Every finding on record at Orchard Hill Rehabilitation and Healthcare Center

Based on medical record review, resident and staff interview, and the facility investigation record, it was determined that the facility staff failed to follow the physician's order or the resident's care plan to prevent a resident (Resident #25) from experiencing a fall that resulted in harm. This was evident for 1 (25) of 1 resident.The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facility's plan and action were verified during this survey; therefore, this deficiency was found to be past noncompliance with a compliance date of 3/6/2026 The findings Include On 4/16/2026 10:50AM, during the initial interview, Resident #25 stated that GNA #41 had dropped me on the floor and broke my ankle. The resident then showed their pink lower leg cast. On 4/16/2026 9:05AM, during the initial medical record review, it was discovered that the resident had a physician's order for the use of a Hoyer lift with a 2 person assist with a start date of 11/29/2023 and the most recent care plan that stated the resident required a total mechanical and 2 person assist for transfers that was dated 11/30/2025On 4/17/2026 9:55 AM, during an interview with the Director of Nursing (DON), the surveyor asked what had occurred that caused Resident #25's broken ankle and was told GNA #41 on 3/1/2026 had not checked the Kardex for the resident's transfer status and consequently was unaware of the order for the resident to use the Hoyer Lift with a 2 person assist and had single handedly attempted to transfer the resident from the bed to a wheelchair. GNA #41 reported that the resident's leg got tangled with the wheelchair and they dropped the resident on the floor causing the resident's ankle fracture.On 4/17/2026 at 1:55 P.M. the DON provided the facility investigation documents that included a statement from Employee #41 stating they did not use the Hoyer while transferring the resident. The DON also provided the training that Employee#41 had received at the beginning of the employment on 12/19/2025 with Orchard Hill that included the proper procedure to transfer a resident using a Hoyer lift and how to use the Kardex to find the proper way that each individual resident needed to be transferred due to the physical and mental limitations. The documentation also stated that Employee #41 had been suspended at the time of the incident until a full investigation could be completed. The Employee opted to not return to their position and was terminated on 3/6/2026.The facility's investigation determined that Employee #41 had not checked the Kardex to determine Resident #25's transfer status and had inappropriately attempted to transfer the resident by themselves and had caused the resident to fall and break the ankle. In response to this incident, the facility re-educated all nursing staff on locating transfer status; types of abuse and failure to follow plan of care and terminated GNA #41. In determining the Past Non-Compliant status for this citation, Employees #12, 13, 14, 15, 16 and 26 were interviewed on whether they had training regarding finding the resident's transfer status and how to use a Hoyer Lift. All 6 stated they had received these trainings and were able to answer the surveyor's question regarding resident transfer. Based on the actions taken by the facility and verified by the surveyors on site, it was determined that the facility's deficient practice was past noncompliance with a compliance date of 3/6/2026

Based on observations and staff interviews, it was determined that the facility failed to stock appropriate personal protective equipment (PPE) near resident rooms that were on enhanced barrier precautions (EBP). This was found to be evident in 2 (station 1 and station 2) of 4 unit stations reviewed during the recertification survey.The findings include: PPE refers to specialized clothing or equipment worn by healthcare workers to create a barrier against infectious materials, protecting themselves and residents from contamination. It consists of gloves, gowns/aprons, masks/respirators, face shields, and goggles.EBP is an infection control strategy for long-term care facilities, requiring staff to wear gowns and gloves during high-contact care for residents with MDROs, chronic wounds, or indwelling devices.On 4/16/2026 at 8:48 AM, the following resident rooms on Station 2 were observed to have EBP posters placed on entrance doorways: Rooms 202, 203, 204, 206, 207, 208, 209, 210, 211, 212, and 213. Station 2 had two PPE dispensers hanging from walls located in the hallway that were observed at 8:57 AM. Neither PPE dispensers had gowns stocked. Additional observations inside rooms with EBP posters on Station 2 did not reveal PPE stocked inside the rooms.On 4/16/2026 at 8:54 AM, Licensed Practical Nurse (LPN) #6 was interviewed and stated that the overnight supervisor is responsible for stocking PPE dispensers if they are empty during night shift.On 4/16/2026 at 8:56 AM, Registered Nurse (RN) #5 was interviewed and stated that gowns are kept in PPE dispensers in hallways, and it is expected that they should be stocked.On 4/16/2026 at 9:18 AM, the following resident rooms on Station 1 were observed to have EBP posters placed on entrance doorways: Rooms 101, 103, 104, 105, 110, 112, 113, and 115. Station 1 had two PPE dispensers hanging from walls located in the hallway that were observed at 9:20 AM. Neither PPE dispensers had gowns stocked. Additional observations inside rooms with EBP posters on Station 1 did not reveal PPE stocked inside rooms.The Director of Nursing was made aware of surveyor concerns on 4/16/2026 at 11:44 AM.

Based on interviews with facility staff and review of employee files, it was determined that the facility staff failed to conduct required performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This was found to be evident for 5 (GNA #42, GNA #43, GNA #44, GNA #45, GNA #46) out of 5 GNA employee files reviewed during the facility's recertification survey. The findings include:Performance reviews are to be completed for each GNA at least every 12 months to identify specific, in-service education based on the outcome of those individual performance reviews. On 4/17/26 at 1:55 PM the surveyor requested the complete employee files including, but not limited to, health records, training records, evaluations, disciplines, et cetera for GNA #42, GNA #43, GNA #44, GNA #45, and GNA #46.On 4/22/26 at 9:31 AM in an interview with the Director of Nursing (DON) when asked if performance reviews were conducted for the GNAs she stated, yes. During the interview when asked how often she stated, It's supposed to be yearly. When asked where they were stored, she stated with HR (Human Resources). On 4/22/26 at 9:34 AM in an interview with Regional HR with the DON present, she verified and confirmed that the GNA performance reviews were stored in their employee files.On 4/22/26 at 10:07 AM review of GNA #42's employee file revealed she was hired on 4/17/13; however, failed to reveal a performance review from 2025.On 4/22/26 at 1:31 PM review of GNA #43's employee file revealed she was hired on 8/8/24; however, failed to reveal a performance review from 2025.On 4/22/26 at 2:03 PM review of GNA #44's employee file revealed she was hired on 3/20/25; however, failed to reveal a performance review from 2025.On 4/22/26 at 2:37 PM review of GNA #45's employee file revealed she was hired on 12/11/24; however, failed to reveal a performance review from 2025.On 4/22/26 at 2:51 PM review of GNA #46's employee file revealed he was hired on 12/27/23; however, failed to reveal a performance review from 2025.On 4/23/26 at 9:57 AM in an interview with GNA #35 when asked if he/she had ever had a performance review, he/she stated, No, I cannot remember having a performance review.On 4/23/26 at 11:10 AM in an interview with the DON the surveyor shared the concern that there were no 2025 performance reviews observed in the 5 GNA employee files reviewed. When asked about the GNA performance reviews she stated, I know from my years of Director of Nursing experience that they are completed annually. Let me check with HR because they're union employees and on top of things like that. When asked if she personally had conducted any GNA performance evaluations, she stated, I haven't done any. On 4/23/26 at 12:14 PM in an interview with the DON she stated, For the performance reviews, I didn't find any. The surveyor shared this was a concern and asked how the facility provided in-service education to GNAs that addressed areas of weakness identified in performance reviews if performance reviews were not conducted. The DON acknowledged the concerns, stated she understood, and offered no further comments at that time.On 4/23/26 at 12:51 PM review of the facility's policy entitled, Performance Evaluations, revealed the Policy Statement: The job performance of every employee is reviewed and evaluated at least annually. Further review revealed, The completed performance evaluation is sent by the director or supervisor to the director of human resources to be placed in the employee's personnel record. A copy is provided to the employee.Cross Reference F947

Based on record review, responsible person interview, and staff interview, it was determined that the facility failed to ensure care plans were reviewed and revised at least quarterly and updated to reflect residents' current needs. This is evident for 6 (Residents #2, #3, #4, #6, #107, and #113) of 9 residents reviewed for care plan review and revision.The findings include: 1.) On 04/17/2026 at 9:11 AM, during review of the electronic medical record, it was revealed that Resident #113's last documented care plan review was on 12/18/2025. At 9:30 AM, review showed that Resident #107's last documented care plan review was on 01/02/2026. At 9:37 AM, review showed that Resident #2's last documented care plan review was on 12/11/2025. At 9:39 AM, review showed that Resident #6's last documented care plan review was on 01/09/2026. At 9:42 AM, review showed that Resident #4's last documented care plan review was on 01/02/2026. These dates exceeded the required quarterly (at least every three months) review timeframe. On 04/21/2026 at 9:54 AM, an interview was conducted with Staff #7, who stated she handles care plans and confirmed that care plans should be completed quarterly. Staff #7 stated she was unsure if she was responsible for completing the quarterly reviews. Staff #7 was informed of the identified concern regarding the five residents with missed quarterly care plan reviews and stated she would ensure quarterly updates moving forward. 2.) 04/22/2026 11:46 AM During the initial interview with Resident #3's family member, identified concerns with the residents hydration stating that the nursing staff did not assist the resident with drinking consistently throughout the day. During observations during the survey the GNA's were observed assisting the resident with drinking water. The medical staff had ordered an IV for Resident #3's hydration. Resident #3's care plan dated 1/9/2026 did not identify hydration as a focus. It was mentioned as a goal for the potential for infection due to the midline catheter and there were no interventions to maintain or restore the resident's hydration. There was a provider's order for Resident #3's hydration.

Based on observation and staff interview, it was determined that the facility failed failed to ensure that medication was secured in the pharmacy issued bubble packs. This was evident in 4 out of 4 medication carts observed during the survey.The findings Include: On 4/22/26, during the medication storage observation, it was observed that in all 4 Medication carts there were a large number of pills and capsules, approximately 2-3 dozen per cart, that had come loose from the bubble packs that the pharmacy provided the resident's medication in. The loose medications were collected and given to the DON for appropriate disposal and the DON was notified of the concern and indicated the facility did not have specific policy regarding medications that came out of the bubble packs but they had ordered 2 additional medication carts since it appeared that the crowding of the bubble packs seemed to cause the medication to be accidently pushed out.

Based on record review and staff interview, it was determined that the facility failed to ensure residents were free from unnecessary medications by failing to ensure a PRN psychotropic medication was ordered with an adequate indication, supporting diagnosis, and within the required 14-day time-limited duration without documented clinical justification for extended use. This is evident for 1 (Resident #2) of 2 residents reviewed for unnecessary medications.The findings include:Psychotropic medications are drugs that affect brain function and alter mood, behavior, or cognition; in long-term care, they must be supported by a specific clinical indication, appropriate monitoring, and time-limited use when ordered on an as-needed basis.Lorazepam is a benzodiazepine psychotropic medication commonly used for anxiety, agitation, or acute seizure activity, but it carries risks such as sedation, respiratory depression, and dependence, and requires clear clinical justification. On 04/20/2026 at 11:05 AM, during review of Resident #2's electronic medical record it was revealed the resident was ordered Lorazepam Injection 1 mg intramuscularly every 24 hours as needed for breakthrough seizures for a duration of 6 months. This order was placed on 2/13/2026. Further review showed no documented diagnosis of seizures and no evidence of seizure activity to support the use of this medication. Additionally, PRN or as needed psychotropic medications are required to have a time-limited duration of 14 days unless there is a documented clinical justification and supporting rationale for continued use. The extended 6-month PRN order for lorazepam lacked documented justification consistent with this requirement.On 04/23/2026 at 10:27 AM, interview with Staff #17, the ordering provider, revealed the medication was ordered as a precaution due to EEG findings during a prior hospitalization; however, the provider was unable to identify a supporting diagnosis for seizures. Staff #17 stated that Resident #2 was on seizure precautions and this order was part of a protocol for seizures.On 04/23/2026 at 10:32 AM, review of physician orders revealed no seizure precautions in place, only an order to monitor for seizure activity.At 12:04 PM, the Director of Nursing (DON) the surveyor shared the concerns about the lorazepam order length of 6 months and the lack of adequate indication, documented justification, or a supporting diagnosis. The DON stated that PRN or as needed psychotropic medications may be ordered longer when used for other clinical conditions such as seizure management; however, no supporting documentation or policy was provided at the time of exit.

Based on record review and staff interview, it was determined that the facility failed to ensure the resident or representative were informed of the risks and benefits of a medication prior to initiation. This is evident for 1 (Resident #2) of 2 residents reviewed for unnecessary medications.The findings include:On 04/20/2026 at 11:05 AM, review of Resident #2's electronic medical record revealed that on 02/13/2026, Resident #2 was ordered Lorazepam Injection 1 mg intramuscularly every 24 hours as needed for breakthrough seizures for a duration of 6 months. There was no documented diagnosis of seizures for the resident and no evidence of seizure activity that would support the use of this medication.On 04/23/2026 at 10:27 AM, interview with Staff #17, the provider that wrote the order, revealed the medication was ordered as a precaution due to EEG findings during a prior hospitalization; however, the provider was unable to identify a supporting diagnosis for seizures. Staff #17 was asked if the resident was informed of the risks and benefits of the Lorazepam and s/he stated Yes'.On 04/23/2026 at 10:52 AM, the surveyor requested the Director of Nursing (DON) provide documentation that the resident had been informed of the risks and benefits of Lorazepam prior to the initiation of the medication.On 04/23/2026 at 11:09 AM, documentation was provided which stated, Diagnosis, prognosis, treatment plan, risk, benefits, alternatives, side effects and adverse reactions of treatment were discussed with client. Informed consent for all medications and treatments was obtained. with a date of service of 04/20/2026, which was after the medication order date of 02/13/2026.

Based on review of the medical record and interview with facility staff, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days of the resident's enrollment and discontinuation in hospice services. This was evident for 1 (Resident #1) out of 1 residents reviewed for hospice during the facility's recertification survey. The findings include:A Significant Change in Status Assessment (SCSA) is a comprehensive assessment that must be completed within 14 days after the Interdisciplinary Team (IDT) has determined that a resident meets the guidelines for significant change for either major improvement or decline. A SCSA is required when a resident: enrolls in a hospice program, changes hospice providers and remains in the facility, discontinues hospice services, or experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from their baseline.On 4/17/26 at 12:03 PM review of Resident #1's medical record revealed an order, Admit to [NAME] Hospice Primary DX (diagnosis): Interstitial Lung Disease, Secondary DX: COPD, Pulmonary Fibrosis, Chronic Respiratory Failure, Dysphagia that was ordered on 11/13/25. Further review revealed Resident #1's primary physician discontinued the 11/13/25 hospice order on 11/18/25. Continued review revealed a second hospice order, Admit to [NAME] Hospice dx (diagnosis): Interstitial lung disease that was ordered on 3/30/26. Additionally, review of Resident #1's medical record revealed a SCSA was completed on 11/20/25; however, further review revealed that on 11/25/25 at 5:22:28 PM Section O0110. Special Treatments, Procedures, and Programs: K1. Hospice care was documented as No. This was the only SCSA completed for Resident #1; therefore, the facility did not complete a SCSA within 14 days of when the resident enrolled in hospice on 11/13/25, was discharged from hospice services on 11/18/25, or when the resident enrolled in hospice on 3/30/26. On 4/20/26 at 12:39 PM in an interview with the Regional MDS (Minimum Data Set) Coordinator #11 when asked when a SCSA must be completed she stated within 14 days if a resident had 2 or more ADL (activities of daily living) changes, was put on hospice or discharged from hospice. The surveyor shared the concern that a SCSA was not completed when Resident #1 enrolled in hospice services on 11/13/25 or 3/30/26 or when the resident was discontinued from hospice services on 11/18/25. The Regional MDS Coordinator #11 confirmed and verified that a SCSA should have been completed within 14 days of each of these three dates and that none were completed and acknowledged understanding of the concerns.

Based on review of Minimum Data Set (MDS) assessment records, MDS validation reports, and interview with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 2 (Resident #84, #106) of 2 residents reviewed for resident assessment.The findings include:On 04/22/2026 at 11:12 AM, review of MDS records revealed Resident #84 was discharged from the facility on 11/30/2025 and Resident #106 was discharged on 12/09/2025. A review of the MDS validation report showed that discharge assessments for both residents had not been transmitted within the required timeframe.On 04/22/2026 at 11:36 AM, Staff #8 stated that both MDS discharge assessments were completed but had not been transmitted, and copies were requested by the surveyor for review.On 04/23/2026 at 9:12 AM, review of the MDS 3.0 Final Validation Report confirmed that the discharge assessments for both residents were transmitted on 04/22/2026 after surveyor inquiry identified concerns, indicating transmission occurred well beyond the required 14-day timeframe.

Based on record review and staff interview, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect residents' clinical status. This is evident for 2 (Residents #1 and #3) of 2 residents reviewed for MDS accuracy.The findings include: The Minimum Data Set (MDS) is a federally mandated, standardized assessment tool used to comprehensively evaluate a resident's functional, medical, psychosocial and cognitive status. It is administered to all residents at admission, quarterly, annually, and whenever a significant change in an individual's condition occurs. It is the foundation for creating an individualized care plan and ensures the appropriate care and services are provided to each resident. MDS assessments must be accurate to ensure each resident receives the personalized and resident specific care they need. A Significant Change in Status Assessment (SCSA) is a comprehensive assessment that must be completed within 14 days after the Interdisciplinary Team (IDT) has determined that a resident meets the guidelines for significant change for either major improvement or decline. A SCSA is required when a resident: enrolls in a hospice program, changes hospice providers and remains in the facility, discontinues hospice services, or experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from their baseline. 1.) On 4/17/26 at 12:03 PM review of Resident #1's medical record revealed an order, Admit to [NAME] Hospice Primary DX (diagnosis): Interstitial Lung Disease, Secondary DX: COPD, Pulmonary Fibrosis, Chronic Respiratory Failure, Dysphagia that was ordered on 11/13/25. On 4/20/26 at 10:30 AM review of Resident #1's medical record revealed an assessment entitled, Interim Skin Check .2 – V1 dated 11/20/25. In Section A: Head to Toe Skin Check and Evaluation, it documented Are there any skin impairments noted? and yes was recorded. The next question, Is this a new skin impairment? was also documented yes. For type of skin impairment, it documented Pressure injury and the site was documented sacrum. Further review of the medical record revealed a note from the Wound Nurse Practitioner #10 also dated 11/20/25 which documented a Stage 3 pressure ulcer. On 4/20/26 at 12:24 PM review of Resident #1's medical record revealed a SCSA MDS was completed. Further review revealed that on 11/25/25 Section O0110. Special Treatments, Procedures, and Programs: K1. Hospice care was documented as No. Continued review revealed that on 11/25/25 Section M0210. Unhealed Pressure Ulcers/Injuries: Does this resident have one or more unhealed pressure ulcers/injuries? was documented as No. On 4/21/26 at 10:40 AM in an interview with the Regional MDS Coordinator #11, a dual observation of Resident #1's Interim Skin Check .2 – V1 and the progress note from Wound Nurse Practitioner #10 both dated 11/20/25 was conducted. When asked if the pressure ulcer should have been captured and coded on the 11/20/25 SCSA, the Regional MDS Coordinator #11 stated, yes. During the interview she also verified and confirmed that, We did not mark hospice on the 11/20/25 assessment. The surveyor shared these were both concerns for inaccurate coding and the Regional MDS Coordinator #11 acknowledged and verbalized understanding of the concerns. 2.) A record review was completed for Resident #3 on 4/22/2026 at 10:30 AM. The review noted that Resident #3 was re-admitted to the facility on [DATE] after a hospitalization that included surgery for an above the knee amputation (AKA) of his/her right leg. The resident's discharge to the hospital had been reported to the MDS with the notation that return was anticipated. His/her readmission was also reported with the initial MDS for the readmission completed. On the quarterly assessment, the facility inaccurately answered the question regarding had the resident had surgery within the last 100 days. The quarterly assessment was dated 4/8/2026 and the resident had the AKA surgery on 2/19/2026 which made the assessment completed 39 days after the surgery. The regional director (Employee #11) was interviewed regarding this assessment and they acknowledged that there was an error made.

Based on record review and staff interview, it was determined that the facility failed to ensure comprehensive care plans were developed and updated timely to reflect residents' current conditions. This is evident for 2 (Residents #1 and #3) of 2 residents reviewed for care planning. Findings include: A care plan is a guide that outlines a person's healthcare needs, treatment goals, and the specific interventions required to meet those goals, ensuring personalized and consistent care. The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). The care plan is used to plan, assess, and evaluate the effectiveness of the resident's care they receive in a facility. A pressure ulcer also known as pressure sore, bed sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying skin. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (partial thickness loss of skin presenting as a shallow open ulcer), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with exposed tendon, muscle or bone) to Unstageable (the depth of tissue damage cannot be determined due to the presence of slough or eschar (both are types of dead skin that prevent healing). Consistent care is essential for treating and preventing pressure ulcers. Inconsistent care can lead to severe complications, including infection and worsening of the wound. 1. On 04/21/2026 at 1:14 PM during a medical record review for resident # 3 it was discovered that the last care update in the resident's e-chart was dated 1/9/2026. Since that date, the resident was discharged from the facility on 2/19/2026 to the hospital where the resident underwent an above the knee amputation. They were discharged from the hospital on 3/10/2026 and returned to the facility. The facility update the Minimal Data Set(MDS) with the resident's discharge and re-admission. The care plan was not updated for the re-admission. The care plan from 1/9/2026 had some addendum added but still contained care areas that did not reflect the resident's change in condition. This included care for an wound on the great toe of the leg that had been amputated. There was nothing in the care plan regarding care for the amputation site.In an interview with the social services assistant, Employee #11, while trying to establish who was responsible for ensuring care plans were completed in a timely fashion, Employees #7, #11 and #2 were interviewed before it was established that the DON was responsible for care plans. Employee #11 stated that they sent out invitations to the care plan meetings and had the sign-in sheets. Sign in sheets were reviewed and it was noted that few of the staff participated in the care plan meeting. 2. A review of Resident #1's medical record on 4/20/26 at 10:30 AM revealed an assessment entitled, Interim Skin Check .2 – V1 dated 11/20/25 which revealed a new, sacral pressure injury. Further review revealed a progress note from the Wound Nurse Practitioner #10 also dated 11/20/25 which documented a Stage 3 pressure ulcer. A review was conducted of Resident #1's medical record on 4/21/26 at 11:26 AM that revealed a care plan for a bilateral coccyx Stage 3 pressure ulcer; however, it was initiated on 2/2/26 10 weeks after the pressure ulcer was identified and documented on by a facility nurse and Wound Nurse Practitioner #10. On 4/21/26 at 11:38 AM in an interview with the Director of Nursing (DON), On 4/21/26 at 11:38 AM in an interview with the Director of Nursing (DON), when asked if the expectation was for a resident with a Stage 3 pressure ulcer to have a care plan, she stated, Yes, I would expect the resident to be care planned. Everyone should have an at risk of pressure ulcer care plan and if the resident has a pressure ulcer, we will update the care plan. When asked when the care plan should be updated, she stated, It should be updated when it is found the resident has a wound. During the interview, a dual observation of the Interim Skin Check .2 – V1 and progress note from the Wound Nurse Practitioner #10 which documented a Stage 3 pressure ulcer both dated 11/20/25 was conducted. The surveyor shared the concerns that the pressure ulcer was noted on 11/20/25; however, a care plan for Resident #1's pressure ulcer was not created until 2/2/26. The DON acknowledged and confirmed understanding of the concerns.

Based on review of medical records and interviews with facility staff, it was determined the facility failed to order and implement the treatment of a Stage 3 pressure ulcer timely. This was evident for 1 (Resident #1) out of 1 residents reviewed for pressure ulcers during the during the facility 's annual recertification survey.The findings include:A pressure ulcer also known as pressure sore, bed sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying skin. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (partial thickness loss of skin presenting as a shallow open ulcer), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with exposed tendon, muscle or bone) to Unstageable (the depth of tissue damage cannot be determined due to the presence of slough or eschar (both are types of dead skin that prevent healing). Consistent care is essential for treating and preventing pressure ulcers. Inconsistent care can lead to severe complications, including infection and worsening of the wound. On 4/20/26 at 10:30 AM review of Resident #1's medical record revealed an assessment entitled, Interim Skin Check .2 - V1 dated 11/20/25. In Section A: Head to Toe Skin Check and Evaluation, it documented Are there any skin impairments noted? and yes was recorded. The next question, Is this a new skin impairment? was also documented yes. For type of skin impairment, it documented Pressure injury and the site was documented sacrum. Further review of the medical record revealed a progress note from the Wound Nurse Practitioner (NP) #10 also dated 11/20/25 which documented a Stage 3 pressure ulcer with four treatment recommendations.On 4/20/26 at 10:36 AM review of Resident #1's orders revealed the following order, Coccyx-cleanse with NSS, calcium alginate border foam gauze daily and prn (as needed). The order date was 1/30/26. Further review failed to reveal a wound treatment order prior to 1/30/26. On 4/21/26 at 11:38 AM in an interview with the Director of Nursing (DON), when asked about the wound team, she stated there is a wound doctor, wound NP, and wound nurse. When asked when she would expect interventions to be put in place for a resident identified with a pressure ulcer, she stated, I would expect interventions to be put in place immediately for a resident found to have a pressure ulcer. During the interview, a dual observation of the Interim Skin Check .2 - V1 and progress note from the Wound Nurse Practitioner #10 which documented a Stage 3 pressure ulcer both dated 11/20/25 was conducted. The surveyor shared the concerns that the pressure ulcer was noted on 11/20/25; however, there was no wound treatment ordered until 1/30/26. The DON acknowledged and confirmed understanding of the concerns. On 4/21/26 at 12:36 PM review of the facility's policy entitled, Pressure Ulcers/Skin Breakdown-Clinical Protocol revealed, The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents if indicated for type of skin alterations. Further review revealed, The physician will help identify medical interventions related to wound management.On 4/21/26 at 12:53 PM in an interview with the DON she stated, I did not see any wound treatment orders prior to 1/30/26. Cross reference F710

Based on medical record review, observations, and interviews, it was determined that the facility failed to provide additional nourishment for a resident as ordered by a physician. This was found to be evident in 1 (Resident #55) of 40 residents reviewed during the recertification survey.The findings include:Magic Cups most commonly refer to high-calorie, nutrient-dense frozen nutritional desserts often used in health settings.During an interview on 4/16/2026 at 10:43 AM, Resident #55 stated that their meals are often missing items they expect to receive.Resident #55's medical record was reviewed on 4/20/2026 at 12:30 PM. The resident was admitted on [DATE] and had a diet order placed by a physician on 4/2/2026 that stated, Magic Cup with meals for risk of malnutrition or equivalent 4 oz. TID and Health shakes with meals for risk of malnutrition 4 oz. TID.On 4/21/2026 at 8:56 AM, Resident #55's breakfast meal was observed. No Magic Cup or health shake were observed on the meal tray and the resident's meal ticket did not include Magic Cup and health shake on listed items to receive. Resident #55 stated they had been admitted to the facility for several weeks and never received Magic Cups or health shakes.On 4/21/2026 at 9:09 AM, Resident #55's care plan meeting notes from 4/15/2026 were reviewed. Under the concerns section it was written, [Resident#55] also stated that [he/she] has not been receiving Health Shakes or Magic Cup at every meal as ordered.Review of Resident 55's Medication Administration Record (MAR) on 4/21/2026 at 9:09 AM showed that facility staff had been documenting administering health shakes and Magic Cups at every meal since the diet order was placed.Review of Resident #55's MAR on 4/21/2026 at 12:30 PM showed that Magic Cup and health shake were administered for breakfast on 4/21/2026.Resident #55 stated during an interview on 4/21/2026 at 12:40 PM that they had not received the Magic Cup and health shake for breakfast or anytime afterwards.On 4/21/2026 at 1:26 PM, Resident #55's lunch tray was observed. No Magic Cup or health shake were on the meal tray, and the lunch meal ticket did not have either item listed.On 4/21/2026 at 1:29 PM, Licensed Practical Nurse (LPN) #20 was interviewed and informed that Resident #55 did not have a Magic Cup and health shake on their breakfast and lunch tray. LPN #20 stated that they went to the facility kitchen and got them for the resident at breakfast. LPN #20 was informed that Resident #55 stated to surveyor multiple times that they did not receive them today and no observations by the surveyor during the day revealed Magic Cup and health shakes being served. LPN #20 was also shown Resident #55's MAR which showed documentation that the Magic Cup and health shake were administered for lunch even though the resident had not received either item. LPN #20 was asked if it was standard practice to document Magic Cup and health shakes as administered before resident received and they replied, not really.The Director of Nursing (DON) was made aware of surveyor concerns on 4/21/2026 at 1:50 PM. The DON stated that they will make sure Resident #55's meal ticket would be updated to include both Magic Cup and health shakes for meals.

Based on review of medical records and interviews with facility staff, it was determined the facility failed to ensure that a resident's primary care provider(s) assessed and monitored his/her pressure ulcer. This was evident for 1 (Resident #1) out of 1 residents reviewed for pressure ulcers during the facility 's annual recertification survey.The findings include:A pressure ulcer also known as pressure sore, bed sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying skin. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (partial thickness loss of skin presenting as a shallow open ulcer), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with exposed tendon, muscle or bone) to Unstageable (the depth of tissue damage cannot be determined due to the presence of slough or eschar (both are types of dead skin that prevent healing). Consistent care is essential for treating and preventing pressure ulcers. Inconsistent care can lead to severe complications, including infection and worsening of the wound. On 4/20/26 at 10:30 AM review of Resident #1's medical record revealed a nursing skin assessment that documented a new, sacral pressure ulcer on 11/20/25. Further review revealed a progress note from Wound Nurse Practitioner (NP) #10 also dated 11/20/25 which documented a Stage 3 pressure ulcer.On 4/21/26 at 11:57 AM review of Resident #1's medical record revealed a physician's note from Resident #1's primary care provider, Medical Doctor (MD #40), dated 11/21/25 that read in part: Chief Complaint/Reason for this Visit: Readmission and Note: The patient's care plan including but not limited to imaging, labs and medications being ordered have been discussed in detail with the care providing nursing staff. Further review of the note failed to reveal the identification and/or assessment of the resident's Stage 3 pressure ulcer in the Physical Examination, Assessment and Plan, or Diagnoses sections of the note. Continued review of the medical record revealed progress notes from MD #40 on 11/22/25, 11/27/25, 11/28/25, 12/5/25, 12/15/25, 12/17/25, 12/31/25, 1/7/26, 1/28/26, 2/18/26, 3/11/26, 3/23/26, 4/1/26; however, the medical provider failed to identify and/or assess Resident #1's Stage 3 sacral pressure ulcer from her visits. Additionally, the facility's Nurse Practitioner (NP #17) failed to identify and/or assess Resident #1's pressure ulcer from her visits on 11/25/25, 1/8/26, 2/17/26, 3/5/26, or 3/19/26. On 4/21/26 at 12:36 PM review of the facility's policy entitled, Pressure Ulcers/Skin Breakdown-Clinical Protocol revealed, The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and history of pressure ulcer(s). Further review revealed, During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds.On 4/21/26 at 12:53 PM in an interview with the Director of Nursing (DON) when asked if there was one provider who was responsible for the overall care of the resident, she stated his/her primary care provider who was [MD #40's name]. The surveyor shared the concern that after Resident #1's Stage 3 pressure ulcer was identified by facility nursing staff and Wound NP #10 on 11/20/25, the resident was seen 14 times from 11/21/25-4/1/26 by Resident #1's primary care provider, MD #40, and 5 times from 11/25/25-3/19/26 by NP #17; however, both medical providers failed to identify and/or assess the resident's Stage 3 pressure ulcer. The DON acknowledged and confirmed understanding of the concern.An interview was conducted with the facility's NP #17 on 4/21/26 at 10:15 AM when asked what residents she was responsible for, she stated, I see everyone. During the interview she stated she was in the facility 5 days a week. On 4/21/26 at 2:26 PM in an interview with the facility's NP #17 when asked if Resident #1 had any wounds, she stated he/she was being followed weekly by the wound team for a pressure ulcer. When asked if she had ever assessed the wound she stated, No, I haven't seen it to be honest since he/she's being followed by the wound team, they usually take care of that. When asked if she was this resident's primary care provider and responsible for the resident's care she stated, Yes, I am one of the resident's primary care provider and he/she's followed by the Wound NP who is more of an expert in that area. The surveyor shared this was a concern. NP #17 stated, I've seen it (pressure ulcer) once when they said the person has a wound. I looked at it and said let's have the wound team see the patient. When asked if that was documented, NP #17 stated, I can check and see if I did. It looks like I captured the rash but did not capture the wound. No, I do not see it. When asked why there was no documentation of an assessment or mention of Resident #1's pressure ulcer, she stated, Well, since he/she was followed by Wound NP #10, I just didn't include it in my notes. I should have included it. It's an oversight. The surveyor shared the concerns and NP #17 acknowledged the concerns and offered no further comments at that time. Cross reference F686

Based on record review and staff interview, it was determined that the facility failed to ensure that the pharmacist performed an accurate medication regimen review and identify a medication without a matching diagnosis. This is evident for 1 (Resident #2) of 2 residents reviewed for medication regimen review.The findings include:On 04/20/2026 at 11:05 AM, a review of the electronic medical record for Resident #2 revealed an order for Lorazepam Injection 1 mg intramuscularly every 24 hours as needed for breakthrough seizures for a duration of 6 months. The order was written by Staff #17 on 02/13/26. Review of Resident #2's documented medical diagnoses revealed no documented diagnosis of seizures and no evidence of seizure activity to support the use of this medication. Monthly medication regimen reviews completed on 02/27/26 and 03/29/26 documented No medication irregularities noted at this time. The pharmacist failed to identify or report that the medication lacked a documented supporting diagnosis.On 04/23/2026 at 10:27 AM, during an interview with Staff #17, the surveyor shared the concern of the lack of a medical diagnosis of seizures in the electronic medical record for Resident #2. Staff #17 stated that the lorazepam order was part of a seizure protocol and that she ordered it because the resident was on Keppra. Staff #17 was unable to identify a supporting diagnosis for seizures. At 12:04 PM, the Director of Nursing (DON) was made aware of the concerns with the medications lacking a diagnosis and a request for any further documentation regarding the concerns was made. At the time of exit, there was no further documentation provided regarding the identified concerns.

Based on record review and staff interview, it was determined that the facility failed to ensure medications were ordered with an adequate indication and supporting diagnosis and failed to ensure appropriate parameters for a psychotropic medication ordered on an as-needed basis, resulting in an unnecessary medication. This is evident for 1 (Resident #2) of 2 residents reviewed for unnecessary medications.The findings include: Lorazepam is a benzodiazepine psychotropic medication commonly used for anxiety, agitation, or acute seizure activity, but it carries risks such as sedation, respiratory depression, and dependence, and requires clear clinical justification. Levetiracetam (Keppra) is an anticonvulsant used to prevent or control seizures and should be supported by a documented seizure disorder or related neurological condition.On 04/20/2026 at 11:05 AM, during review of Resident #2's electronic medical record it was revealed the resident was ordered Lorazepam Injection 1 mg intramuscularly every 24 hours as needed for breakthrough seizures for a duration of 6 months. This order was placed on 2/13/2026. Further review showed no documented diagnosis of seizures and no evidence of seizure activity to support the use of this medication.On 04/23/2026 at 10:27 AM, interview with Staff #17, the ordering provider, revealed the medication was ordered as a precaution due to EEG findings during a prior hospitalization; however, the provider was unable to identify a supporting diagnosis for seizures. Staff #17 stated that Resident #2 was on seizure precautions and the addition of the lorazepam order was part of a protocol. Staff #17 stated that since the resident was on Keppra that lorazepam should be added. The surveyor also inquired about the lorazepam order having an empty checkbox for Reassessment required, indicating that if the medication were to be given to the resident, reassessment would not be performed. Staff #17 agreed lorazepam is a medication requiring reassessment and did not respond when asked if the box should indeed be checked.At 10:32 AM, review of physician orders revealed no seizure precautions in place, only an order to monitor for seizure activity. Further review showed that Resident #2 was ordered levetiracetam 250mg for seizure. This medication also lacked a matching medical diagnosis.At 12:04 PM, the Director of Nursing (DON) was interviewed and the concerns with the medications lacking a diagnosis were shared by the surveyor. A request for any further documentation regarding the two medication orders was made. The surveyor also requested copies of any policies or related information about the seizure medication protocol mentioned by Staff #17. The DON stated she did not think there was a written policy but would follow up on the concern. At the time of exit, there was no further documentation provided regarding the identified concerns.

Based on interviews and medical record review, it was determined that the facility failed to maintain and document accurate medical records. This was found to be evident in 1 (Resident #44) of 1 resident reviewed for dialysis during the recertification survey.The findings include:On Thursday, 4/16/2026 at 11:08 AM, Resident #44 was interviewed after returning from hemodialysis (HD) and stated that they receive HD 3 times a week on Tuesdays, Thursdays, and Saturdays at 6:00 AM.Resident #44's medical records were reviewed on 4/20/2026 at 8:20 AM and showed that the resident was admitted to the facility on [DATE]. Review of Resident 44's active medical orders revealed an order placed on 1/9/2026 that stated, Dialysis on [NAME] M, W, F as per schedule, every day shift every Mon, Wed, Fri. A nephrology consult dated 4/16/2026 was reviewed that stated under assessment and plan, ESRD on hemodialysis, dialyzes T/Th/Sat via tunneled catheter with stable post-HD returns, continue T/Th/Sat HD.Resident #44's Treatment Administration Record (TAR) was reviewed for the months of January, February, March, and April 2026, which revealed documentation on every Monday, Wednesday, and Friday for HD since Resident 44's admission. The TAR was either documented with a check mark (administered), NA (not applicable), or 22 (drug/treatment not administered). There was no documentation on the TAR for any month reviewed for Tuesday, Thursday, Saturday HD.On 4/20/2026 at 9:33 AM, Resident 44's dialysis communication binder was reviewed with the Director of Nursing (DON). The dialysis communication forms between the nursing facility and dialysis center revealed that the resident had been receiving HD on Tuesdays, Thursdays, and Saturdays since their admission to the nursing facility. The DON was made aware of surveyor concern that Resident 44's medical order and TAR documentation did not accurately address the resident's dialysis schedule. The DON stated they would have the order change to reflect the correct HD schedule.An additional review of Resident 44's medical record was conducted on Tuesday, 4/21/2026 at 9:25 AM. A nurse progress note dated 4/21/2026 at 6:00 AM stated, Resident alert and responsive. Left for her HD section at 6am in stable condition. Review of Resident's 44 medical orders showed the resident still had an active order for Monday, Wednesday, Friday HD.

Based on interviews with facility staff, review of employee files, and review of pertinent documentation, it was determined that the facility failed to ensure the nurses' aides had continuing education that included dementia management training and addressed areas of weakness as determined in nurse aides' performance reviews. This was found to be evident for 2 (GNA #44 and GNA #45) of 5 GNA employee files reviewed during the facility's recertification survey. The findings include:Performance reviews are to be completed for each GNA at least every 12 months to identify specific, in-service education based on the outcome of those individual performance reviews. Relias is an online training provider that offers continuing education (CE) for healthcare, senior care, and disabilities professionals. Relias's CE library covers a wide range of topics and is accredited by many national and state licensing boards. Relias's courses are designed to help healthcare workers improve patient care, grow, and provide high-quality care.On 4/22/26 at 7:55 AM in an interview with the Director of Nursing (DON) when asked if there was a Staff Educator, she stated they lost the Staff Educator last month and the Clinical Managers (Director of Nursing, Assistant Director of Nursing, and Unit Managers) were providing education currently. When asked who the best person was to direct questions regarding education, she stated herself or the Assistant Director of Nursing (ADON). On 4/22/26 at 9:21 AM in an interview with the DON when asked about all ways staff was provided with education she stated upon hire, there was an onboarding. During the interview, she also stated there is a 3 day orientation on the floor for clinical staff, on going in services, such as if there was an allegation of abuse, and Relias. On 4/22/26 at 9:34 AM in an interview with Regional HR (Human Resources) with the DON present, she stated that employees' Relias transcripts can be pulled as needed. The surveyor requested the Relias transcripts for GNA #42, GNA #43, GNA #44, GNA #45, and GNA #46.On 4/22/26 at 10:05 AM the ADON provided the facility's in service and education binders. There were 3 binders: 1) In Service/Education, 2) Staff Education Volume 2 2024-2025, and 3) Staff Education Volume 3 2025. At this time, in an interview with the DON and the ADON present, the DON verified and confirmed this was all the evidence of education for 2025 except maybe some education related to facility self reports.On 4/22/26 at 10:20 AM review of all attendance sheets in the 3 Education binders failed to reveal dementia training. On 4/22/26 at 2:03 PM review of GNA #44's employee file revealed she was hired on 3/20/25; however, failed to reveal a performance review from 2025.On 4/22/26 at 2:37 PM review of GNA #45's employee file revealed she was hired on 12/11/24; however, failed to reveal a performance review from 2025.An interview was conducted with the Director of Nursing on 4/23/26 at 11:10 AM. At this time, the surveyor shared the concern that there were no 2025 performance reviews observed in the GNA employee files reviewed. An interview was conducted with the DON on 4/23/26 at 12:14 PM. During the interview, she stated, For the performance reviews, I didn't find any. The surveyor shared this was a concern and asked how the facility provided in-service education to GNAs that addressed areas of weakness identified in performance reviews if performance reviews were not conducted. The DON acknowledged the concerns, stated she understood, and offered no further comments at that time.On 4/23/26 at 10:50 AM in an interview with the DON she verified and confirmed there was no dementia training associated with the facility self-reported incidents. During the interview, she stated the training was related to abuse and policies and procedures. The surveyor requested a copy of the material covered in the 2025 Skills Fair and the time duration.On 4/23/26 at 11:09 AM in an interview with the DON she stated, For the 2025 Skills Fair, I have to eat that one because I do not have any material to provide on what was covered. During the interview she confirmed dementia training was not part of the 2025 Skills Fair and that for dementia training, that is covered in orientation and the documentation is in the employee's file.On 4/23/26 at 11:10 AM in an interview with the DON when asked about her understanding of the requirements for annual GNA training/education, she stated there should be an annual in service, but the facility goes by Relias. On 4/23/26 at 11:35 AM in an interview with the DON the surveyor shared the concern that review of all 3 staff binders failed to reveal any dementia training. The Director of Nursing acknowledged understanding of the concern. On 4/23/26 at 12:51 PM in an interview with the DON, a dual observation was conducted of the New Hire Orientation checklist where Day 2 lists Hand in Hand Dementia Modules. The surveyor shared the concern that the dementia training from orientation was Hand in Hand Modules; however, the surveyor failed to observe that documentation in any of the GNA employees' files reviewed. During the interview, a second dual observation was conducted of GNA #44 and GNA #45's Relias transcript. The DON verified and confirmed that neither of the 2 GNAs had dementia training on their Relias transcript. The surveyor shared the concern that the in service training for GNAs must include dementia management training. The DON confirmed that the facility did not have such education documentation and validated the surveyor's concern.

Based on review of facility documentation and staff interview, it was determined the facility failed to provide documentation that allegations of neglect were thoroughly investigated. This was evident for 1 (#3) of 5 residents reviewed for facility reported incidents reviewed during a complaint survey.The findings include: On 1/20/26 at 9:47 AM a review of facility reported incident 2697242 was conducted and revealed the facility's Regional Director received a call about potential neglect for Resident #3 after the resident had been sent to the hospital. Review of the facility's investigation revealed a summary that documented the Director of Nursing (DON) had interviewed nursing staff that had provided care to Resident #3 for the 72 hours prior to transfer to the hospital. Review of the facility's investigation revealed the geriatric nursing assistant (GNA) that provided care for Resident #3 the morning of transfer to the hospital was interviewed and wrote a statement that was included in the packet. There were no further statements or interviews of staff from the previous 72 hours. On 1/21/26 at 1:30 PM an interview was conducted with the Nursing Home Administrator (NHA). The investigation was reviewed with the NHA, and she confirmed the lack of interviews with other staff that took care of the resident leading up to transfer to the hospital. The NHA stated she looked through the previous DON's files and could not find any interviews. The NHA confirmed that the staff from the previous shifts should have been interviewed.

Based interview and observed smell of resident's room, the facility failed to provide bedpan or change resident as requested. This was evident for 1 out of 1 resident reviewed.The findings include: On 1/20/26 at 11 am Resident #6 was heard outside of their room requesting to be changed. There were two nurses observed outside the room. Staff # 4 was the resident's assigned nurse. Staff # 4 stated to resident, you just put on your call bell, give us a chance to get there. Resident #6 continued to call out for help. There was a strong odor of urine coming from the resident's room. During the interview with resident Resident # 6 at the time of the observation, they complained about not being changed on a timely basis. Resident # 6 stated the last time I was changed was in the middle of the night and its now 11 am and I haven't been changed. Surveyor interviewed Resident #6 later in the day at 1PM and resident stated they were changed about 1 hour later or about 12 noon. The Director of Nursing was made aware of the observation and said, ok.

Based on review of facility reported incidents, medical record review, facility documentation review, and staff interviews, it was determined the facility failed to keep residents who required either extensive assistance or total dependence with turning and repositioning in bed free from falling out of bed while providing activities of daily living (ADL) care, resulting in actual harm to Resident #33 and Resident #17. The failure of the facility staff to protect a resident from a fall resulted in a hematoma for Resident #33 and bilateral femur fractures for Resident #17. This was evident for 2 (#33, #17) of 39 residents reviewed for facility reported incidents. The findings include: 1) On 10/16/24 at 7:42 AM a review of facility reported incident MD00191729, that was received by the State Survey Agency (SA), alleged on 4/24/23, Resident #33 was receiving care and rolled from the bed. The facility called 911 and the resident was sent out to the hospital. The hospital reported that Resident #33 had a pelvic fracture and a hematoma in the gluteal area. On 10/16/24 at 7:42 AM a review of Resident #33's medical record was conducted and revealed Resident #33 was admitted to the facility in March 2023 with diagnoses that included end stage renal disease with dependence on renal dialysis, hemiplegia and hemiparesis following a stroke that affected the left non-dominant side, osteomyelitis of vertebra, thoracic region, discitis of the thoracic region and type 2 diabetes mellitus with diabetic neuropathy. The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #33's 4/18/24 5-day MDS, section G, Activities of Daily Living (ADL) Assistance, A. Bed mobility - how residents moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture as a (3) which was Extensive assistance - resident involved in activity; staff provide weight-bearing support with 1-person physical assist. The MDS also coded the resident extensive assistance with 1-person physical assistance with eating and personal hygiene. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Review of Resident #33's activities of daily living care plan (ADL), that was created on 4/13/23 documented, I am dependent on staff for turning and repositioning and I am dependent on staff for grooming/personal hygiene. Review of a SBAR (change in condition) note dated 4/24/23 at 23:25 (11:25 PM) documented, the resident fell in the room from the bed to the floor when staff tried to give patient care. The note documented, there was circular swelling on the left side of the head and 911 was called per administrative directive. On 10/16/24 at 12:50 PM a review of the emergency room report dated 4/25/23 documented, presented after a fall, was being changed when [he/she] rolled off the bed, fell on [his/her] left side. Endorsing left sided head pain. Endorsing LUE and LLE pain diffusely. A secondary survey (assessment of resident) documented, large hematoma on L scalp. The physician documented, large hematoma on left scalp and multiple large ecchymotic areas along the left side of [his/her] body. [He/she] is tender along [his/her] chest wall, [his/her] entire LUE and LLE, with point tenderness in the L hip. A CT scan documented, L gluteal hematoma with active extrav (extravasation) (contrast material leaked) (trauma consulted) and pubic rami fracture (old, seen on 4/4/ CT). The note documented that trauma surgery was consulted and ordered a repeat CBC (complete blood count) and type and crossed for 2U (units of blood). Recommend ice packs, compression and CBC (complete blood count) BID (2 x day). Review of the facility ' s investigation revealed a statement from Geriatric Nursing Assistant (GNA) #20 that documented she was assigned to Resident #33. GNA #20 rolled the resident towards me and didn ' t realize [he/she] was so close to the edge, and I pulled [him/her], and [he/she] fell on the left side of the floor. A witness statement from GNA #21 documented that she was called to the resident ' s room and saw the resident on the floor. The nurse and I and two other aides picked [him/her] up from the floor. A statement from Licensed Practical Nurse (LPN) #22 documented that she was in another patient ' s room when she heard Resident #33 fall and hit the floor. Resident was lying on [his/her] right side. Alert and crying. The statement documented, complained of pain in right arm. In resident normal condition. [He/she] have weakness in both arms and legs. Have large swollen area on left side of resident head. Resident stated, I ' m ok, but I hurt while pointing to [his/her] right arm and rubbing [his/her] left thigh to indicate pain. Also, resident express pain and wanted an oxycodone tab. It was explained to resident because of a possible head injury I cannot give [him/her] an oxycodone at that time. On 10/17/24 at 3:26 PM an interview was conducted with GNA #20. GNA #20 stated, I pulled [him/her] towards me. I don ' t know how much [he/she] weighed; [he/she] was a little stocky. I rolled [him/her], and it must have been too hard, and [he/she] fell on the floor. I must have not realized how hard I pushed to roll [him/her] over. These people come and go, and I can ' t keep up with their names. They never told us if [he/she] was a 1 or 2 person assist. I can ' t remember if I had education after the incident. I can ' t even remember [his/her] name. GNA #20 was asked how she knew a resident ' s mobility status related to turning and positioning. GNA #20 stated, if the person is alert enough to tell me or I will get another aide or nurse. I usually go get the nurse and just ask them about the resident. The surveyor asked GNA #20 if the mobility status was documented somewhere for the staff to know the status. GNA #20 stated, if they have it documented, I don ' t know where it is documented. If it is in their file I don ' t know about it. We are not supposed to go in their file. The surveyor asked GNA #20 where she documented care that she gave the residents every day. GNA #20 stated, the computer on the wall is where I document their care. The surveyor asked if the mobility and bed positioning was in the computer. GNA #20 stated, yes, but at that time when the incident happened to the patient, I didn ' t know you could get the information from the computer. 2) On 10/17/24 at 8:03 AM a review of facility reported incident MD00193742, that was received by the State Survey Agency (SA), alleged on 6/23/23, Resident #17 fell from the bed. A telehealth visit was conducted, and Resident #17 was sent to the emergency room for further evaluation. On 10/17/24 at 8:03 AM a review of Resident #17's medical record was conducted and revealed Resident #17 was admitted to the facility in January 2020 with diagnoses that included end stage renal disease with dependence on renal dialysis, hemiplegia and hemiparesis following a stroke that affected the left non-dominant side, and legal blindness. Review of Resident #17's 6/19/23 quarterly MDS, section G, Activities of Daily Living (ADL) Assistance, A. Bed mobility - how residents moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture as a (4) which was total dependence which was full staff performance; with two + person physical assist. The MDS also coded the resident total dependence with two + persons physical assist for transfers, dressing, toileting, and personal hygiene. Review of Resident #17's ADLs self-care performance deficit related to hemiplegia/hemiparesis, that was created on 5/24/23 documented, I require 2 staff assist with turning and repositioning. Review of a SBAR (change in condition) note dated 6/24/23 at 01:05 AM documented that at approximately 10:15 PM the assigned GNA came to the nurse ' s station and stated that Resident #17 was on the floor during ADL care. Resident #17 was observed on the floor on the left side of the bed, leaning on the right side between the wheelchair and tote box. Resident #17 was assisted back to bed and the resident complained of pain in the left upper thigh. The resident was sent to the emergency room . Review of a 6/26/23 at 17:37 general progress note documented, follow-up call done to [name of initial hospital] patient transferred to [second hospital name] due to fracture from fall. Review of a 6/27/23 at 21:51 after hours telemed patient note documented, had a fall earlier, having severe left leg pain and requested to go to ED (emergency department). Review of the initial hospital ' s emergency room note documented, pt reports that nurse was cleaning [him/her] in bed [he/she] accidentally rolled off the bed and fell on the floor. Pt. c/o severe pain to BLE (bilateral lower extremities). The physical exam documented, is in acute distress. Pt. in mild to moderate distress due to pain. The musculoskeletal exam documented, difficult to evaluate LE due to pain, positive spastic deformity, swelling, pain with light palpation to the left thigh/hip, right hip. The x-ray results documented, positive for proximal fracture of the left femur with angulation, and right intertrochanteric fracture. The CT of the femur documented, comminuted proximal 3rd femur fracture with overriding fracture fragments. The distal fracture fragment is impacted into the left intertrochanteric region with shortening to the left femur. The CT to the pelvis confirmed the right intertrochanteric fracture and the proximal left femoral diaphysis fracture along with a hematoma within the left anterior extensor muscles. The disposition of the resident was to transfer to a higher level of care that was not available at that hospital. Review of the facility ' s investigation revealed a statement from GNA #24 that documented she was assigned to Resident #17. GNA #24 documented that GNA #25 helped her put Resident #17 into the bed, turned the resident, and removed the Hoyer pad from underneath the resident. GNA #24 documented that she then turned Resident #17 on his/her left side to remove the diaper and began cleaning Resident #17 up and the resident was fine on the bed. GNA #24 documented that she started to clean the resident up and applied A&D Ointment when the resident started to lean over towards the floor on [his/her] left side. There was a tote and a wheelchair that broke the resident ' s fall. Review of a written statement from GNA #25 documented that GNA #25 assisted GNA #24 with the Hoyer to put the resident in bed. Resident #17 told her she ' ll need help with changing [him/her]. She insisted she didn ' t. GNA #25 documented that she left the room to finish tending to another resident. Included in the investigation was a complaint form for the Maryland Board of Nursing for GNA #24 that documented at approximately 10 pm on Friday, June 23, 2023, resident [#17] was injured. GNA #24 was assigned to care for Resident #17 that evening during her 3-11 pm shift. GNA #25 assisted GNA #24 with the use of a Hoyer lift to transfer the resident from the Geri-chair to the bed. After the resident was placed in bed, the 2 GNAs turned Resident #17 left to right to remove the Hoyer lift pad that was under him/her. GNA #24 told GNA #25 that she did not need help changing the resident. GNA #25 and Resident #17 both stated he/she required 2 people to care for him/her, but GNA #24 insisted on caring for him/her alone. GNA #25 left the room to assist the other GNA on the unit. While performing ADL to change Resident #17 ' s incontinence device, GNA #24 turned Resident #17 onto his/her left side. On Resident #17 ' s left side of the bed was a Geri-chair and tote. When GNA #24 began to apply A&D ointment, Resident #17 continued to lean more on his/her left side and fell out of bed onto the Geri-chair and tote. Resident #17 was alert and oriented to person, place and time, assessed, and placed back in bed using the Hoyer lift. Resident #17 began to complain of pain in the left upper thigh. Virtual on call physician notified of incident and status of Resident #17 and ordered him/her to be transferred to the hospital for further evaluation. Around 3 pm on Saturday, June 24, 2023, Staff #26 called the hospital for an update and was told he/she had a closed fracture of the right hip and closed displaced oblique fracture of the left femur and was transferred from one hospital to another in the morning. After the investigation was completed, GNA #24 was terminated. On 10/17/24 at 9:00 AM and 10:00 AM a call was placed to GNA #24 with a voice mail message left for a call back. As of 10/18/24 at 10:30 AM GNA #24 had not returned the surveyor ' s phone call. On 10/17/24 at 3:17 PM GNA #25 was interviewed and stated, that night I assisted her with putting [him/her] to bed with the Hoyer lift and [he/she] said you will need another person. She said no I don ' t, I had you before and I have done you myself. I left the room, she had [him/her] before. GNA #25 stated there were certain people that the resident would allow to do him/her by themselves. GNA #25 stated she continued her rounds and came out of another resident ' s room when she was informed of the fall. GNA #25 stated, I went to the room, and [he/she] asked me to stay with [him/her]. GNA #25 stated that Resident #17 was in pain. [He/she] was in a lot of pain. GNA #25 stated, [he/she] was a 2 person assist with bed mobility. It said it on the Kardex, but [he/she] would allow certain people to just do it by themselves. GNA #25 stated, She declined the help. On 10/17/24 at 3:47 PM LPN #26 was interviewed and stated, I remember [he/she] fell out of bed during care. LPN #26 stated he was called to the resident ' s room. [He/she] said help me, help me please, they made me fall. We assisted [him/her] back to bed. I can ' t remember anything else. [He/she] just kept saying please help me [name], get me up. On 10/17/24 at 3:54 PM the ADON stated they did bed mobility training on all staff along with abuse training after each incident. The ADON stated they took the fall ' s issue to QA (Quality Assurance) and did a QA Ad hoc meeting for both falls along with audits. The ADON stated that it was self-identified that the care plan and Kardex was not patient centered related to specifics of 1 person assist, or 2 person assist or if mechanical lift for transfers and bed mobility was needed. Review of the facility ' s in-service documentation revealed GNA #24 ' s signature for the 4/27/23 to 5/1/23 in-service on documentation and communication of transfer/bed mobility status and for the 6/3/23 in-service on turning and repositioning. On 10/17/24 at 4:14 PM the Director of Nursing (DON) joined the interview with the ADON. The surveyor discussed how Resident #33 fell out of bed during care in April 2023 and then it happened to Resident #17 in June 2023 even though the GNA involved in the June 2023 incident (GNA #24) had received training in April 2023 and on 6/3/23 which was 20 days prior to the incident in June 2023.

Based on observation, interview and record review, it was determined the facility failed to prevent an accident with injury to Resident #1 during transport in a facility van/shuttle bus after placing Resident #1 in a wheelchair with no assessment or evaluation of the Resident's needs regarding the assistive device. As a result, Resident #1 suffered a fall with harm (injury and significant pain restricting his/her freedom of movement). This was evident for 1 (#1) of 11 residents reviewed during a complaint survey. The findings include: In the State Operations Manual, Appendix PP last updated 11/28/17, the Centers for Medicare and Medicaid Services (CMS) indicated that an avoidable accident means that an accident occurred because the facility failed to identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or the facility failed to evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible. CMS indicates that assistance device or assistive device refers to any item (e.g., fixtures such as handrails, grab bars, and mechanical devices/equipment such as stand- alone or overhead transfer lifts, canes, wheelchairs, and walkers, etc.) that is used by, or in the care of a resident to promote, supplement, or enhance the resident's function and/or safety. CMS indicates that hazards refer to elements of the resident environment that have the potential to cause injury or illness. Hazards over which the facility has control are those hazards in the resident environment where reasonable efforts by the facility could influence the risk for resulting injury or illness. Free of accident hazards as is possible refers to being free of accident hazards over which the facility has control. Anti-tippers attach to any wheelchair and, like training wheels, prevent the chair from tipping over backwards. On 8/7/20, per interview with Resident #1 on 8/25/2020 and review of a facility incident report, the facility provided Resident #1 an assistive device (wheelchair without tipping precautions) and placed Resident #1 on a van for transport without securing the chair appropriately. During transport the chair tipped over resulting in harm to Resident #1. In interview on 8/25/20, Resident #1 stated that during the prior week, last week, he/she stayed in bed later in the day due to pain in his/her ribs after suffering a fall in a wheelchair while in the facility transport van. This was corroborated in interview with Resident #8, (Resident #1's roommate) on 8/26/2020 at 7:54 AM. Resident #1 stated, they didn't have me in my normal wheelchair which is this electric wheelchair. They said they couldn't use my electric wheelchair. I don't think the wheelchair they had me in was secure and it tipped backwards when the driver stepped on the gas after sitting at a stop light. I hit the back of my head and my ribs hurt. When asked if he/she went to the hospital the resident stated, no, they didn't ask me if I wanted to go. They got an x-ray and they did it in my room. An interview was conducted on 8/25/2020 at 9:35 AM with the driver of the van/shuttle bus. He stated, we were going to the bank. The way the van is set up is he/she can't be transported in an electric wheelchair because there is a 450 lb. weight limit on the lift gate and the electric wheelchair weighs a lot. Therapy put the resident in a regular wheelchair instead of the electric wheelchair. Once we put Resident #1 on the bus, the GNA (geriatric nursing assistant) strapped the resident in. There were 4 straps to support Resident #1 on each corner of the wheelchair and one around the resident's waist. Resident #1's weight is in the back because there is no front support. When I pulled off from the light, Resident #1 just went back. When I turned the corner, he went back, and I turned around and helped him up. There was nothing to support Resident #1's weight in the front. The lift gate is slow when you use the electric wheelchair and it blows the fuse because it doesn't support the weight of the wheelchair. The chair is several hundred pounds. The driver stated, I have never transported Resident #1 before in a regular wheelchair. Resident #1 usually goes out with (name) (contracted transport company) in his/her electric wheelchair. I may have taken him/her 1 time before and we noticed the lift gate wouldn't support the chair. We knew that was the one (wheelchair) that was blowing the fuse. At 9:45 AM on 8/25/2020 the van/shuttle bus driver and maintenance director took the surveyor out to see the van. The van was a mid-sized bus. Behind the driver's seat were 2 rows of 2 seats on each side of the bus. Behind the second row were metal strips on the floor. There was an approximate 10 ½ ft. open space from behind the second row to the back of the bus. There was 5 ft. between the front metal strips and the back metal strips. There were 2 hooks, (1) on each end of the front strip and 3 hooks on the back strip, (1) on each end and 1 that was attached to a strap that would wrap from behind the wheelchair, around the resident's waist to a black stationary object to the left of the strips. The van driver stated that normally residents will hold onto the head rest bar on the back of the second row seat. He stated that Resident #1 did not hold onto the head rest bar. The van driver also stated that the brakes were locked on the wheelchair and the GNA was not seated beside or behind the resident but rather sat in a seat in front of the resident. The van driver stated that the GNA hooked the resident in and then he checked the wheelchair to make sure it was secure before driving. On 8/25/2020 at 10:35 AM the Director of Nursing (DON) gave the surveyor a copy of the incident report. Accidents/falls were recorded in a section of the electronic system titled QA (Quality Assurance). Resident #1's incident number 6722, was documented on 8/7/2020 at 12:45 PM. The report was 2 pages. The surveyor asked the DON if there were any other pages to the report. The DON gave the surveyor 1 page of physician's orders [REDACTED].#1. The surveyor asked 3 times if there were any other papers or if there was any further investigation. The DON responded, I gave you everything. Review of the x-ray report on 8/25/2020 at 11:40 AM, of the chest and pelvis that the physician ordered stat after the fall on 8/7/2020, revealed the findings were within normal limits. On 8/25/2020 at 11:40 AM the DON gave the surveyor the Off-Premise Activities policy which documented, c. Prior to departure and upon return to the facility the van driver will perform a safety check of the bus/van. This will include verification that wheelchairs are secured to the floor of the vehicle and the resident's safety belts are secured. On 8/25/2020 at 12:34 PM Staff #10, the therapy director, was interviewed and asked if the resident had been assessed for a proper wheelchair prior to going out on the van. Staff #10 stated that Resident #1 was not on the therapy case load, therefore therapy did not pick out a wheelchair for the resident. Staff #10 stated none of her staff stated that they helped the resident with the wheelchair. An interview was conducted with GNA #8 on 8/25/2020 at 12:38 PM. GNA #8 was the escort on 8/7/2020 when Resident #1 was going to the bank. GNA #8 stated that he got in the bus, strapped the resident in and the bus drove off and they came to a traffic light. GNA #8 stated, we stopped at a light and then the bus jumped forward to go and the weight of the resident pushed him/her back. The whole wheelchair flipped backwards. The wheelchair wasn't stable enough for him/her for his/her weight. Both me and the driver strapped him/her in. I strapped the wheelchair back and the front tire and the seat belt attached around the resident to a hook on the floor of the bus. He/she was in there secure. GNA #8 was asked if he got the wheelchair for the resident and he said, no, I think therapy picked out the wheelchair. I was told the next morning that they already got the chair. When asked if Resident #1 had an injury, GNA #8 stated that the resident had a bruise on a finger and that the resident hit his/her head, but they didn't see any physical injury to the head. Review of Resident #1's medical record on 8/25/2020 at 12:45 PM revealed Resident #1 had [DIAGNOSES REDACTED]. Review of Resident #1's quarterly MDS (minimum data set) with an assessment reference date of 6/3/2020 revealed the resident required total assistance with at least 2 people for transfers. Further review of Resident #1's medical record revealed a physician's progress note dated 8/9/2020 which documented, BKA (below knee amputation) status [REDACTED]. The [DIAGNOSES REDACTED]. [MEDICATION NAME] is the brand name for [MEDICATION NAME]. [MEDICATION NAME] is a narcotic to treat moderate to severe pain, is an opioid and carries a high risk of addiction. Review of Resident #1's August 2020 Medication Administration Record [REDACTED]. The resident received [MEDICATION NAME] on 8/9, twice on 8/10 and 8/11, 8/13, 8/14, 8/15, 8/16, 8/17, 8/, 8/20, 8/21 and 8/22 for pain scale ranges from 5 to 9 on a scale of 1 to 10 with 10 being the worst pain, 1 being the least amount of pain. Review of nursing progress notes revealed the following documentation: 8/7 at 17:32 hoyered into bed. Bilateral side pain, 8/8 at 21:41 generalized pain 6/10, 8/10 at 14:23 side pain, no apparent discoloration, 8/10 at 22:49 rib pain, 6/10, 8/11 at 15:47 pain across abdomen left to right, 8/12 at 16:01 rib pain, 8/15 at 15:07 general body pain and 8/19 at 13:00 body pain. On 8/25/2020 at 1:22 PM an interview was conducted with Staff #11 who had the roles of Quality Assurance Nurse, Assistant Director of Nursing, Infection Control and Educator. Staff #11 was asked if the incident had been discussed in quality assurance. Staff #11 stated that they discussed in clinical stand-up meeting and that the incident would be under QA in the system. Staff #11 confirmed that the QA paper that the DON gave the surveyor was the only paperwork regarding the incident. When asked if they did a risk/cause analysis she said that is the QA report that the DON gave the surveyor. The surveyor asked where the analysis was, and Staff #11 stated it was the investigative statements. Staff #11 stated after someone falls, they gather around and do a huddle. Staff #11 could not provide documentation to the surveyor. Staff #11 stated she talked to Staff #8 and the van driver. When asked if staff were educated Staff #11 stated, right after that I went on vacation. The unit managers talked to the staff. Typically, when an issue arises, we talk to the unit and then the whole building. I would be responsible. I did educate the GNA, the nurse and the driver. I told them to ensure that the patient is in a good sitting position and strapped in. I did not give any literature or have anyone watch a video. I demonstrated. Staff #11 went to her office and looked through a binder of education sign-in sheets and confirmed there were no educational sign-in sheets done for that incident. On 8/25/2020 at 1:50 PM Staff #12, the RN unit manager was asked if any education had been done after the incident. Staff #12 stated, I told the driver to next time be careful and to use the belt. Staff #12 stated again, next time has to be careful. Staff #12 stated she told Staff #8 to use the right Hoyer pad. A Hoyer lift is a mechanical lift used for transfers when a person requires 90 to 100% assistance to get into and out of bed. A Hoyer pad is placed under a person's body in the bed and connects with chains to the Hoyer lift frame. The pad will stay under the person while in the wheelchair and is disconnected from the frame. Staff #12 stated, I told the GNA to use the right Hoyer pad, that sometimes they use the wrong one. When asked if the right Hoyer pad was used that day Staff #12 said yes. She said she also spoke to the nurse on duty that day about using the right pad. The surveyor stated in the presence of Staff #11, I thought the chair tipped backwards and Staff #11 stated, yes, it did. It was not from the pad. On 8/25/2020 at 1:58 PM the van driver was asked if he had received education after the incident and he said no. He stated he was just asked by his supervisor what happened. He said he had training the first day when he started working at the facility but nothing since then. On 8/25/2020 at 3:02 PM Staff #8 was asked if he had any training or education after the incident and he replied, the unit manager did not talk to me and I did not receive any education after the incident. On 8/25/2020 at 2:20 PM Staff #10 informed the surveyor that Staff #13, the physical therapist, was the one that gave the wheelchair to the resident. Staff #10 placed a phone call to Staff #13 in the presence of the surveyor, NHA, DON and ADON and put her on speaker phone. On 8/25/2020 at 2:26 PM Staff #13 was asked by the surveyor if she assessed Resident #1 for an appropriate wheelchair. Staff #13 stated, I didn't have time to make an assessment. He/she is not on (therapy) case load. I looked around and got him/her a wheelchair and took it to his/her room. It was a big one for his/her size. I was on my way to assess another patient. When asked if the wheelchair had anti-tippers, she said she did not remember. At that time Staff #10 was asked if the resident should have been assessed prior to a wheelchair being given to the resident and the response was yes. According to the website https://www.ncbi.nlm.nih.gov/ which is the National Center for Biotechnology Information, National Library of Medicine, National Institute of Health website, the following wheelchair measurements must be taken before seat fitting: seat width, depth and height; patient hip, trunk and shoulder widths, patient shoulder and axillae heights, wheelchair leg length, arm height, back height, wheelchair width, height and size; knee to seat depth; knee to heel length; seat to back support angle; seat to lower leg support angle and lower leg support to foot support angle. On 8/26/2020 at 8:05 AM Resident #1 stated, it took 4 people to get me up from the fall. I didn't think I was badly hurt at the time but in the afternoon before the van came back to pick me up from the bank I took a deep breathe, and I said, oh that hurt and when I got back here and got in bed I stiffened up. The therapist gave me a w/c that (didn't fit me). They hooked it to the floor. The forward motion caused it to go back. It was a plain wheelchair and it didn't have those things to prevent it from going backwards. You know, they have an unofficial rule about no electric wheelchair because they are afraid the van will break. They have a manual bar they could use. The last time I went out was back in February. I normally go with (name), but they were not taking people places for a while. I was told I would have to go in a regular wheelchair. The surveyor was informed on 8/27/2020 at 10:25 AM by the DON and Corporate Nurse that the van driver stated he had been doing safety checks monthly and now he would be doing them daily.

Based on medical record and facility investigation review as well as interviews with the director of nursing (DON) and resident #4 it was determined that the facility failed to properly position the resident in bed. This resulted in the resident rolling out of bed, sustaining a fractured right shoulder, pain, and decreased use of her right arm. This was evident for 1 of 7 residents selected for review. The findings included the following: On 1/14/15 the surveyor reviewed the facility reported incident, medical record and the facility investigation involving resident #4 rolling out of bed onto the floor and suffering a fractured right shoulder. By way of history the resident had been in the hospital prior to admission to the facility from 8/8/14 - 8/14/14. Her [DIAGNOSES REDACTED]. On 8/14/14 resident #4 was admitted to the facility and assessed by nursing and the certified nurse practitioner (CRNP) to be alert and oriented x 3. Her medication regime included anti-coagulant therapy, coumadin, for deep vein thrombosis prophylaxis which can increase the risk of bleeding/bruising. The admission minimum data set (MDS) assessment, section G, noted that the resident required extensive assistance and 2 staff persons for bed mobility and was totally dependent on 2 staff members for transfers. On 10/26/14 at around 8 pm, per the nursing notes, Resident #4, was found on the floor laying on her right side, alert, verbal, and oriented x 3. She complained of pain in her right shoulder at a level of 10/10, on a scale of 1-10 - 10 being the worst - and was unable to raise her right arm. She was transferred back to bed with the mechanical lift. At around 8:20 pm the nurse practitioner was notified of the fall and changes in the resident ' s right arm; she ordered X-rays. At about 9:50 pm the X-ray technician spoke with the nursing staff after taking the X-rays. He showed them the computer film which noted that there was a fracture. At about 10 pm the nurse practitioner ordered the resident transferred to the hospital for further treatment and evaluation. At about 10:40 pm the resident was transferred to the hospital. On 10/27/14 at about 4 am the resident returned to the facility with the [DIAGNOSES REDACTED]. The discharge instructions also noted a contusion of the right lower extremity. At 7:53 am the results of the shoulder X-ray were reviewed by the radiologist and noted that the resident had a minimally displaced right greater tuberosity fracture extending to the humeral neck. The humerus is the long bone of the upper arm. The upper end has a large, smooth head that moves in the socket of the shoulder blade; this if the greater tuberosity. The humerus, scapula, and the collar bone form the shoulder joint. Fractured bones may become misaligned - displaced. On 10/27/14 the CRNP wrote an acute progress note. She described the fall, fracture and pain associated with the fall. She noted that the treatment plan would include a larger bed and education to the staff. The education would include always having 2 attendants present for care including transfers, turning and repositioning resident #4. On 1/14/14 the surveyor reviewed documented interviews in the facility investigation. On 10/27/14 the director of nursing (DON) interviewed the resident and Nurse #3 about the fall. The resident was assessed to be alert and oriented and recalled telling GNA #2 that she was falling prior to falling on her right side between the bed and the wall. In addition, she described being cared for by GNA #2 alone prior to the fall. Nurse #3 assessed resident #2 when she was found on the floor following the fall. Nurse #3 noted that GNA #2 told her that he had transferred/positioned the resident back to bed by himself. On 1/14/15 the surveyor reviewed the employee notice given to GNA #2. On 10/31/14 the DON noted that GNA #2 had worked by himself and rolled resident #4 away from his body instead of toward prior to her fall. GNA #2 was terminated for failing to comply with health and safety rules which resulted in injury to resident #4 as well as giving false information during the investigation. On 1/14/15 the surveyor reviewed the occupational therapy (OT) evaluation following the fall. On 10/31/14 the resident was evaluated due to a decline in ability to feed herself as a result of the right arm fracture. The goals were to treat her so that she was able to feed herself with set up using her left hand and put on a shirt using compensatory techniques. On 1/14/15 at 11:30 am the surveyor interviewed resident #4 about the fall that resulted in the fracture. She stated that GNA #2 had been " changing " her and turned her toward the window and left the room. She stated that she told him she was falling and he told her she was not. She said that she fell out of the bed toward the window, when he came back she was on the floor, her shoulder hurt, "everything" hurt, but more than that she said she was so embarrassed because she was " naked " . She said that GNA #2 got help to get her up off of the floor with the Hoyer (mechanical lift) but she asked that they please cover her up first. She recalled going to the hospital because her arm was broken and returning with her arm in a sling. She said that she still had some pain and couldn't ' use her arm like she used to. At 12:15 pm the surveyor interviewed the DON. He confirmed that when he had interviewed resident #4 and Nurse #3 they had told him that the resident was undressed when she fell . (refer to F 241). In summary: On the evening of 10/26/14 GNA #2 transferred Resident #4 back to bed with the Hoyer by himself. He then removed her adult brief and clothing turned on her right side and left the room. When he returned the resident had rolled out of bed onto the floor. She complained of right shoulder pain. X-rays confirmed a fractured right shoulder/ humerus. The MDS noted that the resident was totally dependent and required 2 persons for transfers as well as bed mobility. The resident was alert and oriented x 3 per the medical record and interview with the DON. On 1/14/15 during surveyor interview the resident recalled the fall. She stated that when the GNA left the room she told him she was falling and he replied that she was not. She rolled out of bed and landed on her shoulder. She described pain in her shoulder, discomfort " all over " and embarrassment as she was " naked " . The facility failed to properly position the resident in bed before leaving the area. This resulted in the resident rolling out of bed onto the floor which resulted in a fractured shoulder, pain, and decreased use of the right arm.