Every finding on record at Orchard Park Health Care Center

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in three of seven medication carts and two of three medication storage rooms. Specifically, the facility failed to: -Ensure ophthalmic solutions were labeled with the date when the medications were opened;-Ensure there were no loose pills in the bottom of the medication cart drawers; and,-Ensure that lorazepam and insulin vials were labeled with the dates the medications were opened.Findings include:I. Professional referenceHeath Direct Pharmacy Service's Did You Know? Ophthalmic Medication Beyond Use Date Guide, (revised April 2024) was retrieved on 5/20/26 fromhttps://www.hdrxservices.com/wp-content/uploads/2024/04/799-[NAME]-Ophthalmic-Medication-Beyond-Use-Date-Guide-Apr-2024-Final.pdf. It read in pertinent part, Once the ophthalmic drops are opened, current practice guidelines recommend discarding the medication after 28 days due to concerns of stability and sterility. Novartis, the manufacturer of Pataday, (revised June 2020) was retrieved on 5/19/26 from https://www.novartis.com/sg-en/sites/novartis_sg/files/Pataday-July_2020.SIN-App050221.pdf#:~:text=Results%20from%20clinical%20studies%20up,symptoms%20of%20allergic%20conjunctivitis%20and. It read in pertinent part, Pataday Olopatadine Ophthalmic Solution 0.2%. Store at 2 degrees Celsius (C) to 25 degrees C (36 degrees Fahrenheit (F) to 77 degrees F). Discard four weeks after opening. Joint Commission: What are the Joint Commission's expectations for managing multi-dose vials of sterile, injectable medication? (revised 4/23/26) was retrieved on 5/20/26 from https://www.jointcommission.org/en-us/knowledge-library/support-center/standards-interpretation/standards-faqs/000001529 If a multi-dose vial has been opened or accessed (needle-punctured), the vial should be dated with the last date that the product should be used (expiration date) and discarded within 28 days. The Food and Drug Administration's (FDA) Insulin Storage and Effectiveness (revised 9/19/17), was retrieved on 5/19/26 from fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency. It read in pertinent part, Insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 degrees F and 86 degrees F for up to 28 days and continue to work.II. Facility policy and procedureThe Medication Storage policy dated 2008 was received from the director of nursing (DON) on 5/13/26 at 4:20 p.m. It read in pertinent part, Pharmacy Labels: Prescription medications must have a pharmacy label attached. If the item is very small, the label may be affixed to a plastic bag or vial. Medication carts should be checked monthly and as needed to verify that labels and dates are correct. Individual use items follow the manufacturer's guidelines listed on the packaging. III. ObservationsOn 5/11/26 at 5:39 p.m. the Evergreen medication cart was observed with licensed practical nurse (LPN) #1. The following items were found:-One opened bottle of Artificial Tears ophthalmic drops without a label to indicate the date it was opened;-One opened bottle of Pataday ophthalmic drops without a label to indicate the date it was opened;-One opened vial of Humalog insulin in the top drawer, without a label to indicate the date it was opened; and,-Seven loose medications were found at the bottom of the second drawer. The pills were not in a container and there was no label to identify what any of the pills were.On 5/12/26 at 2:15 p.m. the Aspen unit medication cart was observed with registered nurse (RN) #1. The following item was found:-One loose pill was found at the bottom of the second drawer. The pill was not in a container and there was no label to identify what the pill was. On 5/12/26 at 3:05 p.m. the Columbine unit medication cart was observed with LPN #2. The following items were found:-Eight loose pills were found at the bottom of the second drawer. The pills were not in a container and there was no label to identify what any of the pills were; and,On 5/12/26 at 3:15 p.m. the Columbine medication storage room was observed with LPN #2.The following item was found:-One opened vial of lorazepam in the refrigerator without a label to indicate the date it was opened. IV. Staff interviewsLPN #1 was interviewed on 5/11/26 at 5:55 p.m. LPN #1 said every nurse should clean the medication carts on their shift. She said the night nurses performed a more thorough cleaning, and the unit nurse managers checked the medication cart for labels, open dates, and expiration dates of medications. LPN #1 said medications should be labeled with the open dates to prevent giving expired medications to a resident.RN #1 was interviewed on 5/12/26 at 2:35 p.m. RN #1 said every nurse was responsible for cleaning the medication cart and labeling the medications with the date when they opened the medications. RN #1 said if a nurse dropped a medication in the medication drawer, the nurse should pick it up. LPN #2 was interviewed on 5/12/26 at 3:20 p.m. LPN #2 said that the nurses were responsible for keeping the medication carts clean. LPN #2 said the nurses who opened the medications should date the medications with the date they opened it so staff did not give an expired medication to a resident. She said the unit managers checked the medication carts for labels and expired medications. The DON was interviewed on 5/12/26 at 5:15 p.m. The DON said that the medication carts should be cleaned by the nurses on their shifts. She said if a medication was dropped in the drawer of a medication cart, the nurse should pick it up. The DON said the nurses should date the medications when they opened them, to prevent the administration of expired medications to residents.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to ensure food was held at the correct temperature. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 5/18/26. It revealed in pertinent part, Except during preparation, cooking, or cooling, or when time is used as the public health control time/temperature control for safety food shall be maintained at 135 degrees Fahrenheit (F) or above and 41 degrees F or less. (3-501.16) II. Facility policy and procedureThe Dietary Guidelines Manual / Food Temperatures policy, dated 2015, was provided by the nursing home administrator (NHA) on 5/15/26 at 5:13 p.m. The policy read in pertinent part, The temperatures of the food items will be taken and properly recorded for each meal. Hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F. Hot food items may not fall below 135 degrees F after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees F and reheated to at least 165 degrees F prior to serving. Temperatures should be taken periodically to ensure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the portioning, transporting and serving process until received by the resident. Normally hot foods will be 165 to 180 degrees F or higher when removed from the cooking heat source. If held at 160 to 180 degrees F this will ensure serving at 135 degrees F or above. III. ObservationsDuring a continuous observation of the dinner meal service on 5/12/26, beginning at 4:05 p.m. and ending at 6:09 p.m., the following was observed:At 4:05 p.m. cook (CK) #1 checked the temperatures of food lined up on the steam table ready for the meal service. CK #1 used a digital thermometer and the following temperatures were recorded:-The pureed beef was 127 degrees F.-The hamburger patties were 127 degrees F.At 4:22 p.m., without reheating the food, CK #1 and CK #2 began serving the hamburger patties, pureed beef and the banana pudding. -CK #1 assembled meal plates with the hamburger patties and the pureed beef at an inappropriate holding temperature.IV. Staff interviewsCK #1 was interviewed on 5/13/26 at 3:13 p.m. CK #1 said he checked the food temperatures after cooking, on the steam table less than 30 minutes prior to meal service and during the meal service. CK #1 said he documented the temperature checks in the food temperature log. He said the ideal holding temperature should be 170 degrees F for hot food. CK #1 said the steam table helped maintain proper holding temperatures as they put food on the line 30 minutes before the meal service. CK #1 said serving food at 127 degrees could get residents sick.CK #2 was interviewed on 5/14/26 at 3:26 p.m. CK #2 said they checked temperatures while cooking, after cooking and before meal service. She said she documented the temperature checks in the temperature binder. She said the holding temperature should be 165 degrees F for hot food and 35 to 40 degrees F for cold food. CK #2 said she would throw away food that was not held at an appropriate temperature. She said residents could become ill if food was served at an inappropriate holding temperature. The dietary manager (DM) was interviewed on 5/13/26 at 3:44 p.m. The DM said cooks checked food temperatures while cooking, before meal service and during the meal service. She said cooks documented temperature checks in the food temperature log and she personally followed up to ensure the logs were up to date. The DM said she educated the staff regarding temperature checks and how properly to follow recipe instructions. She said the holding temperature should be 140 degrees F for hot food on the line table. The DM said cooks should keep food covered and stir the food.to maintain proper holding temperatures on the steam table. She said CK #1 did not recall the hamburger patty was 127 degrees F, but she provided temperature checks in-service for the staff. She said if food was not at an appropriate temperature, she would tell cooks to throw it away and cook another one.

Based on observations, record review and interviews the facility failed to maintain accurately documented medical records for one (#13) of four residents reviewed for ADLs out of 40 sample residents.Specifically, the facility failed to:-Ensure Resident #13's bathing record was accurately documented related to whether the resident received or refused her scheduled bed baths; and,-Ensure Resident #13's care plan included documentation to indicate the resident refused her offered bed baths at times.Findings include:I. Facility policy and procedureThe Clinical Manual/Activities of Daily Living (ADL) policy, dated 2008, was provided by the nursing home administrator (NHA) on 5/15/26 at 5:13 p.m. The policy read in pertinent part, ADL documentation to reflect resident performance and staff assistance provided. Documentation must be completed in accordance with system workflows and facility standards. Enter information to reflect the resident's true functional status. Documentation to be completed prior to the end of the shift. Notify the nurse of resident changes in status or refusals.II. Resident #13A. Resident statusResident #13, age less than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included paraplegia (paralysis in the lower part of the body affecting both legs), multiple sclerosis (abnormal hardening or thickening of body tissue) and colostomy (a surgical procedure creating an opening in the belly so stool could leave the body through that opening).The 3/4/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment revealed the resident was dependent on staff assistance with toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear and personal hygiene.The MDS assessment did not indicate Resident #13 refused care.B. Observations and interviewOn 5/11/26 at 5:29 p.m. Resident #13 was in her room. The resident's hair was disheveled and looked uncombed and tangled. Resident #13 said she was not getting her regularly scheduled bed baths. She said she was scheduled for bed baths three times a week, but the certified nurse aides (CNA) only provided her with a bed bath once a week, sometimes two times a week. Resident #13 said she smelled bad and her hair was disgusting. She said she felt awful when she did not get her bed baths. Resident #13 said she voiced concerns to the unit manager and she filed grievance forms regarding not receiving her bed baths. Resident #13 said the facility tried to address it for a few weeks, then it went back to how it was before. She said she had not told the unit manager again. Resident #13 said she had refused bed baths twice, one time when she was in pain and the other time was when the staff member wanted to provide a bed bath at 12:00 a.m.On 5/12/26 at 1:30 p.m. Resident #13 was lying in bed on her back and looking at her computer screen. The resident's hair was disheveled and looked uncombed and tangled.C. Record review-Review of Resident #13's comprehensive care plan failed to reveal documentation related to the resident's bathing preferences or documentation to indicate the resident refused her bed baths at times.The 2026 shower book revealed Resident #13 was scheduled for bed baths on Tuesdays, Thursdays and Saturdays.Review of Resident #13's February 2026 shower sheets revealed the following:Bed baths were provided for Resident #13 on 2/3/26 and 2/12/26.Resident #13 refused bed baths on 2/5/26, 2/7/26, 2/14/26, 2/17/26, 2/24/26 and 2/28/26.-However there was no documentation to indicate if Resident #13 was offered and/or refused a bed bath on 2/10/26, 2/19/26, 2/21/26 and 2/26/26. Review of Resident #13's March 2026 shower sheets revealed the following:Bed baths were provided for Resident #13 on 3/3/26, 3/6/26, 3/12/26, 3/16/26, 3/23/26 and 3/26/26. Resident #13 refused a bed bath on 3/5/26, 3/7/26, 3/19/26, 3/21/26, and 3/31/26.-However there was no documentation to indicate if Resident #13 was offered and/or refused a bed bath on 3/10/26, 3/14/26, 3/17/26, 3/24/26 and 3/28/26. Review of Resident #13's April 2026 shower sheets revealed the following:Bed baths were provided for Resident #13 on 4/2/26, 4/9/26, 4/23/26 and 4/29/26.Resident #13 refused a bed bath on 4/16/26.-However there was no documentation to indicate if Resident #13 was offered and/or refused a bed bath on 4/4/26, 4/7/26, 4/11/26, 4/14/26, 4/18/26, 4/21/26, 4/25/26, 4/28/26 and 4/30/26. III. Staff interviewsCNA #1 was interviewed on 5/14/26 at 9:08 a.m. CNA #1 said he was aware of residents' shower schedules from the shower book at the unit manager's office. He said if a resident refused a shower, he would reapproach the resident a couple of times later. CNA #1 said he would document on the shower sheet if the resident still refused and let the nurse know. He said Resident #13 was scheduled for bed baths on Tuesdays and Thursday evenings. He said he was not aware of the reason Resident #13 missed her scheduled bed baths.-However, CNA #1 reviewed the shower book and acknowledged Resident #13 was scheduled for bed baths three times a week.The unit manager was interviewed on 5/14/26 at 9:38 a.m. The unit manager said she was the one who updated the shower book and let the CNAs know when it was updated. She said if residents refused showers, she would expect CNAs to try three times and then document the refusal. The unit manager said Resident #13 was scheduled for bed baths on Tuesdays, Thursdays and Saturdays. The unit manager was not able to provide an explanation regarding missing bed bath documentation for Resident #13. The director of nursing (DON) stopped in during the interview and said they would provide more documentation.-However the additional bed bath documentation provided by the DON did not include information for the dates when there was no documentation to indicate if Resident #13 received or refused her scheduled bed baths (see record review above).The DON and the unit manager were interviewed together on 5/14/26 at 5:45 p.m. The DON said she expected CNAs to re-approach Resident #13 if she refused her bed baths. The DON said the facility tried to accommodate Resident #13 when she expressed her preferences regarding which staff members she wanted to provide her care. The DON said she educated CNAs to make sure their documentation was accurate and said the facility was in transition to electronic charting for showers. The DON said Resident #13 had behavior issues leading to refusals of her bed baths sometimes. The DON said she encouraged CNAs to always offer bed baths to Resident #13.

Based on record review and interviews, the facility failed to ensure one (#1) of five residents reviewed for accident hazards received adequate supervision out of 12 sample residents. Resident #1 was admitted to the facility on [DATE] with diagnoses of dementia with agitation, muscle weakness and reduced mobility related to left lower leg fractures sustained prior to admission to the facility. Resident #1 was dependent on two staff members providing maximum physical support/ assistance to complete positioning and transfer activities of daily living (ADL). Resident #1 had severe cognitive impairments, per staff interview, and was unable to understand the operation of the bed controls safely or appropriately (see staff interviews below). On [DATE], according to documentation, staff found Resident #1 with her bed controller in her hand and reaching toward her bed, potentially attempting to self transfer from her wheelchair to the bed. The resident was in distress and complaining of left lower leg pain. The resident was noted to have swelling to her left leg below the knee and pain with movement. A STAT (urgent) Xray was obtained, which identified the resident had two fractures in her left lower leg, specifically, the tibia and the fibula. Resident #1 was transferred to the hospital, where she underwent an intramedullary nailing (a surgical procedure used to stabilize and align fractured long bones by inserting a metal rod (nail) into the hollow medullary cavity of the bone) to repair the fractures. Following Resident #1's injury, while looking at possible causes of the resident's injury, the facility concluded that the likely cause of Resident #1's injury was due to her lack of ability to safely and properly operate the bed controls independently and unknowingly lowering the bedframe onto her legs, resulting in the fractures in her left lower leg. -However, the facility failed to thoroughly investigate the cause of Resident #1's injury. Cross reference F610 for failure to timely and thoroughly investigate a significant injury of an unknown origin. Staff interviews during the survey revealed Resident #1 was discovered on multiple occasions, prior to her injury on [DATE], using the bed controller in an unsafe manner and they worried about her being injured, leading them to provide more frequent checking on the position and location of the resident while she was in bed with the bed controller in hand (see staff interviews below). -However, the facility did not identify Resident #1's potential risk for injury related to her lack of ability to use the bed controls safely or identify effective interventions in order to prevent a potential injury to the resident. Specifically, the facility failed to ensure Resident #1, who was assessed to have poor safety awareness, impulsivity and severely impaired cognition, remained free from injury related to the resident's potential for self-transferring and the unsafe use of her bed controller. Findings include: I. Facility policy and procedure The Nursing admission at Risk Post Fall and Quarterly Evaluation policy, dated 2010, was provided by the director of nursing (DON) on [DATE] at 8:30 a.m. It revealed in pertinent part, The licensed nurse will evaluate residents for appropriateness of fall interventions per response obtained in effort to minimize the risk for resident's fall and or injury. The licensed nurse will ensure application of safety equipment interventions and notify other applicable staff of residents' risk for fall and related injury. The resident's care plan, Kardex and task assistance instructions are to be updated as indicated to reflect fall risk and interventions, as indicated. II. Bed manufacturer's manual The Invacare Long Term Care Bed User Manual, for bed model CS600, dated 2023, provided by the DON on [DATE] at 3:30 p.m. The manual documented in pertinent part, The bed is intended to be used as a mattress support system. The bed allows for articulation of the head and foot sections to provide different positions for the user. It is intended to be used at home and in long-term facilities. Warning: Danger -risk of death or injury. Conditions such as restlessness, mental deterioration, and dementia or seizure disorder, sleeping problems and incontinence can significantly impact the user's risk of entrapment. Monitor users with these conditions frequently. To avoid injury or damage from misuse or engraving, read and understand the instructions or label provided. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included femur (upper leg) fracture, dementia and anxiety. The [DATE] minimum data sets (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. The resident required substantial assistance from staff with dressing, sitting up and balancing unsupported. The resident needed two-person staff assistance to perform any surface-to-surface transfers and was dependent on staff assistance for toileting and for transfer from sitting to standing. The resident was unable to stand unsupported and did not walk. B. Observation On [DATE] at 11:15 a.m., several Invacare long-term care beds model CS600 were observed in the company of the nursing home administrator (NHA). The beds had been removed from occupied residents' rooms and were no longer in use by residents in the facility. The bed control on each of the beds had several buttons to operate the head and foot of the bed, the height of the bed and the angle of the bed. The bed controllers had a red button labeled CPR (cardio pulmonary resuscitation), which lowered and flattened the bed to an appropriate position in order to facilitate CPR, when needed. Additionally, the beds had the capacity to lower within inches of the floor. The beds observed with the NHA included the bed that Resident #1 had used while she was present in the facility. The NHA demonstrated the facility's theory of what the interdisciplinary team (IDT) believed was the most likely scenario of how Resident #1 sustained the fractures in her left lower leg. The NHA said after the IDT investigated the events of the resident's fractures, the IDT determined that when certified nurse aide (CNA) #7, who responded to Resident #1 when she was yelling out in pain, discovered the resident was injured and almost falling out of her wheelchair, CNA #7 left Resident #1 to get licensed practical nurse (LPN) #4, who was the nurse for Resident #1's unit. The NHA said the IDT determined that while CNA #7 was out of the room, Resident #1 grabbed the bed controller, pulled herself towards the bed so her legs were under the bed frame and, due to her confusion, Resident #1 hit buttons on the bed controller and lowered the bedframe down on her knees causing her injuries (fractures). C. Record review The [DATE] physical therapy assessment documented Resident #1 was dependent on two staff members providing maximum physical support/ assistance to complete positioning and transfer ADLs. The resident had contractures in both ankles and was unable to sit upright, unsupported or stand and balance on her own. The resident was unable to walk any distance. Resident #1 had muscle atrophy (the decrease in size and strength of muscle tissue). Additionally, Resident #1 had moderately impaired decision making skills, decreased safety awareness and lacked the capacity to understand her condition and risk factors, with reduced skill for self-monitoring. Resident #1's dementia care plan, initiated [DATE], revealed Resident #1 refused care, was impulsive and had poor safety awareness. Interventions instructed staff to anticipate and meet the resident's needs. Resident #1's fall care plan, initiated [DATE], revealed Resident #1 was at risk for falls related to confusion, agitation and attempts to self-transfer from her chair. Interventions included screening the resident for fall risk and identifying fall risk factors, encouraging the resident to use her call light for assistance, as needed, providing physical therapy, occupational therapy and speech therapy to evaluate and treat, as ordered and as needed. -The care plan did not address the resident's risk of injury related to her bed controls. A nurse progress note, dated [DATE] at 10:54 p.m. and written by LPN #4, documented Resident #1's change of condition on [DATE] at 7:40 p.m. The note documented Resident #1 was in distress, complained of left leg pain and the resident wanted to go to bed. LPN #4's note revealed Resident #1 had swelling below the left knee and pain with movement. The note revealed a STAT Xray was performed, Tramadol pain medication was administered, the physician and family were notified and Resident #1 was transferred to the hospital. The hospital Discharge summary, dated [DATE], documented Resident #1 was admitted to the hospital on [DATE] after being found in her wheelchair complaining of left lower leg pain. In the emergency room, an Xray of the resident's left tibia and fibula revealed the bones were fractured. The resident was admitted to the trauma service unit and orthopedic surgery was consulted. Resident #1 underwent an intramedullary nailing surgery to repair the fractures. Review of the facility's incident report of Resident #1's injury documented that on [DATE], CNA #7 heard Resident #1 yelling my foot, my foot. CNA #7 checked on the resident. Resident #1 was found in her manual wheelchair, turned toward the bed and was trying to grab the bed frame to pull herself into the bed. CNA #7 left the resident in her room unattended while she walked down the hall get the floor nurse The incident report documented the nurse (LPN #4) noticed swelling to Resident #1's left lower leg that was not present in previous rounds. The incident report included staff interviews, which revealed Resident #1 was found with the bed controller in her hand. The report concluded that staff documentation and interviews suggested Resident #1 had been attempting to self-transfer back to her bed. IV. Staff interviews CNA #6 was interviewed on [DATE] at 6:00 p.m. CNA #6 said Resident #1 used her call light a lot and often did not know why she was calling. CNA #6 said Resident #1 was often impulsive and would use the bed controls without knowing what the purpose of the buttons were that she was pushing. CNA #6 said she had hidden the bed controller from the resident before. The medical director (MD) and the DON were interviewed together on [DATE] at 3:30 p.m. The MD said she reviewed Resident #1's medical record and discussed the incident with facility leadership and determined that the Invacare beds and their complex bed controllers should be removed from use with the residents who had impaired cognition. The MD said the IDT determined that the bed controllers had too many options and potentially caused a danger to residents with impaired cognition and impaired vision. The MD said the CPR red button posed an additional concern because it was assessed that the resident could misidentify the red button for a nurse call light (all of the newly purchased Invacare beds had controllers that had the red CPR button). She said if the resident continually pressed the CPR button, thinking it was the nurse call light button, it would cause the bed to lower to a low bed position and flatten The DON said Resident #1 had been working on safe transfers with the therapy department and had more recently not displayed signs and symptoms of impulsivity to get up on her own. The DON said the resident had a history of pressing her call light frequently and she said, based on the information she was told by the staff on duty the night of the incident ([DATE]), that Resident #1 had pressed the call light and was attempting to self-transfer when she injured herself. LPN #8 was interviewed on [DATE] at 12:20 p.m. LPN #8 said she was familiar with Resident #1 and used to care for the resident. LPN #8 said she observed the resident in bed after the injury occurred and the resident was very worried about being in pain when LPN #4 informed the resident she was going to sit her up to take a pain pill. LPN #8 said in all the time she worked with Resident #1, the resident never tried to self-transfer herself. The certified occupational therapy assistant (COTA) was interviewed on [DATE] at 1:20 p.m. The COTA said she had worked on slideboard transfers with Resident #1; however, the resident was only able to perform slideboard transfers with maximal assistance from the therapist, where the therapist did all the effort to move the resident across the slideboard. The COTA said Resident #1 did not have the strength to perform a self-transfer. She said the resident could have pulled herself forward but did not have the strength to pull herself up into a standing position due to severe contracture in both ankles, weakness and the inability to balance while seated, let alone to balance in a standing position. The COTA said the resident was not able to bear weight due to severe contractures and muscle weakness. She said Resident #1 was not motivated to attempt a self or assisted transfer without the staff doing all of the mobility effort and the resident worried about being injured. LPN #2 was interviewed on [DATE] at 3:30 p.m. LPN #2 said Resident #1 had poor safety awareness, poor eyesight and needed someone to describe her surroundings in order to feel more secure. LPN #2 said she had not known Resident #1 to attempt to self transfer herself from surface to surface, but she said she had observed that the resident would sometimes scoot herself forward in her seat. The DON and the NHA were interviewed together on [DATE] at 5:00 p.m. The DON said Resident #1 was unable to identify the buttons on her bed controller to know which button moved the parts of the bed she was using. The DON said the resident was a habitual call light user and would press the red button call light over and over without purpose or knowing what she was pressing. The NHA said the Invacare beds would remain out of use until the facility could obtain bed controllers without the red CPR button or find another appropriate resolution. The NHA said the facility had been researching options to see if the beds could be used safely by the resident population.

Based on record review and interviews, the facility failed to thoroughly investigate an allegation for an injury or unknown origin for one (#1) of two residents out of 12 sample residents. Specifically, the facility failed to complete a thorough investigation to clarify conflicting facts after Resident #1 sustained an injury of unknown origin to her left lower leg (fractured tibia and fibula), which required hospitalization and surgical intervention. Findings include: I. Facility policy and procedure The Resident Mistreatment, Abuse and Neglect Prohibition policy, dated 2017, was provided by the director of nursing (DON) on 6/17/25 at 11:32 a.m. It read in pertinent part, All allegations of injuries of unknown origin are to be reported immediately and investigated by the administrator, risk manager or designee. Injury of unknown origin is an injury in which both of the following conditions are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury (its location is in an area that is not generally vulnerable to trauma) or the number of injuries observed at one particular point in time, or the incidence of injuries over time. Each facility will thoroughly investigate injuries of unknown origin in accordance with federal and state regulations. The electronic incident report and investigation system forms should be completed for all incidents of injuries of unknown origin. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 5/9/25. According to the May 2025 computerized physician orders (CPO), diagnoses included femur (upper leg) fracture, dementia and anxiety. The 5/8/25 minimum data sets (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. She required substantial assistance for lower body dressing and chair to bed transfers and was dependent for toileting and for transfers from sit to stand. B. Record review The hospital discharge summary documented Resident #1 was admitted to the hospital on [DATE] and discharged on 5/14/25. It documented Resident #1 was found in her wheelchair at the nursing facility complaining of lower left leg pain. The discharge summary further documented the resident was diagnosed with left leg tibia (front lower leg bone) and fibula (rear lower leg bone) fractures. The resident required surgical intervention to repair the fractures. III. Incident of injury of unknown origin on 5/8/25 The facility's investigation report, dated 5/14/25, revealed Resident #1 sustained an injury of unknown origin on the evening of 5/8/25 and there was no witness to what caused the resident's fractured lower left leg. The facility initiated an investigation on 5/9/25 after the sheriff's office arrived at the facility and informed the facility that they were investigating due to the injuries Resident #1 presented to the hospital with. The investigation documented the following series of events, which occurred from 5/8/25 to 5/9/25. The timeline of events (listed below) was generated by the facility based on staff interviews and video surveillance from the facility's hallway camera, which was positioned just outside Resident #1's room. The camera did not have a view inside of Resident #1's room. -Resident #1's room layout included a vestibule area just off the main hallway, adjoining two resident rooms and a separate bathroom with a shower. -On 6/18/25 and 6/19/25, during the survey, video footage was observed in the presence of the NHA and DON; however, the footage available did not have the time and date stamp available. The NHA provided clarification of the times during observation of the video. A. Timeline The facility established the following timeline of events based on the camera footage and staff interviews (see below). The facility's investigation timeline of the incident on 5/8/25, documenting the events occurring on the evening /night shift when Resident #1 was injured, was provided by the NHA on 6/16/25. The details of the timeline were reviewed at the same time that the video surveillance was viewed on both 6/18/25 and again on 6/19/25. The NHA clarified and explained the details of the timeline during review of the footage on 6/18/25 and 6/19/25. At 5:30 p.m. Resident #1 returned to her room from therapy to eat her dinner. At 6:00 p.m. the day shift nurse and certified nurse aide (CNA) told the facility investigator Resident #1 was observed sitting in her wheelchair eating dinner when they were leaving their shift. At 6:30 p.m. the evening/night shift nurse, licensed practical nurse (LPN) #4 said she performed first rounds and observed Resident #1 eating her meal. At 7:00 p.m. LPN #4 passed medications to the resident in the room adjacent/ adjoining to Resident #1's room and did not observe Resident #1 to be in any distress. At 7:08 p.m. CNA #7 was at the laundry cart outside of Resident #1 and Resident #12's rooms. At 7:11 p.m. CNA #7 entered the vestibule area to Resident #1's room; however, the camera was unable to see which resident's room she entered. At 7:12 p.m. CNA #7 was back in the hall at the laundry cart. At 7:14 p.m. CNA #7 went back into the vestibule. At 7:17 p.m. CNA #7 exited the resident vestibule and reentered at 7:19 p.m. From 7:20 p.m. to 7:23 p.m. LPN #4 was observed one room away at the medication cart. At 7:26 p.m. Resident #1's call light was on for nine minutes and 18 seconds. At 7:27 p.m. LPN #4 was outside Resident #1's room, checking on the resident and CNA #7. At 7:28 p.m. LPN #4 entered Resident #1's neighbor's room to pass medication and exited the room at 7:29 p.m. At 7:33 p.m. CNA #7 was observed exiting the vestibule of Resident #1's room and going back in at 7:34 p.m. then was observed looking out of the vestibule and going back into the vestibule. At 7:45 p.m. CNA #7 picked up meal trays from Resident #1's room and told Resident #1 she would assist her into bed once her food was digested. At 7:50 p.m. Resident #1's call light was on for three minutes and 28 seconds. At 7:50 p.m., CNA #7 was reported (by the NHA) to have observed Resident #1 sitting comfortably in her wheelchair and then proceeding on to assist Resident #12 from the adjacent adjoining room with a shower. At 7:59 p.m. CNA #7 exited the residents' doorway and entered the hall. At 8:00 p.m. CNA #7 went back into the vestibule of Resident #1 and Resident #12's rooms (no call light was observed turned on). At 8:02 p.m. CNA #7 said she heard Resident #1 yelling My foot! My foot! and she rushed out of the adjacent room to check on Resident #1. CNA #7 said she found Resident #1 in her wheelchair with a turned body trying to grab the bed frame to pull herself into the bed. CNA #7 said Resident #1 was twisted and yelling about her foot hurting. Resident #1's call light was activated at 8:03 p.m. CNA #7 said she called out for LPN #4 from Resident #1's doorway and LPN #4 ran to the room to assist. -However, during observations of the video during the survey, CNA #7 was observed on video entering the hallway from Resident #1's room and standing in the hallway for a few seconds and then walking down the hallway and returning to Resident #1's room, walking in the company of LPN #4. At 8:05 p.m. LPN #4 assessed Resident #1 and noticed swelling to Resident #1's left lower leg that was not present during her previous rounds (checking on the resident). LPN #4 was observed leaving Resident #1's room. LPN #4 said she left to call LPN #5 for assistance to assess Resident #1. At approximately 8:05 p.m. or 8:06 p.m. LPN #4 reentered Resident #1's room. At 8:10 p.m. LPN #4 exited Resident #1's room. At 8:14 p.m. LPN #5 entered Resident #1's room and recommended they have Resident #1's leg Xrayed. At 8:16 p.m. LPN #5 exited Resident #1's room. -It was not clear by staff interview and video surveillance during the survey what time and who assisted Resident #1 into bed because LPN #5 said in interview during the facility investigation (see below) that the resident was in bed when he arrived to the resident's room and the only other staff members in and out of the resident's room were CNA #7 and LPN #4, which contradicted CNA #7 and LPN #4's witness statements (see below). At 8:20 p.m. a nurse (not identified which nurse) called the on-call physician about Resident #1's change in condition. At 8:20 p.m. the unspecified nurse received orders for a STAT (urgent) Xray and 50 milligrams (mg) of Ultram (pain medication) for pain. At 8:25 p.m. LPN #5 provided Resident #1 with an ice pack and elevated her injured leg. At 9:15 p.m. Resident #1's pain was re-assessed by LPN #4, following the administration of the pain medication, and it was determined the medication was effective. At 9:45 p.m. the radiology technician arrived to take Xrays of Resident #1's leg. At 10:08 p.m. preliminary Xray results were received and facility staff called the on-call physician. The physician told staff to call the resident's guardian to see if they would like to send Resident #1 to the hospital for treatment, because the resident had previously signed an advanced directive for comfort care. At 10:28 p.m. the final results radiology results report confirmed Resident #1 had fractures in her left lower leg. At 10:25 p.m. the residents' guardian called back and said they wanted Resident #1 to be sent to the hospital, where her orthopedic physician would see her. At 10:35 p.m. LPN #4 called for non-emergent medical transport for Resident #1 to be taken to the hospital. At 12:30 a.m. the emergency medical services (EMS) transported Resident #1 to the hospital. B. Staff interviews conducted during the facility investigation of the 5/8/25 incident Staff interviews by the facility documented the following information: CNA #7 was interviewed on 5/9/25. CNA #7 said she arrived on shift at 6:00 p.m. and started rounds at 6:30 p.m. Resident #1 was eating dinner when she was checked on during rounds. Resident #1 did not need anything at the time, so she continued onward. CNA #7 said she checked on Resident #1 again at 7:30 p.m. Resident #1 was still eating and had no complaints. CNA #7 said she checked on Resident #1 at 8:05 p.m. and took her tray and told the resident she would come back in one hour after she had time to digest her meal. CNA #7 said she proceeded to assist Resident #12, the resident in the room adjacent/adjoining to Resident #1, to take a shower. The two resident rooms were connected by a vestibule connecting the two rooms and also a bathroom/shower room. -However, according to the timeline above and the NHA, CNA #7 checked on Resident #1 and proceeded to assist Resident #12 with a shower at 7:50 p.m., not 8:05 p.m. (see timeline above). CNA #7 said after approximately 15 minutes, she heard Resident #1 yelling my foot, my foot so she ran into Resident #1's room and found the resident holding the bed controller in her hand. CNA #7 said the resident was twisted to the left with her leg up under the wheelchair, reaching to the bed. CNA #7 said she yelled for LPN #4 to come and assess the resident. The nurse came with a second nurse. CNA #7 said they got two more CNAs to help transfer the resident back to bed. CNA #7 said the resident was transferred without putting pressure on her foot. Review of CNA #7's witness statement revealed a handwritten note that her witness statement was updated on 5/14/25 (six days after the incident occurred), upon reenactment of the incident. The addition to the statement, which was not signed by CNA #7, documented the position of Resident #1's leg and foot as being under the bed (instead of under the resident's wheelchair, as was originally documented by CNA #1 - see above). The updated statement indicated the resident's bed was in a low position at the same height as her wheelchair so that her lower leg (below the knee) aligned with the bed frame and it appeared Resident #1 lowered the bed on her leg. LPN #4 was interviewed on 5/9/25. LPN #4 said she took care of Resident #1 two times a week and the resident did not like to get into bed early. LPN #4 said she made rounds at 6:30 p.m. (on 5/8/25). She said at that time, Resident #1 was in her chair, eating dinner and watching television. Resident #1 was in no distress. LPN #4 said she next saw the resident around 7:30 p.m. when she administered medications to the resident in the adjacent room and Resident #1 was still in no distress. LPN #4 said around 8:45 p.m. CNA heard screaming from Resident #1's room. CNA #7 ran into her room and saw her attempting to get into bed. Resident #1 had the bed controller in her hand and was reaching for the bed. Resident #1's leg was caught up in the wheelchair, preventing her from falling on the floor. LPN #4 said she went down to assess the resident and saw a lump on her leg that was not there before. She said she got another nurse to look at the resident's leg and they decided to get her into bed to evaluate. LPN #4 said they got two more staff members and a gait belt to transfer Resident #1 without putting weight on her left leg. Once the resident was in bed, LPN #4 said she called the physician for Xrays, got the resident a pain pill and some ice and elevated her leg. LPN #4 said after the Xrays came back she called Resident #1's family, who said to send the resident to the hospital for assessment by her orthopedic physician. LPN #2 (on-call LPN) was interviewed on 5/9/25. LPN #2 said she had never received a report from staff that Resident #1 had tried to get in or out of bed on her own prior to this incident (on 5/8/25) but the resident used the call light a lot. LPN #2 said the resident sometimes used the call light every 10 to 15 minutes but her use of the call light was when she needed help. -LPN #2's interview did not document her knowledge of the events of 5/8/25 or her being on-call and responding to LPN #4's call to report Resident #1's injury. LPN #5 was interviewed on 5/14/25. LPN #5 said around 8:00 p.m. (on 5/8/25) that LPN #4 came to his unit to ask him for a second opinion about the injury to Resident #1's leg. He said he observed Resident #1's leg had a swollen bump on it and it hurt just when touched. He advised LPN #4 to get an Xray. He assisted LPN #4 to get the Xray while LPN #4 cared for Resident #1. C. Resident interviews conducted during the facility investigation of the 5/8/25 incident During the facility's investigation of the 5/8/25 incident involving Resident #1, several residents (including Resident #12, who was Resident #1's suitemate) were interviewed regarding their experience living in the facility. Questions asked of the residents were generic and closed-ended and some were not relevant to the investigation of the incident of Resident #1's serious injury of unknown origin. Questions asked included: -Do you feel safe here; -Do you have any care concerns; -Is your call light answered timely; -Do you get your meals and medications timely; -Are you happy here; -Do staff treat you with respect; and, -Do you get the care you asked for? -However, the facility failed to ask the residents if they had any concerns with the care provided to them by CNA #7 and LPN #4. -Additionally, the facility failed to ask Resident #12, Resident #1's suitmate, who was cognitively intact, whether or not she witnessed or overheard any of the events involving Resident #1 on the evening of 5/8/25. D. Investigation conclusion The facility concluded that their investigation of the 5/8/25 incident of the injury unknown origin involving Resident #1 suggested that the resident attempted to self-transfer herself after learning how to use a slide board to transfer with therapy on that day (5/8/25), and had been previously working with slide board transfers with therapy since 4/16/25. The facility concluded the resident'sleg got caught up under her wheelchair and caused her injuries. -However, the facility's leadership said in interview during the survey (from 6/16/25 to 6/19/25) that based on additional review by leadership and a reenactment of the incident (conducted on 5/14/25, six days after the incident) with staff, they concluded that Resident #1'sinjuries were caused when the resident lowered the hospital bed down on her leg which resulted in the fractures to the fibula and tibia bones in her left leg. -Review of the facility's investigation failed to reveal how the facility came to their conclusion of the incident when the initial version of events reported by staff and observed during video surveillance review on 6/18/25 and 6/19/25 did not match the version of events reported and reenacted on 5/14/25. IV. Facility's investigation failures and discrepancies between staff reports and video footage on 5/8/25 Review of the timeline of events established by the facility for the 5/8/25 incident involving Resident #1, documentation of staff members witness statements and video footage from 5/8/25, revealed several discrepancies related to the investigation of the incident related to Resident #1's serious injury of unknown origin. The discrepancies and investigation failures were as follows: 1. The facility failed to clarify who assisted Resident #1 into bed after the injury was discovered. CNA #7 and LPN #4 both said they got two additional CNAs to assist them in getting Resident #1 into bed after she was found to be in distress. -However, review of the video footage revealed no other CNAs or staff members entered Resident #1's room prior to LPN #5 entering to assess Resident #1. LPN #5 said in an interview during the survey (on 6/18/25 at 5:45 p.m.) that Resident #1 was in bed when he arrived to examine her injured leg (see LPN #5's interview below). 2. CNA #7 and LPN #4 both initially reported (during their interviews with the facility investigator on 5/9/25) that CNA #7 heard Resident #1 yelling and went into the resident's room to find the resident with her bed controller in her hand and reaching for the bed. Both staff members initially reported that Resident #1's leg was caught under her wheelchair and did not mention her leg being caught under the bedframe in their initial interviews. After a reenactment of the incident on 5/14/25 (six days after the incident occurred), the facility concluded that Resident #1's left leg was under the bed and the resident lowered the frame of the bed onto her own leg using the bed controller that was in her hand, which resulted in the fractures to the resident's leg. -However, the facility failed to clearly document who was involved in the reenactment of the incident on 5/14/25 or identify why the scenario changed from the resident's leg being found underneath the bed instead of the wheelchair, as was initially reported. 3. CNA #7's witness statement documented she was in and out of Resident #1 and Resident #12's suite area so frequently on 5/8/25 because she was assisting Resident #12 with a shower. -The facility failed to identify how much of the time that CNA #7 was seen on the video footage going in and out of the residents' suite area was spent assisting Resident #1 when she activated her call light versus how much time was spent assisting Resident #12. 4. The facility failed to ensure clear communication during the interviews with CNA #7 and LPN #4. The DON said in an interview during the survey (see below) that English was not the first language of either CNA #7 or LPN #4. Additionally, the DON said she may not have gotten the correct facts from CNA #7 and LPN #4 due to the language barrier and that she may have misunderstood the staff or they may have misunderstood her when they talked over the phone on 5/9/25 about the details of the prior evening (5/8/25) when Resident #1 was injured. V. Staff interviews LPN #5 was interviewed on 6/18/25 at 5:45 p.m. LPN #5 said he was working on the evening of 5/8/25 when Resident #1 sustained her fractures. LPN #5 said he was working on another unit when LPN #4 came and asked him to look at Resident #1 for a second opinion of her injuries. LPN #5 said when he arrived to Resident #1's room, she was already in bed with her left leg elevated below the knee. He said CNA #7 and LPN #4 told him they transferred Resident #1 back to bed. LPN #5 said the resident was guarded and did not want them to touch her leg. He said he recommended an Xray for the resident and said he did not have any information on how the resident was injured. The DON was interviewed on 6/19/25 at 3:30 p.m. The DON said she did not speak to CNA #7 or LPN #4 on the evening of Resident #1's injury to her leg (5/8/25). The DON said after being notified by the sheriff's office on 5/9/25, she called both CNA #7 and LPN #4 that day (5/9/25) for additional information She said she had separate conversations with each of them about the events leading up to Resident #1 being injured. The DON said English was not either CNA #7's or LPN #4's first language and she might have heard the staff members incorrectly with a couple of their responses during their initial interviews. The DON said after the initial interviews with CNA #7 and LPN #4, the leadership team conducted a reenactment of the events with the staff and came up with the most likely scenario of how Resident #1 was injured. The DON said the leadership team believed that the resident was trying to press the call light button, wanting to get into bed, but she was pressing the bed controller button by mistake, and her actions caused the bed frame to lower onto her leg and resulting in fractures to her lower left leg.

Based on record review and staff interviews, the facility failed to ensure the services provided met professional standards of quality for one (#1) of seven residents out of 12 sample residents. Specifically, the facility failed to ensure Resident #1 was assessed by a registered nurse (RN) after a significant change of condition when she experienced a fracture of the left fibula and tibia (lower leg bones). Findings include: I. Professional reference According to Nurse Journal's Licensed Practical Nurses (LPN) Versus Registered Nurses (RN), (8/27/24), retrieved on 6/25/25 from https://nursejournal.org/resources/lpn-vs-rn-roles/, LPNs and RNs both monitor patients, administer medications, perform wound care, help patients with basic tasks like bathing and feeding, and often educate and support patients and their loved ones. However, there are differences in the education requirements and scope of practice between RNs and LPNs. LPNs perform vital work in collaboration with RNs, physicians and other healthcare professionals. LPNs work alongside or under the supervision of RNs to deliver care and support to patients. This role also requires gathering patient data, which other licensed healthcare providers later interpret. Unlike RNs, LPNs typically do not have state authorization to make health assessments, create nursing care plans or triage patients. Compared to LPNs, RNs generally operate independently. RNs use their specialized judgment, skills, and knowledge to provide direct patient care in various settings. Generally speaking, only RNs provide initial assessments. Therefore, an RN must perform all tasks that require close monitoring and frequent assessment, such as initiating blood products, the first round of antibiotics, and initial patient assessments. II. Facility policy and procedure The Notification of Change in Condition policy, dated 2016, was provided by the nursing home administrator (NHA) on 6/19/25 at 8:30 a.m. It read in pertinent part, When a resident is evaluated or assessed as having a change in condition, the charge nurse will follow through in documenting notification to family/legal representative/resident, the health care provider and other licensed nurses as indicated. A change in condition is a clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on 5/9/25. According to the May 2025 computerized physician orders (CPO), diagnoses included femur (upper leg) fracture, dementia and anxiety. The 5/8/25 minimum data sets (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. She required substantial assistance for lower body dressing and chair to bed transfer and was dependent for toileting and for transfers from sit to stand. B. Record review The facility's incident report, dated 5/14/25, documented that on 5/8/25 at 8:02 p.m., certified nurse aide (CNA) #7, who was assigned and working on the unit, heard Resident #1 yelling out my foot, my foot. CNA #7 entered the room to find the resident trying to pull herself into bed. CNA #7 alerted LPN #4, who was working on the unit, to assess Resident #1. At 8:05 p.m., LPN #4 noticed new swelling to Resident #1's left lower leg, but she was not sure what was wrong with the resident. LPN #4 assisted CNA #7 to get Resident #1 into bed and then went to get LPN #5, who was also working in the facility, to look at Resident #1. -However, the time documented in the incident report regarding when LPN #4 noticed new swelling to Resident #1's left lower leg on 5/8/25 did not match the time documented in the 5/8/25 progress note in the resident's electronic medical record (EMR) (see progress note below). A review of Resident #1's EMR revealed the following progress notes: A nurse progress note, dated 5/8/25 at 10:54 p.m. and written by LPN #4, documented that at 7:40 p.m., Resident #1 was in distress, complained of left leg pain and the resident wanted to go to bed. LPN #4's note revealed Resident #1 had swelling below the left knee and pain with movement. The note revealed a STAT (urgent) Xray was performed, Tramadol pain medication was administered, the physician and family were notified and Resident #1 was transferred to the hospital. -The timing of the progress note contradicted the time documented on the facility's incident report (see incident report above). -Review of LPN #4's progress note revealed no documentation to indicate a comprehensive (head to toe) nursing assessment was completed by the RN on site, upon the discovery of a change in Resident #1's condition on 5/8/25 at 7:40 p.m. The director of nursing's (DON) late entry progress note, dated 5/16/25 at 11:38 a.m., (eight days after Resident #1's change of condition) documented that on 5/8/25 at 10:15 p.m. (almost two and a half hours after the resident's change of condition) LPN #2 (who was on-call and not in the facility) called the DON (who was also not in the facility) regarding Resident #1's condition change (fractured leg) on 5/8/25. The progress note revealed the DON advised LPN #2 to call the physician with Resident #1's Xray results for further treatment recommendations and to notify the resident's representative. -The DON's progress note indicated LPN #2 called her on 5/8/25 at 10:15 p.m., however, the facility did not receive results of Resident #1's Xrays until 11:28 p.m. (see radiology results report below). -The DON's progress note did not reveal communication with an RN, or that an RN assessment was completed at the time of the injury. The progress note did not reveal contain documentation to indicate that the DON instructed LPN #2 to notify the RN on duty to ensure an RN assessment was completed for Resident #1. -Additionally, there was no documentation in Resident #1's EMR to indicate LPN #2, LPN #4 or LPN #5 notified the RN on duty to conduct an assessment of Resident #1 after the resident's change of condition was identified. Review of the 5/8/25 radiology results report revealed an Xray of Resident #1's left tibia and fibula was obtained at the facility on 5/8/25 at 9:28 p.m. (one hour and 48 minutes after LPN #4's progress note (see above) indicated Resident #1 was in distress and had swelling below the left knee and pain with movement). The radiology results report further revealed Resident #1 had sustained fractures to both her left tibia and left fibula. The Xray results were not reported to the facility until 11:28 p.m. on 5/8/25 (two hours after the Xray was obtained and three hours and 48 minutes after LPN #4's progress note (see above) indicated Resident #1 was in distress and had swelling below the left knee and pain with movement). Review of the 5/9/25 emergency medical services (EMS) documentation revealed EMS arrived at the facility at 11:14 p.m. on 5/8/25 and found Resident #1 with severe left leg pain which began four hours prior. EMS transferred the resident to a stretcher and transported her from the facility at 12:07 a.m. on 5/9/25 (four hours and 27 minutes after LPN #4's progress note (see above) indicated Resident #1 was in distress and had swelling below the left knee and pain with movement). Further review of the 5/9/25 EMS documentation revealed that EMS arrived at the hospital at 12:35 a.m. on 5/9/25 and transferred care of Resident #1 over to the hospital staff at 12:42 a.m. Cross-reference F689 for failure to keep residents free from accidents/hazards. Cross-reference F610 for failure to timely and thoroughly investigate a significant injury of an unknown origin. IV. Staff interviews LPN #5 was interviewed on 6/18/25 at 5:18 p.m. LPN #5 said that LPN #4 asked for his assistance to evaluate Resident #1's change of condition (on 5/8/25). LPN #5 said the resident was guarded and did not want anyone to touch her left leg. LPN #5 said Resident #1 could not say what had happened. LPN #5 said he called the resident's physician to request a physician's order for a STAT Xray and then went to the resident and applied an ice pack for the injury. LPN #5 said they monitored the laboratory portal for the Xray images and reported the results back to the on-call physician once the Xray results were received. LPN #5 said Resident #1 was then transferred to the hospital for further assessment and treatment. LPN #5 said he did not know how Resident #1 was injured; however, because the resident had not fallen out of her wheelchair to the floor, they did not call for the RN on duty to come to the unit to perform a post-fall assessment; an RN assessment was not completed. RN #1 was interviewed on 6/18/25 at 6:55 p.m. RN #1 said the process to follow if a resident experienced a condition change, including an injury, was for the LPN to call the RN on duty to assess the resident. LPN #2 was interviewed on 5/19/25 at approximately 3:30 p.m. LPN #2 said she was on-call the night of 5/8/25 when LPN #4 called her to report Resident #1 had sustained an injury to the lower left leg. LPN #4 said CNA #7 alerted her that the Resident #1 was complaining of pain and thought that she had an injury while trying to self-transfer. LPN #2 said LPN #4 told her that she was worried because after getting the resident back into bed, she noticed something sticking out of the resident's left lower leg and it did not look right. LPN #2 said once the Xray images came in over the laboratory portal, she called the DON to report the fractures. LPN #2 said the DON told her to call the physician for next step orders. LPN #2 said the on-call physician said since the resident had signed a do-not-resuscitate order with directives for comfort care, the family should make the decision for treatment type. LPN #2 said the resident's family gave directions for the facility to send Resident #1 to the hospital for further assessment and treatment. The DON was interviewed on 6/19/25 at 5:15 p.m. The DON said she was notified by the off-site on-call LPN unit manager (LPN #2) around 10:00 p.m. on 5/8/25, after LPN #2 was notified by the floor nurse on duty (LPN #4) that Resident #1 had sustained a left lower leg fracture confirmed by Xray results. The DON said she told LPN #2 to notify the resident's on-call physician and request further treatment orders. The DON said she did not lay eyes on Resident #1 and did not assess the resident's injuries on 5/8/25. The DON said she had not talked directly to LPN #4 who was in charge of the resident's care on the evening and night shift. The DON said the RN on duty at the facility on the night of 5/8/25 never observed the resident after the injury or prior to Resident #1's transfer to the hospital. The DON said she felt it was sufficient that she talked to the on-call LPN (LPN #2) over video chat and informed LPN #2 to call the floor nurse (LPN #4) back and give her directions to notify the on-call physician of Resident #1's Xray results.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, temperature and texture. Findings include: I. Resident interviews Resident #108 was interviewed on 5/6/24 at 1:37 a.m. Resident #108 said his meal trays were often missing an ordered item. He said he was served a hamburger for lunch with no lettuce and tomatoes and sugar and creamer and no tea. The resident said warm food was usually cold when it was delivered. Resident #215 was interviewed on 5/6/24 at 2:02 p.m. Resident #215 said the food in the facility was not good. He said he had not had a good meal in so long he could not remember when the last good meal was. He said he told the kitchen not to serve him rice anymore because it was always served with hard pieces in it and the pork and beans that were served recently as a main meal was hardly a meal. He said instead, it was a cup of beans with one small piece of a hotdog [NAME]. Staff served his food with plastic utensils that usually broke off in his food and food that was supposed to be hot was often served cold. The last cheeseburger he was served was not only cold but was hard like it had been sitting around. Resident #22 was interviewed on 5/7/24 at 9:07 a.m. Resident #22 said the food tasted terrible, that it was dry and tasteless, especially the chicken. He said his meal trays were often missing an ordered item and the hot foods were served cold most of the time. Resident #69 was interviewed on 5/8/24 at 12:13 p.m. Resident #69 said he was served salisbury steak, green beans and mashed potatoes for lunch and it was terrible and the temperature was cold. He said he could only eat a few bites of food. He said he tried to get staff to bring him something else but staff did not return until the meal service was over so he just went without. Resident #69 said if you ate in the main dining room there were no good alternative foods offered. II. Observations On 5/8/24 at 12:37 p.m. five surveyors evaluated a test tray for a regular textured diet and a pureed textured diet immediately after the last resident had been served their lunch. The regular textured meal consisted of chicken pot pie, carrots, mashed potatoes and and individual cheesecake pudding pie with a graham cracker crust. -The mashed potatoes had a chicken stock flavor. -The chicken pot pie was present in a messy scooped pile that was unidentifiable as a pot pie and was way too salty. -The carrots were not seasoned but tasted like a cooked carrot. -The cheesecake pudding pie with a graham cracker crust had a strange slightly floral taste and was warm and not cold as you would expect. The pureed consistency meal consisted of chicken pot pie, carrots and an individual crustless cheesecake pudding. -The chicken pot pie was too salty. -The carrots tasted bland and had a gritty slightly chunky texture. -The crustless pie was bland and warm tasting. When the temperature was taken both the cheesecake crusted and crustless pies temperatures were over the acceptable temperature range for safe and palatable foot temperature. The test tray crusted cheesecake pie temperature was 52 degrees Fahrenheit (F) and the crustless cheesecake pie temperature was 73 degrees F. -In both cases the cheesecake pudding pies were removed from the refrigerator and placed directly on the meal trays and then taken shortly after to be delivered to the resident and delivered as the test tray. At 1:05 p.m., after testing the meal trays, the temperature was taken of the leftover cheesecake pudding pies that remained in the facility's main kitchen refrigerators. The temperature of the individualized cheesecake pudding pies that remained in the refrigerators was 49 degrees F. On 6/8/24 at 4:30 p.m., dietary manager (DM) #2 provided the cheesecake pie recipe. The recipe revealed the cheesecake pudding pies were made of a milk product containing cream cheese, canned vanilla pudding, and a graham cracker pie shell. The ingredients were to be mixed together and chilled for two to three hours before serving. The pie was to be held and served cold at or below 40 degrees F. III. Staff interviews DM #1 and DM #2 were interviewed on 5/8/24 at 2:50 p.m. DM #1 said the kitchen staff should have obtained the temperature of the cheesecake before serving it to the residents. DM #1 said it was important to ensure food items were kept at a safe temperature to avoid bacteria growth, which could lead to food-borne illnesses. DM #1 said the chicken pot pie might have been salty due to the chicken base the cooks used. DM #1 said he would try a different chicken base the next time pot pie was on the menu. DM #2 said the pureed carrots did not reach the proper pureed texture. She said inconsistent diet texture could result in aspiration and possible weight loss when residents did not eat due to an incorrect diet texture. DM #2 said the facility immediately provided education on proper pureed textures for all kitchen staff.

Based upon observations, interviews and record review, the facility failed to ensure two (#65 and #69) of five residents reviewed for assistance with activities of daily living (ADL) received fingernail care out of 45 sample residents. Specifically, the facility failed to: -Ensure Resident #65 fingernails were trimmed and clean; and, -Ensure Resident #69 received staff assistance with fingernail care, applying lotion on his dry skin and showering assistance. Findings include: I. Facility policy and procedure The Fingernails policy, revised June 2008, was provided by the nursing home administrator (NHA) on 5/9/24 at 5:00 p.m. It revealed in pertinent part, The purpose of this procedure is to promote circulation to the hands and to clean fingernails. Procedure includes, assisting residents into comfortable positions, cleaning under the fingernails with an orange stick if indicated and using nail clippers to cut the fingernails if permitted. II. Resident #65 A. Resident status Resident #65, age greater than 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia, blindness right and left eye category three, chronic pain, unspecified osteoarthritis, muscle weakness and the need for assistance with personal care. The 3/23/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. He required set-up assistance with transfers, dressing, eating, toileting and personal hygiene. B. Observations and interview Resident #65 was interviewed on 5/6/24 at 9:12 a.m. Resident #65 was sitting on his bed in his room. His fingernails were long, chipped and cracked. Resident #65 said he needed assistance to get his fingernails cut and filed. He said his fingernails were too long and that bothered him. The resident said, although he received showers twice a week, the certified nurse aides (CNA) did not cut and trim his fingernails. At 2:35 p.m. Resident #65 returned to his room from an activity and sat on his bed. His fingernails were long and chipped. On 5/7/24 at 4:15 p.m. Resident #65 sat in his wheelchair in his room with long, chipped and cracked fingernails. On 5/8/24 at 9:40 a.m. Resident #65 was escorted to the shower room by CNA #1 for a shower. The resident returned to his room with CNA #1 following the shower. At 10:00 a.m. CNA #1 left Resident #65' s room after assisting the resident with the shower and escorting him back to his room. Resident #65' s nails remained long, cracked and chipped. -CNA #1 failed to provide fingernail care to the resident even though she assisted the resident with a shower. C. Record review The ADL care plan, initiated on 9/12/23 and revised on 4/1/24, identified Resident #65 had an activities of daily living (ADL) self-care performance deficit related to his diagnosis of dementia. -The care plan did not include interventions for fingernail care. III. Interviews Certified nurse aide (CNA) #1 was interviewed on 5/8/24 at 10:25 a.m. CNA #1 said Resident #65 required one person extensive assistance with his activities of daily living (ADL), including cutting and trimming his fingernails. She said she noticed during the resident' s shower that his fingernails were long but she did not have fingernail clippers to cut them. CNA #1 said long fingernails could cause injuries such as skin tears and could carry bacteria that could cause infections. Registered nurse (RN) #1 was interviewed on 5/8/24 at 10:35 a.m. RN #1 said Resident #65 was dependent on staff and required extensive assistance with his ADLs. RN #1 said the nurses were responsible for providing fingernail care for all dependent residents. She said she was not sure if CNAs could provide nail care for residents. She said Resident #65' s nails were long and chipped. RN #1 said the resident' s fingernails should be kept cut and trimmed. RN #1 said long fingernails could collect bacteria and result in sickness. The director of nursing (DON) was interviewed on 5/8/24 at 3:15 p.m. The DON said the nursing staff were responsible for ensuring residents were assisted with fingernail care. The DON said long and chipped fingernails could lead to illness and injuries, such as skin tears. The DON said she would immediately provide education to the nursing staff to ensure staff assisted dependent residents with nail care. 41032 IV. Resident #69 A. Resident status Resident #69, age 69, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the May 2024 CPO, diagnoses included diabetes, need for assistance with personal care and reduced mobility. According to the 3/26/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required extensive assistance with bed mobility, transfers, bathing and with dressing and grooming. B. Resident interview and observations Resident #69 was interviewed on 5/6/24 at 10:06 a.m. Resident #69 said he preferred to shower over a bed bath but the staff would not get him up for the shower. He said, instead, the staff just gave him a bed bath. The resident said he had not had a bed bath in several days and he at least wanted a bed bath if they could not provide him a shower. Resident #69 said when staff did assist him with a bed bath there was only one certified nurse aide (CNA) who assisted him to apply lotion to his dry skin and apply deodorant. He said the other CNAs would not make the effort even when he requested lotion and deodorant. Resident #69 pointed to a box he kept at the foot of his bed and said his lotion and deodorant was in the box. He said the staff would not have to move far to reach his hygiene supplies. Resident #69 said he had been asking the staff to help with a shower for over a week and he had not received one. Resident #69 said he had refused an offer to go to the shower room on one occasion because he was not feeling up to getting out of bed. He said he thought a shower would help relieve his dry itchy skin and the itchiness in his groin area. Resident #69 said he had asked staff to assist him with cutting his fingernails as they were getting long. The resident showed his long curling nails. He said his fingernails needed to be clipped and cleaned, but the CNAs would not assist him with nail care. He said one CNA left a pair of clippers in his room, but they disappeared. He said he was unable to clip his nails on his own. He said he had a bad itching in his groin area and had been scratching the area. Resident #69 said his long nails irritated his skin even more but it itched so much he had to scratch the area. Resident #69 said he had even tried to rip off his nails to shorten them, but he was unsuccessful. He did not know what else to do. On 5/6/24 at 10:06 a.m., 5/8/24 at 2:11 p.m and 5/9/24 at 3:30 p.m., Resident #69 was observed with long and dirty fingernails. There was a brown substance underneath each nail and the skin on the resident' s arms and back were dry with flakes of dead skin visible. C. Record review The resident' s comprehensive care plan, initiated on 1/12/24, revealed Resident #69 had an ADL self-care performance deficit due to bed confinement and impaired skin integrity. Interventions included referral to podiatrist/foot care, nurse to monitor/document foot care needs and to cut long nails, conduct daily skin inspections and report abnormalities to the nurse. -However, the resident had both legs amputated below the knees and the care plan did not have interventions to maintain fingernails or a treatment for dry skin. According to the resident' s bath schedule for the past 30 days the resident received bathing assistance two times out of eight opportunities. The record documented that the resident had a bed bath on 4/10/24 and 4/19/24 and refused only one showering opportunity on 4/17/24. The schedule documented that showers did not apply to this resident on four occasions and no bathing assistance was provided. The last scheduled bathing date was not documented and none were given. -A review of the resident's electronic medical record did not reveal documentation indicating how much assistance the resident needed for nail care or the last time he received nail care. V. Interview Licensed practical nurse (LPN) #1 was interviewed on 5/8/24. LPN #1 said Resident #69 should get two showers per week. She said there had been a staff shortage and that could be why the resident did not get his scheduled showers. LPN #1 said Resident #69 should receive nail care on his bathing days. Registered nurse (RN) #2 was interviewed on 5/9/24 at 3:06 p.m. RN #2 said Resident #69 recently moved to the unit, so he was not sure why the resident had not received showers or nail care. He said the CNAs were supposed to follow the schedule and provide bathing and nail care for Resident #69. RN #2 checked the shower schedule and verified the resident was on the showering schedule. He said he would make sure the resident received a shower and nail care care that evening. CNA #2 was interviewed on 5/9/24 at 5:30 p.m. CNA #2 said Resident #69 told her he preferred a shower over a bed bath because it made him feel better. CNA #2 did not know why the resident had not been showered. The director of nursing (DON) was interviewed on 5/9/24 at 5:50 p.m. The DON said the resident should receive his showers on his scheduled shower days. She said showers or baths could help with skin issues and keep body odor under control. CNA #1 was interviewed on 5/9/24 at 6:15 p.m. CNA#1 said the resident was not showered earlier in the week because the facility did not have a second staff member to assist with showers and the nurses had been too busy. CNA #1 said they would be more attentive to Resident #69 especially due to his skin issues. 42193

Based on observation, record review and interviews, the facility failed to ensure two (#5 and #23) of two residents reviewed for communication out of 50 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure strategies were in place to effectively communicate with Resident #5 and Resident #23, who spoke a language other than English. Findings include: I. Facility policy and procedure The Auxiliary Aide and Services Assessment policy and procedure, revised 2019, was provided by the nursing home administrator (NHA) on 1/26/23 at 6:02 p.m. It documented, in pertinent part, Appropriate auxiliary aids and services are necessary for effective communication will be provided by the facility as soon as practicable without compromising resident care to residents and their companions who are deaf, hard of hearing. Effective communication is communication with people with disabilities that is as effective as communication with others, that is provided in an accessible format, in a reasonably timely manner, and that protects privacy and independence. The determination of appropriate auxiliary aids or services and the timing, duration, and frequency with which they will be provided will be made by the facility staff in consultation with the resident and or companion with a disability or where appropriate, the Resident's responsible party. The assessment made by the facility will take into account the relevant facts and circumstances, including the individual's communication skills and knowledge, and the nature and complexity of the communication needs at issue. The facility will not rely on an adult accompanying an individual with a disability to interpret or facilitate communication, except: in an emergency involving an imminent threat to the safety or welfare of an individual or the public or where the individual with the disability specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide such assistance, and reliance on the that adult is appropriate under the circumstances. The following are examples of issues that have arisen where a facility has not provided effective communication: Enlisting family members, friends and/or staff members to facilitate communication. Our facility complies with applicable federal civil rights laws, provides free language services to people whose primary language is not English such as: qualified interpreters and information written in other languages. II. Resident #5 A. Resident status Resident #5, age 86, was admitted on [DATE]. According to the January 2023, computerized physician orders (CPO), the resident's diagnoses included depressive episodes and encephalopathy (functional and/or structural disorder of the brain caused by diseases). According to the 12/27/22 minimum data set (MDS) assessment, the resident had short-term and long-term memory impairment with severe impairment in making decisions regarding tasks of daily life. The resident had unclear speech and sometimes understood and responded adequately to simple and direct communication. She required extensive assistance of two people with bed mobility and transfers and extensive assistance from one person with dressing, toileting and personal hygiene. B. Observations On 1/23/23 at 2:15 p.m. the residents room did not have signs indicating communication needs or interventions staff could use. C. Family interview Resident #5's family member was interviewed on 1/23/23 at 2:15 p.m. She said her mom did not always understand English and preferred to communicate in Hindi. She said that staff often misunderstood what her mom was trying to say. She said that she stayed in the facility around ten hours per day and had only missed 12 days in two years because she was afraid staff would not understand her mom's needs. D. Record review The communication care plan, revised on 10/2/22, documented Resident #5 had a language barrier and that her primary language was Hindu. It indicated the resident preferred to communicate in Hindi. The interventions included discussing concerns or feelings regarding the resident's communication difficulty with the resident's family, providing a translator as necessary to communicate with the resident. It indicated that the resident's daughter was the translator. E. Staff interviews Certified nursing assistant (CNA) #1 was interviewed on 1/25/23 at 11:40 a.m. He said that Resident #5's needed help with communicating with staff. He said the resident's daughter helped with communication. He said that he was unaware of any communication tools at the facility. The social worker (SW) was interviewed on 1/26/23 at 3:45 p.m. She said that Resident #5 understood English. She said there were no signs in Resident #5's room to indicate that the resident may have a communication impairment. She said that the care plan would indicate if the resident had communication concerns and interventions to address the concern. She said Resident #5's daughter was at the facility every day and she was able to help translate. She said that there was a Stratus (translation device) available for staff to use. She said that staff would know to use the Stratus or other communication tools by looking at the resident's care plan. -However, according to the comprehensive care plan and resident's medical record, the Stratus device was not included nor instructions on how to use the device to assist in communicating with the resident in her preferred language. The director of nursing (DON) was interviewed on 1/26/23 at 5:38 p.m. She said individuals who had a primary language other than English, should be provided with communication tools like the Stratus machine. She said staff could also use Google Translate. She said Resident #5's daughter was in the facility everyday and her daughter translated for her. She said that Resident #5 seemed to understand her when she communicated with her. 43135 III. Resident #23 A. Resident status Resident #23, age over 80, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included Alzheimer's Disease, dementia, chronic obstructive pulmonary disease (COPD), unspecified mood disorder, dysphagia in oropharyngeal stage (which causes the inability to swallow), sleep disorder, and difficulty in walking. The 11/3/22 minimum data set (MDS) assessment revealed the resident was unable to provide a brief interview for his mental status score (BIMS). The resident had short and long term memory problems. The resident had severely impaired cognitive skills for daily decision making. The resident did not have disorganized thinking or problems with focused attention. The resident required extensive assistance with dressing, toilet use, and personal hygiene. He was totally dependent on staff for bathing. He required supervision with bed mobility, walking in his room, and locomotion on and off the unit. It was somewhat important for the resident to have books or magazines to read, listen to music that he liked, keep up with the news, do things with groups of people, go outside when the weather was good, and participate in religious activities. B. Resident interview Resident #23 was interviewed on 1/23/23 at 2:46 p.m. He was asked if he spoke English. He shook his head no several times. He said Mandarin. (Mandarin is the official state language of China) C. Observations On 1/23/23 at 2:50 p.m. the resident had a book on his bedside table in his room titled Christmas and it was in English. His room did not have any translation boards, flash cards, communication papers, magazines, or books in his primary language of Mandarin. During the observation his roommate said He doesn't speak English so we can't talk. I think he only speaks Chinese. On 1/24/23 at 12:39 p.m. an unidentified certified nurse aide (CNA) sat next to Resident #23 in the dining room and used a fork to assist the resident Mexican food. The CNA did not speak to the resident before she assisted him for 10 minutes. The CNA then said in English, Do you want something else? Are you sure? Are you done eating? The resident did not answer and stared straight ahead. The CNA then spoke Spanish to the resident and said loudly, Mas, mas? Mas, mas? (The word mas in Spanish translated to mean more). The resident did not answer the CNA and looked at his plate. The CNA then propelled the resident in his wheelchair out of the dining room. D. Record review The comprehensive care plan on 4/28/21 and revised on 1/19/23 revealed, -Focus: The resident's primary language was Mandarin. He had a communication problem with a language barrier. The resident had impaired cognition. -Interventions: The resident preferred to communicate in Mandarin. (The facility to) Provide (a) translator as necessary to communicate with the resident. The nurse practitioner (NP) progress note on 11/17/22 revealed that due to dementia and language limitations the resident did not answer some (yes/no) questions during the visit with the NP. The NP progress note on 1/13/23 revealed the NP tried to communicate with the resident's wife but English was not her primary language and the NP was not sure the wife understood even with several communication attempts. -There was no documentation of an interpreter being provided for the resident or his wife during either visit with the NP. E. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 1/24/23 at 4:20 p.m. CNA #4 said she did not know what language the resident spoke. She said she just talked to him and maybe he understood but she could not be certain. She said she did not carry any translation cards with her or use her phone to find words to communicate with him. She said when she worked in a hospital a translator service was used but the facility did not use a service like that for the residents. She said menu cards were provided every day in English only. She said she did not know if the resident could read a menu card in English. CNA #5 was interviewed on 1/24/23 at 4:45 p.m. He said when the wife came into the facility she would circle the menu card in English what food her husband would want. He said the wife had not been in recently so CNA #5 circled food items he thought the resident would like but did not ask him personally. CNA #5 said the resident seemed depressed and kept to himself. He said the facility had a translator type service but the facility did not have it anymore. He said he did not know where the translator machine went or where it would be in the facility if it was still in the building. He said the resident spoke Mandarin and he could not speak English. The CNA said one time the resident's wife brought a newspaper that was written in Mandarin and the resident was very happy when he could read in his own language. The dietary manager (DM) was interviewed on 1/25/23 at 9:25 a.m. She said she did not know what language Resident #23 spoke nor did she know how to communicate with him. She said the dietary staff did not communicate with him. She said the dietary staff did not have any translation cards to use to communicate with him. She said she relied on the CNAs to fill out menu cards for each person and turn the menu cards into the kitchen. She said she had met the resident's wife about three months ago but they did not speak about food, or what the resident liked to eat. The DM said she never called the family to discuss what the resident liked to eat or what foods the resident disliked. She said she was unaware that today in the morning for breakfast the resident had a large portion of scrambled eggs on his plate that he did not eat. She said she thought he liked hard boiled eggs. She said maybe he had both scrambled and hard boiled eggs on his plate but she was not sure. She said the CNAs brought him to the dining room but the dietary staff did not speak to him once he was in the dining room. She said the dietary staff did not use a translator service to communicate with the resident. She said he liked oatmeal for breakfast and she did not know how to communicate with him if he changed his mind and wanted something besides oatmeal to eat. The social service director (SSD) was interviewed on 1/25/23 at 12:23 p.m. She said the facility had a translator service machine but she did not know where it was in the building. She said she did not know who was responsible to print out flashcards or to make a communication board in a foreign language to communicate with residents who did not speak English. She said she was unaware the facility staff did not have a way to communicate with Resident #23. She said she could get him reading materials, flash cards, a flip book in Mandarin, a translator dictionary, and a basic communication board put up on the wall in his room. She said today she would get speech cards printed up and laminated, and put in his room so the facility staff could communicate with him. The nursing home administrator (NHA) was interviewed on 1/25/23 at 3:19 p.m. The NHA said the resident's wife had been out sick and had not been in the facility recently. He said he would make sure the staff were trained on how to use the translator service machine that was in the facility. He said the management team would come up with strategies and ideas on how to fix the communication situation for Resident #23. He said the SSD today would print out laminated flash cards and put them in the resident's room for the staff to utilize to help communicate with the resident in Mandarin Chinese.

Based on observations, record review and interviews, the facility failed to ensure one (#62) of seven out of 50 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure that Resident #62 received a prescribed wound treatment after every incontinence episode on a coccyx wound. Findings include: I. Professional reference The Joint Commision (March 2022). Quick Safety 25: Preventing pressure injuries. The European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) (2019). The International Guideline (Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline). https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-25-preventing-pressure-injuries/preventing-pressure-injuries/#.Y9gDenbMI2w retrieved on 1/30/23 at 11:09 a.m. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist and may represent as an intact or ruptured serum filled blister, adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage cannot be used to describe moisture associated skin damage (MASD), including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns and abrasions). Skin Care. Protecting and monitoring the condition of the patient's skin is important for preventing pressure sores and identifying Stage 1 sores early so they can be treated before they worsen. Inspect the skin upon admission and at least daily for signs of pressure injuries, assess pressure points temperature, and the skin beneath medical devices, clean the skin promptly after episodes of incontinence, use skin cleanser that are pH (a measure of how acidic or basic a solution) balanced for the skin, and use skin moisturizers, avoid positioning the patient on an area of pressure injury. II. Facility policy and procedure The Skin Integrity policy and procedure, last revised September 2017, was provided by the nursing home administrator (NHA) on 1/26/23 at 6:00 p.m. It read in pertinent part, To provide consistent assessment and evaluation, monitoring, documentation, and implementation of therapeutic interventions to heal and maintain skin integrity, unless clinically unavoidable. To promote the prevention of pressure ulcer/injury development. To promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible), and to prevent development of additional pressure ulcer/injury. III. Resident #62 A. Resident status Resident #62, age 90, was admitted on [DATE]. According to the January 2023 computerized physician order (CPO), the diagnoses included chronic osteomyelitis of the left ankle and foot, peripheral vascular disease (PVD) and protein calorie malnutrition. The 12/5/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 13 out of 15. He was totally dependent with the assistance of one person for dressing and toileting, required extensive assistance of two people with bed mobility and transfers and extensive assistance with one person for personal hygiene and the supervision of one person for eating. The resident was admitted with two unstageable pressure ulcers. B. Observations On 1/26/23 at 10:45 a.m. Resident #62 was observed in bed and positioned on the left side for incontinence care. -Licensed practical nurse (LPN) #1 donned gloves and unfastened the resident's brief. The resident was incontinent of a moderate amount of soft brown stool and barrier cream residue was not observed over resident sacrum or coccyx. -LPN #1 cleaned the resident's rectal area and buttocks using incontinence wipes. -Three scattered reddened non open areas and excoriation to the left ischial area were observed. One small open, round circumscribed (a clearly defined edge) area was observed on coccyx. The wound edges were pink with a wound bed that had a small white area in the center. -LPN #1 disposed of dirty incontinence wipes and briefs, donned new gloves and applied a new brief. LPN #1 did not apply wound cleanser or barrier cream, as was directed in the physician's treatment order. C. Record review The January 2023 CPOs documented a physician's order to cleanse the right upper buttock with normal saline or wound cleanser and apply Triad cream three times a day and as necessary. The skin integrity care plan, initiated on 12/2/22 and revised on 1/11/23, documented the resident was at risk for potential skin impairment due to the resident's impaired mobility. The interventions included treating the resident's skin, per facility protocol and notifying the physician, if skin breakdown occurred, providing a specialty air mattress for the resident's bed and providing a cushion while the resident was sitting up in a chair. -No personalized interventions were care planned for incontinence or wound care for sacral MASD (moisture associated skin disease). The 1/17/23 wound care physician note revealed the resident had MASD located on the coccyx. The wound measurements were 1 cm (centimeter) x 0.5cm x 0.1 cm. The prior wound measurements on 1/10/23 (when it was first identified) were 1.0 cm x 1.0 cm x 0 cm. The wound had 100% epithelialization (formation of skin tissue) with scant serosanguinous (yellow blood tinged) drainage. The treatment orders indicated Triad cream should be applied three times per day and as needed. IV. Staff interviews Certified nurse assistant (CNA) #3 was interviewed on 1/26/23 at 11:00 a.m. She said that Resident #62 had skin issues on his buttocks and was incontinent of stool. She said he needed to be cleaned with a wound cleanser and a barrier cream applied. She said the barrier cream was kept at the resident's bedside and should be applied after every incontinent episode. LPN #1 was interviewed on 1/26/23 at 10:50 a.m. She said Resident #62 had skin issues on his sacrum. She said that she was not aware of any physician ordered treatment for Resident #62's skin issues for his sacrum or coccyx. The wound care specialist (WCS) was interviewed on 1/26/23 at 1:30 p.m. She confirmed, after assessing the coccyx wound, that the wound was no longer considered MASD and appeared to be a pressure injury. She confirmed that the Triad cream was ordered to be applied three times a day and as needed after incontinent episodes. Unit manager (UM) #2,was interviewed on 1/26/23 at 1:45 p.m. She said, after observing the coccyx wound, that the wound was no longer MASD and it was something more. She confirmed that the Triad cream should be applied after each incontinence episode and three times per day. The director of nursing (DON) was interviewed on 1/26/23 at 5:40 p.m. She said when there were wound care orders in place the orders were to be followed. She said a barrier cream treatment order was in place for every resident. She said Triad cream was to be applied according to the physician's order three times a day and as needed for Resident #62. The wound care physician was interviewed on 1/26/23 at 2:00 p.m. He said Resident #62's coccyx wound now had defined edges which was the definition of a pressure ulcer. He said that he would be speaking with the current wound physician regarding the staging of the wound. He confirmed that the Triad cream was ordered to be applied three times a day and after each incontinence episode as needed. He said all treatments should be applied as directed to ensure skin breakdown and wounds healed.

Based on interviews and record review, the facility failed to honor resident choices for one (#357) of three out of 50 sample residents. Specifically, the facility provide Resident #357 bathing according to her preference. Findings include: I. Resident #357 status Resident #357, age 71, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included unilateral primary osteoarthritis, left knee, strain of other muscles and tendons at lower leg level, unspecified fracture of left patella (kneecap), subsequent encounter for closed fracture with routine healing and presence of left artificial knee joint. The 11/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one person with bed mobility and toileting and extensive assistance with transfers, dressing and personal hygiene. A. Resident interview Resident #357 was interviewed on 1/23/23 at 3:13 p.m. She said she received a bed bath in the late evening, sometimes at 8:00 p.m. The resident said she preferred to receive bathing during the daytime. She said she had informed the facility staff of her preference several times, however she still received bathing at night. B. Record review The resident specific to the tasks for the certified nursing assistant (CNA) read that Resident #357's bathing days were documented as Tuesdays and Fridays, during the day shift. The shower book, located at the nursing station, was provided by CNA #1 on 1/26/23 at 5:07 p.m. It documented Resident #357's bathing schedule was on Tuesdays and Fridays, during the night shift. III. Staff interviews CNA #1 was interviewed on 1/26/23 at 5:07 p.m. She said each resident's bathing schedule was listed on the front of the shower book. She said the facility staff followed the schedule that was documented in the shower book. She said Resident #357's bathing schedule was Tuesdays and Fridays, during the evening shift. Registered nurse (RN#1) was interviewed on 1/26/23 at 5:11 p.m. She said Resident #357 received bathing in the evening. The director of nursing (DON) was interviewed on 1/26/23 at 5:45 p.m. She said bathing schedule preferences were discussed with residents as part of the admission process. She said the resident's preference was documented in the resident's tasks in the point of care (POC) electronic medical record system. She said the bathing schedule was also documented in the shower book kept at the nursing station. She said the unit manager was responsible for updating the shower book if the resident preferences changed.

Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#36) of four out of 50 sample residents. Specifically, the facility failed to meet Resident #36's socialization needs. Findings include: I. Facility policy and procedure The Group Activities policy and procedure, undated, was provided by the nursing home administrator (NHA) on 1/26/23 at 6:02 p.m. It revealed, in pertinent part, Group activities assist residents with social interaction. Group activities, the involvement of a number of people in physical and mental interactions, are vital to the effectiveness of the facility's activity program.Group activities maximize resources, involve many people, and promote social interactions.Group activities are encouraged to assist residents in overcoming feelings of loneliness and/or isolation, which often accompanies long-term care and illness. Group activities are divided into these categories: spectator group activities; performing group activities; independent group activities; and interdependent group activities.Residents are encouraged to participate in all group activities, but especially those in which they are best able to participate physically, mentally, and emotionally. II. Resident #36 status Resident #36, age 70, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included depression and anxiety. The 12/20/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 12 out of 15. She required supervision of one person with mobility, transfers, toileting, dressing and personal hygiene. A. Resident interview Resident #36 was interviewed on 1/24/23 at 12:14 p.m. She said she did not prefer to participate in group activities. She said the facility staff did not offer her any activities to do in her room. She said she only engaged with staff when they provided her medication or meals. B. Observations During continuous observation on 1/25/23 beginning at 9:30 a.m. and ended at 4:14 p.m. Resident #36 was observed lying in bed, watching television. -At 12:00 p.m. Resident #36 was provided with a lunch tray. -At 2:28 p.m the resident remained lying in bed with the television on. There were no meaningful activities observed in the resident's room. -At 4:14 p.m. Resident #36 remained in the same position, with the television on. The resident did not have any staff interaction since 12:00 p.m., when the lunch meal tray was delivered to her room. During continuous observation on 1/26/23 beginning at 9:06 a.m. and ended at 1:36 p.m. Resident #36 was observed lying in bed. -At 9:06 a.m an unidentified physical therapist entered the resident's room to converse with Resident #36 regarding her therapy time for that day. The resident did not have any meaningful activities observed in her room. -At 12:00 p.m. the lunch meal tray was delivered to the resident. -At 1:36 p.m. the same unidentified physical therapist returned to room of Resident #36 and assisted the resident to ambulate in the hallway. Aside from lunch tray being delivered and picked up from Resident #36's room, the resident's only interaction was with the physical therapist. C. Record review The 12/27/22 activity evaluation revealed the resident enjoyed games, arts and crafts, music, writing, conversation, watching tv (television) or movies, and cooking. It documented that her preferred social contact was visits, telephone, or mail. It documented the resident's preferred activity environment was independent in her own room, and she had no interest in participating in group activities. The mood care plan, initiated on 12/8/22, documented the resident had depression. The interventions included providing one to one conversations with the resident, providing hand massages, offering the resident music or going outside, offering the resident food or drinks, providing redirection and reassurance and facilitating deep breathing exercises. A review of the resident's medical record on 1/25/23 revealed the facility had failed to develop and implement a care plan with person-centered interventions to meet the resident's socialization needs. III. Staff interviews The activities director (AD) was interviewed on 1/26/23 at 5:02 p.m. He said he was not familiar with Resident #36. He said he did not realize he had completed an activity assessment for the resident because he did not remember meeting her. He said he had not provided any one-to-one activities or independent activities for the resident. The director of nursing (DON) was interviewed on 1/26/23 at 6:00 p.m. She said that every resident should be evaluated for their socialization needs upon admission to the facility. She said the activity director was responsible for developing a care plan to meet each resident's socialization needs. She said if the resident did not enjoy attending group events, the activities department should provide independent activities for the resident, of their preference, in their room and one-to-one activities with an activity staff member.

Based on observations, interviews, and record review the facility failed to honor food preferences for one (#28) of four residents reviewed out of 50 sample residents. Specifically the facility failed to ensure Resident #28's requests and preferences for gluten free foods were served to her. Findings include: I. Facility policy and procedure The Dietary Diet Orders policy, dated 2008, was provided by the nursing home administrator (NHA) on 1/26/23 at 5:00 p.m. It revealed in pertinent part, Diets will be served per physician order. II. Resident #28 A. Resident status Resident #28, age under 70, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included multiple sclerosis, vascular dementia, cerebral infarction (stroke), mood disorder, depression, reduced mobility, dysphagia (difficulty swallowing), anemia, and prediabetes. The resident was allergic to gluten. The 12/21/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance with bed mobility and dressing. She required total dependence on staff for toilet use and transfers. She required supervision (oversight, encouragement, cueing) from staff for eating. The resident did not reject care from staff. B. Resident interview Resident # 28 was interviewed on 1/23/23 at 1:07 p.m. She said she was allergic to gluten. She said she had multiple sclerosis. She said her body felt better when she did not eat foods with gluten. She said she could tell the difference in how she felt when she would eat gluten. She said she did not want to eat food items which contained gluten. She said she felt the facility staff would not listen to her about her desire to have gluten free food items. She said she had told anybody who would listen to her. She said when she lived in a previous hallway in the facility, a dietary manager who no longer worked in the facility, always provided her gluten free items for her diet. She said she had lived in her current room for about a year and she no longer received gluten free items except some very dry gluten free sandwich bread, but not on a consistent basis. She said she never received gluten free desserts. C. Observations On 1/24/23 at 5:27 p.m. the resident was provided a room tray on her bedside table with her evening meal. The tray contained a piece of cake with pink frosting. Licensed practical nurse (LPN) #2 came into her room and asked what she needed. Resident #28 held up the piece of cake and asked for a dessert that was gluten free. LPN #2 took away the cake and said she would try to find a dessert that was gluten free. D. Record review An allergy progress note on 7/20/22 revealed in the category of food that the resident had a gluten allergy. The comprehensive care plan 8/24/22 and revised 9/20/22 documented: -Special instructions: Gluten free -Allergies: Gluten The January 2023 medication and treatment administration record (MAR and TAR) documented the resident had an allergy to gluten. The MAR and TAR documented the resident had a dietary preference for gluten free with her diagnosis of multiple sclerosis III. Staff interviews The dietary manager (DM) was interviewed on 1/25/23 at 9:25 a.m. She said she was not sure how many people in the facility had gluten free diets but she thought it was three or four residents. She said for some people it was just a fad to eat a gluten free diet. She said other people had medical reasons. She said she knew she was responsible to serve gluten free items if that was what the resident preferred or it was a medical order. She said she was aware Resident #28 was to receive a gluten free diet. She said she was unaware Resident #28 had not had gluten free items to eat. She said she did not have any gluten free desserts in the facility kitchen. She said she did not have any premade dessert items such as gluten free brownies or gluten free cookies. She said she was unaware yesterday Resident #28 was served the strawberry cake that was made with gluten and was not offered a gluten free alternative. She said she had spoken to the NHA recently about expanding special diet options with gluten free items. She said she did not buy gluten free pasta either but said she would look into how to purchase gluten free pasta. The corporate consultant (CC) and the registered dietitian (RD) were interviewed together on 1/25/23 at 10:06 a.m. The CC said the facility was looking into an action plan today on how to train the kitchen staff to read gluten free on menu cards and place the correct gluten free items on the resident's meal trays. She said the facility would honor the gluten free diets. She said if there were substitute food items on the menus the facility would also offer gluten free alternatives. She said We're on it, and we're going to fix it. The RD said she did not feel the resident needed gluten free foods. The RD said she would call the physician and ask that the sentence on the diagnosis which read allergic to gluten be discontinued in the resident's medical record. She said she would honor the resident's preference for gluten free items whether the food preference was a physician's order or a resident's taste preference. She said the resident had a right to choose to eat gluten free foods and the facility must offer the items of their preference. During the survey on 1/25/23 at 5:15 p.m. a progress note written by the assistant director of nursing (ADON) revealed, MD (physician) notified and gave verbal order to remove gluten free from (the) patient's (medical) record. -However, the gluten free was removed from the resident's record, she preferred to have gluten free foods due to them making her feel better with her multiple sclerosis (see resident interview). The NHA was interviewed on 1/25/23 at 3:19 p.m. He said a lot of staff changes had happened in the kitchen over the past year. He said because of a kitchen management change, the gluten free items were not served. He said he and the management had begun work today on the gluten free items being purchased and served. He said he had begun an education with the kitchen staff on how to read the meal tickets correctly for gluten free. He said he put a performance plan in place with the admissions department. The plan was to ensure the admissions staff correctly communicated what a new resident's diet preferences or medical diagnoses were for foods. He said a list of items were purchased today at the local grocery store that were gluten free items, which included pastas and desserts. He said today Resident #28 would receive gluten free pasta for her meal along with others who had regular pasta with gluten. He said the facility would fix the situation and offer and provide gluten free items.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for two (#82 and #51) out of 50 sample residents for services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to ensure the comprehensive care plan addressed Resident #82 and Resident #51's nutritional status and needs. Findings include: I. Facility policy and procedure The Baseline, Resident Centered Comprehensive Care Plans, and Care Plan Summary policy and procedure, undated, was received by the nursing home administrator (NHA) on 1/26/23 at 6:00 p.m. It read in pertinent part, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to primer continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary. Within the first 48 hours of admission.The facility staff must implement the interventions to assist the resident to achieve care plan goals and objectives period. Baseline care plans must be updated to reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to development of the comprehensive care plan. II. Resident #82 A. Resident status Resident #82, age 85, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included unspecified protein calorie malnutrition. The 12/23/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. He required supervision of one person with mobility, transfers, dressing, personal hygiene and toileting. B. Record review The 12/22/22 nutritional assessment documented Resident #82 reported he had a fair appetite. The registered dietitian (RD) put a Boost Plus supplement once per day in place to provide nutritional support. It indicated the resident's weight was 189 lbs (pounds). Resident #82's weights were documented as: -189 lbs (pounds) on 12/16/22; and, -174.2 lbs on 1/11/23. The 1/24/23 nutrition progress note documented the resident sustained a weight loss and now weighed 174.2 lbs. It documented that the resident was on a regular diet with Boost plus twice daily and Magic cup once daily, which had been recently added due to the resident's weight loss. The RD recommended a reweigh in order to track for accuracy and changes to the resident's weight. It indicated that the resident was on an antidepressant which could cause a decreased appetite. The January 2023 CPO documented: -Regular diet with thin liquids; -Boost Plus nutritional supplement-give in the afternoon for malnutrition and skin integrity - ordered 12/19/22 and then changed to two time per day on 1/17/23; and -Magic Cup nutritional supplement-give a chocolate cup with lunch for malnutrition - ordered 1/18/23. A review of the resident's electronic medical record did not reveal documentation the facility had developed or implemented a comprehensive care plan that included and addressed the resident's nutritional status to include goals and person-centered interventions. C. Staff interviews The registered dietitian (RD) was interviewed on 1/26/23 at 4:44 p.m. She said a nutritional care plan was developed upon each resident's admission and was revised quarterly and as needed. She said the comprehensive care plan was developed once the initial nutritional assessment was completed. She said the nutritional care plan should address the resident's nutritional status, document the resident's nutritional goals and personalized interventions to assist the resident in meeting the identified goals. She said Resident #82 had experienced some weight loss since his admission to the facility. She said she had reviewed the resident's weights, met with the resident and put Boost Plus and a Magic Cup supplements in place to address the weight loss. The RD confirmed Resident #82's medical record did not contain a nutritional care plan. The director of nursing (DON) was interviewed on 1/26/23 at 6:00 p.m. She said that a care plan for the resident's nutritional status, to include goals and interventions, should be included in a comprehensive care plan. She said it was the responsibility of the dietitian to develop the comprehensive care plan. She said the care plan should be completed after the dietary assessment had been conducted. 38185 III. Resident #51 A. Resident status Resident #51, age 84, was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 CPO, the diagnoses included type two diabetes and unspecified protein calorie malnutrition. The 1/13/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. He was independent with eating. It indicated the resident was on a prescribed weight loss regimen. B. Record review The January 2023 CPO revealed the following physician orders: -Regular no added salt diet, mechanical soft texture with thin consistency; extra moisture with meats-ordered 10/3/22. The 1/24/23 nutrition progress note documented the resident had a recent weight loss of 11.2 lbs (pounds) in 30 days, from 220 lbs to 209.2 lbs. It indicated the weight loss was attributed to the resident being placed on a diuretic medication and was beneficial due to the resident's obese status. The resident had good meal intake ranges between 75 %-100%. The resident had declined any nutritional supplements and was agreeable with the weight loss. A review of the resident's electronic medical record did not reveal documentation that the facility had developed or implemented a care plan that addressed the resident's nutritional status and needs, established goals and person-centered interventions. C. Staff interviews The RD was interviewed on 1/26/23 at 2:25 p.m. She said Resident #51 was in the obesity range and a gradual weight loss was medically beneficial for the resident. She said the resident had asked that all nutritional supplements be discontinued and was agreeable with the weight loss. She said she was responsible for developing a care plan to address the resident's nutritional status, goals and implement person centered interventions. She confirmed a nutritional care plan had not been developed for Resident #51, who had resided at the facility for over a year.

Based on record review and interviews the facility failed to ensure the resident right to formulate advanced directive decisions for one (#1) out of five sample residents. Specifically, the facility failed to ensure the resident's medical orders for the scope of treatment (MOST) form was filled out completely and accurately to reflect the resident's wishes to receive full treatment. Findings include: I. Facility policy and procedure The Obtaining Information: MOST, Advanced Directive, Resident Choice policy was provided by the nursing home administrator (NHA) on 8/17/22 at 1:30 p.m. It read, in pertinent part: The facility will make efforts to obtain resident care decisions from residents and complete documentation on them in a timely manner. II. Resident #1 A. Resident status Resident #1, age 72, was admitted on [DATE] and transferred to the hospital on 6/15/22. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/14/22 admission assessment revealed the resident was alert and oriented to person, place, time and situation and verbal communication was appropriate. He required assistance with bed mobility, transfers, dressing, toileting, hygiene and bathing. He ambulated with a walker and two person assist. His last known fall was 5/25/22. B. Record review A nursing admission note dated 6/14/22 at 12:28 p.m. revealed the resident's MOST form was in place and he had chosen to be a full code. A change of condition note dated 6/15/22 at 1:30 a.m. revealed the resident was found on the floor of his room unconscious, was assessed by two registered nurses and was sent to the emergency department for further treatment. The resident's vital signs were normal and the neurological assessment was abnormal. There were no signs of external injury. C. Hospital records The 6/15/22 hospital records revealed the resident was sent to the hospital with a blank MOST form and the resident was intubated by emergency medical services as the MOST form was blank and assumed to be a full code. The MOST form sent to the hospital with the resident revealed the MOST form had the resident's name, date of birth, and gender filled out, though there were no check marks for decisions made related to cardiopulmonary resuscitation, medical interventions, artificially administered nutrition, or who the decisions were discussed with. The form did include the resident's signature and the date 6/14/22. III. Staff interviews Registered nurse (RN) #1 was interviewed on 8/16/22 at 10:45 a.m. She stated the nurse who completed the resident admission was responsible for completing the MOST form when a resident was admitted . RN #2 was interviewed on 8/16/22 at 11:05 a.m. He stated the nurse who completed the resident admission, paperwork and admission assessment was responsible for discussing wishes and completing the MOST form with the resident or the family. RN #3 was interviewed by phone on 8/16/22 at 10:31 p.m. She stated she was the nurse who sent the resident out to the hospital and made the transfer packet of paperwork. She stated she did not remember the MOST form being blank, though she did not remember double checking the paperwork. She stated the MOST form should not be signed by the resident if it was not completed. Licensed practical nurse (LPN) #1 was interviewed by phone on 8/17/22 at 11:33 a.m. She stated she was the resident's nurse upon admission and remembered discussing advanced directives and completing the MOST form with the resident. She stated the resident wished to be a full code, he was alert and oriented and answered all questions with precision. She stated the resident had previously not wanted resuscitation prior to admission, though he changed his mind and said he wanted to be a full code. She stated she believed she marked all of the resident wishes on the form prior to having him sign the form. The director of nursing (DON) was interviewed on 8/17/22 at 11:40 a.m. She stated the MOST form should be completed and decisions should be marked prior to the resident signing the form. She stated education would be provided to the staff related to ensuring MOST forms were completed upon admission and prior to the resident signing the form. The medical director (MD) was interviewed on 8/17/22 at 12:35 p.m. She stated the facility had identified the problem previously and had a performance improvement plan in place through the July 2022 quality assurance and performance improvement committee (QAPI) which included a whole house audit of MOST forms and requesting physicians to review and sign MOST forms within 24 hours.

Based on record review and interviews, the facility failed to ensure appropriate information was communicated to the receiving health care institution or provider during a transfer for one resident (#1) out of five sample residents. Specifically, Resident #1 was transferred to the emergency department on 6/15/22 with incomplete and incorrect paperwork including a blank MOST form (cross-reference F578) and another resident's medication list. The resident received an unnecessary prothrombin medication ([MEDICATION(S)]) at the hospital as a result of the incorrect medication list. Findings include: I. Resident #1 A. Resident status Resident #1, age 72, was admitted on [DATE] and transferred to the hospital on 6/15/22. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/14/22 admission assessment revealed the resident was alert and oriented to person, place, time and situation and verbal communication was appropriate. He required assistance with bed mobility, transfers, dressing, toileting, hygiene and bathing. He ambulated with a walker and two person assist. His last known fall was 5/25/22. B. Record review A change of condition note dated 6/15/22 at 1:30 a.m. revealed the resident was found on the floor of his room unconscious, was assessed by two registered nurses and was sent to the emergency department for further treatment. The resident's vital signs were normal and the neurological assessment was abnormal. There were no signs of external injury. C. Hospital records The resident's hospital records revealed a note on 6/15/22 at 2:56 a.m. the patient was a [AGE] year old male with a history of [CONDITION(S)] and was on [MEDICATION(S)] (an anticoagulant medication). A CT (computed tomography) scan revealed a severe acute hemorrhage (bleeding) consistent with a spontaneous bleed and [MEDICATION(S)] was ordered and administered when available from the pharmacy. A hospital note on 6/15/22 at 5:01 a.m. revealed the patient was erroneously given pcc due to another patient's medication administration list being sent from his living facility indicating the patient was on [MEDICATION(S)]. This patient is not on [MEDICATION(S)] nor any other anticoagulant medication. II. Staff interviews Registered nurse (RN) #3 was interviewed on 8/16/22 at 10:31 p.m. She stated she was the nurse who sent the resident out to the hospital and made the transfer packet of paperwork. She stated she had called the hospital about a half an hour after he was transported to check on his status, she stated she was informed during that call that the resident was sent with another resident's medication list. She stated as soon as she was informed of the mistake, she faxed the correct medications to the hospital. She stated she was not sure how the wrong medication list was sent, though did not remember if the double checked the packet prior to handing it off to the EMTs. The director of nursing (DON) was interviewed on 8/17/22 at 11:40 a.m. She stated the nurses should be ensuring the correct paperwork was sent with the correct resident when transferring out to the hospital. She stated the nurses would be educated related to double checking paperwork prior to the resident leaving the facility to ensure it was correct.

Based on record review and interviews, the facility failed to ensure services provided to one (#9) of 39 sampled residents met professional standards of quality. Specifically, the facility failed to ensure an assessment was completed and documented in the resident's medical record by a registered nurse (RN) following falls sustained by Resident #9. Findings include: I. Resident #9 status Resident #9, age 73, was admitted on [DATE] and readmitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/6/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required supervision with bed mobility and dressing and was independent with transfers, eating, toileting and personal hygiene. II. Record review The fall risk care plan, initiated on 1/3/19 and revised on 10/11/21, documented the resident was a high risk for falls due to the resident's history of falls, gait and balance problems and the resident's use of an antidepressant. It indicated the resident frequently declined to wear footwear when walking and often walked barefoot, which increased the resident's risk for falls. The 9/3/21 change of condition progress note documented Resident #9 was ambulating to her room after she received her morning medications. The resident tripped on the back of the walker, lost her balance and fell to her bottom. It indicated the resident did not incur any injuries. The change of condition was completed by licensed practical nurse (LPN) #1. The resident's medical record did not indicate the resident was assessed by a registered nurse (RN) or had such assessment documented in the resident's medical record. The 10/5/21 interdisciplinary (IDT) progress note documented Resident #9 sustained a fall on 10/2/21. It indicated the resident was waiting in the front lobby for a family member. The resident stood up and held onto the front wheeled walker to remove her jacket. Resident #9 lost her balance and fell to the ground. The resident did not sustain an injury. The IDT note was completed by an LPN. The resident's medical record did not reveal documentation that the resident had been assessed by an RN following the fall. The 10/6/21 change of condition progress note revealed Resident #9 was found on the floor. The resident said she was on her way to the bathroom, when her left knee gave out and she fell to the floor. She sustained an abrasion on the left forearm approximately 4 centimeters (cm) in length. The change of condition was completed by LPN #1. The resident's medical record did not indicate the resident was assessed by an RN following the fall. III. Staff interviews LPN #1 was interviewed on 10/14/21 at 2:51 p.m. She said following a fall, the resident should be assessed by a registered nurse (RN). She said the LPN should immediately contact the RN in the facility to perform an assessment of the resident to determine if the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] She said the RN assessment should be completed prior to moving the resident off the floor. She said conducting an assessment was not within an LPN's scope of practice. The director of nursing (DON) was interviewed on 10/14/21 at 12:54 p.m. She said an RN assessment should be completed after a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . She said it was important for an RN to complete an assessment to ensure the resident did not sustain any underlying injuries. The DON and regional nurse consultant (RNC) were interviewed on 10/14/21 at 10:30 a.m. The DON said the facility was unable to locate documentation indicating an RN had performed an assessment for the falls Resident #9 sustained on 9/3/21, 10/2/21, and 10/6/21. IV. Additional information The DON and RNC were interviewed on 10/14/21 at 2:25 p.m. The RNC said she had interviewed the RNs who were on shift during the falls sustained by Resident #9. She said she had them write down an interview which indicated they remembered the falls. She confirmed an assessment was not documented in the resident's medical record or any other location. The DON said the assessment was not considered to have been completed if it was not documented in the resident's medical record.

Based on interviews and record review, the facility failed to ensure a copy of medical records were provided to one (#1) of three out of three sampled residents. Specifically, the facility failed to provide a copy of Resident #1 medical record upon resident request. Findings include: I. Facility policy and procedure The Resident Amendment of Protected Health Information policy and procedure, revised in (YEAR), was provided by the nursing home administrator (NHA) on 9/17/19 at 12:22 p.m. It revealed, in pertinent part, Upon receipt of a request of PHI (protected health information) .complete the top portion of the form with the date, the name of the facility, the name of the resident and the name of the person completing the form, along with the specific date the PHI was received. Gather medical record documents and copy. II. Resident #1 status Resident #1, age 73, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 6/18/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. S/He required supervision with all activities of daily living. [NAME] Resident interview The resident was interviewed on 9/17/19 at 12:30 p.m. She said she had called multiple times since her discharge asking for copies of her medical records. She confirmed she discharged from the facility on 6/18/19 and went to another skilled nursing facility. She said she had still not received copies of her medical records. She said she had spoken with the medical records department multiple times. She said they will no longer return her phone call. B. Record review The medical records request log was reviewed on 9/17/19 at 10:45 a.m. It did not reveal documentation of the resident ' s request for copies of her medical records. The 6/18/19 discharge summary revealed the resident discharged on [DATE] to another skilled nursing facility, upon the resident ' s request. C. Staff interviews The medical records coordinator (MRC) and the NHA were interviewed on 9/17/19 at 10:19 a.m. The MRC said when a resident and/or responsible party requested a copy of medical records, a request form should be filled out by the resident and/or responsible party. She said the request form was provided by the facility to the resident and/or responsible party. She said once the form was completed, the facility has ten days for current residents and 30 days for discharge resident ' s to fill the request. She said she was responsible for making the copies of the requested PHI and then send it to a third party risk management company. The risk management company would review the documents and then send them to the individual requesting the copies. She said she was responsible to ensure each request was documented on the PHI request log. She said the log should indicate when the request was made, who made the request, the reason and the corresponding completion dates. She said each request should be documented on the PHI request log. The MRC was interviewed again on 9/17/19 at 11:00 a.m. She said she remembered Resident #1. She said the resident called after she had discharged from the facility asking for a copy of records sent to the nursing facility where she was currently residing. She said she mailed a copy of the medical records, after the resident had discharged from the facility, to the resident ' s current facility where she was residing. She said she did not mail the resident ' s medical records directly to the resident. She said she mailed it to the facilities medical records department. She said she did not know why she did not mail the records to the resident as requested. She said she did not have documentation to show the medical records were mailed to the current facility where the resident resided. She said she did not fill out a records request form for Resident #1. She said she did not mail the resident a medical records request form. She said she did not have any tracking information or documentation the information was sent. The MRC was interviewed again on 9/17/19 at 11:10 a.m. She said she did not mail records to the current facility where the resident was residing. She said she faxed documents to the facility. She provided the faxed information. According to the date indicated on the faxed documents to the facility where the resident was currently residing, the documents were faxed on 6/6/19. The MRC confirmed this was prior to the resident ' s discharge on 6/18/19. She said she did not send a copy of the resident ' s medical records as requested by the resident. The NHA was interviewed on 9/17/19 at 11:10 a.m. He said when the MRC received a request for copies of medical records, she should immediately initiate the facility process and give the request to him to be signed off and sent to the third party risk management company. He said all requests made by a resident and/or responsible party for copies of medical records should be documented on the medical records request log.

Based on observations, interview and record review the facility failed to ensure for one (#81) were removed from public view to prevent exposure of body parts out of 39 sample residents. Specifically, the facility failed to provide privacy while Resident #81 was being dressed or using the restroom. I. Resident status Resident #81, age 84, was admitted [DATE]. According to the (MONTH) 2019 computerized physician orders, [DIAGNOSES REDACTED]. The 6/28/19 minimum data set (MDS) assessment , the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance with personal hygiene, dressing, transfer, and all walking. The MDS revealed the resident required total dependence with bathing, transferring from surface to surface, moving on and off the toilet. The resident utilized a wheelchair for all mobility. II. Observation and interview Resident #81 shared a two bedroom suite with another resident. Resident #81 ' s bed was closest to the door next to the residents bed facing the door and at the end of the bed was a commode. The commode was about 5ft from the door with full visibility from the hallway. In an observation on 6/26/19 at 8:32 a.m. Resident #81 was observed shaking as she was trying to pull down her pants with one hand. The resident used her other hand to balance herself, the resident shuffled as she shakily plopped herself onto the commode. The resident was trying to use the comde placed by the end of the bed closest to the door. Certified nursing assistant (CNA) #3 was informed and the CNA shut the door. In an observation on 6/26/19 at 9:25 a.mResident #81 was sitting on the commode with the door wide open. Registered nurse #3 shut the door. It was observed the other residents roommate was in the room laying on her bed with full view of the resident on the toilet. In an observation 6/26/19 at 9:32 a.m. CNA #6 opened the door and asked the resident how she was doing. The resident was sitting on her bed. In an observation 6/26/19 at 12:42 p.m. the resident was observed pulling down pants while transferring to the commode. RN #3 was informed and pulled the door shut. The RN #3 said the resident should be using her call light and asking for assistance. RN #3 stated the resident liked the commode at the end of the bed as she recently had an episode of [MEDICAL CONDITION]. RN #3 was interviewed on 6/27/19 at 9:57 a.m and said the resident was able to get out of bed depending in the day. The RN #3 stated the resident was sometimes very shaky from recent falls. The resident has been having an unusual amount of hallucinations lately and has been falling. The RN said the resident will ask for help only sometimes And the commode was placed at the end of the day to prevent falls. RN #3 said resident likes the door open and the staff encourage the resident to notify them when she goes to the restroom but they do not always catch her in the process of using the commode and the staff tried to pull the curtain closed or shut the door. In an observation on 7/1/19 at 8:34 a.m. Resident #81 had an infection notice on her door. The resident was sitting on her bed bare bottomed with a soiled depend on around her knees. LPN #3 was interviewed and said that Resident #81 tested positive for [MEDICAL CONDITION] again over the weekend and the residents roommate had been moved to another room. It was observed the resident had tried to transfer and had an accident on the floor and in her depends. The LPN #3 said she must be feeling weak today. The LPN #3 sent for help. In an observation on 7/1/19 at 8:40 a.m. the Resident #81 was sitting on bed very clumsy trying to put her shirt on. The resident was sitting in full view of the hallway with her breasts exposed to anyone who walked past in the hallway. LPN #3 was informed and assisted the resident with her clothing. CNA #1 was interviewed on 7/1/19 at 9:29 a.m. the CNA said the resident wants to do things herself and was very confused. She does not understand what she is doing. They try and pull the curtain closed or shut the door if she is not wearing clothing. The CNA said he did not think the resident could be taught to wait for assistance or to cue staff. The corporate consultant was interviewed 7/1/19 at 1:02 p.m. she said they were going to put a curtain in place as the resident does not care who sees her naked. The consultant said it was hard to judge if the resident understood what was going on as she recently had been seeing things and was at times scared. The resident wanted the commode to be placed there so she could reach it by herself. The consultant said the resident had fallen a lot in the last month. RN #3 was interviewed 7/2/19 at 8:56 a.m. the RN #3 said resident #81 needed help with dressing and transferring surface to surface. The RN revealed Resident #81 was not aware of her strength and had a hard time with reality as she hallucinated.RN #3 said they had started using the call light and pulling the curtain. RN #3 said the resident did not care but it did offer privacy and safe transfers. The RN said the resident needed reminders to be brought back to present day and out of the hallucinating state. The RN said it was unpredictable and they are unsure when it happens as they don't know until she starts talking to in animated things and pointing at things that are not there. The DON and corporate consultant was interviewed on 7/2/19 at 0:45 a.m. revealed there was no way to know the residents current state of mind if she could make the choice to be seen naked or not and her needs were to be anticipated. The resident was interviewed on 7/2/19 during morning hours and afternoon.The resident was unable to answer questions about being seen on the toilet or without her shirt, The resident talked about getting out of the box she was in and it feeling like a prison. III. Record review According to the (MONTH) 2019 care plan the resident had an activity of daily living self-care deficit related to impaired balance, pain, contractures to upper extremity. The goal being to increase ability in transfers and activities of daily living. Interventions used in activities of daily living include 1/4/19 side rails for bed mobility and transfers. The (MONTH) 2019 care plan revealed the resident required extensive assistance by staff to turn and reposition in bed, to shower, and to dress. The care plan revealed the resident requires extensive assistance by staff to dress. The (MONTH) 2019 care plan revealed the resident required extensive assistance with personal hygiene, eating, toilet use,and transfers from surface to surface. The facility is to provide the amount of assistance/ supervision that is needed (specifically stand by-cueing, prompting, contact guarding and weight bearing.) The resident is encouraged to use the call light for assistance. The resident ' s (MONTH) 2019 care plan revealed the resident had a communication problem in regards to a hearing deficit. The intervention calls for the resident to be monitored and document the residents ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend. The care plan revealed the resident has episodes of confusion with delusion and hallucination. The interventions call for staff to redirect and provide gentle reality orientation as required. The plan consists of reorienting the resident to the person, place, time, and situation as required. The care plan revealed the resident has a history of bowel incontinence due to immobility, repair, gastroenteritis, [MEDICAL CONDITION] and dementia. The resident is able to toilet self and prefers the use of a bedside commode. Interventions show the staff will check on resident frequently during each shift and assist with toileting as needed. Provide bedside commode

Based upon observation, record review and interview, the facility failed to have an accurate assessment that accurately reflected the residents status for one (#102) out of two residents reviewed for accidents of 36 sample residents. Specifically, the comprehensive assessment failed to identify the behavior of wandering for the use of a wandering/elopement alarm for Resident #102. Findings include: I. Facility procedure and policy The Elopement procedure, dated (YEAR), provided by the director of nursing (DON). It read, residents exhibiting new onset of exit seeking behavior will be evaluated by the electronic risk evaluation. If the resident scores a 5 (five) or higher (meaning higher risk) a 48 hour evaluation checklist will be initiated to determine patterns of potential behaviors and individualized interventions for redirection. Residents exhibiting active exit seeking behaviors will have a wander tracking device applied and a 48 hour sheet initiated. The procedure also revealed the facility will develop a care plan and the resident will be identified as a risk for elopement. The procedure also revealed the facility when a resident has been observed to be wandering to an unsafe situation or exiting the facility the staff will intervene. The Resident Elopement Risk Management guidelines policy, dated (YEAR), revealed the definition of elopement is, the resident is found outside the property line of the facility. The policy documented the facility interdisciplinary team (IDT) will assess the environment to identify potential risks associated with the elopement. Facility interventions will be developed and implemented to reduce the risk of elopement. II. Resident status Resident #102, age 80, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The last minimum data set (MDS) assessment, the resident had limited cognitive impairments with a brief interview status (BIMS) score of 15 out of 15. The resident required supervised assistance with grooming and toilet use. -The MDS did not identify the resident as having a wander risk and or the use of a restraint/alarm of a wandering/elopement alarm (wanderguard). III. Record review The care plan dated (MONTH) 2019, revealed Resident #102 has a history of refusing care. Interventions include conversations, hand massage, outside activities, offer food and drink, provide redirection and reassurance. The care plan also revealed the resident has behavior problems thinking that she has items missing and paranoia that staff and residents are taking her things. The items are eventually found in her room. The resident does not like assistance and will rearrange items in room and closet and not remember. The (MONTH) 2019 care plan revealed the resident is a risk for fall. Pertinent information documented was: The resident had two falls on 8/21/18 and 6/19/19. Both falls were attributed to resident bending over and losing her balance. The interventions to avoid falls include education, alarming device/bracelet with audible reminder to notify staff that resident was going into the courtyard. Resident #102 had a elopement/neurological assessment done on 5/27/19. The resident scored a four out of 20. The scoring portion of the assessment revealed the total score of five or greater equaled the resident was at risk for potential elopement. The assessment documented the resident was not at risk for elopement. The (MONTH) 2019 care plan does not specifically address a plan for wander guard. According to the treatment administration record (TAR), dated 6/20/19, the resident had a device for safety, location of right arm. The TAR said the device was to remind staff that staff was needed for a resident to go outside into the courtyard. The device would be checked every shift. Progress note dated 6/19/19 documented the resident had fallen. The resident stated she was trying to pick something up in the courtyard and lost her balance. The resident was taken to the emergency room , it was discovered the resident had broken her left wrist during the fall in the courtyard. An informed consent for the use of side rails, alarming devices or restraints dated 6/19/19 revealed the resident gave verbal consent to wear the alarming device. The guidelines on the form revealed the use of the alarming device or restraints will be utilized after assessment and care planning deem it appropriate to treat the residents medical symptoms and the resident or the resident representative has given consent. The type of alarming device listed as alarming bracelet wander guard was to alert staff to attempts to go to courtyard. The box was checked as I do consent to the alarming devices recommended above. The signatures was filled out by two registered nurses. Next to the signature box it is handwritten that verbal consent was obtained. IV. Interviews Resident #102,was interviewed on 6/27/19 at 8:36 a.m. the resident states she doesn't know why she was wearing the wanderguard on her wrist. The resident says she has to wear it. Registered nurse (RN) #3 was interviewed on 6/27/19 at 9:57 a.m. says the resident has hallucinations. The RN#3 said resident # talks about monkeys coming from the ceiling or midgets under the bed. The resident like to walk around the building and talk to the staff. The RN states the reisndte is not exit seeking. CNA #1 was interviewed on 6/27/19 at 10:04 a.m. said the resident does not try to leave the building. The resident wears the bracelet for the courtyard as she fell . LPN #3 was interviewed on 7/1/19 at 10:36 a.m. said the resident wears the wanderguard to prevent her from going into the courtyard alone. The LPN #3 said the resident was bending over looking at a flower and had fallen. The LPN #3 said she had fallen earlier in the year from bending over in her room. The resident has an unsteady gait. The LPN #3 said the residents would hallucinate and see people stealing her items, she would see cats, midgets, and monkeys. The LPN#3 said the resident #102 would not leave the facility, she liked the courtyard and the garden. The LPN #3 revealed the resident had not gone to the courtyard since she had broken her arm. Unit manager RN #5 was interviewed 7/1/19 and said the resident is not trying to leave its for her safety. The facility staff is concerned the resident will fall in the courtyard and no one would know. CNA #1 was interviewed on 7/1/19 at 10:40 a.m. and said the resident is not a wonder risk and its for her safety on the courtyard. The corporate consultant was interviewed on 71/19 1:02 p.m. and said the resident wears a wanderguard for her safety and it's not a restrictive device. The facility is worried she will fall in a corners that were not easily visible. The alarming device is for the residents protection. The maintenance manager was interviewed on 7/1/19 1:15 p.m., the maintenance manager said the alarm is not as loud as the fire alarm but it is loud. It will startle people if it goes out and staff will run to the courtyard doors. The director of nursing (DON) and the corporate consultant was interviewed on 7/2/19 at 10:45 am it was said the resident was not exit seeking, the monitor was put in place so staff would know when the resident #102 was going into the courtyard. The resident had fallen and broken her arm and they were concerned if she should go outside without staff and no one would know she was outside. The resident was free to go outside they just wanted to make sure she was safe doing it. The DON and corporate consultant said the resident had fallen twice in the last couple months and both times the resident reported she was bending over and lost her balance. The DON confirmed the resident had a hard time with short term memory and would forget things. The Don revealed the resident had been hallucinating and they were concerned she could not remember to notify staff of visits to the courtyard. The facility did not consider it a restraint as they used it to alert staff when the resident would go into the courtyard. The DON satiated the resident was not seeking to leave the facility and was not in danger of elopement. The DON was interviewed was interviewed on 7/2/19 at 11:48 a.m. when the DON brought the informed consent for alarming devices or restraints. The DON said the resident does not exist seek. The DON said the resident can come and go into the courtyard, but an alarm will sound. Resident #102 was interviewed on 7/2/19 at 10:30 a.m. the resident said the wanderguard bracelet meant that she can not go into the courtyard alone. Corporate consultant was interviewed on 7/2/19 at 11:48 a.m. said the fact the resident said she wears the bracelet as a reminder showed the resident the resident #102 needs it as it helps remind her to not go into the courtyard unassisted. The administrator was interviewed on 7/2/19 at 12:15 p.m. he confirmed the resident wears the wander guard for safety. The administrator said the resident does not seek to leave the facility. The facility was concerned for resident safety in the courtyard as the resident could fall and no one would know. The administrator said the doors to the courtyard were now locked at night. The facility also was in the process of putting in cameras and call lights in the courtyard. This would eliminate the need for the wander guard when it was completed.

Based on record review, observation, and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents, affecting one (#1) out of three sampled residents. Specifically, during a transfer, the resident's electric wheelchair was not secured properly. The wheelchair moved, catching the resident's right leg. The resident sustained [REDACTED]. The findings included: a. Resident Status Resident #1, age 72, was admitted to the facility on [DATE], discharged to the hospital on [DATE], and re-admitted on [DATE]. According to the April 2017 computerized physician orders [REDACTED]. According to 3/31/17 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. There were no behaviors or resistance to care identified. The resident was totally dependent upon staff requiring two-persons assistance with transfers. The resident's care plan, initiated on 1/12/17, identified the resident required one-to-two-persons assistance with transfers due to limited mobility. The care plan also noted the resident had been cleared by therapy to use a power (electric) wheelchair in the facility on 1/18/17. b. Incident 2/23/17 Interview and record review revealed on 2/23/17, the resident sustained [REDACTED]. X-ray confirmed a tibia/fibula fracture. Family interview The resident's family member was interviewed on 4/26/17 at 12:15 p.m. He said when he entered the facility on 2/23/17 to inquire about his wife, he spoke with the nurse on duty around 2:00 p.m. He was told that certified nurse aide (CNA #1) transferred the resident and the CNA forgot to turn off the electric wheelchair. He said the resident inadvertently hit the control and the chair moved forward, catching the resident's right leg between the chair and the wheel of the chair. He said the facility x-rayed the wrong leg initially, which indicated the resident had no fractures. However, a subsequent x-ray revealed the resident suffered a right lower extremity fracture. Record review The 2/23/17 occupational therapy note, signed at 12:26 p.m. read, Certified nursing aide (#1) reported that during a transfer this am, the resident's right ankle twisted when wheelchair moved, education to turn the power off during transfers, the CNA verbalized understanding . The 2/23/17 physical therapy note, signed at 2:37 p.m. read, The resident performed a wheelchair transfer with max assistance and the resident yelled out in pain with weight bearing on the RLE (right lower extremity). Intervention by the therapist was to place boots for comfort . The 2/23/17 telephone order read, Obtain a stat (immediate) x-ray of the RLE knee to foot for increased pain . The 2/23/17 x-ray of the right knee and right lower extremity read, May or may not be a fracture. The bones are osteopenic (low bone density) and there are degenerative changes in the knee and ankle . The 2/26/17 nurse's note revealed a late entry for 2/23/17 that read, The resident complained of increased pain to the Right lower extremity (RLE). The physician and nurse practitioner were in the facility and were aware of the events surrounding the increase pain in RLE from trauma. A mobile x-ray company was called to complete an x-ray. The resident was resting in bed with leg elevated with ice to affected area, husband at bedside . The 3/3/17 therapy notes continued to indicate the resident had pain daily to the RLE. The 3/6/17 telephone order written read, x-ray RLE . The 3/7/17 telephone order read, X-ray RLE and x ray LLE increase Butrans pain patch to 15 micrograms per hour change patch every seven days for pain . The resident's prior dose of the Butrans pain patch ordered on [DATE] was 10 micrograms per hour change patch every seven days. The 3/7/17 x-ray at 12:23 p.m. confirmed the resident's RLE had a stable fracture of the tibia and fibula. The 3/7/17 skilled charting note read, Legs placed in boots for support . c. Facility failures (1) Failure to safely transfer the resident Record review Review of the facility's investigation of the incident, dated 3/23/17 (29 days after the incident), and provided by the assistant nursing home administrator (ANHA) on 4/27/17 at 2:42 p.m., confirmed CNA #1 failed to turn the electric wheelchair off while preparing to transfer the resident from wheelchair to bed. The report included the following: -The resident had been involved in a transfer, one person assistance by certified nurse aide (CNA #1). The CNA was interviewed on 3/24/17 by the facility; he said that he had notified the registered nurse (RN) who was working at the time. He said the resident was in the electric wheelchair and the chair was positioned next to the bed, he removed the pedals and while he was moving her bedside table away from the bed, he looked back and saw her make a movement with her hand and the electric wheelchair propelled forward. He said her right foot caught on the floor and was turned in an outward angle. He said the resident did not call out in pain or grimace. He claimed he had still left the electric chair on because he had to move it forward after removing the foot rests. -The RN working the day shift was interviewed 3/24/17. She said she worked with the resident all day but she only worked the particular unit once a week. She said a week after she had worked with the resident she was called in to the director of nursing (DON) office and asked about the incident, but she did not know what it was about. She said that no one had told her about the resident's leg. She said she specifically asked the CNA (#1) about the incident and he said to her that he was sorry and forgot to report it to her. -The oncoming nurse who started at 2:00 p.m. (on 2/23/17) was interviewed on 3/24/17. She said the resident's husband had been inquiring about what had happened with the resident. The nurse said she was not sure as she had not received a report, so she spoke with the physician assistant who said she had ordered an x-ray. She said she had asked CNA #1 what occurred and he said that he was trying to transfer the resident but left the chair on and during the transfer her hand fell on the wheelchair joystick and moved the chair forward causing the bedside table to fall on her leg. He told her he reported the incident to day shift RN when it happened. She assumed the nurse was coming back in the morning to complete an incident report. Staff interviews CNA #3 was interviewed on 4/27/17 at 10:56 a.m. She said she had worked at the facility for two and a half years and routinely took care of resident #1. -She said her daily routine consisted of getting report from the nurse. She said prior to transferring the resident, she checked the resident's board and asked therapy how a resident was to be transferred. She said the board was located in the resident's room on the wall. The board contained information on the resident's transfer status, diet restrictions, and other pieces of information related to the resident's care. She said the resident required two-persons assistance with transfers. -She said resident #1 sustained a RLE fracture during a transfer with another employee. She said she had not received education/training surrounding the resident's transfers prior to the incident. She said that after the resident sustained [REDACTED]. The training did not include transferring into the electric wheelchair. CNA #1 was interviewed on 4/27/17 at 3:17 p.m. He said he provided care to the resident on 2/23/17 from 6:00 a.m. until 10:00 p.m. He said he assisted the resident with a transfer from her electric wheelchair to her bed. He said he positioned her electric wheelchair next to her bed. He moved her flat foot panel up out of the way. He said he forgot to turn off the wheelchair. He said when he went to move her bedside table out of the way; the resident inadvertently moved her hand over the control. He said the wheelchair started moving forward. He said he was able to stop the chair, but not before her right leg made contact with the floor and twisted to the right. He said he repositioned her foot and then placed her into bed. He said he reported the incident to the nurse. The resident's primary physician was interviewed on 4/27/17 at 10:35 a.m. He said the resident was physically compromised and had severe osteoporosis. He said the fracture she sustained was due to her disease process and could have occurred with repositioning and or a slight bump. (2) Failure to address safety concerns with the resident's use of an electric wheelchair Registered nurse #1 was interviewed on 4/26/17 at 5:05 p.m. She said she read an incident report where the resident had run into the wall with her electric wheelchair, and record review revealed a 2/3/17 nurse's note and a 2/18/17 interdisciplinary note team (IDT) note documenting the resident fell asleep while driving her electric wheelchair and ran into handrails in hallway without sustaining an injury. Nonetheless (see care plan above), the resident's care plan was not updated to include safety information or concerns about the resident's ability to operate the electric wheelchair or need for supervision when in the wheelchair. (3) Failure to timely assess the resident's injury and investigate the 2/23/17 incident See above; the facility's incident investigation was dated 3/24/17, 29 days after the incident occurred. Unit manager (UM#1) was interviewed on 4/27/17 at 1:06 p.m. He said that there was no registered nurse assessment or incident report completed on 2/23/17 incident involving resident #1. The director of nursing (DON) was interviewed on 4/27/17 at 1:06 p.m. She said she was new in training for the DON position. She said there was no registered nurse assessment or incident report completed on the resident on 2/23/17. The regional nurse consultant was interviewed on 4/27/17 at 11:29 a.m. and again at 2:42 p.m. -She said the incident and investigation were completed the week she started working for the facility on 3/23/17. She confirmed that the facility did not complete a registered nurse assessment of the resident or complete an incident investigation on 2/23/17. -She said the facility's corporation had recognized that there were problems with systems with identifying and reporting at this particular facility and she was specifically assigned to the building for oversight. (4) Failure to timely re-train staff on proper transfer of resident #1 The rehabilitation manager was interviewed on 4/27/17 at 2:42 p.m. The manager said she provided education on 3/28/17 to nurses and CNAs on the procedure for resident #1's bed mobility, activities of daily living (ADL), and transfers. (5) Failure to update resident #1's care plan regarding her assistance needs. Although the resident's 3/31/17 minimum data set (MDS) assessment documented the resident was totally dependent upon staff requiring two-person assistance with transfers, the resident's 1/12/17 care plan, as of 4/25/17, read the resident was a one-to-person assist for transfers. The regional clinical nurse on 4/27/17 at 2:42 p.m. provided an updated care plan on 4/26/17 (during survey), that identified the resident as requiring two-person assistance with transfers; however, another updated care plan provided by the facility regional nurse consultant on 4/27/17 at 2:42 p.m. identified the resident required a one-to-two-person assistance with transfers.

Based on record review and interviews the facility failed to ensure the resident's environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for two (#232, #384) of 31 sample residents. Specifically: 1. Resident #232, known to be confused and to wander, required a front wheel walker (FWW) to address instability when ambulating, exited the facility on [DATE] without his walker or staff supervision. He fell , sustained a cervical C2 vertebral fracture from a mechanical fall, and subsequently died . 2. Fall interventions were not appropriately implemented for resident #384. The Findings include: Review of a policy for out of facility release of responsibility (Revised 2010), documented in pertinent part, --Purpose; to obtain and document signature of resident/resident's party when leaving/taking resident out of the facility, to acknowledge release of responsibility to facility, its personnel or the attending physician for any decline in condition or accident occurring while resident is away. --Procedure; the Out of Facility Release of Responsibility form is kept in the resident's medical record at the nurse's station. This form should be signed each time a resident leaves the facility and should be signed again upon return, the resident can sign the form or the resident's responsible party should sign if the resident is physically or mentally incapable ...when a resident is being signed out, the nurse is responsible for ensuring the following: physician order [REDACTED]. Review of the facility Elopement risk policy (revised 2012); documented in pertinent part: --Purpose; It is the practice of the facility that on admission, readmission, and quarterly, residents will be evaluated for potential elopement risk." --Procedure; 1) an elopement risk evaluation will be completed on admission, readmission, and quarterly, by the licensed nurses and documented on the Elopement Risk Evaluation form. A) potential for elopement will be determined by risk factors which may include but is not limited to (ambulatory status, wandering history, cognitive status, psychiatric history, functional status). 2) If a resident is identified as a potential elopement risk, based upon the evaluation documented on the Elopement Risk Evaluation form, a care plan will be developed. 3) A resident identification form, which includes a current photo of the resident, will be completed for all residents identified as a potential elopement risk. 4) The completed Elopement risk evaluation form is to be maintained in the resident's medical record. 1. Sample resident #232, [AGE] years of age, was admitted to the facility on [DATE]. A closed record was reviewed. According to the ,[DATE], computerized physicians order (CPO) the resident had [DIAGNOSES REDACTED]. a. Resident Status on Admission According to the admission minimum data set ((MDS) dated [DATE], the resident had moderate cognitive impairment scoring a ,[DATE] on the BIMS (brief interview of mental status). The resident required extensive assistance with bed mobility and transfers, extensive assistance of one staff for walking in the corridor and on and off the unit. The resident's balance was poor and he was only able to stabilize with human assistance. The resident's method of mobilization was coded as use of a walker and wheelchair during the review period. The resident was identified as a fall risk during the review period. b. Record review: --A comprehensive nursing admission assessment dated [DATE], (three days after admission on [DATE]) documented in pertinent part the resident was alert to person, time and situation, ambulated with a walker with assistance of one staff. In the section entitled "Behavior/Mood," there were two boxes marked as follows: " Verbalized desire to exit," and, "Repetitive phys (physical) movements." The section entitled "Fall Risk" had the following boxes checked: "Cardiovascular drug use, impaired safety awareness, impaired balance, unable/unwilling to ask for mobility assistance." In the section entitled "Elopement risk," the following box was marked: "Independently mobile." This section read in pertinent part: "3 or more checked boxes indicates elopement risk and need care plan." (Assessment did not trigger an elopement care plan.) --The admission fall risk assessment documented in pertinent part the resident scored "8." A score of "8" or greater indicated the resident was a high risk for falls and preventative interventions should be initiated immediately and documented on the care plan. --A fall care plan initiated [DATE], documented in pertinent part the resident was at risk for fall related to injury based on his fall risk assessment score of "8," and related to lower back kyphoplasty, and medications included narcotics. The goal was the resident would not sustain a fall related to injury by utilizing fall precautions through the next review date of [DATE]. Some of the approaches included: use fall risk screen to identify risk factors, observe for side effects of any drugs that can cause gait disturbance, orthostatic hypotension, weakness, sedation, lightheadedness, dizziness, change in mental status, provide/monitor use of adaptive devices (walker, cane, wheelchair), remind resident and reinforce safety awareness (educate/remind resident to request assistance prior to ambulation) ...pressure alarm in wheelchair (,[DATE]). --A cognitive loss care plan initiated [DATE], documented in pertinent part the resident had impaired cognitive skills as evidenced by decision-making problems, short term memory problems and long-term memory problems related to dementia. The goal was the resident would exhibit decreased episodes of memory loss through the next review date of [DATE]. Some of the approaches included: report unanticipated changes in cognitive status to physician, provide orientation and validation PRN (as needed), provide cues, prompting; demonstration if resident is unable to complete a task independently. --Nurses ' notes from admission, [DATE], through [DATE], documented in pertinent part the resident (identified as a fall risk upon admission), mobilized with a wheelchair and had bed and chair alarms placed since admission. The resident would attempt to get up from his wheelchair and walk without assistance and was documented to get out of bed and walk without an assistive device or calling for help. The alarms were only utilized when the resident was in the room/in bed or in his chair. As the resident gained strength and became more independent he became more ambulatory and would often forget to use his walker. He had poor safety awareness and did not utilize his call light. Staff had to remind him to use his walker on several occasions. (See documentation below) c. Resident status after admission --A physical therapy (PT) assessment and plan of care, dated [DATE], documented in pertinent part the resident had functional deficits of bed mobility, gait with distance involving assistive devices and level surfaces and transfers. He was able to ambulate 100 feet with a front wheel walker (FWW). His underlying impairments included: increased pain which moderately affected his function, and moderate cognitive impairment. --An initial social services assessment dated [DATE], documented in pertinent part the resident was alert and oriented x2 and was able to communicate all needs. The resident had a discharge plan (with no anticipated discharge date ) to go to an assisted living facility with recommended services upon completion of his therapy. --A resident education evaluation form dated [DATE], and signed by the resident, documented in pertinent part the assessing nurse identified the resident's need for education regarding diagnosis, equipment, safety and self-care. The form further documented the resident was receptive and verbalized recall. --A room change notification form dated [DATE], documented in pertinent part the resident was moved to a room closer to the nurses' station for safety reasons. --Daily occupational therapy (OT) treatment notes from the beginning of treatment [DATE], through the resident's last day in the facility ([DATE]), documented in part the resident had poor safety awareness regarding safety of wheelchair use (locking brakes) and use of forward wheeled walker. He required verbal cues and reminders. --A PT progress note dated [DATE], documented in pertinent part the resident/caregiver was educated in ambulation outdoors, body mechanics from low surfaces and safety with navigation with FWW. The resident was a fall precaution and "pleasantly" confused. --A daily OT treatment noted dated [DATE], approximately ten days prior to the resident's last day in the facility documented in part the resident ambulated outdoors using his FWW with stand by assist and cues for safety on different surfaces. --Daily PT notes for [DATE], and [DATE], documented in pertinent part the resident was confused and frustrated but did participate in therapy. --A PT progress note dated [DATE], documented in pertinent part the resident's current level of function was assessed. The resident was progressing with ambulation but required supervision with FWW on outdoor surfaces. --A PT daily note dated [DATE], documented the following: "I have just been walking around outside ...education on not ambulating outside without supervision ...pt (patient) is pleasantly forgetful but does well with verbal cues." --A PT daily note dated [DATE], documented in pertinent part the resident ambulated greater than 200 feet on various surfaces including side stepping, curb, stairs, and outdoor surfaces with contact guard assist and stand by assist. The resident's balance was good with the use of the FWW and a cane. The therapist noted the resident might do better with the cane on outdoor surfaces. --A nurse ' s note entry dated [DATE], at 6:14 p.m. documented in part the resident was cleared to be independent in his room and facility with FWW and was reminded to utilize FWW during ambulation. --A PT daily note dated [DATE], documented in pertinent part the resident ambulated 400 feet with FWW supervised. PT recommended the resident use FWW with slow progression to a single point cane for short distances. --A telephone order dated [DATE], documented in pertinent part the resident was to discharge to an assisted living home on [DATE], with home health, and physical and occupational therapy. He was to have a standard forward wheeled walker (FWW) with five inch wheels. --A post discharge plan of care dated [DATE] (prepared in anticipation of the resident discharging to an assisted living on [DATE]), documented in pertinent part information regarding the name of the home health company, medical equipment provider, diet, activities of daily living and a list of discharge medications. The form had a section for the resident/family to sign upon discharge verifying discharge instructions were reviewed. The form was unsigned as the resident was not discharged to an assisted living from the facility on [DATE], but transferred to the hospital via paramedics instead. --An occupational therapy (OT) progress note dated [DATE], documented in pertinent part the resident ' s remaining functional deficits/underlying impairments included the resident continued to be limited by decreased balance on uneven surfaces necessary to complete his gardening task. --A nurse ' s note entry dated [DATE], at 1:14 p.m. documented in pertinent part the resident was ambulating around the unit using his walker with a slow steady gait but needed redirection. d. Events of [DATE] --A nurse ' s note entry dated [DATE], at 12:21 a.m. (night shift) documented a visual check of the resident was made lying in bed with his fall mat in place, call light in reach and bed alarms turned on. --The last nurse note entry dated [DATE], at 12:25 p.m. documented the following, "This morning pt (patient) was found wandering across the street at the library and he fell . A witness called the paramedics and he was sent to (name of hospital). An incident report was made. MD (name of physician) and (name of family member) his daughter was notified." --An incident report dated [DATE], (no time documented on the form) and completed by the unit manager (UM) overseeing the unit where the resident resided, documented the resident was last observed by staff in the common area on the Columbine unit and that the resident was found outside by the library on the ground and taken to the hospital. --On [DATE], at 9:50 a.m., 12:00 p.m. and 1:17 p.m. the nursing home administrator (NHA) was asked to provide the investigation of the incident on [DATE]. At 1:25 p.m. the NHA provided the information requested. --Review of the information provided by the NHA at 1:25 p.m. included staff interviews and a copy of the occurrence report submitted to the health department. In addition, a risk assessment was completed, (after the incident occurred) that documented the resident was identified walking out the front door of the facility at 9:15 a.m. without his FWW. The resident's daughter was notified by the paramedics the resident's fall occurred at (name of street intersection) by the library. The NHA stated the facility had a video camera system located at the front exits and on the outside of the building for surveillance purposes but the cameras are not monitored. The NHA stated the cameras were on a 72 hour recording loop that repeated every 72 hours. The NHA confirmed there were no physical monitors in place but that he could review the footage through his computer. --Review of the death certificate report revealed the resident's manner of death was listed as an accident. The immediate cause was related to complications of a cervical (C-2) vertebral fracture from a mechanical fall. e. Observations --On [DATE], at 10:35 a.m. the 300 nurses station (Columbine) was toured where the resident resided. The resident resided in room 302. The room was located very close to the nurses' station, but not within direct view. --On [DATE], at 10 a.m. the walking distance was measured from the facility, out the parking lot and on to the sidewalk area leading towards the main intersection in front of the local library where the resident was reported to have been found on the ground by Paramedics. The distance measured was over 1050 feet (0.2 miles) one way. f. Interviews --On [DATE], at 11:53 a.m. a certified nurse aide (CNA #4) was interviewed. She stated if there was a missing person, overhead page would be announced and staff would start looking for that person right away. CNA #4 stated she took care of the resident on [DATE] (the day he was to be discharged ). She stated he was very happy to be leaving. When she came on duty he was already dressed and ready to go to breakfast. CNA #4 acknowledged the resident was a fall risk and used a walker, although he would walk away and leave the walker. CNA #4 stated she walked with the resident from the dining room back to Columbine unit around 8 a.m. She then saw him in the television (TV) room around 8:45 a.m. and this was the last time she saw him. She stated she heard later the resident had gone out of the building out the front door. She was asked how she knew he had gone out the front door and she stated because they had a camera that saw the resident going out the building. --On [DATE], at 11:40 a.m. the unit manager (UM #1) was interviewed. UM #1 stated she was working the day the resident was scheduled to be discharged . UM #1 confirmed the resident was a fall risk and was ' on the confused side. ' UM #1 stated the resident had poor safety awareness and was moved closer to the nurses' station for closer observation. The resident would often forget to use his walker. She stated he required re-direction in order to find the dining room and his room. UM #1 stated she was working the medication cart on [DATE]. The resident took his medications, went to breakfast and came back to watch TV. UM #1 stated the last time she saw the resident was around 8:30 a.m. The resident's family was due to pick him up around 11 a.m. that morning and the resident was not yet discharged when he left the building. UM #1 stated when she returned from her morning meeting (about an hour later) she was informed the resident had gotten out of the building and fell by the library. She stated the resident was not a wanderer and was not one to get out and walk without a purpose. UM #1 stated that all residents received an elopement risk assessment on admission and with any change of condition. UM #1 stated there was a new elopement risk procedure (a second page) implemented after the incident with resident #232 occurred. UM #1 stated most residents knew to sign the sign out book before they went out of the building. She heard the resident had gone out the front door. When asked how she knew this if no one had seen the resident leave the building UM #1 stated she believed there was an exterior camera that visualized the resident's path. --On [DATE], at 11:48 a.m. the occupational therapist (OT #1) was interviewed. OT #1 stated that a home safety evaluation was done about a week ago with the resident to prepare him to go back to assisted living and that he did well and passed. OT #1 stated this was the only time she personally saw the resident outside the building and the family transported him. OT #1 stated the only other outside therapy conducted with him was within the facility grounds/courtyards. OT #1 stated she would not have expected him to wander off any further than the front of the building. OT #1 confirmed the resident used a walker to ambulate. --On [DATE], at 12 p.m. a physical therapy assistant (PTA #1) was interviewed. PTA #1 stated the resident had poor safety awareness at times and occasionally staff would catch him without his walker. He needed to be reminded to use his walker PTA #1 stated the resident did well without his walker for short distances such as in his room, but he did better with his walker for longer distances. PTA #1 stated she had never walked with the resident outside of the building, only in the courtyards and throughout the building and in the gym. She stated at discharge the resident had the endurance to walk long distances but with the use of his walker; not without it. PTA #1 stated that she would estimate the distance from the facility to the main intersection to be about [PHONE NUMBER] feet. --On [DATE], at 2:40 p.m. the director of nursing (DON) was interviewed with the NHA. The DON and NHA stated the resident was not an elopement risk and that all residents expressed the desire of wanting to go home when they got to the facility. The NHA acknowledged the resident liked gardening and being outside. The DON stated residents knew the resident ' s whereabouts because the CNAs provided direct care, were familiar with their residents ' patterns, and worked at a one to ten ratio with nursing providing oversight. The DON stated it would depend on the situation, but if the resident left the building they must sign out. The DON stated residents were aware upon admission that they must sign out anytime they left the building. The NHA acknowledged the resident would have signed that he was made aware of this upon completing his admission paperwork; however, both the DON and NHA acknowledged the resident did not sign out when he went for a walk outside the building on [DATE]. The NHA stated they did not know the exact time the resident had left the building, however; they became aware of the incident at approximately 9:45 a.m. The NHA stated the unit manager (UM) from Columbine informed him she had received a call from the resident's daughter who had received a call from emergency medical services (EMS). The DON stated staff last saw the resident after breakfast around 8:30 to 8:45 a.m. and the UM saw the resident sitting in the day room by Columbine around 9 a.m. The DON acknowledged that although the resident was to be discharged [DATE], he was still a resident of the facility at the time he exited the facility and fell (See post discharge summary above which documents the resident and family did not sign discharge paperwork on [DATE]). The NHA confirmed it was the responsibility of the facility to oversee this resident's care while he remained a resident. Both the DON and NHA stated it was an unfortunate situation that occurred because the resident presented so normally that no one would have noticed him going out the front door. --On [DATE], at 3:07 p.m. the front door receptionist on duty [DATE], (the day the resident left the building) was interviewed. She stated she did not know the resident or what he looked like. She stated one of her duties was to make sure people checked in and out but that this was not always strictly enforced. She stated on the day the resident got out of the building the fire department came in and let her know they found one of the facility ' s residents and had taken him to the hospital. --On [DATE], at approximately 10:45 a.m. the NHA was interviewed regarding the number and location of the surveillance cameras around the building and his review of the footage from [DATE]. The NHA confirmed the number of cameras on the outside of the building and that when he reviewed the camera footage from [DATE], it showed the resident leaving out the front door of the building without his walker, turning right, walking around the building coming from the left side of the building and leaving the facility grounds toward the main street area. g. Facility action after incident On [DATE], at 2:40 p.m. the DON and NHA stated the facility revised their admission nursing assessment after the above incident occurred, to prompt the nurses to do an elopement risk evaluation if there was any indication the resident may trigger as a potential elopement risk. The DON stated another thing they started the same day of the occurrence was to implement visitor tags to distinguish visitors from residents. The front door receptionist had been trained on encouraging family and residents to sign in and out of the facility; however, there was no new intervention in place to alert nursing staff when residents exited the building, and there were no new interventions in place to ensure residents choosing to leave were cognitively capable of safety or provided appropriate safety devices such as front wheel walkers. 2. Resident #384, age 78, was admitted to the facility [DATE]. According to the face sheet, printed [DATE], [DIAGNOSES REDACTED]. Minimum Data Set (MDS) information was not available due to his recent admission. According to the [DATE] Nursing Admission/Readmission Evaluation, the resident was alert to person, place, time and situation, and had clear speech, with adequate hearing and vision. He was non weight-bearing, and used a wheelchair for mobility. He required the assistance of two persons to transfer, and had impaired balance. He was incontinent of bowel and received intermittent urinary catheterization to empty his bladder. He had pressure ulcers on both heels. According to his [DATE] Interim Admission Care Plan, the resident had a history of [REDACTED]. This surgery enlarges the spinal canal to relieve pressure on the spinal cord or nerves). The goal was minimization of resident injury related to falls. Approaches included resident education on fall risk, placement of the call bell within easy reach, cueing for safety awareness, keeping the environment clear and safe, therapy as ordered, and observe for medication side effects. Revision on [DATE] showed an additional approach of two staff to assist, with use of a gait belt for all transfers. Review of the [DATE] Interim Admission Care Plan showed the resident required assistance with activities of daily living (ADLs). The goal was the resident would attain and/or maintain ADL skills at the highest practicable level. Approaches included referring him to therapy, and two persons were to assist him to transfer using a sliding board. a. Record Review: Review of the [DATE] electronic Interdisciplinary Notes Report (EINR) at 3:48 p.m. revealed the Certified Nurse Aide (CNA) reported the patient slid out of the slide board during a transfer, so she lowered the resident to the floor. No injuries were noted. The physician and family were notified by staff. Review of the Daily Quality of Care (QOC) review in the EINR on [DATE], at 4:34 p.m. regarding the [DATE] fall revealed the following: The resident was being assisted to transfer from his bed to the wheelchair by sliding board when the resident started to slide off the sliding board. The CNA lowered him to the floor. The resident was assessed by a Registered Nurse, and had a small bump in the sacral area. He had no complaints of pain, and was considered to be at baseline. An x-ray of the lumbar-sacral spine revealed an osteoporotic compression fraction of thoracic vertebra 12 (T-12) and lumbar vertebra 1 (L-1) of undetermined age. Upon admission, due to his fall risk status, staff implemented resident education to call light usage, and physician-ordered therapy services for increased strength and endurance to decrease his fall risk, or injury if a fall should occur. After this fall, additional interventions included placement of a low bed, non-skid socks, and care plan updated to reflect resident would be provided with a two person assist with all transfers (including slide board transfers), using a gait belt. Review of the EIRA for [DATE] at 3:21 p.m. showed at 10:30 a.m. that day, the resident had an assisted transfer to the floor as he was being transferred from his bed to his wheelchair via slide board, with assistance of one CNA. Assessment by a RN showed no apparent injury. b. Fall investigations: Review of the fall investigation for Saturday, [DATE] showed the wheelchair with brakes locked slid sideways while he was transferring from his bed to his wheelchair using his slide board. CNA #5 eased him to the floor, and there was no apparent injury. A gait belt was used. New interventions were to have two persons transfer him at all times, use a low bed, and use non-slip socks. Review of the fall investigation for the Sunday, [DATE] fall showed CNA #2 transferred the resident by herself, instead of using another CNA as determined in the investigation from the [DATE] fall, above. CNA #2 transferred the resident by herself as the resident insisted in getting up then. c. Interviews: In an interview on [DATE], at 11:15 a.m., the resident confirmed he had two falls, and was glad he was not hurt. In an interview on [DATE], at approximately 11:15 a.m., CNA #2 confirmed she attempted to transfer resident #384 on [DATE]. She said he insisted she do it then, instead of waiting to get another staff person to assist her. In an interview on [DATE], at 11:20 a.m., the Director of Nursing (DON) confirmed she counseled CNA #2 for transferring the resident by herself, when the plan of care determined two persons were needed to safely transfer this resident. d. Observation: Observation on [DATE], at 11:05 a.m. revealed CNA #2 and another CNA successfully transferred the resident from his bed to his wheelchair using his slide board. This was a collaborative effort with directions and sequencing by the resident and the CNAs.

Based on observation, record review, and staff interview, the facility failed to provide care and supervision in a manner that prevented accidents with injuries, for one (#6) of 18 sample residents. Specifically, the facility failed to provide adequate supervision for resident #6, who wore a wander guard bracelet, was assessed as high risk for falling and elopement, and required frequent visual checks due to wandering through out the facility. The resident fell from her wheelchair outside the facility's alarmed entrance resulting in a left humerus fracture. The findings included: Wander guard Information Let WanderGuard help you manage wandering - Stanley Healthcare ... <http://www.stanleyhealthcare.com/node/124> www.stanleyhealthcare.com > ... > Wander Management <http://www.stanleyhealthcare.com/solutions/security-protection/wander-management> > WanderGuard <http://www.stanleyhealthcare.com/solutions/security-protection/wander-management/wanderguard>Cached <http://webcache.googleusercontent.com/search?q=cache:c19O6P-IYhsJ:www.stanleyhealthcare.com/node/124+wanderguard&cd=4&hl=en&ct=clnk&gl=us> "When the person wearing a FirstQ (Wanderguard) bracelet passes through a monitored area, staff receive an alert. The alert sounds until staff check on the person to make sure they are safe. Then staff reset the alert. Everyone else can pass through the monitored area - the FirstQ system is a " selective system " so the alert is given only for the person wearing the FirstQ bracelet." I. Record Review Resident #6, a [AGE] year old female, was admitted to the facility on [DATE] and re-admitted on [DATE]. According to the April 2013 computerized physician orders, the resident had the following diagnoses; dementia, depression, fall risk, humerus fracture, osteoporosis and pain. According to her 3/26/13 Minimum Data Set (MDS), resident #6 had both long-term and short-term memory impairment. She was sometimes understood by others and sometimes understood others. The resident was moderately cognitively impaired for daily decision-making and had no behavioral symptoms. She required extensive assistance for activities of daily living but needed only limited assistance for bed mobility and eating. The resident used a wheelchair for mobility with assistance from others. Although the MDS read that the resident required assistance from others for wheelchair mobility, the nurses' notes from 11/18/12 until 3/17/13 documented that the resident could self propel her wheelchair and wandered through the facility. The resident's elopement care plan, initiated on 11/4/10, and most recently updated on 2/15/12, identified a problem of the "Resident is at risk of elopement as evidenced by wandering related to dementia." The goal for resident #6 was documented as, "Resident would not successfully elope from the facility and would be monitored of her whereabouts on a ongoing basis over the next 90 days." Some of the interventions listed included: -Monitor resident for "tailgating" when visitors are in the building. -Use verbal and if necessary physical cues for redirection of exit-seeking behaviors. -Use diversion activities when exit-seeking behavior is occurring (i.e. . : offer food, activities, one-on-one company). -Reassure resident when distressed over placement. -Use discrete resident identifier, so staff is aware of the resident's elopement risk. -Facilitate resident to call close family/friend for reassurance when exit-seeking behaviors occurring. -Use audible monitoring system to alert staff of exit seeking behavior. -Check for proper functioning of audible alarm system every shift and PRN (as needed). -Frequent visual checks. The resident's fall care plan (initiated after the 3/18/13 fall) read the resident was at risk for falls related to history of falls, left humerus fracture with sling (3/18), decreased mobility, cognitive deficit and poor safety awareness. The resident's goal read, "Potential for falls/fall-related injuries will be minimized during the next 90 days." Some of the interventions included: -Use fall risk score to identify risk factors. -Report falls to physician and responsible party. -1/4 side rails x 2 for positioning and bed mobility. -1/14/12: Lipped coverlet for bed related to rolling out of bed every shift and PRN. (Changed to lipped mattress-no date). -5/21/12: Bed in low position with fall mat at bedside while in bed due to risk falls. -7/30/12: hipsters every shift daily. Document accept or refuse. -Therapy screen as indicated. -9/2/12: Hipster discontinued for refusal. -3/18/13: Report any changes to physical pain. Treatment as ordered. -3/19/13: Positive for fracture left arm. Sling to left arm. Observe for signs/symptoms of impaired circulation every shift and document on medication/treatment administration record. -Bed alarm initiated on 3/20/13 after the fall, identified; -Chair alarm -Invite, encourage, and assist to adaptive sports, exercise groups/programs for increased mobility. -Maintain personal/frequently used items within reach. -Encourage, and assist as needed, with rest periods. -Observe for side effects of medication (i.e.: sedation, ataxia, weakness, dizziness, vertigo, dehydration, confusion) II. Facility Failures A. Fall Risk Assessment The "Nursing Admission at Risk/Post Fall Quarterly Evaluation," documented that if a resident received a total score of 8 or greater, the resident was a high risk for falls and preventive interventions should be initiated and care planned. There were nine parameters used in determining the resident's fall risk score, they were; level of consciousness/mental status, history of falls, ambulation and elimination status, vision status, gait/balance, fall interventions, medications, predisposing disease and conditions/additional issues. The 3/4/13 "Nursing Admission at Risk/Post Fall Quarterly Evaluation "documented that the resident scored a 12 which represented a high risk for falls. The facility however, failed to identify the resident's dementia and osteoporosis as predisposing disease factors; the Lisinopril for hypertension, and as well as her previous fall in January which would have given the resident a score of 18. The 3/20/13 "Nursing Admission at Risk/Post Fall Quarterly Evaluation" documented that the resident scored a 19 which represented a high risk for falls. B. Elopement Risk Evaluation The resident's "Elopement Risk Evaluation," documented that if a resident received a total score of 5 or greater that were at potential risk for elopement and preventive interventions should be initiated and care planned. There were 5 parameters used in determining the resident's elopement risk, they were; ambulatory status, wandering history, cognitive status, functional status and conditions/additional information. The 2/19/13 quarterly "Elopement Risk Evaluation," documented that the resident scored a 14 which represented a high risk for elopement. The 3/20/13 "Elopement Risk Evaluation," documented that the resident scored a 16 which represented a high risk for elopement. The resident was given a score of 4 for wandering history which indicated that the resident had prior episodes of elopement. III. Lack of Supervision Resulting in a Fall Further record review revealed the resident had a fall on 3/18/13 at approximately 6:30 p.m. A 3/18/13 (no time) nurse's note documented the resident fell out of her wheelchair in front of the facility and sustained a bump and a skin tear on her left upper eye brow. The resident was unable to move her left shoulder and could only verbalize pain and cried when the left shoulder was touched. She was medicated for pain with Tylenol 650 mg and a cold pack was placed on the bump on her right forehead and eye brow area. Vital signs included a temperature 97.4, respirations 18, pulse 72, oxygen saturation 94% on room air and blood pressure was 118/82. The physician ordered a CT scan to the resident's head and an x-ray to the left shoulder immediately. The CT scan could not be completed until the morning so the physician gave an order to send the resident to the emergency room for evaluation and treatment. The resident was started on neuro checks, a call was placed to 911 and the resident was transported at 10:30 p.m. to the hospital. However, review of the "Incident Report" revealed, the resident was wearing her wanderguard bracelet when she was found on the ground in front of the facility entrance (and by her wheelchair) on 3/18/13 at approximately 6:30 p.m. Documentation by the review team also revealed the resident's wanderguard was on and functioning at the time of the fall. According to the report, the resident was unable to explain what happened. She had no recent elopement attempts. New interventions included the hall doors were to remain shut after lobby hours, staff were to be educated on the resident's risk of elopement, and a wanderguard was to be installed on the hall doors. On 3/19/13 (no time), an Interdisciplinary Team (IDT) note documented, "a daily quality care note, IDT review of fall outside facility. Patient was observed in front of facility on the ground out of her wheel chair. Nurse was down the hall and did not reach resident in time to prevent fall or exit out of facility. Resident was assessed and pain noted to the L(left) shoulder and L upper eye with small skin tear. Risk for bruising. Call placed to MD and orders received for stat x-rays and CT Scan." . . . The wanderguard was in place and functioning at time of fall, neurological assessment was completed and wound care was provided to the skin tear. A statement taken on 3/19/13 from the facility receptionist revealed on 3/18/13 at 6:20 p.m. (ten minutes before the fall), she had not observed the resident in the receptionist area (by the front entrance). A statement dated 3/19/13 from the nurse on duty at the time of the fall, reported she was down the "long hall" when she was notified that the resident fell outside and she heard the alarm sounding. The nurse reported that she had seen a little boy earlier on the unit and saw him in the parking lot with his father as they were leaving. It was unclear how the facility determined that the resident had gone 10 minutes without supervision, as none of the staff interview statements revealed the time the resident had last been seen. IV. Staff Interviews On 4/3/13 at 10:05 a.m., the Director of Nursing (DON) stated resident #6 held the door handle down for the 15 seconds until it opened and she went outside and fell . However, she did not explain why no staff member responded to the door alarm that would have sounded with the working wanderguard bracelet the resident was wearing. On 4/8/13 at 10:09 a.m., the former DON discussed that as a result of resident #6's fall, the facility did a 100% alarm audit to ensure everyone who was at risk for elopement had their WanderGuards on and they were working. There were elopement books (with resident information and pictures) at the receptionist desk to identify residents who are an elopement risk. She discussed that during the time of the incident, staff reported that there was a child running around and they believe resident #6 was following him. (However, a review of the documentation provided by the facility revealed no statement from the nurse regarding a small child in the building who may have opened the hall doors for the resident). She explained that the resident had not had a prior elopement, but an elopement risk care plan was initiated anytime a resident verbalizes they want to go home or would wander. She stated since the incident, they had started several interventions that included, education with the staff on elopement risk, added gravel outside so the side walk was not lipped, the hall doors were to be shut after 6:00 p.m. and they received an order to get the hall doors alarmed. She discussed that the certified nurse aide reported taking the resident to the TV room after dinner but she was not sure at what time. (The Evergreen dining times were noted to be from 5:00 p.m. to 5:45 p.m. daily.) She added the resident was not observed to be in the lobby at 6:20 p.m. when the receptionist left for the day. On 4/9/13 at 10:35 a.m., the unit manager on Evergreen stated resident #6 did have a wander history and she had a wander guard which would sound anytime she was near a door. She stated there were pictures of the residents who have been identified as an elopement risk in the elopement book at each nursing station and at the front desk. She stated staff should be watching residents that wander and ensuring that they are in the common areas in visual sight. She added there was no check list regarding residents needing visual checks, but they were aware of those residents who were on the elopement list. She stated that the resident was not on a routine monitoring schedule. On 4/9/13 at 10:45 a.m., the Certified Nursing Aide (CNA) assigned to resident #6 was aware that some residents were on frequent checks but did not identify which residents were on frequent checks. The CNA was unaware of any residents who were on scheduled checks. Even though the resident's elopement care plan identified that the resident needed to be on frequent checks (See above), the CNA reported that the last time she recalled seeing resident #6 today was at 7:00 a.m. (3 hours and 45 minutes earlier) and was not sure of the resident's whereabouts when asked. On 4/9/13 at 10:50 a.m., a second CNA assigned to the Evergreen unit stated that it was his second week of employment at this facility. He stated they were informed by a "briefing" before shift of residents who have safety issues. He continued that there was no one on fall or elopement precautions at this time. See above and below that Resident #6 was currently both on elopement and fall precautions. On 4/8/13 at 10:38 a.m., the Vice President of Clinical Operations (VPCO) stated that they knew resident #6's where-about's prior to her fall at 6:30 p.m. She stated the receptionist left at 6:20 p.m. and did not see the resident in the area, so there was 10 minutes in between that time and when she was found outside. She added when the receptionist leaves at night she does close the hall doors by the main dining room. She discussed that the facility had been proactive regarding placing the resident as an elopement risk (as wandering behavior or verbalizations of wanting to leave the facility will trigger a high elopement risk) and had care planned the resident appropriately. However, the VPCO did not explain why no one responded timely to the alarming door that the resident's bracelet would have triggered. In addition, there was no supporting information at what time the resident was last seen by nursing staff and where the resident was, when last seen prior to her 6:30 p.m. fall. The VPCO continued to say, the resident had the wander guard on and it was working. The resident got out of the building, her wheel went off the sidewalk and she fell out of the chair. She stated that there had been no change in the resident's level functioning post incident; her level of functioning was the same. She discussed that although she did sustain an injury, her highest level of functioning had not been comprised by the fall. She stated that they were releasing an interview report, "QI " (Quality Improvement) from the nurse that there was a small child in the building and they believed resident #6 was attracted to the child and she may have followed the child out the door. V. Observations On 4/4/13 at 12:30 p.m., the resident was observed sitting in the main dining room at an assisted table. Her left arm was in a sling and she was eating with her right hand with cues from staff. The resident had yellow and purple bruises to her left eyebrow and a small bruise on her right cheek. On 4/8/13 at 9:30 a.m., the layout of the building was observed. Despite resident #6 being on frequent visual checks, the resident, somehow traveled unsupervised about 50 feet down a hallway from the TV room, (in which the CNA stated she had placed the resident), went around a corner, then down a long hall way of about 100-150 feet past the main dining room, through double doors that led to the alarmed front door and then out the front entrance. The distance was approximately 200 feet or greater to exit out the front door from the TV room. In addition, the resident would have had to push on the alarmed front door for approximately 15 seconds before the door would open, if she was unassisted. Post Fall A 3/20/13 telephone physician's orders [REDACTED]. The resident was only receiving Tylenol 325 mg every 6 hours prior to the fall.

Based on record review and staff interviews, the facility failed to ensure one (#2) of 18 sample residents was free from significant medication errors. Specifically, the facility failed to ensure resident #2 received a medication that was not ordered and was transferred to the hospital at family request for increased confusion, dizziness and pacemaker evaluation. Professional Reference: According to Lippincott Manual of Nursing Practice, 7th edition, page 178-179, "Age-related changes predispose older adults to problems with medication side effects .... Drug absorption is affected by age-related changes; decreased [MEDICAL CONDITION] acid, decreased [MEDICAL CONDITION] blood flow. . . Drug distribution is affected by decreased body size, decreased water content in the body, increased total body fat . . . Drug metabolism in the older adult is altered by a decrease in liver size, blood flow, enzyme activity and protein synthesis . . . Drug Alert - Drugs that may have severe adverse reactions in the elderly include [MEDICATION NAME]". ([MEDICATION NAME] and [MEDICATION NAME] are [MEDICATION NAME]). "Nursing assessment . . . Drug toxicities are different than they are in younger people . . . Fewer symptoms may be identified, and they may develop slower; however, the reaction may be more pronounced and further advanced once they do present . . . Behavioral side effects are more common in elderly people because the blood-brain barrier becomes less effective; the first reaction to a drug is confusion. . . Many potential drug side effects are not identified because they are attributed to old age; fatigue, confusion, anorexia, or indigestion as drug side effects may not be reported. Nursing patient care considerations. . . Maintain awareness that the older adult is at greater risk for adverse medication reactions. This risk increases from 6% when two drugs are taken to 50% when five different drugs are taken and to 100% when eight or more medications are taken." According to the Geriatric Dosage Handbook, 12th edition, page 940 "Adverse reactions to [MEDICATION NAME] include; Central Nervous System: slight to moderate drowsiness, headache, nervousness, dizziness. Respiratory: thickening of [MEDICATION NAME] secretions, Pharyngitis Gastrointestinal: Appetite increase, weight gain, nausea, diarrhea, abdominal pain, dry mouth Neuromuscular and skeletal: Arthralgia (joint pain) Overdose/Toxicology: Symptoms include CNS depression, confusion, nervousness, hallucinations, dizziness, blurred vision, nausea, vomiting and hyperthermia. There is no specific treatment for [REDACTED]. Drug Interactions increased toxicity: CNS depressants, neuroleptics, [MEDICATION NAME]. According to the Geriatric Dosage Handbook, 12th edition, pages 1417 and 1418 [MEDICATION NAME] is used to prevent motion sickness. Warnings/Precautions: Use with caution in older adults . . . Adverse Reactions include: Central nervous system: Drowsiness, headache, loss of memory, ataxia, fatigue. Overdose/Toxicology symptoms include dilated pupils, flushed skin, hypertension, CNS manifestations resembling acute [MEDICAL CONDITION]. CNS depression, circulatory collapse, [MEDICAL CONDITION] and death can occur." (Closed Record) The findings included: Resident #2, [AGE] year old female, was admitted to the facility on [DATE] and re-admitted on [DATE]. According to the March computerized physician orders [REDACTED]. The acute hospitalization Minimum Data Set (MDS), dated [DATE], revealed the resident scored a 5/15 on the brief interview for mental status (BIMS) which indicated a severe cognitive impairment. The resident was coded as not exhibiting any behaviors. The resident was coded as needing limited assistance bed mobility, dressing, eating and personal hygiene. The resident required extensive assistance with transfers, toileting and bathing. Family Interview In an interview, on 4/2/13 at 9:27 a.m., the resident's daughter stated that on 3/5/13 her husband noticed a patch behind her mother's ear. They got the nurse on duty who removed the patch and threw it in the trash. The family asked the nurse about the patch and the nurse stated he thought it might be [MEDICATION NAME] which is used for motion sickness. He informed the family he did not know how the patch had gotten there as she did not have an order for [REDACTED]. Hospital Discharge The discharge summary, dated 3/8/13, revealed that the resident's discharge [DIAGNOSES REDACTED]. The hospital course documented that the resident was [AGE] years old with advanced dementia who normally was ambulatory, interactive, and verbal. The resident became progressively weak four days prior to hospital admission. The resident had what was reported as [MEDICAL CONDITION] and was placed on [MEDICATION NAME] and [MEDICATION NAME]. Subsequently she developed significant altered mental status, inability to eat and had reportedly fallen twice out of her bed and/or chair. The [MEDICATION NAME] was removed at the skilled nursing facility. The resident was transported to the emergency room and admitted for further care. The resident had a urinary tract infection on admission. Review of a 3/8/13 hospital progress note addendum also noted that the resident was dehydrated. Physician Orders Review of the telephone physician orders, dated 3/2/13 at 3:00 p.m., documented [MEDICATION NAME] 25 mg three times a day as needed for motion sickness. Review of the telephone physician orders, dated 3/3/13 at 10:30 a.m., documented [MEDICATION NAME] 25 mg three times a day as needed for motion sickness. There was no order found for [MEDICATION NAME] in the telephone or computerized physician orders. Nurses' Notes (Note times were not visible) -3/1/12 revealed that the "resident's vital signs (vs) were temperature 97.6, respiration 20, blood pressure was 138/78 and pulse was 119. The resident was alert and able to make most of needs known due to [MEDICAL CONDITION]. Resident continues on skilled services for increase mobility, independence with transfers and activities of daily living she denied pain or discomfort at this time." -3/2/12 revealed that the "resident's vital signs (vs) were temperature 98.9, respiration 19, blood pressure was 110/64 and pulse was 66. The resident was alert and oriented times three, she was able to make needs known, lung sounds clear to accusation, auscultation bowel sounds positive for all four quadrants and abdomen soft and non tender. Resident was up ambulating with use of front wheel walker (FWW) this morning and at 1:30 p.m. the resident complained of feeling dizzy, like everything was spinning around and she was unsafe to walk. The doctor was notified and wrote a new order for [MEDICATION NAME]. The medication was administered with minimal effectiveness noted. Resident was in bed resting. resident encouraged to drink fluids, no further orders received at this time. The resident's daughter was in the facility during the [MEDICAL CONDITION] episode. The resident had no complaints of pain or discomfort." -3/3/13 revealed "vs were, temperature 97.2, respirations 18, blood pressure 146/78 and pulse 82. Resident noted without distress at this time. Resident complained of nausea at night, [MEDICATION NAME] administered. The resident refused her routine night medications. The resident demonstrated a positive effect from antinausea medication. She is alert and oriented times two, forgetful and at times resident was unable to express herself verbally." -3/3/13 nurse note revealed that the "resident had been sitting at her bedside for breakfast, she ate 25% of breakfast and drank approximately 160 cc of fluid. The resident finished eating breakfast and 5-10 minutes after she stated she was "feeling nauseated." The resident had emesis times two, it was yellow in color. The resident was given [MEDICATION NAME] prior to breakfast with no effectiveness, she continued to complain of [MEDICAL CONDITION], daughter at bedside at this time." -3/3/13 revealed that "vs were, temperature 97.6, respirations 19, blood pressure 108/66 and pulse 95. The resident had two more episodes of emesis and at 10:00 a.m. the doctor was notified and received a new order for Rectal [MEDICATION NAME] as well as to start IV fluids [MEDICATION NAME] 5% with 0.45% normal saline at 75 ml/hr. An IV line was placed to the right forearm was flushing well. The IV fluids began at 10:30 a.m. and resident continued to complain of nausea but no further emesis. resident also complained of [MEDICAL CONDITION] and was medicated with as needed (PRN) [MEDICATION NAME] with no relief." -3/4/13 revealed that "vs were, temperature 97.5, respirations 19, blood pressure 113/59 and pulse 71. Resident completed her IV fluids, the right forearm peripheral IV remains in place. Resident was administered [MEDICATION NAME] by mouth at night for nausea, with positive effect noted. The resident was alert and oriented times two." -3/4/13 revealed that "vs were, temperature 96.8, respirations 21, blood pressure 121/69 and pulse 99. Resident was alert and oriented times two. resident needing moderate assist of two for activities of daily living and using a wheelchair propelled by staff. Resident had emesis times one this shift at 6:30 a.m., she had no further emesis noted and was up in her chair for meals." -3/5/13 revealed that "vs were, temperature 97.6, respirations 20, blood pressure 121/62 and pulse 99. The resident continued to receive skilled services for [MEDICAL CONDITION] embolism treatment, dementia, and to increase strength. The resident was alert and oriented times one, she was able to verbalize her needs. The resident complained of dizziness and was administered PRN medication per order with a positive effective. The resident was noted to be somewhat more confused." -3/5/13 "Resident was found on the floor on 3/5/13 at 3:00 a.m., she did not have any injuries. Family and physician notified. The resident's activity of daily living status changed from independent to contact guard assistance. A self releasing alarm was placed on her chair, as resident was not able to understand teaching regarding assistance with cares." -3/5/13 "Addendum to prior note daily quality assurance focus review. The physician was aware of new interventions and updates to plan of care." -3/5/13 "Resident was found on the floor by the nurses station, she was very confused, denied pain or discomfort during the assessment, after injury was ruled out, assisted back to chair, self release seat belt alarm was put on resident. Neuro were started, nurse notified family and physician. The resident required maximum assistance with transfer at this time, she was unable to follow instructions. The resident's family were very concerned and want her sent out to hospital. The nurse called the physician who stated he wanted to collet a urine analysis (UA) and go from there. A stat UA was obtained and sent to the lab and result were still pending, but the resident's family kept on telling the nurse that they would like to take resident with them. The nurse called the physician urgent line and informed them of the worsening of her condition and the UA results were not in. The nurse received an order to send the resident to the hospital. The resident was transported at 6:45 p.m. and her vs were; temperature 96.7, respirations 16, blood pressure 131/55 and pulse 76." -3/5/13 "Late entry 3/4/13 3:00 a.m. resident was found on floor by her bed in her bedroom. The resident's walker fell next to her and she denied pain or discomfort. The resident stated, "fell slowly, not a big deal". The resident was confused and unable to recall whether she hit her head or not. The resident had reported to the CNA that she did not hit her head. The resident was confabulating and has short term memory loss. The resident had no skin tears or bruises, her neuro's and range of motion were within normal limits compare to her previous status at the time. Neuro check and safety check were initiated, denied chest pain or discomfort, no shortness of breath and denied dizziness. The resident's pressure alarm was in place, bed to lowest position, call light within reach. The physician was left a message related to fall incident without injury and family was not notified due to early hour of 3:00 a.m., will continue to monitor." Interdisciplinary Team Review (IDT) -3/6/13 "Quality of Care, IDT review of falls. On 03/04/13 at 3:00 a.m. the resident was observed on the floor next to her walker. She was noted to be confused. She denied hitting her head and stated, "No big deal". She was unable to state what she was attempting to do. Physical therapy was notified of the resident's change in ambulation status to contact guard assist with front wheel walker from independent ambulation. The physician and family were notified and an order for [REDACTED]. Family was at the bedside and was concerned. The resident was sent to emergency room for further evaluation of mental status changes and order received by physician to send to hospital for acute clinical evaluation." Medication Administration Record Review of the electronic medication records for January, February and March 2013 revealed that the resident had not had an order for [REDACTED]. Treatment Administration Record (TAR) The March 2013 TAR identified that the resident had a skin check on 3/1/13. There was no corresponding information skin grid sheet or skin weekly skin check sheet provided when requested on 4/4/13, 4/8/13 and 4/9/13. CNA Bathing Skin Sheets -3/5/13 the resident refused a bath due to not feeling well. -Not dated but between 3/5/13 and 2/26/13 the CNA did not identify anything on the resident's skin. -2/26/13 revealed that the CNA did not identify anything on the resident's skin. -2/22/13 revealed that the CNA did not identify anything on the resident's skin. -2/15/13 documented that the resident had her bath done by physical therapy on 2/14/13. Nursing Skin Assessments The skin grids and weekly skin checks provided by the facility were not dated or signed. There was one skin grid that identified bruising to bilateral arms and abdomen as well as her coccyx. A weekly skin check dated 3/16/13 documented no changes. Staff Interview On 4/3/13 at approximately 10:30 a.m., the nurse who was identified by the family to have removed the patch on 3/5/13 was interviewed. He stated that he did remove a patch as family had asked him what it was. He stated he had told them and believed that the patch was [MEDICATION NAME] but the resident did not have an order for [REDACTED]. Facility Medication Variance Report An investigation conducted by the facility on 3/5/13 revealed that the nurse who removed the patch reported the variance to the DON. The variance involved, one patch the party responsible for the variance was unknown, and when it occurred was unknown. The resident was given the wrong medication which was possibly [MEDICATION NAME]. The description documented that the nurse removed an unidentified patch from the resident that family stated they believed to be [MEDICATION NAME]. The report stated, "Unable to determine or who placed patch or what patch is [MEDICATION NAME]." The resident did not have an order for [REDACTED]. The dates for the investigation were 3/5/13 and 3/13/13 which were conducted by the former DON and the current DON. The findings were that an order was requested by the nurse per a discussion with family. There was no order received and no [MEDICATION NAME] was ordered for the resident. They were unable to determine when the patch was placed. The pharmacy was contacted regarding medications and (there was no further info under findings). They determined the variance was significant. The actions taken were the resident went to the emergency room for evaluation, staff was interviewed and unable to substantiate. The patch was removed by the day nurse and the physician was notified. The resident's lab results were positive for a urinary tract infection which could contribute to her altered mental status. The DON contacted the pharmacy and received an e-mail response on 3/11/13 which stated that the last time [MEDICATION NAME]es were sent was on 2/7/13 for resident #18 and 4 patches were sent. The MAR for resident #18 was reviewed on 4/3/13 and revealed that 3/4 patches had been given to the resident. Two interview records were provided by the facility on 4/8/13 regarding the variance investigation which had not been previously provided on 4/3/13 or 4/4/13 and were not dated by the person who conducted the interviews. The first interview was from the day nurse who removed the patch on 3/5/13. The content of the interview documented in part, the daughter informed the nurse that the resident had a patch behind her ear. The nurse assessed and removed the patch. When the family asked the nurse what he thought the patch was he stated it could be [MEDICATION NAME] but was not sure. The nurse denied ever seeing the patch before and felt it could have been there from a previous hospitalization . The nurse stated that there were no orders for the patch and there was not anything like that ordered before. The second interview was from the nurse who was working on 3/2/13. The nurse reported that on 3/2/13 when she was administering her morning medications and assessment of the resident she was ambulating with her front wheel walker independently. The resident denied any pain or discomfort. At around 10:00 a.m., the resident's daughter was visiting and the resident had complaints of dizziness and nausea. The resident's blood pressure was low and she laid down in bed and the pressure improved. The physician was notified and an order for [REDACTED]." The nurse stated that on 3/3/13 the resident again had emesis and the physician ordered IV fluids and did not feel that the resident needed to go to the hospital at this time. She noted that the IV was administered, resident still complained of nausea and [MEDICAL CONDITION], but no new orders were received. DON Interview On 4/4/13 at 9:45 p.m., the DON stated that nursing staff had to log all returned medications and account for all medications. She stated that they had spoken to the nurses and checked the medication carts, but were not able to account for one of resident #18's [MEDICATION NAME]es. They did not do an action plan. Pharmacy Interview On 4/4/13 at 2:42 p.m. the pharmacy consultant stated that if a resident received [MEDICATION NAME] and [MEDICATION NAME] these medications are both [MEDICATION NAME] which dries things up, such as dry eyes, urine retention, dry mouth, and could lead to falls, could cause urinary tract infections and altered mental status. If used in combination or having a reaction to the medication, the reaction would be quick. The medications were usually used for [MEDICAL CONDITION], dizziness and nausea. Although, there was no way to identify where the patch had come from, based on the resident's documented change in condition, the DON's interviews that one [MEDICATION NAME] was unaccounted for and the pharmacy consultant who stated the reaction would be quick, it appears that the patch was applied at the facility. The resident's last hospitalization was in mid February and there had been skin assessments completed from the time the resident was discharged from the hospital, in February, until the patch was discovered on 3/5/13 and there was no evidence a patch was in place during these assessments.