expired Moxifloxacin eye drop on the North 2100 medication cart. There were 110 residents residing in the facility at the time of recertification survey. The findings included: Observation on [DATE] at 9:29 AM revealed a tubing labeled, Triamcinolone at Resident # 53's bedside (photo evidence). On [DATE] at 9:50 AM two eye drops were observed at Resident #313's bedside. (photo evidence) On [DATE] at 10:26 AM two eye drops, a nasal spray and two small circular pink colored pills inside a cup were observed at Resident # 314's bedside. (photo evidence). On [DATE] at 9:56 AM an ointment and two nasal sprays were observed at Resident #315's bedside. (photo evidence). On [DATE] at 10:31 AM, the Assistant Director of Nursing (ADON) was asked what the facility's protocol was related to medications in residents' rooms. The ADON revealed residents are not able to keep medications or ointments in their rooms; when medications are seen in a resident's room the nurse should remove them and educate both residents and family. The ADON was informed about the medications observed at the residents' bedside. The ADON accompanied the surveyor to each residents' room (#53, #313, #314 and 315) and removed the medications, disposed of the pills into a drug buster and stored other medications in medication room and educated each resident (#53, #313, #314 and 315). On [DATE] at 9:43 AM Staff F, RN was asked if any residents are allowed to keep medications at the bedside. Staff F, RN stated, Residents are not allowed to keep medications at the bedside. I check during rounds to make sure there are no medications left at the bedside. The surveyor made Staff F, RN aware that a resident had ointments and nasal sprays at bedside. Staff F, RN entered Resident # 315's room and removed the ointments and nasal sprays and educated the resident. On [DATE] at 3:27 PM a medication storage check was completed with Staff E, Registered Nurse (RN) on The North 2100 medication cart. One eye drop (Moxifloxacin Sol HCL) was in the top drawer with an open date of [DATE] (photo evidence). Surveyor asked what the expiration date was. Staff E, Registered Nurse (RN) revealed he did not know the expiration date and will check with pharmacy. On [DATE] at 9:18 AM, the Pharmacy consultant stated, The Moxifloxacin Sol HCL eye drop has the suggested expiration of 28 days, but it can be used for up to 30 days. The eye drop was one day expired and shouldn't be on the cart. Interview on [DATE] at 10:44 AM, the Director of Nursing (DON) was asked about the facility's policy related to medication storage. The DON stated: Medications are kept in the medication room and medication carts. The medication carts and rooms are locked, and the nurse keeps the key for the safety of the resident. Residents are not allowed to keep medications in their rooms. The nurse does an inventory with the Certified Nursing Assistant (CNA) upon admission and if any medications are found they are removed immediately. The nurse is to make frequent rounds with CNA to look for any medications at the bedside and should remove them immediately and educate residents and family that no medications should be brought to facility. Expired eye drops should be removed immediately from cart. Every nurse every shift are in charge of checking their cart to ensure no expired eye drops are in the cart. Record review of a policy titled, Medication Storage in the facility [DATE] Policy: Medications and biologicals are stored safely, securely and properly, following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, record review and interviews, the facility failed to follow infection control protocol in the laundry room. As evidenced by observation of lint traps that were not cleaned, the lint log indicated lint traps were cleaned every two hours and was signed daily at 5:00 AM although laundry staff start at 6:00 AM. The findings included: On 11/21/24 at 11:00 AM a laundry tour was conducted with Maintenance and Housekeeping Director, Staff A, Laundry staff. During the tour, there were two working dryers with 75-pound capacity each. The surveyor asked if there was a lint log kept in the laundry room to indicate when the traps were last cleaned. The Maintenance and Housekeeping Director stated, There is a lint log to show when staff clean the traps. The Maintenance and Housekeeping Director gave the surveyor a lint log sheet. The Lint log was reviewed, and it was noted that it was last signed at 7:00 AM on 11/21/24 (photo evidence). Both dryers were in progress. The Maintenance and Housekeeping Director opened the dryers and both lint traps were noted to be full of lint. When asked how often lint was removed and lint log signed. The Maintenance and Housekeeping Director stated: The laundry staff start at 6:00 AM and are required to sign every two hours, each time they clean the traps. The surveyor asked at what time were the lint traps last cleaned. Staff A, Laundry staff replied, I cleaned the lint traps at 9:00 AM and forgot to sign at 9:00 AM. Staff A was asked if anyone was in the laundry room at 5:00AM. Staff A, Laundry staff replied, I start work at 6:00am and signed for 5:00am by mistake. The Maintenance and Housekeeping Director stated, No one is here at 5:00 AM. The staff have been signing for 5:00 AM this month because this is an old paper, and they are used to it. Record review of the facility policy titled, Departmental (Environmental Services)-Laundry and Linen Med Pas, Inc Revised January 2024. Purpose: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen.

Based on observations, record reviews, and interviews, the facility failed to treat one resident (Resident #18) out of one resident with dignity and respect who was observed during dining, as evidenced by staff member standing while feeding the resident. This deficient practice had a potential to affect the health and wellbeing of all 39 residents who are dependent with eating. The findings included: Observation of resident #18 on 08/06/2023 at 12:34PM revealed, the resident sitting up in bed, Staff A, Certified Nursing Assistant (CNA) started to set up the lunch tray and open containers. Staff A was observed feeding the resident and standing by the resident's bed. Interview with Staff A, (CNA) on 08/06/2023 at 12:45 PM. She stated that she never grabs a chair and sits to feed the resident. She stated it doesn't matter if she's standing when feeding the resident. Record review of Demographic Face sheet revealed, resident # 18 was admitted on [DATE] and discharged on [DATE] with diagnoses to include Metabolic Encephalopathy; Major Depressive Disorder, Single Episode; Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. Record review of Admission Minimum Data Set (MDS) Section C-Cognitive Status dated 07/12/2023 revealed, the resident Brief Interview for Mental Status (BIMS) summary score was 06 out of 15, indicating severe cognitive impairment; Section G-Functional Status revealed the resident needed limited assistance for bed mobility, dressing and eating. The resident needed extensive assistance with one-person physical assistance for transfer, locomotion, toilet use and personal hygiene. Record review of Care Plan initiated on 07/05/2023 and the next review date 10/12/2023 revealed, the resident had and Activities of Daily Living (ADL) self-care performance deficit related to weakness, metabolic encephalopathy. Goal: The resident will improve current level of function in ADLs through next review date. Interventions: Bed Mobility: the resident required assistance by one staff member to turn and reposition in bed as necessary, Encourage the resident to fully participate if possible with each interaction. Praise all efforts at self-care. Encourage the resident to use the bell to call for assistance. Interview with Staff B (CNA) on 08/09/2023 at 10:46 AM. She stated, the protocol to feed the residents, is to be seated at the same level as the residents and feed them. She stated, for resident # 18 she takes the resident to the dining room to be more comfortable for lunch or dinner. She stated, if she must feed the resident in bed, she grabs a chair and sits to be at the same level as the resident. Interview with the Director of Nursing (DON) on 08/09/2023 at 10:46AM revealed, the Certified Nursing Assistants (CNAs) receive orientation training when they were hired. In the training the CNAs were trained with the protocol for feeding the residents, to grab a chair and be seated to be at the same level as the resident in a dignified manner. She stated, the CNAs when they were hired, they were following the prior hired CNAs to see the process with care. After those days of training, if the CNAs required more training, the facility gave it to them. The DON reported, Staff A had a 1:1 teachable moment on Monday 08/07/2023. Review of the facility's Policies and Procedures for Residents rights dated 03/01/2021 revealed, the Policy: It is the policy of the facility to provide Resident Rights in accordance with State and Federal regulations. Procedure: The facility will follow the Resident Rights as follows: 1-The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on interview and record review, the facility failed to electronically transmit the Quarterly Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) System within 14 days after completing the resident's assessment for one out of one sampled resident (Resident # 43 ) reviewed for timely submissions of resident assessments. Findings included: Review of the resident #43's MDS Quarterly assessment revealed a completion date of 05/10/2023 but the MDS had not been submitted. During an interview with Staff C, the MDS Coordinator, on 08/09/23 at 09:38 AM, Staff C stated, What happened is someone put do not submit. I've only been here since March 2023. The person that was before me, always put do not submit or maybe that's how the system was set up. I don't know why they do that. Maybe because the resident was Medicare Part A, and he changed his insurance to another insurance. I don't know what really happened. Up here it says do not submit to CMS. It was completed. I'm going to submit it now. On 08/09/23 at 09:53 AM, a review of the resident MDS Quarterly assessment completed on 05/24/2023 revealed, a submission and accepting date of 08/09/2023. Review of the MDS policy and procedures with an effective date 11/30/2014 and a revision date 09/25/2017 revealed: Policy: The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses and preferences using the federal and/or state required RAI (Resident Assessment Instrument). Procedures: Maintain all resident assessments completed within the previous 15 months in the resident's active clinical record or in a centralized location that is easily and readily accessible. Specified section of the RAI process are completed by the center designated interdisciplinary team members. Each person completing a section or portion of a section of the MDS signs the attestation statement indicating its accuracy. A Registered Nurse signs and certifies that the assessment is complete.

Based on observation, interview, and record review, the facility failed to follow pharmaceutical procedures for Residents (#44, #295) as evidenced by medications being left on the overbed table for Resident #44, Omission of one (1) medication for Resident #295 during the medication administration observation and two (2) loose pills found in the medication drawer of North Station 2100 Hall cart. Three residents were observed for medication administration totaling 29 opportunities. Three medication carts and One medication storage room was observed. There were 116 residents residing in the facility at the time of the survey. The Findings included: During an observation on 08/06/23 at 12:17 PM, Resident #44 was observed in the room about to have lunch, several pills observed in a medication cup on the resident's overbed table (Photographic evidence obtained). Resident #44 was unable to communicate properly, has a speech impediment, is hard of hearing and speaks primarily Spanish. Resident #44 refused to be interviewed by the surveyors. Review of the medical records for Resident # 44 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Unspecified Hearing Loss. Record review of Resident #44 's Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C - Brief interview for Mental Status Score 15 on a 0-15 scale indicating the resident is cognitively intact. Section G for Functional Status documented the resident requires supervision for activities of daily living (ADLs). Interview on 08/08/23 at 12:15 PM with the Director of Nursing (DON) revealed when told about the medications observed in the resident's room on the overbed table stated, I will do an in-service with the nurses about this issue. This resident is not allowed to take his medicine on his own. The DON was shown the picture taken of the pills on the overbed table in Resident#44's room. During the medication administration observation on 08/07/23 at 9:55 AM with Licensed Practical Nurse (Staff D) the medication Nifedipine Extended Release (ER) 30 Milligrams (MG) 1 tablet was not given to Resident #295, the medication was available but couldn't be crushed since it was an extended release tablet. Interview/observation on 8/7/23 at 10:05AM with Staff D, Licensed Practical Nurse recorded the resident's Blood pressure 118/45, dispensed medications from the bingo cards, crushed all the resident's medications, mixed with apple sauce, proceeded to enter resident's room to give the resident medications. The Surveyor requested the nurse to return to medication cart. Staff D was asked to check the Nifedipine ER 30 MG tablet, Staff D stated the ER means extended release and the medication can't be crushed, Staff D stated, he will have to prepare the medications over again because they were all mixed up and afterwards call the Physician (MD) for new orders for the medication. Staff D proceeded to dispense new medications for the resident, crushed the medications, added apple sauce, disposed of the initially crushed medications into a drug buster, entered the resident room, identified the resident, completed hand hygiene, administered the medications, removed the lidocaine patch from the resident's lower back, applied another lidocaine patch initialed and dated the patch on the resident's lower back, repositioned the resident for comfort, washed his hands, exited the room, and signed off on the medications administration. Review of the medical records for Resident #295 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Essential Primary Hypertension, Chronic Systolic Congestive Heart Failure, and Presence of Cardiac Pacemaker. Review of the Physician's Orders Sheet for August 2023 revealed, Resident #295 had orders that included but were not limited to: Discontinued on 8/7/23 Nifedipine ER 30 MG-give 1 tab by mouth every 12 hours for hypertension Hold if systolic blood pressure less than 110 or pulse less than 70. Start date 8/7/23, discontinue 8/8/23 Amlodipine 10 milligrams (MG)-give 1 tablet by mouth one time a day, hold if systolic blood pressure less than 110. 8/9/23-Amlodipine Besylate Oral tablet 10 MG-Give 1 tablet by mouth one time a day for hypertension, hold for systolic Blood pressure less than 110 and diastolic blood pressure less than 60. Interview on 8/7/23 at 10:48 AM with the Director of Nursing (DON) revealed, the Physician (MD) was called about the residents Nifedipine ER 10 MG ER, and the MD changed the order to Amlodipine 10 mg, 1 tablet, the medication was obtained from the e-kit and administered to the resident. On 08/08/23 at 10:54 AM during the medication cart observation with Registered Nurse (Staff E), Two (2) loose pills, one (1) red in color and one (1) white in color were found in the third drawer on the North station 2100 medication cart. Interview on 08/08/23 at 11:00 AM with Staff E revealed, when asked what you do with loose pills when found on the cart, Staff E stated I will put them in the drug buster. Interview on 08/08/23 at 11:25 AM with the DON, when told about the loose pills and the nurse's response of how to dispose of loose pills, stated I will talk to the nurse and will have to do an in-service with her. Interview on 08/08/23 at 11:38 AM Director of Nursing (DON) and Staff E spoke with surveyor, stated there was a language communication issue, the nurse meant she disposes the medication in the drug buster, the nurse speaks primarily Spanish. Review of the facility's Policy and Procedures titled, Administering Medications revision date April 2019 states: Residents may self-administer their own medications only if the attending physician in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the facility's Policy and Procedure titled, Medication and Medication Supply Storage and Disposal dated 11/30/14 states: Medication will be stored in an organized manner under proper conditions and in accordance with manufacturers instructions.

Based on observation, record review and interview, the facility failed to ensure a resident was free of a significant medication error, as evidenced by Resident #295 Extended Release (ER) blood pressure medication being crushed by the nurse to be administered to the resident during the medication administration observation. Three residents were observed during medication administration totaling 29 opportunities. There were 116 residents residing in the facility at the time of the survey. The findings included: During the medication administration interview/observation on 8/7/23 at 10:05AM with Staff D, Licensed Practical Nurse recorded the resident's Blood pressure 118/45, dispensed medications from the bingo cards, crushed all the resident's medications, mixed with apple sauce, proceeded to enter resident's room to give the resident medications. The Surveyor requested the nurse to return to medication cart. Staff D was asked to check the Nifedipine ER 30 MG tablet, Staff D stated the ER means extended release and the medication can't be crushed, Staff D stated, he will have to prepare the medications over again because they were all mixed up and afterwards call the Physician (MD) for new orders for the medication. Staff D proceeded to dispense new medications for the resident, crushed the medications, added apple sauce, disposed of the initially crushed medications into a drug buster, entered the resident room, identified the resident, completed hand hygiene, administered the medications, removed the lidocaine patch from the resident's lower back, applied another lidocaine patch initialed and dated the patch on the resident's lower back, repositioned the resident for comfort, washed his hands, exited the room, and signed off on the medications administration recrd. Review of the medical records for Resident #295 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Essential Primary Hypertension, Chronic Systolic Congestive Heart Failure, and Presence of Cardiac Pacemaker. Review of the Physician's Orders Sheet for August 2023 revealed, Resident #295 had orders that included but were not limited to: Medications included: Discontinued 8/7/23 Nifedipine ER 30 MG-give 1 tab by mouth every 12 hours for hypertension Hold if systolic blood pressure less than 110 or pulse less than 70. Start date 8/7/23, discontinue 8/8/23 Amlodipine 10 milligrams (MG)-give 1 tablet by mouth one time a day, hold if systolic blood pressure less than 110. 8/9/23-Amlodipine Besylate Oral tablet 10 MG-Give 1 tablet by mouth one time a day for hypertension, hold for systolic Blood pressure less than 110 and diastolic blood pressure less than 60. Interview on 8/7/23 at 10:48 AM with the Director of Nursing (DON) stated the Physician (MD) was called about the residents Nifedipine ER 10 MG ER, MD changed the order to Amlodipine 10 mg, 1 tablet, the medication was obtained from the e-kit and administered to the resident. Review of the facility's Policy and Procedures titled, Medication Oral Administration revision date 05/15/2019 states: Review physician orders and refer to pharmacist if unsure if a medication should be crushed. Review of the facility's Policy and Procedures titled, Administering Medications revision date April 2019 states: Each Nurses' station has a current Physician Desk reference and/or other medication reference as well as a copy of the surveyor guidance for 755-761 (pharmacy services) available.

Based on record review and interview, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F640 Encoding/Transmitting Resident Assessments and F755 Pharmacy Services/Procedures/Pharmacist/Records. This practice has the potential to increase the risk of negative resident outcomes and affect all 116 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed, during a recertification survey with an exit date 07/28/2022, Encoding/Transmitting Resident Assessments was cited related to the facility failed to timely transmit an Minimum Data Set (MDS) assessment for one resident reviewed for timely submissions of resident assessments and failed to provide pharmacy services to meet the needs of the residents. Review of the facility's policy titled, Performance Improvement Quality Assurance/Quality Improvement (QAPI) Policy and Procedure with the revision date of 10/29/2020, the policy documented: The center and organization have an ongoing Performance Improvement Program with a design and scope that is ongoing and comprehensive dealing with a full range of services offered by the center that addresses aspects of care. The design and scope of the program is to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified problems and identify opportunities for improvement. During an interview on 08/09/2027 at 03:28 PM, the Administrator revealed that the Quality Assessment and Assurance Committee (QAA) meets the third Wednesday of every month. The administrator stated that the QAA Committee is comprised of the following members: the Director of Nursing Services, Administrator, Medical Director, Business Office Manager, Registered Dietitian, Environmental Director, Maintenance Director, the heads of all departments, and two regular staff members to include one nurse and one CNA. The last meeting was conducted 7/19/2023 and before that 6/21/2023. The meeting was conducted with all required members and they reviewed the last 6 months of QAPI. Regarding quality concerns, Nursing Home Administrator further stated, we are working on a Performance Improvement Plans (PIP) right now for falls. We are aware of the call light issue because it is attached to falls. We did a QA on 6/26/2023 all the call lights were working. On 6/23/2023, we did a QA where the call light on room [ROOM NUMBER] was not working. We also got a QAPI forms from each department. We also review psychotropic medication for each resident. On 6/19/2023, we had a grievance on call lights. We continue to do audits on call lights. For June 2023, we had discussed call lights, the falls committee met every 2 weeks. In addition, we had a meeting on changing the mattresses so the residents can have good mattresses to sleep. We continue training CNAs about answering the call lights and how to reduce falls. Regarding corrective actions taken, the Nursing Home Administrator stated, We review all medications and meet with the pharmacy to see how we can correct medications issues. We continue to do rounds, continue to check the mattresses. We check them weekly, and the nurses do them daily. The CNAs get educated and observed when we do rounds, so they can improve their communication with our residents. We do have less staff during the weekends, but we still do activities. We also use the 24-hour communication log so the nurses can be aware of the issues. We reviewed the issue, met with the pharmacy. Continued to do rounds, to check the mattresses. For example, since we started doing that, I can talk about the call lights and falls because right now I can see a decrease from falls. We do stop and watch. We have some forms that family members can report any issue or concerns. We prioritize all the issues that are arisen. The highest priorities right now are falls. We work on all the issues, so we don't leave anything behind. We look at any intervention we did before, what we had implemented, and see how the trends are going. We also base it on the data we collect. We keep track of trends. Right now, we know what we implemented for falls is working because there is big decline on falls. Call lights are monitored twice daily. If something is out of compliance, we monitor it for a minimum of 3 months or until the compliance is met. Our falls have been monitored for 9 months now. We want to make sure we don't have any repeated citation.

Based on record review and interview the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. There were 111 residents residing in the facility at the time of the survey. The Findings included: Resident #4 was investigated as part of complaint investigation # 2022017006 On 6/27/23 at 9 AM Record review of the Agency for Healthcare Administration (AHCA) Immediate Report #168319 documented: Date of Incident was 10/27/22. Report Filed 11/1/22 at 11:30AM. Type of Incident-Misappropriation of resident property Description of Incident Alleged Perpetrator: Registered Nurse (Staff A) Allegation Details: On 10/27/22 at 11:30am Resident #4 requested her prescription for pain oxycodone 5 Milligrams (mg) Twice a day (BID) due to a Joint Replacement Surgery. Registered Nurse (Staff B) assigned to resident at the time discovered that the resident's medication was not in the Medication Cart. Registered Nurse Staff A was called via telephone, he replied I messed up, I have it here at home, followed by I thought it was discontinued. The Unit Manager Licensed Practical Nurse (Staff C) was notified on 10/27/22@ 11:30am, former Director of Nursing (Staff D) was notified on 10/27/22 @ 1:30pm, former Executive Director (Staff E) was notified on 10/27/22 @2:12pm. Allegation Details (Outcome)- No physical harm, pain, or mental anguish was done to the alleged victim. Notification to Law Enforcement: Law Enforcement was contacted on 11/1/22 @ 1:15pm. Notification to Department of Children and Family was on 11/1/22 at 2:10PM. Interview on 6/27/22 at 9:45AM with Nursing Home Administrator (NHA), stated I started working at this this facility on 10/31/22, the former NHA, Staff E was here and stayed for an extra two weeks, him and former Director of Nursing (DON) Staff D oversaw the investigation. From my recollection the Resident #4 was alleging that her pain medication was not given to her, an investigation started the nurse involved was called to the facility for investigation. I advised the former NHA Staff E to report the incident to AHCA. The incident occurred on 10/27/22 and it was reported on 11/1/22 to AHCA, DCF and the police Department. The nurse involved License was also reported to the nursing board. The nurse involved was suspended and later resigned from the facility. The resident was able to receive her scheduled pain medications from what we had in stock at the facility. The five-day investigation concluded no physical harm, pain or mental anguish was done to the resident. The complaint allegation of misappropriation of resident property was substantiated, the nurse was terminated and then he resigned. I am aware that the report should have been filed within two (2) hours of the alleged incident. Review of the medical records for Resident #4 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Aftercare following Joint replacement and Presence of left artificial knee joint. Resident #4 was discharged on [DATE]. Review of the Physician's Orders Sheet for October 2022 revealed Resident #4 had orders that included but not limited to: 10/23/22-10/28/22-Oxycodone HCI tablet 5 Milligrams (MG)-Give 1 tablet by mouth every 4 hours as needed for pain. 10/28/22-11/2/22-Tylenol with codeine #3 tablet 300-30MG-Give 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident # 4's Discharge Return not anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 13 on a 0-15 scale, indicating the resident is cognitively intact. Section J for Health conditions documented the resident received scheduled pain medications in the last 5 days. Section N for Medications documented the resident received antidepressants, and antibiotics in the last 7 days. Record review of Resident # 4's Care Plans Dated 10/24/2022 revealed: The resident is at risk for pain related to arthritis, left total Knee Replacement. Interventions included: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Monitor and document the side effects. Provide the resident with assurance that pain is time limited. Review of the discharge summary progress note for Resident #4 dated 11/02/2022 timestamped 13:53 documented Patient went home with son, vital signs were stable, patient was alert, certified Nursing Assistant assisted patient to the vehicle. Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation revision date 11/16/2022 states: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrence of resident abuse. Misappropriation of resident property is the deliberate misplacement, exploitation or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent. Employee Misappropriation includes but is not limited to: o Diversion of resident's medication(s), including, but not limited to, controlled substances for staff use or personal gain. Reporting/Response Any employee or contracted service provider who witness or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with state law.

Based on interview and record review, the facility failed to provide adequate supervision to ensure the safety of vulnerable residents and to prevent falls that resulted in major injuries for two (Resident number 1, Resident number 2) out of three residents reviewed for falls. Resident number 1 sustained a left hip hemiarthroplasty posterior approach, secondary to left femoral neck fracture and Resident number 2 sustained a displaced nasal bone fracture. This practice has the potential to affect all 107 residents present in the facility at the time of the survey. The findings included: 1) Record review of the facility's Lifting and Moving Residents Policy and Procedure (effective November 2014) documented the following: Policy-All residents will be assessed before attempting a transfer or move. Employees will employ proper body mechanics when lifting or moving residents to prevent a resident fall; Procedure: 1) Asses the resident's condition and mobility (Determine if resident has been designated as a 2 or 4 person lift), c) Strength/Endurance: Will fatigue and/or lack of strength prevent the resident from completing a transfer, d) Balance: Does the resident have a tendency to fall or lean to one side or have muscle spasms?, g) Lifting Aids: Are Hoyer Lifts or Gait Belts beneficial or required for transfer?; 2) Get help if at all in doubt about your ability to move the resident alone. Use resident transfer equipment as required. (Do not attempt to lift any resident alone that has been designated as a 2 or 4 person lift). Review of the facility's Fall Management Policy and Procedure (effective November 2014) documented the following: Overview-Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. A fall refers to unintentionally coming to rest on the ground, floor or other lower level but not as the result of an overwhelming external force; Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury; Process: A) Fall Mitigation: 1) Residents to be evaluated for fall risk on admission, B) Fall Mitigation Strategies: 1) Develop resident centered interventions based on resident risk factors. Observation and interview of Resident number 1 on 3/28/23 at 12:24 PM revealed the resident sitting in a wheelchair in her room, watching tv and eating CHO [Consistent Carbohydrate] Controlled, No Added Salt diet, Mechanical Soft texture lunch. She revealed via a Spanish translator that she was being transferred from the wheelchair to the bed by one cna (certified nursing assistant). The one cna could not transfer her and went and got 2 cnas to transfer her. In the process her left foot was crossed and she had pain on her left hip. Review of the Demographic Face Sheet for Resident number 1 documented the resident was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease, encounter for other orthopedic aftercare, diabetes mellitus, acute kidney failure, morbid obesity, hypertension, depression and presence of left artificial hip joint. The resident was discharged to the hospital on 3/19/2023 and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Admission Assessment for Resident number 1 dated 3/10/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 10 out of 15 indicating mild cognitive impairment. The resident required extensive assistance with two+ persons physical assist for ADLs (Activities of Daily Living) and total dependence with two+ persons physical assist for transfers and impairment on one side for the lower extremity. Review of the Physician's Order Sheets (POS) for Resident number 1 dated March 2023 documented the following: Temazepam Oral Cap (capsule) 30 mg (milligrams) 1 cap PO (by mouth) HS (at night) for insomnia, Insulin Lispro 100 unit/ml (milliliters) Solution pen-injector inj (inject) per sliding scale for diabetes mellitus, Abilify oral tab (tablet) 20mg 1 tab PO one time a day for mood disorder, Enoxaparin Sodium Injection Solution Prefilled Syringe 30mg/0.3ml inj 30ml subq (subcutaneous) one time a day for dvt (deep vein thrombosis) prophylaxis, Bupropion HCL (hydrochloric acid) ER (extended release) oral tab 24 hour 300mg 1 tab PO one time a day for depression and the bed in low position. Review of Resident number 1's ADL Self Care Performance care plan dated 3/03/23 documented the resident was at deficit related to impaired balance, limited ROM (range of motion) and pain; Goal: Will improve current level of function in ADLs through the review date; Intervention: Transfer-The resident requires Mechanical Lift with 2 staff assistance for transfer. Review of the incidents/falls list dated February 2023-March 2023, documented that Resident number 1 had a fall on 3/18/23 at 6:00 PM. Review of the skilled progress notes for Resident number 1 documented the following: Dated 3/19/23 08:43-19:15pm making round pt (patient) stated was transferred from wheelchair to bed by 2 cnas on previous shift her L (left) foot was crossed and feeling pain on her L hip pt was informed will be medicated soon for pain, 19:30pm tramadol 50mg was given around, 19:35pm pt family member called the facility was informed the situation and also MD (medical doctor) will be called for STAT (immediately) L hip Xray order MD was called, order received. Portable Medical Xray was called around 12:30am L hip Xray was done upon rounds pt was sleeping easily with no complain awaiting for Xray result, around 5am pt was medicated for pain with effect, 7am Xray result received showed L hip dislocation MD notified order received to send pt out for further evaluation, daughter was also notified. Dated 3/19/23 09:00-General Progress Note: Resident received in bed on rounds without distress, c/o (complained of) pain to left hip r/t (related to) to hip dislocation. Resident transfer to hospital as per doctors order. Family member visiting accompanied resident. Review of Resident number 1's X-rays dated 3/19/23 documented the Hip X-ray Unilateral 2-3 views, Findings: There is left hip arthroplasty with superior dislocation. Review of the Nursing Home Transfer Form dated 3/19/23 for Resident number 1 documented the resident was sent to a local hospital on 3/19/23 and the reason for the transfer was a left hip dislocation. Review of the five day federal report for Resident number 1 documented the following: Resident requested CNA to be transferred from her bed to her wheelchair, CNA tried to do the transfer and was unable to. Resident had no strength in lower extremities, resident had a hip replacement. CNA called a second CNA to help her, resident was lowered to floor gently by both CNAs to avoid fall. A third CNA was called, and resident was transferred to her wheelchair. The facility reeducated related to transfers policy with competency to include transfer with gait belt, [mechanical lift] and sit to stand. Interview with Staff A, Certified Nursing Assistant (CNA) on 3/28/23 at 2:37 PM via telephone. She stated, The patient asked to be switched from the bed to the wheelchair and when she asked that I tried to do it on my own but I realized she was to heavy and went to go get my coworker and she sat back on the bed. Me and my co-worker tried to switch her to the wheelchair and we gently lowered her to the floor due to her having no lower body strength. I have not worked with her often and when I realized it wasn't possible to transfer her, I sat her back on the bed. We had to get three workers to lift her back into the bed. She didn't speak of having any pain. Interview with Staff B, CNA on 3/28/23 at 2:43 PM. She stated, This was on a Saturday. The CNA [Staff CNA, A] came and asked me to put the patient in the wheelchair. When we came into the room, she was sitting on the bed. We proceeded to lift her and realized she had no lower body strength. When we realized we couldn't up lift her up, we gently placed her on the ground. [Staff CNA, A] went out to get [Staff D, CNA] the CNA to help. The resident was on the ground when [Staff D, CNA] grabbed her legs. I grabbed the back part of her and [Staff CNA, A] lifted up the middle part. We placed her on the bed. We asked her if there was any pain and she shook her head no. I worked with her before and she was able to move herself, she had lower body strength then. Interview with Staff C, Registered Nurse (RN) on 3/28/23 at 3:03 PM via telephone. She stated, The cna told me they were trying to transfer the patient from the bed to the wheelchair and the patient did not have enough strength and they lowered her to the floor. The patient started complaining of pain and I called the doctor and called the family to tell them what happened. The doctor said to transfer to her the hospital for an evaluation. The x-rays were done at the facility. She had a dislocation of the hip, no fracture. Interview with Staff D, CNA on 3/28/23 at 3:13 PM via Spanish translator. She revealed, it was on a Saturday. I was in another room and the other two cnas they were in the room helping the patient. They called me to come and help and I grabbed the patient by the legs to help put her back in the bed. The resident was already on the floor when I came into the room. I have worked with the patient before. When she is in bed, she will assist you and I can help her by myself but to transfer her I always need two people to help. Interview with Staff E, Licensed Practical Nurse (LPN) Unit Manager on 3/29/23 at 12:21 PM. She stated, When transferring a patient from bed to the wheelchair is based on the mobility of the patient. If they are extensive or more we have a stand up lift or a [mechanical lift] for the cna to use. If the care plan says the patient needs two persons to lift, it should be two persons to lift the patient. Interview with the Registered Nurse, Assistant Director of Nursing on 3/29/23 at 12:34 PM. She stated, If the patient needs two cnas, two have to be there before the transfer begins. They need to check the Kardex, the information is there to make sure the patient is able to assist or if the patient needs the [mechanical lift] lift. Interview with the Administrator on 3/29/23 at 12:36 PM. She stated, The resident came in for left hip replacement at the hospital and came in for rehab. Three cnas were trying to transfer her from the bed to the chair. Two of them put her on the floor and the other one came to help to put her back in the bed. The cnas are supposed to see the Kardex to see if the patient needs more than one to assist them. She sustained a dislocation of the hip. Review of the local hospital records dated 3/19/23 documented the resident had a left hip hemiarthroplasty posterior approach, secondary to left femoral neck fracture. 2) Closed record review of the Demographic Face Sheet for Resident number 2 documented the resident was admitted on [DATE] with a diagnoses to include arthritis, difficulty in walking, hemiplegia, blindness left eye, morbid obese, depression, hypertension and edema. The resident was discharged to the hospital on 3/14/2023. Review of the Minimum Data Set (MDS) Admission Assessment for Resident number 2 dated 3/06/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 13 out of 15 indicating no cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and transfers and impairment on one side for the upper extremity. Review of the Physician's Order Sheets (POS) for Resident number 2 dated February 2023 and March 2023 documented the following: Melatonin oral tab 5mg 1 tab PO HS for insomnia, Paroxetine HCL oral tab 40mg 1 tab PO in the morning for depression, Furosemide oral tab 20mg 1 tab PO one time a day for edema for 30 days, Apixaban Starter Pack oral tab Therapy Pack 5mg 2 tab PO every 12 hours for dvt and the bed in low position. Review of Resident number 2's ADL Self Care Performance care plan dated 3/08/23 documented the resident was at deficit related to generalized weakness, left upper extremity and hemiparesis; Goal: Will improve current level of function through the review date; Intervention: Toilet use and Transfer-The resident requires extensive assistance x (times) 1-2 staff. Review of the incidents/falls list dated February 2023-March 2023, documented that Resident number 2 had a fall on 3/14/23 at 9:05 AM. Review of the Adverse Log dated February 2023-March 2023 documented the incident occurred on 3/14/23 and an investigation was in progress. Review of the alert progress notes for Resident number 2 documented the following: Dated 3/14/23 12:06-Was called for help by the CNA in patient room. Pt was observed on the floor lying on the left side. Assessed patient. Patient noticed bleeding from nose, pressure applied. Observed swelling on nose and left side of the mouth. Observed skin tear to left upper arm, dressing applied. Assisted patient back to bed with help of CNAs and therapist. Pt was able to move all extremities with no pain. Rescue came and assessed patient. Patient was transferred to [local hospital] at 9:53AM. Son and daughter called twice, left message. Received call back from daughter at 10:47AM and I let her know about her mom clinical condition and transferred to [local hospital]. ARNP (advanced registered nurse practitioner) made aware. Interview with Staff F, CNA on 3/28/23 at 1:56 PM. She stated, I was the cna for the day this was my first time with her. After she finished the breakfast, I tried to clean her. I don't know if the mattress was a problem, the mattress was too big and the bed was too little. She was a big woman, well over 200 pounds. When I finished cleaning the face, I tried to turn her over to clean the back. I told her I was going to clean her back she said okay. I tried to hold her with my left hand and put the [adult brief] on with my right hand and then she fell over on the bed. After that I saw that the mattress was too big for the bed. I did not know that she needed more than one person to move her. She was bleeding in the face, then I called the nurse. Five people came in to move her back to the bed, one man and four women. I finished dressing her and the nurse called 911. Interview with Staff G, Registered Nurse (RN) on 3/29/23 at 8:04 AM. She stated, I was in the hallway passing medication and the cna came out of the room and asked me to help her. When I went in the room I saw the patient on the floor on the right side of the bed, she was laying on her left side. I assessed the patient to see if she had any injuries. I noticed she was bleeding from the nose and had a skin tear to the left side of the arm. We called for help, so we can put the patient back to bed. I checked the patient vital signs. I asked the cna and the patient what happened. The cna stayed with the patient. I went to the DON (Director of Nursing) to tell her what happened, then I called 911. I stayed with the patient while I was waiting for 911. I cleaned the skin tear and put a dressing on it. The doctor and the family was called to let them know what happened. She was obese and heavy. I am not really sure how many people needed to transfer her. Interview with the Administrator on 3/29/23 at 12:39 PM. She stated, The resident came in for rehab and as the cna was providing care to her the mattress was bigger than the frames. So, when the cna went to turn her over on the right the resident rolled off the bed and rolled off the bed. She had injuries from the fall, a fractured nose. Review of the Adverse Incident Report for Resident number 2 documented: Date of Incident: 3/14/2023, Incident Time: 0832; Incident Location: Patient Room; Equipment Involved: Yes; List Equipment Involved: Mattress/bed; Outcome: Fracture or dislocation of bones or joints; Investigation: Resident on 3/14/23 was receiving care by assigned cna. When cna rolled resident over she proceeded to roll off the bed onto the floor sustaining injury requiring transfer to hospital; Analysis: While turning over the resident during care she rolled out of bed. The mattress did not fit the bedframe; Corrective Action: Facility wide audit to ensure all bed frames have an appropriate sized mattress. Facility wide audit to evaluate bed for entrapment zones. Review of the local hospital records dated 3/14/23 documented the resident had a displaced nasal bone fracture with overlying soft tissue injury.

Based on record review and interview, the facility failed to implement a written care plan for activities of daily living (ADLs) related to transfers for two residents (Resident number 1, Resident number 2) out of three residents reviewed. Resident number 1 and Resident number 2 had a fall that resulted in major injuries. This practice has the potential to affect all 107 residents present in the facility at the time of the survey. The findings included: 1) Record review of the facility's Plans of Care Policy and Procedure (effective November 2014) documented the following: Policy-An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements; Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Observation and interview of Resident number 1 on 3/28/23 at 12:24 PM revealed the resident sitting in a wheelchair in her room, watching TV and eating CHO [Consistent Carbohydrate] Controlled, No Added Salt diet, Mechanical Soft texture lunch. She revealed via a Spanish translator that she was being transferred from the wheelchair to the bed by one cna (certified nursing assistant). The one cna could not transfer her and went and got 2 cnas to transfer her. In the process her left foot was crossed and she had pain on her left hip. Review of the Demographic Face Sheet for Resident number 1 documented the resident was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease, encounter for other orthopedic aftercare, diabetes mellitus, acute kidney failure, morbid obesity, hypertension, depression and presence of left artificial hip joint. The resident was discharged to the hospital on 3/19/2023 and readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) Admission Assessment for Resident number 1 dated 3/10/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 10 out of 15 indicating mild cognitive impairment. The resident required extensive assistance with two+ persons physical assist for ADLs (Activities of Daily Living) and total dependence with two+ persons physical assist for transfers and impairment on one side for the lower extremity. Review of the Physician's Order Sheets (POS) for Resident number 1 dated March 2023 documented the following: Temazepam Oral Cap (capsule) 30 mg (milligrams) 1 cap PO (by mouth) HS (at night) for insomnia, Insulin Lispro 100 unit/ml (milliliters) Solution pen-injector inj (inject) per sliding scale for diabetes mellitus, Abilify oral tab (tablet) 20mg 1 tab PO one time a day for mood disorder, Enoxaparin Sodium Injection Solution Prefilled Syringe 30mg/0.3ml inj 30ml subq (subcutaneous) one time a day for dvt (deep vein thrombosis) prophylaxis, Bupropion HCL (hydrochloric acid) ER (extended release) oral tab 24 hour 300mg 1 tab PO one time a day for depression and the bed in low position. Review of Resident number 1's ADL Self Care Performance care plan dated 3/03/23 documented the resident was at deficit related to impaired balance, limited ROM (range of motion) and pain; Goal: Will improve current level of function in ADLs through the review date; Intervention: Transfer-The resident requires Mechanical Lift with 2 staff assistance for transfer. Interview with Staff A, Certified Nursing Assistant (CNA) on 3/28/23 at 2:37 PM via telephone. She stated, The patient asked to be switched from the bed to the wheelchair and when she asked that I tried to do it on my own but I realized she was to heavy and went to go get my coworker and she sat back on the bed. Me and my co-worker tried to switch her to the wheelchair and we gently lowered her to the floor due to her having no lower body strength. I have not worked with her often and when I realized it wasn't possible to transfer her, I sat her back on the bed. We had to get three workers to lift her back into the bed. She didn't speak of having any pain. Interview with Staff B, CNA on 3/28/23 at 2:43 PM. She stated, This was on a Saturday. The CNA [Staff CNA, A] came and asked me to put the patient in the wheelchair. When we came into the room, she was sitting on the bed. We proceeded to lift her and realized she had no lower body strength. When we realized we couldn't up lift her up, we gently placed her on the ground. [Staff CNA, A] went out to get [Staff D, CNA] the CNA to help. The resident was on the ground when [Staff D, CNA] grabbed her legs. I grabbed the back part of her and [Staff CNA, A] lifted up the middle part. We placed her on the bed. We asked her if there was any pain and she shook her head no. I worked with her before and she was able to move herself, she had lower body strength then. Interview with Staff C, Registered Nurse (RN) on 3/28/23 at 3:03 PM via telephone. She stated, The cna told me they were trying to transfer the patient from the bed to the wheelchair and the patient did not have enough strength and they lowered her to the floor. The patient started complaining of pain and I called the doctor and called the family to tell them what happened. The doctor said to transfer to her the hospital for an evaluation. The x-rays were done at the facility. She had a dislocation of the hip, no fracture. Interview with Staff D, CNA on 3/28/23 at 3:13 PM via Spanish translator. She revealed, it was on a Saturday. I was in another room and the other two cnas they were in the room helping the patient. They called me to come and help and I grabbed the patient by the legs to help put her back in the bed. The resident was already on the floor when I came into the room. I have worked with the patient before. When she is in bed, she will assist you and I can help her by myself but to transfer her I always need two people to help. Interview with Staff E, Licensed Practical Nurse (LPN) Unit Manager on 3/29/23 at 12:21 PM. She stated, When transferring a patient from bed to the wheelchair is based on the mobility of the patient. If they are extensive or more we have a stand up lift or a [mechanical lift] for the cna to use. If the care plan says the patient needs two persons to lift, it should be two persons to lift the patient. Interview with the Registered Nurse, Assistant Director of Nursing on 3/29/23 at 12:34 PM. She stated, If the patient needs two cnas, two have to be there before the transfer begins. They need to check the Kardex, the information is there to make sure the patient is able to assist or if the patient needs the [mechanical lift] lift. Interview with the Administrator on 3/29/23 at 12:36 PM. She stated, The resident came in for left hip replacement at the hospital and came in for rehab. Three cnas were trying to transfer her from the bed to the chair. Two of them put her on the floor and the other one came to help to put her back in the bed. The cnas are supposed to see the Kardex to see if the patient needs more than one to assist them. She sustained a dislocation of the hip. 2) Closed record review of the Demographic Face Sheet for Resident number 2 documented the resident was admitted on [DATE] with a diagnoses to include arthritis, difficulty in walking, hemiplegia, blindness left eye, morbid obese, depression, hypertension and edema. The resident was discharged to the hospital on 3/14/2023. Review of the Minimum Data Set (MDS) Admission Assessment for Resident number 2 dated 3/06/23 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 13 out of 15 indicating no cognitive impairment. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and transfers and impairment on one side for the upper extremity. Review of the Physician's Order Sheets (POS) for Resident number 2 dated February 2023 and March 2023 documented the following: Melatonin oral tab 5mg 1 tab PO HS for insomnia, Paroxetine HCL oral tab 40mg 1 tab PO in the morning for depression, Furosemide oral tab 20mg 1 tab PO one time a day for edema for 30 days, Apixaban Starter Pack oral tab Therapy Pack 5mg 2 tab PO every 12 hours for dvt and the bed in low position. Review of Resident number 2's ADL Self Care Performance care plan dated 3/08/23 documented the resident was at deficit related to generalized weakness, left upper extremity and hemiparesis; Goal: Will improve current level of function through the review date; Intervention: Toilet use and Transfer-The resident requires extensive assistance x (times) 1-2 staff. Interview with Staff F, CNA on 3/28/23 at 1:56 PM. She stated, I was the cna for the day this was my first time with her. After she finished the breakfast, I tried to clean her. I don't know if the mattress was a problem, the mattress was too big and the bed was too little. She was a big woman, well over 200 pounds. When I finished cleaning the face, I tried to turn her over to clean the back. I told her I was going to clean her back she said okay. I tried to hold her with my left hand and put the [adult brief] on with my right hand and then she fell over on the bed. After that I saw that the mattress was too big for the bed. I did not know that she needed more than one person to move her. She was bleeding in the face, then I called the nurse. Five people came in to move her back to the bed, one man and four women. I finished dressing her and the nurse called 911. Interview with Staff G, Registered Nurse (RN) on 3/29/23 at 8:04 AM. She stated, I was in the hallway passing medication and the cna came out of the room and asked me to help her. When I went in the room I saw the patient on the floor on the right side of the bed, she was laying on her left side. I assessed the patient to see if she had any injuries. I noticed she was bleeding from the nose and had a skin tear to the left side of the arm. We called for help, so we can put the patient back to bed. I checked the patient vital signs. I asked the cna and the patient what happened. The cna stayed with the patient. I went to the DON (Director of Nursing) to tell her what happened, then I called 911. I stayed with the patient while I was waiting for 911. I cleaned the skin tear and put a dressing on it. The doctor and the family was called to let them know what happened. She was obese and heavy. I am not really sure how many people needed to transfer her. Interview with the Administrator on 3/29/23 at 12:39 PM. She stated, The resident came in for rehab and as the cna was providing care to her the mattress was bigger than the frames. So, when the cna went to turn her over on the right the resident rolled off the bed and rolled off the bed. She had injuries from the fall, a fractured nose.

Based on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to adequate supervision and a safe environment resulting in repeated deficient practice. The facility's history includes deficient practice for failing to supervise residents. The facility was cited for Free of Accident Hazards, Supervision and Devices in 2022. These repeated deficient practices has the potential to affect any of the 107 residents residing in the facility. The findings included: Review of the facility's policy titled, Quality Assurance Performance Improvement Program (QAPI) effective date was on 11/2014, documented the following: Policy: The Center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. The Quality Assessment and Assurance Committee (QAA) meetings are at least quarterly but may be held more frequently as appropriate. The committee members include, at minimum, the Medical Director, Executive Director, Director of Nursing, Infection Preventionist, Social Services Director, Community Life Director, Medical Records, Staff Development, Business Office, Director of Dining Services, Rehabilitation Manager and Pharmacy Consultant. The purpose of the Committee is to review and analyze facility related data and direct appropriate actions for the facility response. The appointment of a QAPI team may be necessary to explore the depth of the issue and identify the root cause so that interventions are appropriately resourced. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 1/18/23, 2/22/23 and 3/15/23: documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. On 3/29/23 at 12:50 PM, the Administrator stated, The QAA Committee meets monthly on the third Wednesday of the month. Committee members consist of the Administrator, DON, Medical Director and Department Heads. We have a QAPI tool for each department for anything that needs to be improvement or that was improved. The purpose of the QAA committee for us to know how we are performing facility wide, if we have any room for improvement or to make any changes or implementation of new policies that we encounter the same concern.

Based on observation, interview and record review, the facility failed to ensure food was stored and prepared under sanitary conditions, and dishes were cleaned and stored under sanitary conditions as evidenced by failure to ensure air conditioner (AC) vents directly above food preparation and storage areas and the dish room were clean and free of condensation and walls and ceiling in the dry storage room and the dish room were intact and free of loose peeling paint. This has the potential to contaminate the food and clean dishes. The has the potential to affect 94 residents who eat orally out of 99 residents residing in the facility at the time of the survey. The findings included: Observation in the kitchen on 07/25/22 at beginning 11:09 AM revealed staff placing hot food into the steam table in preparation to serve lunch. Observation revealed a heavy accumulation of a black colored substance and condensation on the air conditioner (AC) vents above the milk box which was open exposing cold food items, above the serving side of the steam table, and directly above food preparation table observed with clean utensils and an open box of plastic wrap. The wall in the hot food preparation area above the hood had an accumulation of dust. The staff was observed preparing food in this area. The A/C vent in the dry storage room where food was stored was observed with an accumulation of black colored residue. The wall in the dry storage room directly above the ready to eat condiment packages was observed to be cracked and the paint was peeling. Observation in the dish room at 11:56 AM revealed peeling paint on the ceiling directly above the soiled dish handling area. Observation above the area where the clean dishes exit the dish machine revealed the ceiling had some rust-colored spots. The ceiling had rough dry wall substance with areas that appeared loose. The surface was rough and uncleanable. Clean dishes were observed in a rack directly below the ceiling. The sprinkler heads in the dish room area were rust colored. Interview with the Dietary Supervisor (Staff J) on 7/25/22 at 11:55 AM revealed the only maintenance request she has pending is to repaint the wall behind the pot storage rack. I also requested that they paint the wall in the dry storage room. Staff J stated that maintenance is responsible for cleaning the AC vents and repairing the damaged walls. Interview with the Director of Maintenance on 7/27/22 at 11:59 AM revealed, I have a little system in my computer to track maintenance issues. I make rounds daily to check the water temperatures, exit signs, fire alarms, eye washing stations. When I tour the building, I also look for other environmental concerns. Usually, other maintenance concerns are reported to me by staff during my environmental rounds or they report to me by radio and concerns. We also have a maintenance work request form located at each station, but most of the time it is just reported to me verbally. If something is reported to me verbally, I just go and fix the problem. The system I created for myself includes preventative maintenance scheduled or completed. The AC vents are cleaned every two months. This includes the vents in the kitchen as well. We cleaned the AC vents in the kitchen yesterday. We also had to repair a crack in the wall in the dry storeroom. We have been working on the ceiling in the dish room. They had a hole in the ceiling covered by plastic. We continue to repair the ceiling in the dish room. I was not aware of any paint chipping in the dish room. Review of the facility policy and procedure titled Maintenance revealed: Policy: The facility's physical plant and equipment will be maintained through a program of preventative maintenance and prompt action to identify area/items in need of repair. Photos submitted

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the transmission of communicable diseases such as Coronavirus Disease 2019 (COVID-19). There were 99 residents residing in the facility at the time of the survey. The findings included: Upon entrance into the facility on Sunday, 7/24/2022 at 8:30 AM, the facility's Receptionist told the survey team that everyone did not need to go through the facility's full screening process and only one person needed to go through the full screening at the kiosk. All team members, temperatures were checked. On 7/24/2022, the survey team was provided a letter from the Nursing Home Administrator (NHA) that the facility had one COVID 19 positive resident. The resident was Resident # 93 and located on 2 North, 2300 wing. On 07/24/22 at 12:18 PM, while observing dining on the 2 North wing, the following was observed: On 7/24/2022 at 12:19 PM, Staff K, a Certified Nursing Assistant (CNA) was observed inside Resident #93's room, who was COVID 19 positive and on Transmission Based Precautions, Staff K had a mask on and did not have on proper Personal Protective Equipment (PPE). Staff K did not have on a gown, gloves and face shield. A PPE cart was observed outside the door of Resident #93's room. Resident #93's room had the proper signage on the door for Transmission Based Precautions. Staff K also left the room door open. On 07/24/22 at 12:27 PM, observed Resident #93's call light on, Staff K was observed to enter the room with a mask and gown. No face shield was observed on Staff K. The room door was left open. On 07/24/22 at 12:31 PM, Staff K, was observed to take Resident #93's lunch tray into the room. Staff K did not put on a gown, gloves or face shield prior to entering the room. Resident #93's lunch was served on a disposable Styrofoam tray and containers. On 7/24/22 at 1:30 PM, the Nursing Home Administrator (NHA) was informed about the staff observed not wearing proper PPE when going into Resident #93's room. The NHA reported that, staff should be wearing proper PPE and he would follow up. On 7/25/22 at 1:00PM, the NHA notified the survey team about an COVID 19 outbreak on the 2200 wing. He reported, this was possibly from a family member that had recently visited the facility and reported they tested positive for COVID 19. There were nine (9) new residents that had tested positive for COVID 19. On 7/26/22 at 7:30 AM, upon entrance to the facility, staff were observed entering the facility without masks on and were not being screened for COVID-19. No staff member was observed sitting at the front desk to ensure staff and visitors were properly screened for COVID-19 precautions. During an interview on 7/28/2022 at 2:15PM with the Director of Nurses (DON)/Infection Preventionist and Staff A, the Acting 2 South Unit Manager/Licensed Practical Nurse, it was reported that multiple infection control in-services had been given to staff to include: An Outbreak in-service for 7/25/22, PPE in-service on 7/1/22, 5/19/2022, Infection Control on 6/16/22, 4/13/22 and General Infection Control Practices on 3/10/22. The DON and Staff A were notified about the observations on 7/24/2022 for screening and on 7/24/2022 where Staff K did not wear proper PPE in Resident #93's room and about staff entering the facility without mask and without screening on 7/26/2022. During the review of the facility's COVID 19 Pandemic Plan dated 3/2/2020 and revised on 5/26/2022, it was determined the facility did not follow this Policy and Procedure. The following was not followed, . Procedure . 1. Employee's including contract employees, should be evaluated and observed at the beginning of each shift for signs and symptoms of COVID 19 (including temperature check) . 4. Healthcare personnel (including but not limited to, physicians, physician extenders, hospice providers, laboratory and radiology staff) will be screened and observed for COVID 19 signs and symptoms (including temperature check) . 14. Residents with suspected COVID-19: .Initiate Transmission based precautions per the CDC [Center for Disease Control] including PPE-N 95 or higher respirator, eye protection, gown and gloves . 2. Visitation - a. All visitors will be screened for signs and symptoms of COVID-19 (including questions about and observations of signs and symptoms and temperature checks)

Based on observation, interview and record review, the facility failed to ensure residents were free from physical restraints that are not required to treat the residents' medical symptoms for one (Resident # 11) out of one resident reviewed. Resident #11 was observed wearing the wrong trunk restraint and observed bed against and furniture blocking the opposite side of the bed that restricted freedom of movement. This has the potential to affect one resident with physical restraints out of the 99 residents residing in the facility at the time of the survey. The findings included: Observation on 7/24/22 at 12:37 PM, revealed Resident # 11 in the hallway in a wheelchair wearing a mesh vest type restraint which was placed over her shoulders extending down to her waste and secured with a click belt which restrained her trunk. Resident # 11 was not observed releasing the belt. Observation on 7/25/22 at 8:45 AM, revealed Resident # 11 in her room in bed. The privacy curtain was drawn all the way around the bed. The bed was pushed directly up against the wall. There was a large chair and a wheelchair pushed directly up against the other side of the bed. The chairs were touching the bed and blocking the full length of the side of the bed that was not against the wall. Resident #11 was observed lying on a scoop mattress. Observation on 7/25/22 at 9:57 AM revealed Resident # 11 in her wheelchair in the hall. Three staff were observed attempting to apply the mesh vest type restraint with the click belt around Resident #11. Resident # 11 was observed resisting and thrashing about in the chair. The staff removed the mesh vest and applied a Velcro ® belt that wrapped around the resident's waste and was secured closed with Velcro ® behind the wheelchair out of Resident # 11 's reach. Observation on 7/25/22 at 2:30 PM, revealed Resident # 11 in the hallway. The Velcro ® belt remained in place. Resident # 11 was observed trying to bend over and remove her socks, her shoes had already been removed. Observation on 7/26/22 at 9:19 AM, revealed Resident # 11 in her room in bed. The bed was in a low position with a scoop mattress. During this observation the bed was not pushed up against the wall and there was no furniture pushed up against the side of the bed. Observation on 7/27/22 at 4:54 PM revealed Resident # 11 near the nurses' station in her wheelchair with the Velcro ® belt in place. Resident # 11 was observed without shoes and socks, very anxious and making loud repetitive verbalizations. She was thrashing about in the chair and attempting to get up. Record review of the demographic face sheet revealed Resident #11 was admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #11's annual minimum data set (MDS) dated [DATE] revealed: Section C for cognitive pattern indicated the resident rarely/never understood, impaired memory, severely impaired decision making. Section D for mood indicators included feeling down, depressed, moving slowly, or being so fidgety or restless or that she has been moving a lot more than usual. Section E Behaviors included physical behaviors, verbal behaviors, and other behaviors not directed towards others. Section G for functional status indicated need for limited to extensive ADL (activities of daily living) assistance. Section for health status indicated J no falls. Section N for mediations included antipsychotic, antidepressant, antianxiety, and hypnotic use. Section O indicated no special treatments and Section P indicated Restraints - not used (not coded for use of trunk restraint in bed or out of bed. No bed alarms, no floor mats, no motion sensor alarms. Review of Resident #11's care plan revealed: Implemented 5/18/21, revised 6/17/22 Resident has limited physical mobility related to poor balance and coordination, unsteady gait, dementia progression, continuously bending forward when in wheelchairs. Intervention included: Velcro ® safety belt when in wheelchair to promote independent wheelchair mobility and to maintain upright seating position when in wheelchair (6/17/22) Implemented 5/18/20, revised 5/19/22. Resident has an ADL self-care performance deficit related to disease process, need assistance for all ADLs. Interventions included: Monitor for any signs or symptoms of decline in function due to use of Velcro safety belt. Implemented 5/18/20, revised 5/19/22. Risk for further falls related to gait /balance problems, history of falls, confusion, poor communication/comprehension, psychoactive drug use. Unaware of safety needs. Interventions included: soft Velcro ® safety belt when in wheelchair to maintain posture and independent wheelchair mobility to prevent falling forward out of chair. Scoop mattress on bed. Review of an initial restraint assessment dated [DATE] revealed the reason for use of the physical restraint was unsteady gait, agitated behavior, frequent falls, sliding out of chair/ wheelchair, attempts to self-transfer. Others: leans forward. Resident continuously leans forward while in wheelchair. She had falls out of chair due to leaning over too far forward. Alternative attempts to reduce risk of harm to resident or others prior to application of restraint: recliner, activities, alternate seating, regular toileting, wedge cushion, therapy. Alternatives did not work; resident continues to lean/bend over when in wheelchair due to cognitive impairment. IDT (interdisciplinary team), doctor and family agreed that a soft Velcro belt will be implemented to allow her to maintain independent wheelchair mobility, to maintain her seating posture in wheelchair to minimize risk of her falling forward in the chair. Review of a quarterly restraint assessment dated [DATE] revealed: Reason for use of physical restraint: agitated behavior, frequent falls, attempts to self-transfer, climbs out of bed. Resident continuously leans forward when in wheelchair. Resident is severely cognitively impaired, unable to ambulate or transfer, she has poor safety awareness, poor decision-making skills, and a longstanding history of falls from bed/chair. Alternatives in past quarter: increased restraint free episodes through day, family companion, 1:1 activities, high-low bed, regular toileting, anticipated hunger/pain, med review, blood work/labs, physical and occupational therapy, and Psych consult, None of the interventions were successful. Team recommends Velcro safety belt while in wheelchair. Family agreed with safety belt use. Review of the physician order sheet revealed Resident #11 had an order 8/3/21, discontinued on 2/3/22 and reordered 6/16/22 for a soft Velcro safety belt when in wheelchair to maintain posture and independent wheelchair mobility to prevent falling forward out of char. Review of the informed consent for use of physical restraint dated 8/3/21 revealed: I give my consent that Soft Velcro ® Belt restraint be used for the purpose of maintaining seating posture, maintaining independent wheelchair mobility, minimize risk of falls for (Resident #11). The consent was received via telephone from the responsible party on 8/3/21. Review of the informed consent for use of physical restraint dated 6/16/22 revealed: I give my consent that (blank) restraint be used for the purpose of maintaining seating posture, maintaining independent wheelchair mobility, minimize risk of falling forward out of wheelchair for (Resident # 11). Signed by responsible party 6/16/22. During an interview the Nursing Home Administrator (NHA) on 7/28/22 at 8:07 AM, revealed [Resident # 11] is my cousin. She has no family, and I am her responsible party. She is a handful. She has a lot of energy. She was initially admitted to the assisted living unit from home. She did not last long in assisted living as she started to have a cognitive decline. She was always wandering, and she wanted to go home. She was placed in the skilled unit. For two years to now the declines have been cognitive. She does not recognize me anymore. She grabs at everything; she is very flexible, and you will see her moving her legs up and all over the place. About a year and half ago she fell and fractured her hip. I wanted her to have a belt on because she is always grabbing onto to someone or something and without the belt she is at risk for falls. She has like an abdominal binder on that keeps her seated in the wheelchair. She is unable to release it so that is why it is considered a restraint. She is on medication for that fidgeting and the nervousness. She is good in bed, and she sleeps throughout the night. She does not try to get out of bed. She likes to sleep until around 9 or 10 am. All the incidents are when she is out of bed when she is constantly grabbing at everything. We do keep the bed in the lowest position, and I believe she has the scoop mattress to keep her safe. The bed could be up against the wall to help her not to fall but I do not believe they do this. If so, the other side of the bed is free. She has not had a fall from bed. I am aware that this belt is considered a restraint, but it is only used when she is up to the wheelchair. Interview with a Certified Nursing Assistant (Staff G, translated by Spanish speaking Licensed Practical Nurse (Staff F) on 7/28/22 at 10:11 AM revealed, Resident # 11 has a restraint. We try to speak to her in a way that she can understand but she is very confused. Emotionally she does not repeat anything, but physically she is always moving around and grabbing at everything. One minute she will be here and the next minute she will be grabbing on to the railings. The restraint we put on her is a belt. I do not know the name of the belt, but we put it over her the belly, insert it through slits in the wheelchair and then secure it in the back with the Velcro. She tries to remove pretty much everything, clothing items such as shoes and socks, but she cannot remove the belt. The reason they told me she needs the restraint is she is a fall risk, and she will try to get up. I work the 7-3 shift. [Resident # 11] usually gets up after breakfast, sometimes around 9 or so. Today she is still sleeping. I have never seen any type of bed restraints. We have to constantly keep going into the room. She is okay when sleeping but if she is awake, we have to get her up right away. She can get out of bed, but she is at risk for falls. She can walk but not without assistance. When I come in, I did not notice that the bed is up against the wall. She uses a special mattress and a regular wheelchair. Interview with a Licensed Practical Nurse (Staff H) on 7/28/22 at 1:42 PM revealed Resident # 11 at times becomes a little restless and she will hold on to objects really tight. She is not really aggressive, but she is always moving. She is very confused, and she came ambulate in the wheelchair about the unit. She also disrobes at times. She will try to go into other resident rooms, but she does not try to get out of the exits. She wears a belt due to previous falls; she is constantly trying to reach and tries to bend down. The belt helps assure she does not fall over. She has good flexibility. Sometimes she will cry but mostly she is just restless. The medications help. She takes both [MEDICATION(S)] and [MEDICATION(S)], and we monitor her behaviors and side effects. The only type of restraint device they use is the soft Velcro ® belt. This is the device the staff is supposed to use, and it is ordered by the doctor. The staff are not supposed to be using any other type of restraint. She should not have the vest type with the click belt. I work the 7 am - 3 PM shift. She is in bed when I make my rounds. We have to make sure her bed is low, so she does not get out of bed. We are not supposed to put the bed up against the wall and there should not be furniture against the bed. We cannot block her from getting up. She is able to get out of bed, but she would fall. We get her up to the chair as soon as she wakes up. She sleeps late at times but other days she wakes early so we have to monitor her closely. We all look after her. She is calm today but at times she will pull hard on the arms of the wheelchair and grip the handrails. To calm her down, we will place her near the station, and we will talk to her and hold her hand. Review of the facility policy and procedure titled Physical Restraints revised 8/22/17 revealed: Policy: Residents always have the right to considerate and respectful care and under all circumstances, with recognition of their personal dignity and safety in the least restrictive manner. As needed, the interdisciplinary team will evaluate the resident for the potential need for physical restraint. This restraint must be the least restrictive means available .Monitoring and release of restraints will be done according to any state specific regulation. Procedure: A restraint evaluation will be performed by nursing to assess physical, mental and other contributing factors which indicate the need for a restraint/enabler. The responsible party will sign the consent for the use of a safety device after review of risks/benefits .The nurse will obtain the physician's order for the restraint. This order will include the medical reason for the restraint. Photo evidence submitted

Based on observation, interview, and record review the facility failed to revise the fall care plan with appropriate interventions. This practice resulted in the resident having a second fall, in which the resident sustained [REDACTED]. Findings include: An interview was conducted with Nurse B on 07/22/2015 at 12:58 pm revealed the interventions in place for Resident #3 were to make sure that the bed was in the lowest position, repositioning, monitoring resident #3 closely, that she does not get out of the bed or from her wheel chair. The interventions also included that resident #3 went to activities and that she was with someone, so that she was monitored. An observation conducted on 07/22/2015 at 1:06 pm observed Certified Nursing Assistant (CNA) A outside of the dining room with a resident in a wheel chair. There were 10 residents in dining room and no one inside dining room supervising residents. The CNA was observed, at 1:08 pm, entering the dining room and CNA A left with the resident in the wheel chair. During an interview on 07/22/2015 at 6:14pm, the Administrator stated that the resident had an incident on the 5th of June and a plan was put in place for a wedge cushion for the bed. On the 17th of June, she was in activities and she stood up quickly from her wheel chair, but before the nurse got to her, she fell to her side. The nurse saw her but could not get to her on time. The administrator stated that all interventions were in place, so there is nothing that we could have done to stop her from falling. Resident #3 had the intervention in place for falling which was the wedge cushion on the bed. An interview was conducted on 07/22/2015 at 6:58 pm with Nurse C, revealed that the wedge cushion was on the bed for resident #3. Nurse C demonstrated the wedge cushion use for resident #3. Nurse C revealed the interventions in placed to prevent resident #3 from falling, were to place the bed in the lowest position, door open at all times so CNAs or Nurses can make rounds and check the resident. Nurse C revealed someone is present if the resident is in the dining area. Resident #3 cannot be alone in the dining area, every half hour the CNAs rotate. A review of the care plan showed at risk for further falls due to unsteady gait, history of falls, possible side effects of medication. The care planned showed that from the two times the resident fell the revision was made on 06/05/2015 for wedge cushion and on 06/20/2015 Psychiatric evaluation. The revision after the first fall on 06/05/2015 was for the wedge cushion, as a device on the resident's bed to prevent resident #3 from falling off the bed, but did not relate to the incident of resident #3 falling off the wheel chair. The revision after the second fall on 06/20/2015 for a Psychiatric evaluation did not show any other revision to prevent future falls or falls from resident #3's wheel chair after the Psychiatrist was consulted on 06/23/2015. The care plan did not show interventions related to supervising the resident while she was sitting on her wheel chair. An interview conducted on 07/22/2015 at 7:41 pm with the Director of Nursing (DON), revealed that she does not know why the psychiatric evaluation was the care plan's revised intervention for at risk for further falls. The DON revealed that resident #3 just came back on June 20th and that the resident came back with [MEDICATION NAME] and [MEDICATION NAME]. Normally, what was supposed to happen, was that you have to close the care plan and initiate a new one. The DON revealed that the only revision she saw, since the second fall, was the psychiatric evaluation. A review of resident #3's Psychiatric Consultation dated June 6, 2015 showed The attending requested for a psychiatric consultation to assess for [MEDICAL CONDITION] and agitation patient needed constant redirection and assistance still patient shows severe cognitive impairment as well as poor insight and judgement into his condition. The Plan and Recommendations showed as I discharged the patient and [MEDICATION NAME] 12.5mg twice a day along with [MEDICATION NAME] 0.5 mg, the patient is taking the lowest dose of [MEDICAL CONDITION] medication. I will monitor for the risk, benefits and side effects related to the medication. Efforts will be made to contact family when is necessary. A review of resident #3's Psychiatric Consultation dated June 23, 2015 showed The attending requested for a psychiatric consultation to assess for [MEDICAL CONDITION] use of [MEDICATION NAME] patient assistance for early stable does not seem to have acute emotional distress patient currently denies any sense of worthlessness or hopelessness or difficulty concentrating. The patient does have some mild to moderate cognitive impairment The plan is that the Patient will continue taking the [MEDICATION NAME] as prescribed, to the patient for symptoms of akathisia and [DIAGNOSES REDACTED] The patient is taking the lowest dose of [MEDICAL CONDITION] medication. I will monitor for the risk, benefits and side effects related to the medication. Efforts will be made to contact family when is necessary. The psychiatric consultation was completed after the revision on the care plan dated 06/20/2015, and did not show any relation to resident #3 medication's and her falling. A review of the nursing progress notes dated 06/05/2015 at 3:45 pm showed Pt (patient) received in bed, alert but confused, V/S (vital signs) monitored and stable . no pain and distress noted, after therapy around 11:30 am patient was put in the dining room for lunch, and consumed all lunch with help of the CNA, then she repositioned in bed because noted sleeping in her wheelchair and put in bed, when CNA was making a round noted trying to get up from bed and repositioned again in wheelchair and put in front of desk and pt (patient) fell The care plan was updated for a wedge cushion, which is a device for the bed, as per the interview with the nurse, there was no update in the care plan for the first fall regarding the resident getting up from the wheel chair. A review of the nursing progress notes dated 06/17/2015 at8:07 pm showed Pt received in bed resting, awake and disoriented . Spoke to family member regarding request for PEG tube placement. MD notified at time of request at 19:45 pt was in activities when she was observed standing. Pt has unsteady gait, loss balance and fell to floor on right side of body. Pt assisted back to w/c (wheel chair). Discomfort verbalized to knee and elbow. Small skin tear to right elbow noted . MD made aware, order to transfer to hospital The family was made aware and was ok with transfer. The ambulance was called for transfer to the Hospital. A review of resident #3's nursing notes dated 6/17/2015 at 10: 40 pm showed, Pt left facility via stretcher accompanied by EMT (Emergency Medical Technician) at 2100 (9:00 pm). No distress noted. Belongings left in facility will notify MD (physician) to follow up. A review of the Nurse progress note on 6/20/2015 at 7:11 pm showed resident #3 arrived from the hospital, awake and disoriented. Accompanied by Emergency Medical Technician (EMT)on stretcher. Resident #3 was status [REDACTED].#3 has a history of dementia, hypertension, [MEDICAL CONDITION] . No pain noted .Some missing teeth. Resident #3's skin was warm to touch, bruising along bilateral upper extremities, a skin tear to right elbow, and both hands with swollen. Resident #3 had 2 surgical sites to right hip closed with 7 and 6 staples. No drainage noted.Pillow placed between legs. Bed in low position, call light in reach and will continue to monitor. A review of resident #3's documentation titled Falls dated 06/05/2015 showed resident #3's physical Performance Limitations were difficulty maintaining standing position, Impaired balance during transitions and Gait problem. Care Plan initiated and revised marked yes and Additional observations/ comments not captured in the previous sections: wedge cushion provided. A review of resident #3's documentation titled Falls dated 06/17/215 showed Physical Performance Limitations showed Difficulty maintaining standing position, Impaired balance during transition, and Gait Problem. Care plan initiated/ revised marked yes. Additional observations/comments not captured in the previous sections area was not documented. On review of resident #3's Hospital Discharge instructions dated 06/20/2015 showed that resident was being discharged to a Skilled Nursing Facility. The resident was admitted for [MEDICAL CONDITION]. Surgery/Procedures that were conducted open reduction internal fixation. On review of resident #3's Hospital History and Physical dated 06/18/2015 showed admitting [DIAGNOSES REDACTED].#3 had a history of [REDACTED]. Resident #3 was admitted for orthopedic evaluation and treatment. The Assessment and Plan showed that resident #3 was medically clear for orthopedic to do surgery and resident #3's home medication should be restarted. On review of resident #3's Hospital Discharge Summary showed Assessment and Plan the patient underwent surgery and tolerated procedure well Cross reference F274 and F323.

Based on observation, interview, and record review the facility failed to provide adequate supervision to 2 (Resident #2 and Resident #3) out of 5 residents reviewed for accidents out of 111 residents residing in the facility on the day of survey. Resident #2 was in a wheel chair pushed by a family member in an area of the facility parking lot not designated for residents. The resident was struck by an automobile, injured, and transported to the hospital. Resident #3 was left unsupervised in the South Unit main dining room. The resident had a history of [REDACTED]. This resulted in a hip fracture, hospitalization , and surgery. The findings include: 1.) An interview was conducted on 07/22/2015 at 9:08 am with the Occupational Therapy Aide (OTA). The OTA revealed that the residents usually goes outside in the front of the facility, residents are taken outside to the back for a different terrain, but someone is with them. An interview was conducted on 07/22/2015 at 9:10 am with the Physical Therapy Aide (PTA). The PTA revealed that both doors at the end of the hallway on the first floor required a code, and if the door is pushed an alarm would sound, if the door is left open for a certain amount of time an alarm would sound too. An observation was conducted on 07/22/2015 at 9:19 am of the facility's parking lot. There were no residents outside at this time around the entire parking lot. A patio area was observed behind the building with a garbage compactor. there was one door to enter and exit the Physical Therapy Department. During observation, there was a second patio in the back with one door to enter and exit the employee lounge. During the observation of the entire parking lot, there was a side walk and patio area in the front of the facility, but there was no side walk, that would lead visitors, staff, or residents to the back of the facility. During the observation, it was also observed that there were no speed bumps around the facility, to slow down vehicles driving around the building. An interview on 07/22/2015 at 11:50 am with Assistant Administrator revealed that there are no procedures for residents who go outside, on the facility's property. An observation was conducted on 07/22/2015 at 12:15 pm, observed the facility's parking lot and around the facility, observed at this time only one resident outside in front of the building next to the facility's main entrance and did not observe any residents in the back of the building. The back of the facility's building does not appear to be a resident centered area. An observation was conducted on 07/22/2015 at 12:18 pm tested north side exit to the back of the building and attempted to open the door. The door was unable to open, and the alarm sounded. The laundry/housekeeping director arrived and turned the alarm off with a code and revealed that he heard the alarm from the nursing station. During an interview on 7/22/2015 at 3:50 pm, Nurse A stated the resident's family arrived on 7/17/2015 at 6:00 pm. The family member wanted to take the resident downstairs and around the building for some fresh air. The supervisor called Nurse A at 8:30 pm and reported that Resident #2 was hit by a car in the facility parking lot. The resident was sitting in the road when Nurse A arrived. The son had called the supervisor. The resident was awake, alert, and oriented. The resident sustained [REDACTED]. The resident refused an assessment. Nurse A wanted to call 911 but the son had already called. Fire Rescue took the resident within 3-5 minutes. Nurse A confirmed Resident #2 was hit by a car driven by a kitchen staff. Nurse A stated that the police came and took statements. The supervisor also completed statements. An incident report was entered into the computer. Nurse A revealed that the incident happened in the parking lot, on the right side of the building. Nurse A revealed that the employee from the kitchen stated that it happened very quick, the car hit his mother's wheel chair on the left wheel and the wheel chair fell as well. Nurse A confirmed that the employee in the kitchen did provide a statement. Nurse A revealed that families do sometimes take residents down stairs and walk them around the facility. An interview was conducted on 07/22/2015 at 6:00 pm with the Administrator. The Administrator revealed that she had called the area office on Monday regarding the accident and that resident #2 was hit by a car. The Administrator revealed that the employee was leaving the parking lot, leaving work and the resident was being pushed in the wheel chair by the son at 8:00 at night. The administrator revealed that the employee stated that the son and the resident were dressed in dark clothing and he did not see them. The family member told us that he did not have time to react the car was going too fast. The family member tried to get out of the way, but the car struck the wheel chair and his mother got out of the wheel chair. The employee who hit the resident was suspended and pending investigation. The administrator confirmed that the employee worked in the kitchen. The administrator revealed that the police did not give the kitchen employee a ticket, but they did an insurance verification and completed police report, which is pending. The family member said that the employee was going too fast, and the employee said that he was not going fast. The administrator revealed that it was late at approximately 9:00 pm when they called her, and that she tried to get everyone's statements. The Fire Rescue transported the resident to the Hospital. The administrator revealed that we tried to find out what happened with the resident and sent a nurse to see the resident and the resident was stable. The administrator revealed that statements were taken and also in services were conducted. The in services conducted were to ensure that the staff were driving 5 miles per hour (mph) and monitoring was conducted around the building. The administrator revealed that an immediate report was not completed because she did not feel that it was abuse. The administrator also revealed that the son had a bruise to his left leg and a superficial cut to his right arm. The Administrator revealed that we are proactively making sure that the staff were driving safe in the parking lot. The Administrator did not state any in services conducted with staff regarding educating residents who go outside and visitors who take resident's outside, areas around the building that were not designated for visitors or residents, and areas around the building that were unsafe. An interview on 07/22/2015 at 6:45pm with the administrator revealed that there is no policy and procedures for visitations. An interview was conducted on 07/22/2015 at 6:58 pm with Nurse C, and it was revealed that when a resident goes out on pass or outside, first we have to see if the resident is fine, such as vital signs and medication; if the resident does not need any medications and the vital signs are normal they can go outside with family. The nurse revealed that the chart is checked if the family is authorized as well. If the resident is awake, alert, and oriented by person, place, and time and can make decisions by themselves then the resident can go outside on their own. The nurse revealed that residents and families are able to go to the dining room, activity room, middle of the hallway, and around the building with family. An observation and interview on 07/22/2015 at 8:21pm was conducted with the administrator outside, where Resident #2's incident occurred. The location of the incident was on the parking lot road, on right side of the building, before approaching a sharp curb that leads to the back of the building. The administrator revealed that the employee stated that he did not see the resident. During the observation, it was noted that there was no side walk in the area, for the resident and visitor to safely walk around the facility. During the observation, it was noted when approaching the back of the facility a sign posted on a street light, that showed 5 mph, but there were no speed bumps to ensure that drivers maintain a slow speed. The area had some lighting present and was not completely dark. The Administrator revealed that this is not an area that she would expect residents to be, at this time of the day. The administrator revealed that the second patio is for the staff and that the back is not a resident common area. During observation, observed 2 cars entering the back from the left side of the building, with lights on and parked in a designated area. The cars did approach area in a very slow speed. The Administrator revealed that staff come to the back to park their cars. An observation of the back of the facility there is no sidewalks for visitors and residents to walk through safely and no speed bumps. The administrator revealed that the area was for the delivery of supplies and access to the kitchen. During the observation of the building there were no directional signals observed on the road, to indicate which way cars can or would be approaching. A review of the nursing notes on 07/17/2015 at 8:35 pm reported by son and noted pt (patient) on the floor in sitting position. Reported by son hit by car in back of facility building when he take her around, son called 911 rescues and noted skin check hematoma to right side of head and right site of face small abrasion refused to take care and right knee skin tear small bleeding noted patient continuous alert and oriented. A review of the HCR Manor Care Staff Development Program Attendance Record showed that staff were in serviced from 7/17/15 to 7/20/15 on speed limit in the parking lot 5 mph. A review of the parking monitoring log, created after resident #2's incident, showed that every shift a designated department head staff member would monitor the parking lot. A review of the Admission Packet does not reveal any procedures, policies, or rules regarding residents and visitors going outside, resident common areas, or pertaining to resident and visitor safety. 2.) An interview was conducted with Nurse B on 07/22/2015 at 12:58 pm revealed the interventions in place for Resident #3 are to make sure that the bed is in the lowest position, repositioning , monitoring resident #3 closely and that resident #3 does not get out of the bed or from a wheel chair, and that resident #3 goes to activities and she is with someone so that she is monitored. An observation conducted on 07/22/2015 at 1:06 pm observed Certified Nursing Assistant (CNA) A outside of the dining room with a resident in a wheel chair. There were 10 residents in dining room and no one inside dining room supervising residents. At 1:08 pm observed a CNA enter the dining room and CNA A left with the resident in the wheel chair. An interview was conducted on 07/22/2015 at 6:14pm with the Administrator revealed that the resident had an incident on the 5th of June. A plan was in place for a wedge cushion for the bed. On the 17th of June, she was in activities and she stood up quickly from the wheel chair, before the nurse got to her, she fell to her side. The nurse saw her but could not get to her on time. The administrator stated that the reason she did not report as an Adverse Incident was because resident #3 had all interventions in place, there was nothing that we could have done to stop her from falling. Resident #3 had the intervention in place for falling which was the wedge cushion. An interview was conducted on 07/22/2015 at 6:58 pm with Nurse C, revealed that the wedge cushion was on the bed for the resident. Nurse C demonstrated what was the wedge cushion for resident #3. Nurse C revealed the interventions in placed to prevent resident #3 from falling, were to place the bed in the lowest position, door open at all times so CNAs or Nurses can make rounds and check the resident. Nurse C revealed someone was present if the resident was in the dining area. Resident #3 cannot be alone in the dining area, every half hour the CNAs rotate. An interview conducted on 07/22/2015 at 7:41 pm with the Director of Nursing (DON), and revealed that she does not know why the psychiatric evaluation was the care plan's revised intervention for at risk for further falls. The DON revealed that the resident just came back on June 20th and that the resident came back with Seroquel and Ativan. Normally what is supposed to happen is that you have to close the care plan and initiate a new one. The DON revealed that the only revision she sees since the second fall was the psychiatric evaluation. A review of resident #3's Psychiatric Consultation dated June 6, 2015 showed The attending requested for a psychiatric consultation to assess for psychosis and agitation patient needed constant redirection and assistance still patient shows severe cognitive impairment as well as poor insight and judgement into his condition. The Plan and Recommendations showed as I discharged the patient and Seroquel 12.5mg twice a day along with Ativan 0.5 mg The patient is taking the lowest dose of psychotropic medication. I will monitor for the risk, benefits and side effects related to the medication. Efforts will be made to contact family when is necessary. A review of the resident's Psychiatric Consultation dated June 23, 2015 showed The attending requested for a psychiatric consultation to assess for psychosis use of Seroquel patient assistance for early stable does not seem to have acute emotional distress patient currently denies any sense of worthlessness or hopelessness or difficulty concentrating. The patient does have some mild to moderate cognitive impairment The plan is that the Patient will continue taking the Seroquel as prescribed, to the patient for symptoms of akathisia and [DIAGNOSES REDACTED] The patient is taking the lowest dose of psychotropic medication. I will monitor for the risk, benefits and side effects related to the medication. Efforts will be made to contact family when is necessary . The psychiatric consultation did not show any relation to resident #3 medication ' s and her falling. A review of the residents Admission MDS dated [DATE] showed resident's Active [DIAGNOSES REDACTED]. The Admission MDS did not show that the resident had a Hip Fracture. A review of the resident's Admission MDS dated [DATE] showed the resident had one fall since Admission without an injury. A review of the Medication Administration Record for the Month of June and July 2015 showed that the resident has been taking Seroquel and was ordered Ativan as needed since admission. A review of the nursing progress notes dated 06/05/2015 at 3:45 pm showed Pt received in bed, alert but confuse, V/S (vital signs) monitored and stable .no pain and distress noted, after therapy around 11:30 am patient was put in the dining room for lunch, and consumed all lunch with help of the CNA, then she repositioned in bed because noted sleeping in her wheelchair and put in bed, when CNA was making a round noted trying to get up from bed and repositioned again in wheelchair and put in front of desk and pt fell The care plan was updated for a wedge cushion, which is a device for the bed, as per the interview with the nurse, there was no update in the care plan for the first fall regarding the resident getting up from the wheel chair. A review of the nursing progress notes dated 06/17/2015 at 8:07 pm showed Pt received in bed resting, awake and disoriented Spoke to family member regarding request for PEG tube placement. MD notified at time of request at 19:45 pt was in activities when she was observed standing. Pt has unsteady gait, loss balance and fell to floor on right side of body. Pt assisted back to w/c (wheel chair). Discomfort verbalized to knee and elbow. Small skin tear to right elbow noted . MD made aware, order to transfer to hospital The family was made aware and was ok with transfer. The ambulance was called for transfer to the Hospital. A review of the Nursing notes dated 6/17/2015 at 10: 40 pm showed Pt left facility via stretcher accompanied by EMT (Emergency Medical Technician) at 2100 (9:00 pm). No distress noted. Belongings left in facility will notify MD (physician) to follow up. A review of the Nurse progress note on 6/20/2015 at 7:11 pm showed resident #3 arrived from the hospital, awake and disoriented. Accompanied by Emergency Medical Technician (EMT)on stretcher. Resident #3 was status [REDACTED].#3 has a history of dementia, hypertension, dyslipidemia No pain noted Some missing teeth. Resident #3's skin was warm to touch, bruising along bilateral upper extremities, a skin tear to right elbow, and both hands with swollen. Resident #3 had 2 surgical sites to right hip closed with 7and 6 staples. No drainage noted Pillow placed between legs. Bed in low position, call light in reach and will continue to monitor. A review of documentation titled Falls dated 06/05/2015 showed resident's physical Performance Limitations were difficulty maintaining standing position, Impaired balance during transitions and Gait problem. Care Plan initiated and revised marked yes and Additional observations/ comments not captured in the previous sections: wedge cushion provided. A review of documentation titled Falls dated 06/17/215 showed Physical Performance Limitations showed Difficulty maintaining standing position, Impaired balance during transition, and Gait Problem. Care plan initiated/ revised marked yes. Additional observations/ comments not captured in the previous sections area was not documented. A review of the care plan showed at risk for further falls due to unsteady gait, history of falls, possible side effects of medication. The care planned showed that from the two times the resident fell the revision was made on 06/05/2015 for wedge cushion and on 06/20/2015 Psychiatric evaluation. The revision after the first fall on 06/05/2015 for the wedge cushion is a device on the resident's bed to prevent resident #3 from falling off the bed, but did not relate to the incident of resident #3 falling off the wheel chair. The revision after the second fall on 06/20/2015 for a Psychiatric evaluation did not show any other revision to prevent future falls or falls from resident #3's wheel chair after the Psychiatrist was consulted on 06/23/2015. A review of the Hospital Discharge instructions dated 06/20/2015 showed that resident was being discharged to a Skilled Nursing Facility. The resident was admitted for Hip Fracture. Surgery/ Procedures that were conducted open reduction internal fixation. A review of the Hospital's History and Physical dated 06/18/2015 showed admitting [DIAGNOSES REDACTED].#3 had a history of [REDACTED]. Resident #3 was admitted for orthopedic evaluation and treatment. The Assessment and Plan showed that resident #3 was medically clear for orthopedic to do surgery and resident #3's home medication should be restarted. A review of the Hospital's CT Abdomen and Pelvis without contrast dated 06/18/2105 showed: History Trauma. Impression is subject but not limited to, that showed highly comminuted fracture involving the proximal left femur including the femoral neck A review of the Hospital's Consultation Report showed that resident #3 is unable to provide a history, but had an opportunity to discuss the case a family member over the telephone. According to the family member, resident #3 was recently admitted to the Heartland Skilled Nursing Facility after an admission to the Hospital. Resident #3 reportedly was in her wheel chair and fell injuring her right hip in the process. Resident #3 was brought to the emergency room where radiographs demonstrated that the resident had a fracture. The Consultation report showed X-rays obtained in the emergency room today demonstrated that the patient had an intertrochanteric fracture of the right hip with a fracture of the lesser trochanter with a fracture along medial spike. Assessment showed that the patient who is severely demented, but who is still mobilized and who takes steps with assistance, apparently had a fall earlier today and has sustained a fracture as described above. The Plan showed to take resident #3 to surgery for [REDACTED]. The possible complications of the procedure among other include infection, wound healing problems, failure of fixation, requiring further surgery, neurovascular injuries, malunion, nonunion, and shortening of the extremity. A review of Hospital's Discharge Summary showed Assessment and Plan the patient underwent surgery .and tolerated procedure well . Cross reference F280 and F225.