Every finding on record at On With Life

Based on clinical health record review, facility document review, staff interviews, and policy review, the facility failed to provide adequate supervision resulting in residents attempting to or exiting the building without staff knowledge for 2 of 3 residents reviewed for inadequate nursing supervision (Residents #1 and #2). The facility reported a census of 21. Findings include: 1. The Minimum Data Set (MDS) Assessment completed on 2/18/26 revealed Resident #1 with a Brief Interview for Mental Status score of 9, indicating a moderate cognitive impairment. The MDS further noted Resident #1 as inattentive with disorganized thinking that is continuously present without fluctuations. Diagnoses include attention and concentration deficit, traumatic brain injury, and quadriplegia. Resident #1 required staff supervision for transfers to/from bed and chair and utilized a manual wheelchair independently. The MDS indicated a wander/elopement alarm was not in use at the time. The Care Plan initiated on 11/11/25 and updated on 11/25/25, identified Resident #1 with decreased safety awareness and impulsivity. Interventions included 15-minute safety checks, use of a bed alarm, video monitor while in bed, and use of a wheelchair pin release seatbelt (prevents the resident from unbuckling themselves). The Care Plan was further updated on 12/25/25 to reflect Resident #1 no longer needed staff supervision when moving about the facility in a manual wheelchair. The facility document dated 3/25/26 detailed Resident #1 attempting to exit the building unattended on 3/25/26 at approximately 2:30 PM. One of the facility's therapist made a comment to Resident #1 how nice it was outside and maybe a therapy session would be outside. Shortly after this conversation, Resident #1 self-propelled themselves to a building exit door and pressed the door opener. This immediately set off the door alarm and staff intervened immediately. The facility believed this was not a true elopement as Resident #1 thought they were to go outside for therapy. The leadership team decided to assess the resident's outside privileges. The resident was able to safely self-propel a wheelchair and successfully navigate themselves to/from their room and therapy gym. A wanderguard alarm (a wearable tracking tag to alert staff if leaving a defined area) was brought up but not initiated. Resident #1 remained on 15-minute safety checks. The Incident Report #823 detailed Resident #1's witnessed fall on 3/30/26 at 1:40 PM. Staff noticed the resident outside self-propelling themselves from the front door to the sidewalk along the building. While in the wheelchair, Resident #1 fell off the sidewalk into the parking lot. Immediate medical assistance was provided, 911 called, and the resident transported to the emergency room. Emergency Department records dated 3/30/26 detailed Resident #1 with a cut to their right eyebrow and bruising under the eye. Further testing revealed fractures to the right eye socket, cheekbone, and upper jaw. Resident #1 returned to the facility the same day. Discharge instructions included out-patient management for the facial fractures with an otolaryngologist (ENT) and a 7-day course of an antibiotic. The Post Fall Evaluation Progress Note dated 3/30/26 at 1:58 PM detailed Resident #1 had exited the building, unattended, behind visitors. While self-propelling themselves along the sidewalk, the front wheel of the wheelchair went over the curb and the wheelchair tipped over with the resident belted into the chair. The Chronic Care Management Progress Note dated 3/31/26 at 11:12 AM, completed by the facility's Physician Assistant (PA), noted the facial cut with stitches around the right eye. The PA noted the hospital's discharge instructions to follow-up with ENT for the facial fractures. The Appointment-Departure Progress Noted date 4/9/26 at 1:40 PM noted Resident #1 left the facility to a same day surgery appointment for repair of facial fracture. The resident was expected to return later in the evening. The Post-operative Note dated 4/9/26 documented the surgical repair to Resident #1 facial fracture. The surgeon completed a right zygomatic open reduction and internal fixation (placement of metal hardware to realign the right cheekbone to its correct position). An undated facility document notates an interview with Resident #1 on 3/31/26 at 9:00 AM. When asked why they went outside, the resident replied, Well it must have been nice outside. When asked if they recalled what made the wheelchair tip over, the resident replied, There must have been a curb. In an interview on 6/10/26 at 9:30 AM, Staff A, Administrative Assistant, detailed the events of 3/30/26. They were on the phone when Resident #1 came into the lobby area unattended. The phone was positioned to the right of the main desk area and not facing the front door. They had looked down into a file drawer during the call. When the call ended, Resident #1 was gone. Staff A was not sure where the resident had left to, maybe to the administrative offices which were adjacent to the lobby area. Approximately 5-10 minutes later, Staff A heard commotion outside. Staff A went to see what was going on and saw Resident #1 on the ground. In an interview on 6/10/26 at 9:50 AM, Staff B, Certified Nurse Aide (CNA), detailed the events of 3/30/26. Staff B was sitting in a vehicle with another staff member prior to the start of their shift. Staff B noticed Resident #1 was outside unattended and realized the resident was not cleared to be outside alone. Just after realizing all of this, one of the wheelchair wheels caught the curb and tipped over. They, along with the co-worker, exited the vehicle and ran to the resident. The wheelchair was tipped over on its side with Resident #1 still buckled in. Both staff members stayed with the resident until facility nurses and the ambulance arrived. In an interview on 6/10/26 at 10:10 AM, Staff C, CNA, noted they had completed a 15-minute safety check on Resident #1 at approximately 1:15 PM. The resident was in their room completing a word puzzle, as per their norm. Staff C states the resident did not say anything to them during this interaction. At approximately 1:30 PM, Staff C along with another staff member had just come out of another resident's room and was told of an incident outside. Staff C confirmed Resident #1 able to self-propel themselves in a wheelchair. In an interview on 6/10/26 at 10:25, Staff D, CNA, detailed events of 3/30/26. Staff D was sitting in a vehicle with another staff member prior to the start of their shift. Staff D noticed Resident #1 was outside unattended. A split second later, a wheel went off the curb and the wheelchair tipped over. They, along with the co-worker, exited the vehicle and ran to the resident. Upon arrival, Staff D attempted to remove the pin release seat belt but did not have the appropriate instrument to do so. A therapy staff member, who also ran over, released the seat belt. Staff D noted Resident #1 was moaning in pain and startled. In an interview on 6/10/26 at 11:40 AM, Staff E, Physical Therapy Assistant, detailed events of 3/30/26. Staff E was outside overseeing a therapy session with separate residents and a therapy student. Staff E noticed Resident #1 was outside unattended and started to walk toward them. It did not look like the resident was going back inside and was propelling themselves away from the entrance door. At that moment, Resident #1 tipped over in the wheelchair. Staff E ran to the resident and then inside the facility for help when the two CNA staff members arrived. Staff E returned the resident, released the pin release seat belt, and applied pressure to the resident's head wound as it was bleeding. When medical staff from the facility arrived as well as the paramedics, Staff E left the scene. Staff E stated they had worked with Resident #1 all throughout their admission. The resident appeared to be more alert in the mornings but exhibited more confusion in the afternoons. Staff E believed Resident #1 did not have the cognition to know he was not to be outside alone. Staff E explained Resident #1 moved well throughout the facility independently, did not need staff assistance to get to/from their room to specific locations, such as therapy gym or dining room. However, given overall cognition, was not safe for outside independence. In an interview on 6/10/26 at 4:35 PM, the Director of Nursing, DON, recalled the first event with Resident #1 where they attempted to leave the building. Up until that point in time, the resident had not shown any signs of exit-seeking and was able to navigate inside the facility independently. After discussions, the interdisciplinary team felt this was a one time incident and did not feel the situation would be repeated. The decision was made not to place a wander guard alarm and to further assess outdoor privileges. The DON noted staff spoke with Resident #1 after the event on 3/30/26. The resident could not say where he was going or why he was up front in the lobby area. In a follow-up interview on 6/11/26 at 11:45 AM, the DON explained the following changes were implemented after Resident #1 left the building unaccompanied: a. Front entrance door now alarmed. If a code is not entered or a staff badge swiped, an alarm will sound b. [NAME] tags attached to wheelchairs to alert staff to a resident's outside privileges c. Wander guard alarm implemented immediately with an attempted resident elopement 2. The MDS Assessment completed on 5/15/26 revealed Resident #2 with a BIMS score of 13, indicating intact cognition. The MDS further noted Resident #2 as inattentive with disorganized thinking that is continuously present without fluctuations. The resident utilized a motorized wheelchair independently. Medical diagnoses include history of a traumatic brain injury (TBI).The Occupational Therapy Assessment completed on 5/6/26 noted Resident #1 with decreased safety awareness, decreased awareness of self-limitations, and difficulty sustaining focus/attention.The Speech and Language Evaluation completed on 5/15/26 noted Resident #2 with a history of TBI with chronic cognitive deficits involving attending, short-term and delayed memory, and executive functioning (working memory, self control/inhibition, and mental flexibility). The Care Plan initiated on 5/8/26 described Resident #2 as moderately independently with a self-propelling manual wheelchair.The Incident Report #823 and an undated facility document titled Final Investigation Summary detailed Resident #2's exit from the facility unattended by staff on 5/15/25. The resident informed several staff members they were going outside to wait for their spouse. Each staff member informed the resident they could not go outside alone to wait. The resident waited inside the building by an exit door used by staff and visitors. At approximately 6:17 PM, another resident's family member interacted with Resident #2 and asked if they would like to go outside. The resident said yes and the family member entered the door code to silence the alarm. Resident #2 proceeded to exit the building unaccompanied by staff. Approximately 15 minutes later (6:32 PM), Staff F, RN, was leaving the building at the end of their shift and found Resident #2 outside alone. Staff F sat with the resident outside until the spouse arrived, Staff F then informed the charge nurse of the incident at 6:37 PM. In a statement obtained by facility staff on 5/16/26, the family member who let Resident #2 out the door acknowledged they did so. During an interview on 6/10/26 at 3:15 PM Staff G, RN, explained talking briefly with Resident #2 as they were leaving the building at the end of their shift. This was approximately 6:15 PM. The resident was sitting about 10 feet from the exit door, waiting inside. There were no other staff, residents, or visitors around. During an interview on 6/10/26 at 3:30 PM Staff F recalled reminding Resident #2 they needed to wait for their spouse inside the building. This was approximately 5:30 PM. Resident #2 acknowledged and made no further comments about leaving by themselves. Staff F stated they found the resident outside about 25-30 feet from the door at 6:30 PM. The resident was not in any distress. They explained someone let them out but could not recall who this was. During an interview on 6/10/26 at 11:40 AM Staff E, PTA, noted Resident #2 with impaired cognition. The interdisciplinary team was trying to get the resident more independent but cognition and safety awareness was poor. During an interview on 6/10/26 at 4:45 PM the Assistant Director of Nursing (ADON) acknowledged the incident on 5/15/26. The ADON noted Resident #2 could successfully take themselves to/from the therapy gym. No previous exit-seeking behaviors previously. In a follow-up, the ADON confirmed Resident #2 was removed from 15-minute safety checks on 5/12/26 (admitted to facility on 5/8/26). During an interview on 6/11/26 at 12:00 PM, the DON explained newly admitted residents are placed on 15-minute safety checks for at least 72 hours. If a resident does not display unsafe behaviors, the 15-minute checks can be removed. Staff will also round on residents every 2 hours, regardless if on 15-minutes checks or not. The Elopement Procedure document, revised 05/26, defines an elopement when a resident exits the facility's property without permission, undetected, and unsupervised. A witnessed elopement is when a resident exits the facility's property with staff as a result of appropriate response to door alarms. Staff should not block doors when someone is attempting to elope due to risk of resident and staff injury. If the resident does leave the building, two more staff should accompany the resident. Staff should stay with the resident. An excerpt from the Family Education Manual states the following: a. For safety and security of residents, doors are alarmed with a code needed to exit b. Staff will provide the code as needed c. Do not share code with other residents or family members d. When entering/exiting the building, ensure no other residents leave the building unless accompanied by staff.

Based on observations, staff interviews, clinical record review, and policy review, the facility failed to follow enhanced barrier protection practices for residents with indwelling medical devices for 5 of 5 residents reviewed for infection control (Resident #3, #13, #16, #27, and #25). The facility reported a census of 25. Findings include: 1. The Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #3 had diagnoses of traumatic spinal cord dysfunction, multidrug-resistant organism (MDRO), resistance to Vancomycin, paraplegia, and quadriplegia. The MDS assessment documented the presence of an indwelling catheter. The Care Plan dated 10/9/24 revealed Resident #3 had a suprapubic catheter related to his spinal cord injury. The Care Plan directed staff to follow provider orders for catheter cares and to provide catheter cares every shift. This included staff to drain the catheter bag every shift and as needed. The Care Plan lacked directives for staff to use Enhanced Barrier Protection (EBP). During observation on 10/9/24 at 12:15 PM, Staff E Certified Nursing Assistant (CNA) completed catcher cares for Resident #3. Staff E did not wear a gown while performing catheter cares. 2. The MDS assessment dated [DATE] reviewed Resident #13 had the diagnoses of a non-traumatic brain dysfunction, anoxic brain damage, aphasia, and quadriplegia. The MDS documented the resident received tube feedings due to loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, and coughing or choking during meals or when swallowing. The Care Plan revised on 8/7/24 revealed Resident #13 required enteral nutrition as evidenced by presence of a gastrostomy tube and to provide tube feedings and water flushes as ordered. The Care Plan lacked directives for staff to use EBP. During observation on 10/9/24 at 7:45 AM, Staff F, Registered Nurse (RN), did not wear a gown while administering Resident #13's tube feedings and medications via the gastrostomy tube. 3. The MDS assessment dated [DATE] revealed Resident #16 had diagnoses of non-traumatic brain dysfunction and intracranial abscess and granuloma. The MDS documented the presence of also indicated the presence of intravenous (IV) access for medication administration. The Care Plan revised on 8/15/24 revealed Resident #16 had a Streptococcus Anginosis infection with multiple intracranial abscesses. The care plan directs staff to administer antibiotics as ordered. The Care Plan lacked directives for staff to use EBP. During observation on 10/09/24 at 7:20 AM, Staff F, did not wear a gown while administering Resident #16 IV antibiotic. 4. The MDS assessment dated [DATE] revealed Resident #25 had diagnoses of cerebrovascular accident, gastrostomy tube, and a Stage 2 pressure ulcer. The MDS documented the resident received tube feedings and had a Stage 2 pressure ulcer. The Care Plan revised on 9/17/24 revealed Resident #25 had impaired skin integrity as evidenced by a pressure ulcer due decreased mobility and decreased sensation from a stroke. The Care Plan also revealed the resident had a g-tube. The Care Plan directed staff to follow physician's orders for treatments. The Care Plan lacked directives for staff to use EBP. During observation on 10/09/24 11:45 AM, Staff F, did wear a gown while completed wound cares to Resident #25's right foot. 34817 5. The admission MDS assessment dated [DATE] revealed Resident #27 had diagnoses of traumatic brain injury, quadriplegia, diabetes, and neurogenic bladder. The MDS indicated the resident had a catheter. The Care Plan revised on 9/30/24 revealed the resident an activities of daily living (ADL) performance deficit related to a spinal cord injury. The resident had a catheter related to urinary retention. The resident also had impaired skin integrity as evidenced by a pressure ulcer. The Care Plan directed staff to provide catheter care each shift. The Care Plan lacked directives for staff to use EBP. During observations on 10/8/24 at 11:27 AM, Staff D, CNA, washed her hands and donned a pair of gloves. Staff D emptied the resident's catheter bag and cleansed the catheter port with an alcohol swab. Staff D removed her gloves and washed her hands after she performed catheter care. Staff D did not wear a gown during the procedure while she handled and cared for the urinary catheter. The resident's room lacked signage regarding the use of EBP or PPE required. During an interview on 10/10/24 at 9:30 AM, Staff B, CNA, reported she looked at the white board in the resident's room to know what cares a resident needed or she looked at the resident's Kardex on the computer. Staff B stated staff told her in report if a resident required special precautions. Staff B reported she looked at the sign posted on the resident's door to know what PPE to put on. Whenever a resident on isolation precautions, a bin placed outside the resident's door with PPE such as gown and gloves, and a trashcan placed next to it. During an interview on 10/10/24 at 9:47 AM, Staff C, CNA, reported she looked at the white board on the wall in the resident's room to know what to do for the resident. She also looked at the kardex on the computer but the white board had the most updated information. Staff C reported she received information during shift report about whether a resident required special precautions, such as isolation or PPE required. Staff C stated she donned a gown and gloves or whatever PPE needed before she entered an isolation/precautions room. Staff C reported when she left the resident's room, she removed the PPE outside the room and placed it in the trashcan, and sanitized her hands. Staff C reported a sign on door revealed the what PPE to put on prior to entering the resident's room. Staff C reported she didn't normally put a gown on to empty a resident's catheter unless the resident had an infection. During an interview on 10/10/24 at 11:30 AM, the Director of Nursing (DON) reported they initiated EBP's whenever a resident had an active CDC (Center for Disease Control) targeted MDRO infection. If one resident in the facility had an MDRO, it was considered an outbreak and then EBP's implemented. The DON reported they reached out to the State Department on how to proceed with their resident population. The DON confirmed whenever a resident placed in isolation, a bin with PPE placed outside the room, along with a trashcan. The DON confirmed the trash can outside Resident #32's room did not have a lid over it. The facility's Enhanced Barrier Precautions policy revised 5/2024 revealed EBP utilized as a strategy to decrease transmission of MDRO's. A gown and gloves used for high-contact resident care activities for residents with chronic wounds, indwelling medical devices, or secretions/excretions that are unable to be contained or covered. Persons with acquired brain injury require indwelling medical devices including feeding tubes and/or urinary catheters. All residents who qualified for EBP received education and filled out a consent form indicating their preference for EBP if a MDRO outbreak occurred. Staff donned a gown and gloves during close contact interactions such as wound care, incontinence care/ toileting, and transfers if the resident or guardian indicated they wanted EBP. 6. During observation on 10/7/24 at 10:11 AM, a Contact precautions sign hung on Resident #25's door and a plastic bin with drawers of PPE (gown and gloves) observed outside the resident's room. A trashcan without a lid sat next to plastic bin with drawers. The admission MDS dated [DATE] revealed Resident #25 had diagnoses of MDRO and at an increased risk for facility acquired infections. The MDS revealed the on isolation for an active infectious disease and took antibiotics. The Care Plan initiated 9/25/24 revealed the resident required isolation precautions due to ESBL (Extended spectrum betalactamases). The Care Plan directed staff to don proper PPE when caring for him.

Based on personnel record review, facility policy review and staff interview, the facility failed to ensure one of seven staff members reviewed (Staff A) had mandatory abuse training within six months of hire. The facility identified a census of 23 current residents. Findings include: The facility's abuse policy dated 6/18/12 instructed that within six months of employment, new employees shall participate in the state-required, two hour group presentation for mandatory reporters. Personnel record review for Staff A, cook revealed a hire date if 10/28/13. The personnel file failed to document Staff A had completed dependent adult abuse training by 4/28/14 or six months after hire. During interview on 5/28/14 at 2:10 p.m., Staff B & Staff C, human resources staff stated they had a process in place to ensure the training was completed within the first six months of hire. Staff A worked on an as needed basis and they failed to ensure Staff A completed the training at Staff A's three month evaluation. On 4/17/14, Staff A was scheduled to come in for the training, however the DVD for the training was not available, so Staff A did not complete the training as planned. Staff A is now set up to complete the dependent adult training on 6/3/14, prior to work.

Based on record review and staff interview, the facility failed to adequate nursing supervision for 1 of 4 residents reviewed (Resident #1). The facility identified a census of 24 current residents. Findings include: 1. According to the MDS (Minimum Data Set) assessment tool dated 5/28/13, Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility, transfers and bathing. The care plan dated 5/29/13 directed staff to use an enclosed bed for safety to prevent falling and injury from falling. It also directed staff to apply a lap restraint for the resident while unattended in the wheelchair and to assist with transfers and ambulation per physical therapist's mobility directives. Review of the Occupational Therapy Order dated 5/22/13 directed staff to use tilt'n space wheelchair with seat belt for hip positioning and maximum assist for transfers. Review of the Daily Nursing Notes dated 6/6/13 at 2:30 PM documented a CNA (Certified Nursing Assistant) hollered from the person served's room for help. The resident was lying on the floor towards the left side. The CNA reported she had just finished giving the resident a shower and wheeled in the shower chair to the resident's room with the safety belt connected. The CNA dried the resident and applied deodorant. She then turned into the attached bathroom to put the deodorant away. When she turned around the person served leaned forward in the shower chair and fell to the floor. The resident sustained [REDACTED]. The facility called the emergency service due to the resident's decreased level of responsiveness at the time. At 7:40 PM the person served returned to the facility by ambulance with a 2.6 cm incision with 5 sutures and no redness or drainage. Review of Staff A, CNA's (certified nursing assistant) employee file revealed an unsigned orientation record. During an interview with Staff H, RN (Registered Nurse) on 6/24/13 at 2:00 PM, she stated she was summoned to the room and noted Resident #1 on the floor with a small cut on his/her left temple. Staff H reported the resident was not responding well, so staff called the ambulance, although the resident then came around after the ambulance was called. Staff H stated the resident could, once in a while, get the wheelchair seatbelt undone, so used the lap belt when in the wheelchair. She stated that a resident with impulsivity should not be left alone, staff should not turn their back to that person and should remain in arms length unless the resident is safe with the lap belt in a wheelchair. During an interview with Staff A, CNA on 6/25/13 at 10:05 AM, she reported after resident's shower, she turned with her back to the resident and placed the powder in the connecting bathroom. When she turned around, the resident leaned forward and fell to the floor. She reported she had buckled the safety belt to the shower chair and locked the wheels, but she was not aware at the time the resident could unfasten the seat belt. She further stated she was unaware at the time staff should not turn their back on a resident with impulsivity, but did know not to leave them alone in a room. She had felt the resident was in a safe position prior to the fall. During an interview with the Director of Nursing on 6/25/13 at 2:50 PM, she stated the facility did not have a specific competency for residents with impulsivity. She talked with Staff A, explained the safety concerns and instructed her not to turn her back on a resident and to keep him/her in arms reach. The policy and procedure titled Bath Shower dated 5/1/01 directed staff to do the following: a. Explain procedure to the resident and escort to shower room. Assure privacy. b. Wash hands. c. Assist the resident with undressing and place in shower chair. d. Help the resident with bath as needed. e. If the resident is left alone, stay within easy call. A call button should be within easy reach. f. Help the resident wash and make sure he/she is well dried. Apply lotions and powder as desired. g. Replace toiletry articles in room of the resident. i. Assist the resident with dressing.

Based on clinical record review, observation, staff interviews, and facility policies, the facility failed to maintain infection control measures for 4 of 6 residents in isolation (Resident #1, #3, #5, & #9) . The facility reported a census of 24 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documented Resident #5 had a [DIAGNOSES REDACTED]. The discharge orders to the facility documented the resident with a [DIAGNOSES REDACTED]. The care plan dated 3/13/13 contained no information regarding the need for isolation and directions to staff to maintain the isolation. The resident had a sign on the door directed staff to use gloves, gown, mask, and foot booties. The sign on the door indicated the resident required airborne isolation. During observation on 4/2/13 at 9:54 a.m. the resident participated in therapy. The resident did not use a mask. During observation on 4/2/13 at 10:40 a.m., the resident sat in the lounge area without a mask. The resident had secretions coming from the mouth and nose. During observation on 4/3/13 at 9:26 a.m., staff transported the resident to therapy. The resident did not use a mask. During observation on 4/3/13 at 3:30 p.m., the resident sat in the hallway without a mask. The resident had thick oral and nasal secretions. During an interview on 4/3/13 at 1:38 p.m. Staff C, certified nurse aide (CNA), stated she applied the equipment shown on the door but did not know for which organism the resident required isolation. Staff C stated the resident needed a mask before leaving the room. During an interview on 4/3/13 at 1:38 p.m. Staff B, CNA stated she applied the equipment listed on the sign on the door but received no communication from the nurses regarding the resident's isolation precautions. 2. The MDS dated [DATE] documented Resident #9 had [DIAGNOSES REDACTED]. A progress note dated 8/12/12 documented the resident had MRSA and VRE in the urine. The sign on the resident's door indicated the resident required contact and airborne isolation. The care plan dated 9/26/12 contained no information regarding the resident's isolation or directions for staff to maintain the isolation the resident required. During an interview on 4/3/13 at 11:10 a.m. Staff D, clinical support nurse, stated the resident needed to wear a mask if in airborne isolation. Staff D stated if the resident had no symptoms, the facility needed to complete cultures to determine if the infection remains. Staff D stated currently, the facility had not completed cultures for any of the residents in isolation. 3. The comprehensive monthly assessment dated [DATE] for Resident #1 revealed [DIAGNOSES REDACTED]. Resident #1 received both physical, occupational and speech therapy services. During observation on 4/1/13 at 10:30 a.m., Staff E, Occupation Therapist (OT) sprayed a therapy bed with a hand held pump solution spray bottle and wiped the therapy bed immediately with a cloth. At 10:32 a.m., Staff E assisted with transferring Resident #1 from the wheelchair to the therapy bed to begin occupational therapy exercises with the resident. Following the exercises, Staff E assisted with transferring Resident #1 from the therapy bed to the wheelchair. During interview on 4/1/13 at 10:45 a.m., Staff E said he/she was unfamiliar with the solution used to disinfect the therapy bed but thought it was hdqC2 (a quaternary) solution. Staff E said he/she thought the contact time to disinfect the surface was 2 minutes. Review of the manufacturer's directions for use revealed the spray solution used by Staff E is a disinfectant cleaner used to provide effective disinfection to control cross-contamination of bactericidal organisms including multidrug resistant organisms. The directions for use stated to apply the solution with a hand pump trigger and allow the surface to remain wet for 10 minutes, then remove excess liquid with a cloth. During interview on 4/3/13 at 7:05 am., Staff K, Housekeeping assistant said they used the hdqC2 spray solution to disinfect all surfaces and the contact (kill) time was 10 minutes after spraying the surface. Staff K stated the surface should remain visibly wet for 10 minutes and then they would wipe it down with cloth or paper towel. Additionally, Staff K said in order to make certain surfaces are disinfected properly the solution needed to be used as the manufacturer directed. During interview on 4/3/13 at 7:20 a.m., Staff J, Therapy Manager said hdqC2 spray solutions are used in the therapy room to disinfect all surfaces in between residents. Staff J stated the solution had to sit on the surface for 10 minutes and then therapy staff would wipe it down with a towel. Staff J stated he/she received education on the use of this solution at a safety and/or infection control in-service. Staff J stated therapy staff had been instructed on the use of this disinfectant and the contact time required in order to ensure the surface is disinfected appropriately and to control cross contamination from treated surfaces. 4. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 required extensive assistance of two + for bed mobility, total assistance of two for toileting and was frequently incontinent of bladder and bowel. A laboratory report dated 12/21/12 revealed a tracheal aspirate cultured positive for MRSA, with no other laboratory results related to the respiratory tract. A plan of care dated 1/3/13 revealed actual risk for infection as evidenced by purulent sputum, abnormal cultures and MRSA. The plan of care directed all staff to maintain appropriate isolation techniques. A physician's orders [REDACTED]. A doctor's progress note dated 1/24/13 revealed the resident displayed increased secretions and recent MRSA pneumonia. A sign posted on Resident #3's door instructed all staff who entered the resident's room that the resident had Contact and Respiratory precautions and directed staff to use standard precautions at all times including wearing a mask, gown, and gloves before entering the room. During observation on 4/1/13 at 3:00 p.m., Staff G and H, both CNAs entered the resident's room to provide assist with toileting. Prior to entering the room Staff G and H donned a mask, gown and gloves. During observation on 4/2/13 at 7:45 a.m., Staff F, Registered Nurse (RN) entered the resident's room after donning gloves to administer medications via a feeding tube. Staff F failed to don a mask or gown. At 8:15 a.m., Staff F provided hands on assistance in an attempt to reposition the resident in bed, coming into direct contact with the resident's clothing and body. At 8:20 a.m., the surveyor asked Staff F if there were contact precautions in place for Resident #3 and Staff F said he/she thought the MRSA was colonized so staff did not need to wear anything. (colonization means that MRSA bacteria are present on a person's skin or mucous membranes but are not causing illness). Immediately following the observation, the surveyor informed Staff L, RN/Quality Care Coordinator/ Infection control nurse of the findings. Staff L, reported contact precautions were in effect when staff provided assistance to Resident #3 and Staff F failed to follow facility policy for donning a mask or gown. During an interview on 4/2/3 at 8:30 a.m., Staff F approached the surveyor and said he/she had been instructed by Staff L to go home and change his/her clothes due to failure to don a mask or gown when assisting Resident #3, earlier. During a follow up interview on 4/3/13 at 7:15 a.m., Staff F said he/she received education regarding contact precautions and staff are required for all residents who have contact precautions to don a mask, gown and gloves prior to providing assistance for all cares.

Based on observation and interview, the facility failed to maintain a clean (free of carbon build up) stove top for the stove observed in the kitchen. The facility reported a census of 15 residents. Findings include: 1. Observation on 04/11/12 at 7:08 a.m. revealed one Vulcan stove in the kitchen. The stove's metal back splash contained two large areas of a heavy brown/black substance (carbon build up). The side back splash and also the outer side of the griddle contained a heavy amount of carbon build up. During an interview on 04/12/12 at 9:10 a.m., the Administrator reported the stove as now cleaned.

Based on observation, record review and interview, the facility failed to follow the infection control policy and procedures for 2 of 5 residents reviewed (Residents #3 and #5). The facility identified a census of 15 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 3/20/12, Resident #3 had a [DIAGNOSES REDACTED]. The MDS documented the resident experienced both long and short term memory loss with moderately impaired cognitive skills for daily decision making. The MDS also documented the resident required extensive assistance of 2 staff for dressing, hygiene and toilet use. The Physician order [REDACTED]. Observation on 4/9/11 at 1:15 p.m. revealed Staff C, Registered Nurse (RN), washed her hands, donned gloves and opened a 22 [MEDICATION NAME] pad. Staff C dabbed the scabbed incision located from the right side of the forehead to the area behind and below the resident's right ear. Staff C used one side of the [MEDICATION NAME] pad to apply the [MEDICATION NAME] to the entire area. Staff C did not change the side or surface area of the 2 x 2 [MEDICATION NAME] pad used and again dabbed the areas she already treated. Observation on 4/9/11 at 1:15 p.m. revealed Staff C gloved and removed the soiled 4 x 4 gauze from the feeding tube site. Staff C washed her hands, donned gloves and cleansed the feeding tube with a washcloth. The RN then dabbed the washcloth around the skin surface of the feeding tube site and again dabbed the areas she already washed. Staff C also did not rinse and dry the area around the feeding tube site. 2. According to the Minimum Data Set (MDS) assessment tool dated 3/24/12, Resident #5 had [DIAGNOSES REDACTED]. The MDS documented the resident displayed intact cognition. The MDS also documented the Person Served required total assistance of 2 staff for transfers, dressing, personal hygiene and toilet use. The Physician order [REDACTED]. Observation on 4/9/12 at 11:05 a.m. revealed Staff C washed her hands, donned gloves and cleansed the feeding tube site with a washcloth. The RN then dabbed the washcloth around the skin surface of the feeding tube site and again dabbed the areas she already washed. The facility policy and procedure titled Enteral (tube) Feeding Guidelines, dated 5/04 instructed the staff to wash their hands, don gloves and wash the (tube feeding) site with soap and water while moving away from the stoma (tube feeding opening) in a spiral pattern, using a new, cotton-tipped swab with each spiral. The procedure directed the staff to cleanse under the skin disc in the same manner, rinse well with the above spiral method and dry thoroughly. During an interview on 4/11/12 at 11 a.m. Staff B, Director of Nursing, stated he/she would expect the staff to follow policies and procedures.

Based on record review, observation and interview the facility failed to correctly position the ordered giv-mohr sling (a sling to support the extremity when repositioned) to 1 of 7 Residents (Resident #4). The facility identified a census of 15 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool dated 3/5/12, Resident #4 had [DIAGNOSES REDACTED]. The MDS documented the resident had both long and short term memory problems with severely impaired cognition for daily decision making. The MDS also documented the resident as dependent on 2 staff for mobility, dressing, hygiene and toilet use. The Resident #4's care plan included Occupational Therapy (OT) Orders dated 4/2/12 and 4/5/12 that directed staff to position a "giv-mohr" sling on the upper extremity for transfers and ambulation. The order failed to contain whether the sling went on the right or left extremity. The Physician order [REDACTED]. Observation on 4/9/12 at 9:10 a.m. revealed Staff D, Certified Nursing Assistant (CNA) positioned the giv-mohr sling on the left, upper extremity (the side unaffected by the resident's [MEDICAL CONDITION]). Observation on 4/9/12 at 9:50 a.m. revealed Staff D, CNA, started to position the giv-mohr sling on the left upper extremity. Staff E, CNA corrected Staff D and Staff E positioned the sling on the right upper extremity. On 4/9/12 at 10:00 a.m. Staff D stated to Staff E he/she had placed the giv-mohr sling on the left upper extremity before. During an interview 4/11 /12 at 8:33 a.m., the Director of Nursing (DON) reported during a March 2012 inservice, the therapy department presented staff education regarding range of motion that included therapeutic devices. Staff B stated the orders should provide direction regarding the appropriate side to position the device for Resident #4.

Based on clinical record review, observation and staff and resident interviews, the facility failed to administer medication according to physician's orders for one of three residents reviewed. (Resident #1). The facility reported a census of 25 residents. Findings include: 1. According to the MDS (Minimum Data Set), an assessment tool dated 3/24/2011, Resident #1 had [DIAGNOSES REDACTED]. The MDS indicated the resident had recall and was cognitively intact, transferred with extensive assistance of two staff and did not ambulate (walk) in the room or corridor. The Care Plan directed staff to provide interventions including review blood sugars and administer medications according to physician orders. On 4/22/2011 at 10:40 a.m., Staff A, RN (Registered Nurse) documented Resident #1 received incorrect medications including: [MEDICATION NAME] 500 mg (milligrams), [MEDICATION NAME] 5 mg, [MEDICATION NAME] 40 mg,[MEDICATION NAME] mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 400 mg, [MEDICATION NAME] 1 scoop, and Tylenol 325 mg. Staff A identified the error, called the physician and assessed the resident. The physician ordered staff to transfer the resident to the emergency room , and he/she admitted to the hospital for observation. On 4/23/2011 Resident #1 returned to the facility. The hospital Discharge Note and H & P (History and Physical) consultation documented Resident #1 accidentally received the wrong medication and returned to the facility after hemodynamically and blood sugars stable greater than 12 hours. During an interview on 5/04/2011 at 10:00 a.m., the DON (Director of Nursing) revealed Staff A worked at the facility for [AGE] years and had no prior disciplinary actions. On 4/22/2011 after breakfast, Staff A inadvertently administered Resident #1 medications belonging to Resident #2. Resident #2 received the appropriate medications. Staff A discovered the error and no harm came to Resident #1 although he/she admitted to the hospital for overnight observation. During an interview on 5/05/2011 at 9:30 a.m., Staff A, RN, reported on the morning of 04/22/2011, he/she administered medications belonging to Resident #2 to Resident #1 in error. When Resident #2 reported not receiving pain medications, Staff A realized the error. Staff A notified the physician, assessed the resident and then transferred the resident to the emergency room . Staff A reported receiving a disciplinary write up related to the incident, had worked at the facility for almost [AGE] years with good performance evaluations and no other incidents. The facility Administration of Medication policy included the following staff instructions: a. Read and check medication label against the MAR (Medication Administration Record) three times before administering medication (before removing medication, as drug is removed from container, before returning drug to medication cart or refrigerator). Check and observe for 5 rights of medication administration (right PS ( patient served) right medication, right dosage, right time, right route). b. No medications prescribed for one PS may be administered to or allowed in the possession of another PS.

Based on record review and observation the facility failed to provide complete and updated comprehensive plan of cares for 6 of 6 residents reviewed (Resident #1, #2, #3, #4, #5, #6). The facility identified a census of 21 residents. Findings include: 1. According to the admission record dated 2/16/11, Resident #4 had [DIAGNOSES REDACTED]. The care plan dated 2/16/11, informed staff of the resident's skin tissue concern and the resident's risk for falls. The care plan directed staff to inspect and monitor the skin for any problems. The care plan instructed the staff to monitor the resident's ambulation. The care plan directed the facility's therapies to evaluate the resident and to provide appropriate orders for the staff to follow. The care plan indicated the facility kept the therapy orders located in the resident's room, restorative book, and the medication and treatment records. The care plan failed to provide the staff directives on how to assist the resident with their mobility and their daily care needs. 2. According to the Minimum Data Set (MDS) assessment tool dated 2/10/11 Resident #5 had [DIAGNOSES REDACTED]. The MDS documented short term memory problems and moderately impaired cognitive skills for daily decision making that require cues and or supervision. The MDS identified the resident to require extensive assistance of two staff for bed mobility, transfers, dressing and toilet use. The MDS documented the resident as totally dependent on one staff for personal hygiene. The care plan dated 1/5/11 directed the facility's therapies to evaluate the resident and to provide appropriate orders for the staff to follow. The care plan identified the therapy orders were located in the resident's room, restorative book and the medication and treatment records. The care plan failed to provide the staff directives on how to assist the resident with their mobility and their daily living care needs. The care plan dated 1/13/11 revealed the resident had a Foley catheter (a tube into the bladder). The care plan dated 1/28/11 documented the physician had discontinued the Foley catheter. The care plan revealed the Foley catheter remained in place. Observation on 2/17/11 at 8:20 a.m. revealed the resident had no Foley catheter in place. The physician orders [REDACTED]. The Occupational Therapy Order dated 2/16/11 directed two staff to assist the resident with toileting, dressing, and bath and shower needs. The order for functional mobility dated 2/15/11, identified the resident required 1-2 staff to transfer and ambulation provided by physical therapy. 3. According to the MDS dated 1/5/11 Resident #6 had [DIAGNOSES REDACTED]. The MDS documented the resident as a persistent vegetative state, "coma". The MDS identified the resident as totally dependent on 2 or more staff for bed mobility, transfers, and dressing. The MDS documented the resident required the assistance of one staff for toilet use and personal hygiene. The care plan dated 1/5/11 failed to provide the staff instructions on how to assist the resident with their mobility and their daily living care needs. 4. The MDS dated [DATE] documented Resident #1 as fully dependent on two staff for bed mobility, transfers, and did not ambulate. The care plan dated 1/10/11 listed the following problem areas: Risk for infection Ineffective airway clearance Risk for falls Feeding tubes Nutrition Risk for [MEDICAL CONDITION] Risk for injury Risk for impaired skin integrity Alteration in urinary elimination Psychosocial well being Dysphagia Communication The care plan dated 1/10/11 listed a risk for injury with an intervention to perform transfers and ambulation per physical therapy mobility directives. The care plan failed to instruct staff on how to transfer the resident, the number of staff needed, and that the resident did not ambulate. During observation on 2/17/11 at 11:23 a.m., two staff used a mechanical lift to transfer the resident from the wheelchair to the bed. 5. The MDS dated [DATE] documented Resident #2 required extensive assistance for bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene. The MDS documented the resident utilized a trunk restraint daily. The MDS documented the resident had [DIAGNOSES REDACTED]. The care plan dated 11/2/10 listed the following problem areas: Alteration in urinary elimination [MEDICAL CONDITION] drug use Risk for impaired skin integrity Risk for [MEDICAL CONDITION] Risk for falls Risk for complications from aspiration Cognitive loss Dysphagia Impaired functional mobility Nutrition Occupational therapy Psychosocial well being The care plan dated 11/2/10 listed a problem for risk for falls and directed staff to perform transfers and ambulation per physical therapy mobility directives. The care plan failed to direct staff on how the resident transferred and the number of staff required. During observation on 2/17/11 at 10:38 a.m., two staff assisted the resident to the bathroom from the wheelchair. The resident ambulated into the bathroom with two staff assistance. 6. The MDS dated [DATE] documented Resident #3 as fully dependent on 2 staff for transfers, bed mobility, dressing,toilet use, personal hygiene, and did not ambulate. The care plan dated 12/28/10 listed the following problem areas: Pain Risk for falls Risk for impaired skin integrity [MEDICAL CONDITION] drug use Alteration in urinary elimination Feeding tubes Nutrition The care plan dated 12/28/10 documented a risk for falls and directed staff to perform transfers and ambulation per physical therapy mobility directives. The care plan failed to direct staff on how the resident transferred, the number of staff required, and the amount of assistance for ambulation. During observation on 2/17/11 at 8:38 a.m. two staff used a mechanical device to assist the resident to stand and then lowered the resident into the wheelchair.

Based on clinical record review, observation, and facility policy review, the facility failed to document times staff released the restraint for four of nine residents reviewed. The facility reported a census of 22 residents (Resident #2, #3, #4 & #7). Findings include: The Restraint Usage policy dated 3/17/03 instructed staff to release the restraint every two hours for a minimum of ten minutes and record the release on the Restraint Release Record. 1. The Minimum Data Set (MDS) assessment tool dated 2/3/11 documented Resident #2 required extensive assistance for bed mobility, transfers, ambulation, dressing, toilet use and personal hygiene. The MDS documented the resident utilized a trunk restraint daily. The MDS documented the resident had [DIAGNOSES REDACTED]. The care plan dated 10/14/10 documented the resident utilized an enclosed bed and a lap restraint when up in wheelchair. The physician ordered on [DATE] to discontinue the bed alarm and utilize an enclosed bed. The physician ordered on [DATE] a lap restraint when in the wheelchair. The physician ordered on [DATE] to discontinue the lap restraint and utilize a chair alarm when in the wheelchair. The restraint release record indicated staff must check on the resident in the restraint every thirty minutes, staff must release the restraint for exercise, toilet use, etcetera every two hours for ten minutes. The record instructed staff to document the specific time of release. The restraint release record dated 11/30/10 documented staff applied the lap restraint at 2:00 p.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 2:30 p.m., 4:30 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/02/10 documented staff applied the lap restraint at 7:00 a.m. and released the restraint at 6:30 p.m. The record documented staff provided care at 10:00 a.m., 12:30 p.m., 2:30 p.m., 4:00 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/3/10 documented staff applied the lap restraint at 10:00 a.m. and released the restraint at 6:30 p.m. The record documented staff provided care at 11:00 a.m., 1:00 p.m., 4:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/4/10 documented staff applied the lap restraint at 7:00 a.m. and released the restraint at 6:00 p.m. The record documented staff provided care at 9:00 a.m., 11:30 a.m., 1:30 p.m., and 4:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/5/10 documented staff applied the lap restraint at 11:00 a.m. and released the restraint at 6:30 p.m. The record documented staff provided care at 1:30 p.m., and 4:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/7/10 documented staff applied the lap restraint at 7:00 a.m. and released the restraint at 6:30 p.m. The record documented staff provided care at 9:30 a.m., 10:30 a.m., 1:30 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/8/10 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 4:00 p.m. The record documented staff provided care at 12:30 p.m., 2:00 p.m., and 3:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/9/10 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 12:30 p.m., 3:00 p.m., and 5:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/10/10 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 8:00 p.m. The record documented staff provided care at 9:30 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 5:00 p.m. and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/12/10 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 2:00 p.m. The record documented staff provided care at 9:00 a.m., 11:30 a.m., and 1:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/14/10 documented staff applied the lap restraint at 1:00 p.m. and released the restraint at 7:00 p.m. The record documented staff provided care at 2:00 p.m., 4:00 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/16/10 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 7:00 p.m. The record documented staff provided care at 9:00 a.m., 11:00 a.m., 1:00 p.m., 5:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/17/10 documented staff applied the lap restraint at 2:00 p.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 2:30 p.m., 4:30 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/18/10 documented staff applied the lap restraint at 11:30 a.m. and released the restraint at 6:30 p.m. The record documented staff provided care at 4:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/19/10 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 3:30 p.m. The record documented staff provided care at 9:00 a.m., 11:00 a.m., and 2:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/20/10 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 7:00 p.m. The record documented staff provided care at 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/21/10 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 10:00 a.m., 12:30 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/22/10 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 4:30 p.m. The record documented staff provided care at 9:30 a.m., 10:30 p.m., 12:30 p.m., 2:00 p.m., and 4:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/23/10 documented staff applied the lap restraint at 3:30 p.m. and released the restraint at 8:00 p.m. The record documented staff provided care at 4:00 p.m., 6:30 p.m. and 7:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/24/10 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 10:30 a.m., 12:30 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/26/10 documented staff applied the lap restraint at 11:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 1:00 p.m. and 6:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/27/10 documented staff applied the lap restraint at 10:30 a.m. and released the restraint at 8:00 p.m. The record documented staff provided care at 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 5:30 p.m., and 7:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/28/10 documented staff applied the lap restraint at 3:00 p.m. and released the restraint at 7:00 p.m. The record documented staff provided care at 4:30 p.m. and 6:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/29/10 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 8:30 a.m., 10:30 a.m., 12:30 p.m., 2:00 p.m., 4:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/30/10 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 8:30 a.m., 10:30 a.m., 1:00 p.m., 3:30 p.m., 5:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 12/20/10 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 5:30 p.m. The record documented staff provided care at 9:00 a.m., 11:30 p.m., 12:30 p.m., 1:00 p.m., 3:00 p.m., and 4:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/1/11 documented staff applied the lap restraint at 2:30 p.m. and released the restraint at 7:00 p.m. The record documented staff provided care at 4:00 p.m., and 6:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/2/11 documented staff applied the lap restraint at 9:00 a.m. and released the restraint at 8:00 p.m. The record documented staff provided care at 10:00 a.m., 12:30 p.m., 2:30 p.m., 4:30 p.m., 6:00 p.m., and 7:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/3/11 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 11:30 a.m., 1:00 p.m., 2:00 p.m., 4:00 p.m., and 5:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/4/11 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 9:30 a.m., 11:00 a.m., 12:00 p.m., 3:00 p.m., 4:00 p.m., 5:30 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/5/11 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 8:00 p.m. The record documented staff provided care at 9:30 a.m., 11:30 a.m., 1:30 p.m., 3:00 p.m., 5:00 p.m., and 7:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/6/11 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 9:30 a.m., 11:00 a.m., 1:00 p.m., 2:00 p.m., 3:30 p.m., 5:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/7/11 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 8:00 p.m. The record documented staff provided care at 9:30 a.m., 12:30 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., and 7:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/8/11 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 2:00 p.m. The record documented staff provided care at 9:30 a.m., 10:30 a.m. and 1:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/9/11 documented staff applied the lap restraint at 11:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 1:00 p.m., 1:30 p.m., 5:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/10/11 documented staff applied the lap restraint at 2:30 p.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 4:00 p.m., 6:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/11/11 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 12:00 p.m. The record documented staff provided care at 11:00 a.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/12/11 documented staff applied the lap restraint at 7:00 p.m. and released the restraint at 1:00 p.m. The record documented staff provided care at 8:30 a.m., 9:30 a.m., and 11:30 a.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/13/11 documented staff applied the lap restraint at 12:00 p.m. and released the restraint at 8:30 p.m. The record documented staff provided care at 12:30 p.m., 2:00 p.m., 3:00 p.m., 4:30 p.m., 6:00 p.m. and 8:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/14/11 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 8:00 p.m. The record documented staff provided care at 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/15/11 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 2:30 p.m. The record documented staff provided care at 9:00 a.m., 11:00 a.m., 1:00 p.m., and 2:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/16/11 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 7:00 p.m. The record documented staff provided care at 9:30 a.m., 11:30 a.m., 1:30 p.m., 2:30 p.m., 5:00 p.m., and 6:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/17/11 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 9:00 a.m., 2:00 p.m., 3:30 p.m., 5:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/26/11 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 10:00 a.m., 12:30 p.m., 2:00 p.m., 4:00 p.m., 5:30 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/27/11 documented staff applied the lap restraint at 11:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 1:30 p.m., 4:00 p.m., 6:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/28/11 documented staff applied the lap restraint at 10:00 a.m. and released the restraint at 2:00 p.m. The record documented staff provided care at 12:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/29/11 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 10:00 a.m., 12:00 p.m., 2:30 p.m., 4:30 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/30/11 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 7:00 p.m. The record documented staff provided care at 9:00 a.m., 11:00 a.m., 11:30 a.m., 1:00 p.m., 3:00 p.m., and 5:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 1/31/11 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 8:00 p.m. The record documented staff provided care at 10:00 a.m., 10:30 a.m., 12:30 p.m., 2:00 p.m., 3:30 p.m., 4:30 p.m., 5:30 p.m., 6:30 p.m., and 7:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/1/11 documented staff applied the lap restraint at 2:30 p.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 4:00 p.m., 6:00 p.m. and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/2/11 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 11:00 a.m., 12:30 p.m., 1:30 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., 6:30 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/3/11 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 10:00 a.m. The record documented staff provided care at 8:00 a.m., and 9:30 a.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/4/11 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 7:00 p.m. The record documented staff provided care at 10:00 a.m., 12:30 p.m., 3:00 p.m., and 5:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/5/11 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 7:00 p.m. The record documented staff provided care at 1:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m. and 6:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/6/11 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 8:00 p.m. The record documented staff provided care at 9:00 a.m., 10:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/7/11 documented staff applied the lap restraint at 8:00 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 9:00 a.m., 11:00 a.m., 12:00 p.m., 3:30 p.m., 5:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/8/11 documented staff applied the lap restraint at 8:30 a.m. and released the restraint at 8:30 p.m. The record documented staff provided care at 12:30 p.m., 4:00 p.m., 6:00 p.m., and 8:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/9/11 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 8:30 a.m., 9:30 a.m., 11:30 a.m., 2:00 p.m. 6:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/10/11 documented staff applied the lap restraint at 10:00 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 11:30 a.m., 1:30 p.m., 2:00 p.m., 5:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/11/11 documented staff applied the lap restraint at 7:30 a.m. and released the restraint at 7:30 p.m. The record documented staff provided care at 10:30 a.m., 12:30 p.m., 1:00 p.m., 3:30 p.m., 6:00 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record dated 2/14/11 documented staff applied the lap restraint at 2:30 p.m. and released the restraint at 7:00 p.m. The record documented staff provided care at 2:00 p.m., 4:00 p.m., 5:30 p.m., and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. During observation on 2/17/11 at 10:08 p.m. the resident sat in the wheelchair with a seat belt and a lap restraint hooked in the back of the wheelchair. The resident ambulated with a quad cane and minimal assistance of one staff member. The physician discontinued the lap restraint on 2/15/11 but the facility continued to utilize the lap restraint. 2. The MDS dated [DATE] documented Resident #3 as fully dependent on 2 staff for transfers, bed mobility, dressing,toilet use, personal hygiene, and did not ambulate. The MDS documented staff utilized a trunk restraint daily. The care plan dated 12/28/10 instructed staff to utilize a lap restraint on while unattended in the wheelchair. The care plan also noted the use of an enclosed bed until staff discontinued its use on 2/21/11. The physician ordered on [DATE] a right lower side rail in bed due to the resident throwing legs out of bed. The physician ordered on [DATE] a lap restraint when up in the wheelchair unattended. The physician ordered on [DATE] to discontinue the use of the side rail and ordered an enclosed bed. The restraint release record indicated staff must check on the resident in the restraint every thirty minutes, staff must release the restraint for exercise, toilet use, etcetera every two hours for ten minutes. The record instructed staff to document the specific time of release. The restraint release record for 12/17/10 documented staff applied the lap restraint at 8:00 a.m. and removed the restraint at 8:00 p.m. The record documented staff provided care at 10:30 a.m., 2:00 p.m., 4:00 p.m., 5:00 p.m., 6:00 p.m. and 8:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/18/10 documented staff applied the lap restraint at 7:30 a.m. and removed the restraint at 12:30 p.m. Staff applied the restraint at 12:30 p.m. and release the restraint at 7:00 p.m. The record documented staff provided care at 9:00 a.m., 10:30 a.m., 1:00 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/19/10 documented staff applied the lap restraint at 7:00 a.m. and removed the restraint at 10:00 a.m. The record documented staff provided care at 9:30 a.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/20/10 documented staff applied the lap restraint at 2:30 p.m. and removed the restraint at 8:00 p.m. The record documented staff provided care at 4:30 p.m. and 6:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/21/10 documented staff applied the lap restraint at 2:30 p.m. and removed the restraint at 7:00 p.m. The record documented staff provided care at 1:00 p.m., 2:00 p.m., 4:30 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/22/10 documented staff applied the lap restraint at 8:00 a.m. and removed the restraint at 1:30 p.m. The record documented staff applied the restraint at 2:30 p.m. unit 6:30 p.m. The record documented staff provided care at 9:00 a.m., 11:00 a.m., 1:00 p.m., 2:30 p.m., and 5:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/23/10 documented staff applied the lap restraint at 8:00 a.m. and removed the restraint at 7:00 p.m. The record documented staff provided care at 9:00 a.m., 11:00 a.m., 1:00 p.m., 2:30 p.m., 4:30 p.m. and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/24/10 documented staff applied the lap restraint at 7:30 a.m. until 1:00 p.m. The record documented staff provided care at 10:00 a.m. and 1:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/27/10 documented staff applied the lap restraint at 2:30 p.m. until 6:30 p.m. The record documented staff provided care at 3:30 p.m. and 5:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/28/10 documented staff applied the lap restraint at 3:00 p.m. until 6:30 p.m. The record documented staff provided care at 4:00 p.m. and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/29/10 documented staff applied the lap restraint at 2:00 p.m. until 6:30 p.m. The record documented staff provided care at 4:30 p.m. and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/30/10 documented staff applied the lap restraint at 9:30 a.m. until 1:30 p.m. The record documented staff provided care at 10:30 a.m. and 1:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 12/31/10 documented staff applied the lap restraint at 8:30 a.m. until 1:00 p.m. The record documented staff provided care at 11:00 a.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 1/1/11 documented staff applied the lap restraint at 4:30 p.m. until 6:30 p.m. The record documented staff provided care at 5:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 1/3/11 documented staff applied the lap restraint at 7:30 a.m. until 7:00 p.m. The record documented staff provided care at 9:00 a.m., 10:30 a.m., 12:30 p.m., 1:00 p.m., 2:00 p.m., 4:00 p.m., 5:30 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 1/4/11 documented staff applied the lap restraint at 7:30 a.m. until 12:00 p.m. and 1:30 p.m. until 7:30 p.m. The record documented staff provided care at 9:00 a.m., 10:00 a.m., 12:30 p.m. 2:00 p.m., 4:00 p.m., 5:00 p.m., and 5:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 1/5/11 documented staff applied the lap restraint at 7:30 a.m. until 12:30 p.m. and 2:00 p.m. until 7:30 p.m. The record documented staff provided care at 8:00 a.m., 10:00 a.m., 10:30 a.m., 1:30 p.m., 3:30 p.m., 4:30 p.m., and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 1/6/11 documented staff applied the lap restraint at 10:30 a.m. until 7:00 p.m. The record documented staff provided care at 11:30 a.m., 1:00 p.m., 2:00 p.m., 3:30 p.m., and 5:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 1/7/11 documented staff applied the lap restraint at 7:00 a.m. until 12:30 p.m. The record documented staff provided care at 8:30 a.m. and 12:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 1/8/11 documented staff applied the lap restraint at 4:00 p.m. until 7:30 p.m. The record documented staff provided care at 5:30 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 1/9/11 documented staff applied the lap restraint at 3:00 p.m. until 7:30 p.m. The record documented staff provided care at 5:00 p.m. and 7:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 1/10/11 documented staff applied the lap restraint at 7:30 a.m. until 12:00 p.m. and 3:00 until 7:00 p.m. The record documented staff provided care at 9:00 a.m., 11:00 a.m., 12:30 p.m., 4:00 p.m. and 6:00 p.m. The record did not indicate the care staff provided and the release of the restraint for the required amount of time. The restraint release record for 1/11/11 documented staff applied the lap restraint at 7:30 a.m. until

Based on clinical record review and physician interview, the facility administered medication at the incorrect time for one of six residents reviewed (Resident #2). The facility reported a census of 22 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 2/3/11 documented Resident #2 required extensive assistance for bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene. The MDS documented the resident utilized a trunk restraint daily. The MDS documented the resident had [DIAGNOSES REDACTED]. A physician order [REDACTED]. A physician order [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An emergency room note dated 11/9/10 documented the resident ingested [MEDICATION NAME], had an irregular heart beat, and apneic episodes. The daily nursing notes dated 11/9/10 at 11:00 a.m., the nurse discovered she administered the [MEDICATION NAME] in error and the resident continued to sleep. The daily nursing notes dated 11/9/10 at 12:00 p.m. documented the resident continued to sleep. The daily nursing notes dated 11/9/10 at 1:05 p.m. documented the resident had irregular breathing with apneic episodes. The nurse obtained an order to send the resident to the emergency room . The resident returned to the facility at 6:00 p.m. During an interview on 3/1/11 at 11:56 a.m., the resident's physician stated the resident received the [MEDICATION NAME] in error but most likely did not cause of the resident's cardiac [MEDICAL CONDITION]. The medication error most likely did not cause the resident's apneic episodes but could not definitely rule out the medication error as the cause of the apnea.