Every finding on record at Orchards of Cascadia, The

Based on policy review, record review, and staff interviews, it was determined the facility failed to ensure transfers or discharges were documented in the resident's medical record and failed to provide required written notice of transfer or discharge to the resident or resident representative. This was true for 2 of 3 residents (Residents #2 and #3) whose records were reviewed for discharge processes. The lack of documentation and required notice created the potential for misinformation, poor continuity of care, and uncertainty regarding the resident's rights and discharge planning. Findings include:The facility's Discharge of Transfer policy, revised 8/30/25, documented, The facility must provide the resident the residence representative (if any) in the office of the State Long-Term Care Ombudsman with a written notice at least 30 days before the resident is transferred or discharged , except when:The residents' safety or the safety of others would be endangered by remaining in the facility; The residence health has improved sufficiently to allow a more immediate discharge; The residents' urgent medical needs require an immediate transfer orThe facility ceases to operate.The written notice must include:The reason for transfer or discharge;The effective date of transfer or discharge;The location of which the resident is being transferred or discharged ;The name address and telephone number of the state long term care ombudsman; andFor residents with developmental disabilities or mental disorder the contact information for the relevant protection and advocacy agency.A copy of the notice shall be maintained in the residence clinical record.1.Resident #2 was readmitted to the facility on [DATE] with multiple diagnoses including aftercare following joint replacement and presence of left artificial hip joint.Resident #2's care plan, revised 4/27/26, documented his discharge plans were unclear and directed staff to establish a pre-discharge plan and revised as details became known.A review of Resident #2's progress note, dated 6/26/26 at 2:59 PM, documented Resident #2 notified the CEO and Social Services of an altercation with is roommate earlier that day. Resident #2 then requested to be transferred out of the facility.A progress note dated 6/26/26 at 4:18 PM, documented Resident #2 was discharged and transported safely from the facility.Review of Resident #2's record revealed no transfer documentation or written notice of transfer was provided upon discharge.2.Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including heart failure, respiratory failure, and palliative care.A review of Resident #3's care plan, dated 6/25/26, directed staff to establish a pre-discharge plan with the residents representative.A review of Resident #3's record did not include documentation of Resident #3 or her representative requesting to be discharged .Resident #3's record did not include documentation of a written transfer/discharge notice or discharge documentation provided upon leaving the facility.On 8/5/26 at 8:36 AM, the CEO stated Resident #2 and Resident #3's record did not include discharge documentation.On 8/5/26 at 10:20 AM, the Medical Records Director stated the facility only provides the written notice of discharge to residents who are discharged to the hospital.

Based on policy review, record review, interviews, and BFS portal review the facility failed to ensure a thorough investigation was completed to prevent further resident to resident abuse incidents. This was true for 1 of 3 (Resident #38) and had the potential to cause psychosocial and physical harm to those residents residing in the facility. Findings include:Review of the facility's policy titled, Abuse - Reporting & Response, dated 8/25/25, documented:The facility shall submit a follow-up report within five (5) working days of the incident. This report must include a summary of the investigation findings and identify any corrective actions implemented in response to a substantiated allegation.Any new or revised information that supplements the initial report should be included in the follow-up submission to ensure completeness and accuracy.The facility may choose to submit the follow-up report earlier than the required timeframe Resident #38 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure and depression.Review of Resident #38's MDS dated [DATE], documented that Resident #38 was cognitively intact.A progress note dated 1/2/26 at 2:47 AM, documented that Resident #38 approached the nurses station stating I can't take it anymore. He's threatening to kick my ass referring to his roommate. Resident was offered to go to another room for the night to get some separation and rest for the night. Initially resident stated I don't want to lose my room. CEO was notified of the incident and was able to assist this RN with educating resident on the benefits of going to another room for the night. Resident did then go to room [ROOM NUMBER] for the remainder of the night and slept peacefully. Resident stated during the interview with this RN that there was no physical altercation that took place and that he felt safe in his room.A progress note dated 1/2/26 at 1:49 PM, documented the resident was interviewed regarding events involving his roommate. He appears with no signs of psychosocial harm or distress. He stated that during the verbal altercation, each individual remained on their side of the room. Resident #38 said that his roommate stated, once I get out of bed, I am going to kick your ass. The resident indicated that despite this statement, he did not feel threatened and felt safe within the facility.On 1/8/26 at 12:20, interview with the Administrator with the CRN present, the Administrator stated he received a call at 2:39 AM and he was informed of the situation, residents were separated. He spoke with Resident #38 and ruled out physical and psychosocial harm. When asked, why was this not reported? the Administrator stated he ruled out physical and psychosocial harm. When asked, Did you investigate the allegation? the Administrator did not respond, the CRN stated, the facility did not do a thorough investigation.

Based on interview, record review, and facility policy review, the facility failed to investigate resident grievances in a timely manner for four of four resident (Resident (R) 70, R15, R57, and R59) reviewed for resident council and eight of eight residents (R48, R8, R61, R77, R82, R4, R27, and R14) reviewed for repeated grievances of noise at night and concerns about customer service of 31 sample residents. This deficient practice had the potential to allow grievances to not be responded to in a timely manner for 93 residents.Findings include:Review of the facility's policy titled, Grievance Process, with a revision date of 08/29/25, revealed: Policy: Residents and their families have the right to file a complaint without fear of reprisal. Residents' rights should be protected when voicing complaints to maximize the quality of life for each individual and to promote customer satisfaction with facility care and services. The Grievance program is utilized to address the concerns of Residents, family members and visitors and the facility should make prompt efforts to resolve grievances. Definitions: Prompt efforts to resolve: This refers to a facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. Procedure.7. The Nursing Home Administration/Designee is responsible for overseeing the grievance process, including receiving tracking, and conclusion/resolution.Responsibility of the Nursing Home administrator and/or Designee. 2. Ensuring that all grievances reports have been reviewed and addressed in a timely and appropriate manner and that concerned individuals feel that some type of resolution has been communicated, achieved, and maintained.1.Review of resident council minutes provided by the facility revealed grievances of noise from night shift. Multiple residents complained of noise during the meeting on 04/16/25. During the meeting on 05/21/25 many residents complained of the noise at night. R70 had stated during the 06/18/25 meeting that the staff came into the room at 4:00 AM and made a noise waking her up. During the 09/17/25 meeting, multiple residents complained of noise in the early morning.During a resident council meeting on 10/01/25 at 1:33 PM, the residents were asked if they had any resolution to the grievance of the noises at night. R15, R57, R59, and R70 confirmed there had been no resolution shared with them and the noise level at night was still loud.2. Review of a complaint investigation in June 2025 revealed there was an undated form in which R48 complained about the roommate's television being loud. R48 asked Certified Nursing Assistant (CNA) 5 to turn it down. CNA5 stated to R48 that the roommate had rights. R48 stated in the statement that she had rights also. R48 stated CNA5 was rude to her.Review of the Complaints/Grievances Log provided by the facility revealed R48 was not on the log for June 2025. The grievance did not appear until 08/20/25.3. a. Review of R8's undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R8 was admitted to the facility on [DATE].Review of the five day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/09/25 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R8 was moderately impaired in cognition.During an interview on 09/29/25 at 3:15 PM, R8 stated staff came into his room at 2:00 AM, 2:30 AM, and 3:00 AM. R8 stated staff knocked on the door and sometimes turned the lights on when they came in. R8 stated it interrupted his sleep and was concerning. R8 stated he did not know why staff did this.b. Review of R61's undated admission Record in the EMR under the Profile tab revealed R61 was admitted to the facility on [DATE].Review of the quarterly MDS with an ARD of 08/19/25 in the EMR under the MDS tab revealed a BIMS score of nine out of 15 which indicated R61 had moderately impaired cognition.During an interview on 09/29/25 at 2:04 PM, R61 stated a staff member recently came into his room around 2:00 AM, knocked loud on the door and turned the light on. R61 stated this woke him up and he asked the staff member not to knock on his door so loud. R61 stated the staff member then wrote on the whiteboard the name of the CNA and nurse for the day, turned off the light and left the room. R61 stated he heard knocking on his door three times more that night although no one came into the room.c. Review of R77's undated admission Record in the EMR under the Profile tab revealed R77 was admitted to the facility on [DATE].Review of the quarterly MDS with an ARD of 09/11/25 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 which indicated R77 was cognitively intact.During an interview on 10/02/25 at 11:13 AM, R77 stated staff came into his room at 3:00 AM to offer him ice water. R77 stated he asked them what they were doing. R77 stated they were checking his trash can and delivering ice water. R77 stated They should not be in my room. It wakes me up.4. Review of R82's admission Record in the EMR under the Profile tab revealed R82 was admitted to the facility on [DATE]; diagnoses included Parkinson's disease and insomnia.Review of the quarterly MDS with an ARD of 09/02/25 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 which indicated R82 was cognitively intact. Review of the Care Plan, dated 02/27/24 in the EMR under the Care Plan tab, revealed R82 had a focus area of Sleep. [R82] has a DX [diagnosis] of insomnia and is prescribed antidepressant medication and a supplement to manage his condition. The goal was, [R82] will obtain sufficient quality and quantity of sleep promote optimal daily function through next review date. Interventions in pertinent part included, Investigate and identify potential sources of [R82's] sleep disturbances. i.e., noise. etc. Offer and provide [R82] non-pharmacological interventions to promote sleep: .quiet environment. Rule out . noisy environment other internal/external factors. Solve as able.During an interview on 09/29/25 at 3:09 PM, R82 stated he was not getting sleep due to his roommate's TV that was on all night long at night. R82 stated he had recently moved into this room and had asked numerous staff to assist with the noise at night including the nurses and certified nursing assistants working on night shift. R82 stated the staff turned down his roommate's TV volume if his roommate was sleeping; however, the TV had been turned off only once out of the last six nights. R82 stated that in addition to the noise, the lights from the TV also kept him up. R82 stated he could not go without sleep, and it had been six days since he had slept. R82 stated he was upset, and the lack of sleep affected his Parkinson's with his tremors becoming worse than normal. R82 was observed during the interview with significant tremors to his arms and hands.During an interview on 10/02/25 at 12:16 PM, the Social Services Director (SSD) stated she was aware of R82's concern about his roommate's TV being on and it was too loud at night, affecting his ability to sleep. The SSD stated she had spoken with R82's roommate [R4] about R4 wearing headphones at night when watching TV and had spoken to R82 about wearing earbuds at night to drown out the noise. The SSD stated she had spoken with R82 on 09/30/25. The SSD stated R4 told her he would think about whether he was willing to wear headphones and let her know after a few days. The SSD stated the staff could not force someone to turn their TV off at night and residents were allowed to keep their TVs on all night long because it was their home. The SSD stated staff could ask R4 to turn the volume down. The SSD stated if this could not be resolved, then a room change might be necessary. During an interview on 10/02/25 at 2:30 PM, the SSD stated the facility did not have a policy about TVs. During an interview on 10/03/25 at 11:47 AM, R4 stated the SSD had spoken with him about his TV. The TV was on during the interview at a moderate volume. R4 stated the TV was all he had, and he wanted it on at night and did not want to wear headphones. R4 stated he had turned down the TV when R82 had asked but did not want to turn it off. During an interview on 10/03/25 at 10:35 AM, the Administrator stated he reviewed all grievances to make sure each grievance was handled appropriately. The Administrator stated he did not know about an issue related to R4's TV not being turned off at night. The Administrator stated residents could be asked to be more cognizant of the noise, but they could not be forced to be quieter. During an interview on 10/03/25 at 12:07 PM, R82 stated he considered his complaint about the TV at night a formal complaint/grievance. R82 stated he spoke with the SSD but did not know when she would get back to him about his concern with his roommate's TV. During an interview on 10/04/25 at 2:14 PM, the Administrator and Director of Nursing (DON) stated they could not touch a resident's TV, i.e., turn it down or off unless the resident was sleeping. The Administrator stated they had asked staff to be quiet at night. The DON stated staff should knock on doors at night prior to entering residents' rooms such as when they were making rounds. The Administrator and DON stated they were aware of some residents that did not want to be disturbed at night, and accommodations were made for these individuals. The Administrator and DON stated they had some staff working on night shift that had loud voices and this was a challenge.5. During review of a Facility Reported Incident occurring on 06/26/25 regarding staff to resident abuse, 74 residents were interviewed by staff. Residents were asked if any staff, residents, or other individuals had abused them. Three residents stated they had been abused and the Administrator determined for these three residents; grievances would be completed as follows: a. Review of R57's undated admission Record revealed R57 was admitted to the facility on [DATE].Review of the quarterly MDS with an ARD of 08/12/25 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 which indicated R57 was cognitively intact.Review of the undated questionnaire for R57 provided by the facility revealed R57 expressed a concern with verbal abuse that read, [CNA3] yelled at her about transfer. [R57] told her to stop yelling at her. [R57] was on bathroom floor. Follow up [Administrator] Last week, [R57] fell and [CNA3] got frustrated with [R57] that she hadn't asked for help to make the transfer. They (CNAs/nurses) got her up with the Hoyer [mechanical lift]. Is okay with doing a grievance.See customer service grievance.The Grievance Log from 09/01/24 through the survey was reviewed; there was no grievance completed for this incident.b. Review of R27's undated admission Record in the EMR under the Profile tab revealed R27 was admitted to the facility on [DATE].Review of the quarterly MDS with an ARD of 07/03/25 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 which indicated R27 was cognitively intact.Review of the undated questionnaire for R27 provided by the facility revealed R27 had a concern with verbal abuse with the word uncomfortable documented. The questionnaire read, Workers - very negative words when being addressed after wet. my comments mean nothing. CNA 200. Follow up - [Administrator] Says [CNA6] struggles in her approach and listening to patients. Okay with making this a grievance. [R27] Said she [CNA6] walks in angry and get upset at her for everything. Talks down to her. CNA talks bad about her outside her room. The Grievance Log from 06/01/25 through the survey was reviewed; there was no grievance completed for this incident. c. Review of R14's undated admission Record in the EMR under the Profile tab revealed R14 was admitted to the facility on [DATE].Review of the annual MDS with an ARD of 08/10/25 in the EMR under the MDS tab revealed a BIMS score of 14 out of 15 which indicated R14 was cognitively intact. Review of the undated questionnaire for R14 provided by the facility revealed R14 experienced verbal abuse. The undated questionnaire read, [CNA5] in June, in room. 'Do you think you need that water. You shouldn't drink that much. Follow up - [Administrator] Felt like [CNA5] was telling her that she was drinking too much water because she was going to pee in the night. Says [CNA5's] attitude changes a lot. Feels okay about making this a grievance. The Grievance Log from 06/01/25 through the survey was reviewed; there was no grievance completed for this incident.During an interview on 10/03/25 at 10:14 AM, the Administrator stated grievances had not been completed for R57, R27, and R14. During an interview on 10/02/25 at 12:31 PM, the SSD stated she acted as an intermediary in the grievance process. The SSD stated she collected the initial information and then distributed it to the pertinent department head to address during the clinical/stand up meeting. The SSD stated she followed up with residents to determine if results had been communicated to them by the person completing the investigation and if a resident was not satisfied, she and the Administrator worked with the resident to find a solution. The SSD stated she liked to get grievances completed within about a week. The SSD stated the Administrator signed off on all the grievances once they were complete.

Based on interview, record review, and policy review, the facility failed to ensure an allegation of physical abuse was reported timely to the Administrator and to the State for one out of four Facility Reported Incidents (FRIs) (Resident (R) 82) reviewed for abuse of 31 sample residents. This failure had the potential for abuse to occur and/or continue.Findings include:Review of the facility's policy titled, Abuse, dated 03/01/24, revealed Allegations of verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the resident as well as mistreatment, injuries of unknow source, exploitation, deprivation of foods and services by staff, and misappropriate of resident property are reported to the CEO [Chief Executive Officer] immediately and the state agency. a. Within 2 hours if there was alleged abuse or serious bodily injury as a result of an event. b. Within 24 hours if the event that caused the injury did not involve abuse or did not result in serious bodily injury.Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R82 was admitted to the facility on [DATE]; and diagnoses included Parkinson's disease with dyskinesia (difficulty in performing or controlling voluntary movements).Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/02/25 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R82 was cognitively intact. R82 was impaired in range of motion (ROM) to both upper extremities. R82 required supervision or touching assistance with dressing and partial/moderate assistance with showers/baths. Review of the Care Plan to address activities of daily living (ADLS), dated 02/27/24, under the Care Plan tab of the EMR, revealed [R82] has ADL self-care and mobility deficit r/t [related to] DX [diagnosis] of Parkinson's, failure to thrive, malnutrition, HX [history] of falls, muscle weakness, tremors, and muscle spasms. Interventions in pertinent part included Personal Hygiene: [R82] requires supervision/touching assistance with his personal hygiene cares. Dressing: [R82] requires supervision/touching assistance with upper and lower body dressing and set up/clean up with footwear donning. Bathing: [R82] requires partial/moderate assistance with bathing with assistance of 1.Review of a Nurse's Note late entry for 06/26/25 at 6:45 PM by the Unit Manger/Registered Nurse (RN) 1 in the EMR under the Progress Notes tab, revealed Resident came into Unit Managers office, asking to speak to this nurse. Resident began by stating he wanted to move to a new facility. Nurse stated that that was his right and asked why he was feeling this way. Resident stated that he was angry with [Certified Nursing Assistant (CNA) 4]. Resident described an incident that happened earlier in the day, when [CNA4] was assisting resident to get dressed. [CNA4] pulled resident's shirt down and caught the fabric on resident's umbilical hernia. Resident stated, I told him he was ripping my Fucking guts out. Resident reports that [CNA4] stopped pulling on the shirt and told resident not to say the F-word to him. Resident admitted he continued to swear at [CNA4], and stated, I have a right to say what I want in my own room. Resident reports that [CNA4] Just walked out of my room. Nurse offered resident a room change to another hall with different CNAs, and resident was happy about that idea. Nurse spoke with [CNA4] on hall and instructed him to have another aid provide care for resident. [CNA4] agreed. Discussed event that occurred earlier in the day, and [CNA4] reported the same facts. He had caught the shirt on resident's umbilical hernia, stopped when resident screamed and swore at him, informed resident he did not appreciate being spoken to like that, and when resident continued swearing at him, he left the room having completed his cares and left patient safe and clean.Review of R82's Grievance Resolution Form, dated 06/28/25 at 6:42 PM and provided by the facility revealed R82's concern as follows: On 06/27 [R82] was being changed by [CNA4] and when [CNA4] was taking off [R82's] shirt from behind it got caught on [R82's] hernia, when this happened [R82] told [CNA4] to stop. When he [CNA4] didn't [R82] then stated [CNA4] stated Stop! Your pulling my fucking guts out! [R82] then stated [CNA4] told him he had no power to stop him and You can't go anywhere. [R82] also stated he told the eve CNAs what happened to try and report it and nobody would listen/help him.Review of the Five-Day Follow Up Investigation Report, dated 07/07/25 and provided by the facility, revealed the initial report was made to the State on 06/30/25 at 3:00 PM, four days after R82's initial report. The investigation summary revealed, The alleged victim alleges that on 06/27 (interviews with staff and witness indicate the actual incident occurred 6/26) the alleged perpetrator [CNA4] intentionally caused pain to the alleged victim's umbilical hernia while helping the alleged victim get dressed. The alleged victim stated that he told the alleged perpetrator to stop and then the alleged perpetrator continued to assist him to help him dress further causing discomfort to the umbilical hernia. The alleged victim alleges that the alleged perpetrator told the alleged victim that CNA [CNA3] later that evening swatted away at the alleged victim's hand during cares.During an interview on 09/29/25 at 3:09 PM, R82 stated he had an issue with two CNAs (CNA4 and CNA3). R82 stated CNA4 grabbed his t-shirt from behind (on 06/26/25) and was pulling it up when it caught on his umbilical hernia and his hernia was pulled out. R82 stated he told CNA4 to stop but CNA4 continued to pull on the shirt causing pain. R82 stated CNA4 laughed and told him he wasn't doing anything and CNA4 pulled on the shirt two more times before stopping after R82 swore and yelled at CNA4 that he was pulling his guts out. During an interview on 10/02/25 at 5:27 PM, the Administrator verified that the date the allegation of abuse was reported to the State on 06/30/25 exceeded the initial reporting requirement. The Administrator stated R82's initial report to the Unit Manager on 06/26/25 did not meet the threshold for abuse and R82 seemed to be angrier at CNA4 for leaving the room rather than due to the incident with his shirt catching on the hernia. The Administrator stated he found out about the incident due to the Grievance Form (dated 06/28/25) being placed under his door over the weekend and he first saw it on Monday 06/30/25, when he came to work and he reported the incident to the State on 06/30/25. The Administrator verified that abuse allegations should be reported to him by staff immediately.

Based on interview, record review, and review of facility policy, the facility failed to ensure the resident did not receive the wrong dose contributing to a significant medication error for one of 31 sampled residents (Resident (R) 106) reviewed for medication orders. This deficient practice had the potential to over medicate residents by not following the physician orders.Findings include:Review of the facility's policy titled, Management and Destruction of Controlled Substances, with a date of 11/28/17, revealed Policy: The facility follows a process for management and destruction of controlled substances. Procedures.e. Chief Nursing Officer/designated RN should regularly audit the inventory records to validate accuracy.Review of R106's admission Record located under the Profile tab in the electronic medical record (EMR) revealed an admission date of 05 15/25 with diagnoses of aftercare following surgical amputation, acquired absence of right leg below the knee, and end stage renal disease.Review of R106's Physician Orders located under the Orders tab in the EMR revealed on 05/14/25, an order for hydromorphone oral tablet four milligrams (mg); give one tablet by mouth every six hours for pain. On 06/06/25, the order was written to decrease the hydromorphone oral tablet to four mg; give 0.5 tablet by mouth every six hours for pain.Review of the Controlled Drug Record dated 05/15/25- 07/11/25 and provided by the facility, revealed 14 occasions in which. R106 received a whole four mg pill instead of the ordered two mg.During an interview on 10/03/25 at 11:17 AM, the Registered Pharmacist (RP) stated the pharmacy received the order on 06/10/25. The RP stated that the interface between pharmacy and the facility did not communicate when there was a narcotic order. The RP further stated that the narcotic order must be ordered with a hard copy of the order. The RP was asked about the 14 times in which the medication was given at the wrong dose. The RP stated that it was not caught, and it should have been. The RP agreed the order was not followed.During an interview on 10/03/25 at 11:36 AM, Licensed Practical Nurse (LPN) 9 was asked about the medication order. LPN9 stated the medication should have been taken out of the pack and half the pill given and the other half wasted. It does appear to have been given in whole pill form. LPN9 was asked if any of the initials were on the narcotic sheet. LPN9 stated yes, her initials were on the form, and it looked like she had given a whole pill. LPN9 was asked if the physicians order was followed. LPN9 stated, no.During an interview on 10/03/25 at 12:18 PM, the Director of Nursing (DON) was asked about the wrong dose medication being given to the resident. The DON stated he had to look at a report. At 1:36 PM, the DON returned and stated the orders should have been called to the pharmacy when the order was initially ordered. The DON was shown the 14 opportunities in which the medication was given the wrong dose. The DON agreed the resident was given the wrong dose of medication.

Based on observations, document review, staff interviews, and facility policy review, the facility failed to ensure appropriate storage of medication and vaccine supplies in one of two facility medication rooms. This failure created the potential for residents to experience a negative outcome related to potentially expired/undated and/or improperly refrigerated medications, immunizations, or immunization supplies. Findings include:Review of the facility's policy titled, Medication Storage -Refrigerator/Freezer Policy, dated [DATE], read, in pertinent part, The facility will ensure that medications which require refrigeration are stored appropriately per manufacturer's instructions; and 2. The facility should monitor the temperature of medication storage areas at least once a day. 3. The facility should monitor the temperature of vaccine storage twice a day; and Safe temperature for refrigeration is between the range of 36 degrees F (Fahrenheit) and 46 degrees F.Review of the facility's policy titled, Medication Management Policy, dated most recently revised [DATE], read, in pertinent part, Medication and treatment supplies are not used beyond their expiration dates; and Medications are discarded by the expiration date unless indicated by the pharmacy and/or manufacturer's instructions to discard sooner.Observation conducted along with the Director of Nursing (DON) in the facility's medication storage room located on the 300 hallway on [DATE] at 11:48 AM revealed one vial of open and undated Tuberculin Skin Testing Solution in one of the two refrigerators located in the medication room. The testing solution packaging indicated the solution had been dispensed from the pharmacy to the facility on [DATE]. In addition, temperature logs to indicate temperatures were monitored for both refrigerators in the medication room (one for storing medication and one for storing immunization materials), could not be located to ensure the management of refrigerator temperatures were within the appropriate range. The Tuberculin (TB) Skin Testing Solution instructions, located on the TB Skin Testing solution box located in the facility's medication room indicated, Tuberculin skin test solution must be discarded 30 days after it is first opened or if it has passed its expiration date, whichever comes first; and store refrigerated at 2-8 C (35-46 F) and protected from light to ensure potency. During an interview with the DON on [DATE] at 11:55 AM, he stated his expectation was multi dose vials, including tuberculin testing solution, should be labeled when opened and discarded within 28 days after opening. The DON stated he was not sure where the refrigerator temperature logs were, but he would look for them. He stated he expected the logs to be posted on the door of each refrigerator. During a follow-up interview with the DON on [DATE] at 12:18 PM, he provided a log, dated [DATE], for one of the medication room refrigerators. The log did not indicate which refrigerator the temperatures were being logged for and the DON stated he was not able to tell which log he was providing. He stated the log had been found in the Unit Manager's Office. The DON confirmed the logs were expected to be located on the door of each refrigerator and labeled appropriately to indicate which refrigerator was being monitored. The DON confirmed both refrigerators in the medication room (one for the storage of medication and one for the storage of immunization/supplies) were expected to be monitored at least daily. He indicated he thought the refrigerator used to store immunizations and immunization supplies was supposed to be monitored twice daily to ensure stability of the immunization supplies.

Based on observation, interview, record review, and facility policy review, revealed the facility failed to ensure enhanced barrier precautions (EBP) and hand hygiene were performed after emptying a nephrostomy bag and performing incontinent care for one of 31 sampled residents (Resident (R) 9) reviewed for infection control. This deficient practice had the potential to allow residents to be exposed to pathogens that could cause an infection.Findings include:Review of the facility's policy titled, Transmission-Based Precautions Conventional Plan,revised on 06/16/25, revealed Policy: To protect residents from the spread of infection through the implementation of infection control practices and precautions, Hand hygiene is the single most important factor in the prevention or spread of infection.Hand hygiene indicated, utilizing Alcohol Based Hand Rub (ABHR) and/ or hand washing with soap and water. a. Before and after contact with a resident, b. Before and after contact with objects and surfaces in the resident's environment, c. Before and after wearing gloves, d, Before and after wearing personal protective equipment e. Before eating or assisting a resident with meal f. After using the restroom. Enhanced Barrier Precautions (EBP) are recommended for the use in resident rooms when residents have any of the following conditions, but do not require contact precautions.b. indwelling medical devices, central line, urinary catheter, feeding tube, tracheostomy/ventilator care. A peripheral intravenous line (not a periphery inserted central catheter) is not an indwelling medical device.b. Wear a gown whenever anticipating that clothing will be have direct contact with the resident or potential contaminated environmental surfaces or equipment surfaces or equipment in close proximity to the resident.Review of R9's admission Record located under the Profile tab in the electronic medical record (EMR) revealed an admission date of 09/15/25 with diagnoses of diabetes, chronic kidney disease, and functional quadriplegia.Review of physician orders located under the Orders tab in the EMR revealed on 09/15/25 Enhanced barrier precautions for Nephrostomy Gown and gloves required for high-contact patient care (dressing, bathing, transferring, incontinence or toileting care, dressing, changing linens, or device or wound care). Gown and gloves are not required when not performing high- contact care.On 09/29/25 at 10:56 AM, an observation was made when staff came into R9's room to give her pain medication. Licensed Practical Nurse (LPN) 5 and Certified Nursing Assistant (CNA) 11 started to give cares. LPN5 emptied R9's nephrostomy bag into a measurable container. LPN5 wore only gloves while she emptied the bag and then emptied the container down the toilet. LPN5 came out of the bathroom and threw her gloves in the trash and donned a new pair without hand hygiene. LPN5 went to bed to help CNA11 perform cares. R9 had a bowel movement. CNA11 wore a pair of gloves and cleaned R9's incontinence. CNA11 reached into the wipes after wiping R9's buttock and proceeded to pick up clean depends and place it under R9 without changing gloves or performing hand hygiene between the dirty and clean.During an interview 09/29/25 at 11:13 AM, LPN5 was asked about emptying the nephrostomy bag and pouring the urine down the toilet without a gown on. LPN5 stated Yes, should have had a gown on because the resident is on EBP. LPN5 was asked if she should have washed her hands or used the ABHR before donning the second pair of gloves. LPN5 stated Yes.During an interview on 09/29/25 at 11:14 PM, CNA11 was asked if the gloves should have been changed in between going from dirty to clean. CNA11 stated Yes should have changed gloves and performed hand hygiene before putting on clean gloves. During an interview on 10/04/25 at 11:23 AM, Infection Preventionist (IP) was asked about the observation. The IP stated, The expectation is that staff wash their hands when entering room and before they start any cares. Both the LPN and CNA should have changed gloves after they performed hand hygiene. The IP stated that the LPN should have had a gown on when emptying the nephrology bag. That is the expectation

Based on policy review, record review, the facility's Incident and Accident (I&A) Report, and staff interview it was determined the facility failed to ensure a resident receiving dialysis services were provided appropriate monitoring, emergency response, and staff intervention consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. This was true for 1 of 3 residents (Resident #103) reviewed for hemodialysis. This deficient practice caused actual harm to Resident #103 when her central venous catheter (CVC) experienced a bleeding emergency, followed by loss of consciousness and a Full Code where Cardiopulmonary Resuscitation (CPR) was initiated, EMT called, and she was sent to the hospital where she was pronounced deceased after extensive interventions. Immediate Jeopardy was identified on [DATE] at 3:08 PM and was determined to exist since [DATE], when the facility failed to ensure appropriate nursing response to Resident #103 when her dialysis catheter began to bleed. On [DATE] at 3:08 PM, the facility's Administrator was notified of the Immediate Jeopardy at F698, Dialysis. On [DATE] at 1:30 PM, after the Survey Team verified implementation of the IJ removal plan, the facility Administrator was notified the Immediacy was removed on [DATE]. The noncompliance remained at a scope and severity level of G (isolated actual harm) following the removal of the immediate jeopardy.Findings include:Review of the facility's policy titled, Dialysis Off-Site Policy, revised [DATE], documented, The clinical staff provides ongoing assessment and oversight of the resident before and after dialysis treatments, including monitoring the resident's condition after treatments, monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices.Review of the facility's policy titled, Resident Change of Condition Policy, dated [DATE], documented, Designate someone to stay with resident while physician is notified, if necessary; and Monitor and reassess resident's condition and response to interventions until stable or emergency personnel arrive and take over care for transfer to acute care.The National Library of Medicine website titled Care of a Central Line updated [DATE] and accessed on [DATE], documented: All healthcare professionals working in a setting with indwelling CVCs should receive annual training on central line care. Updates regarding indications for the placement of CVCs, maintenance of CVCs, and infection control measures should be included.The Pulmonary Hypertension Association: Best Practices in Catheter Care article, accessed on [DATE], documents: If blood is backing up the catheter or leaking out, use the clamp to close off the catheter if it is still leaking you must clamp off the line. Resident #103 was admitted to the facility on [DATE] with multiple diagnoses including end stage renal disease (ESRD). Resident #103's Minimum Data Set (MDS) dated [DATE], documented she was cognitively intact and receiving hemodialysis. A Physician's Order dated [DATE], documented Resident #103 had a right chest central venous catheter (CVC) in place for the administration of her dialysis and she was to receive the following:-Hemodialysis three times a week every Monday, Wednesday, and Friday.-Apixaban (a blood thinner) 5 mg two times a day for her irregular heart rate.A Dialysis Care Plan initiated on [DATE], documented Resident #103 had a central line in her right chest used by dialysis, and she attended dialysis every Monday, Wednesday, and Friday. The Care Plan directed staff to monitor Resident #103 for complications such as site discomfort, signs and symptoms of infection, phlebitis, occlusion, infiltration, displacement, and bleeding.The facility's I&A report documented that on [DATE], LPN #1 found [Resident #103] standing naked with her dialysis catheter leaking blood from the red port only it was flowing onto the floor and down her chest due to the clamp the line with the red end was unclamped and there was no end cap. LPN #1 clamped the line, left to obtain a cap, and returned to find the clamp unclipped again and blood was visibly flowing from the line. The resident was then escorted down the hallway by a CNA without continuous licensed nurse supervision of the access site. Bleeding occurred in the resident's room [Resident #103] was slumped back with her back on the bed and her feet were on the floor. There was blood noted coming from the catheter and had leaked onto the bed and it was also noted on the floor in front of where her feet were followed by loss of consciousness, absent respirations and pulse. CPR was initiated until EMS arrival.The facility was unable to provide evidence that the nursing staff had been trained or deemed competent in responding to dialysis access emergencies. On [DATE] at 3:08 PM, the Director of Clinical Services (DCS) stated that the facility had not provided such training and expected nurses to have learned these skills during their initial licensing preparation. In a follow up interview on [DATE] at 5:00 PM, the DCS acknowledged that the nurse should have applied a hemostat when the clamp failed and could not explain why a new cap was not placed on the CVC.

Based on policy review, record review, facility Incident Report review, staff interview, and resident and resident representative interview, it was determined the facility failed to ensure adequate supervision and intervention was provided during a resident's transfer to prevent falls. This was true for 1 of 3 residents (Resident #44) reviewed for falls. This resulted in harm to Resident #44 who sustained a hematoma on the right side of her face, eye, and jaw, and chest pain. Findings include: Resident #44 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including abnormalities of gait and mobility, and contracture (rigidity of muscle or tendons resulting in a fixed deformity of a joint) of muscle to her right upper arm. An MDS assessment, dated 10/25/23, documented Resident #44 was cognitively intact and required extensive assistance for transfer with the support of two staff. Resident #44's Care Plan, dated 4/7/23, documented Resident #44 was a fall risk due to impaired mobility, weakness, deconditioning, spinal stenosis, dementia, history of falls, and psychotropic medication use. A facility Incident Report, dated 1/3/24, documented Resident #44 had a fall the morning of 1/3/24. The report documented the CNA reported to the nurse Resident #44 had her feet at the edge of her bed and while the CNA was getting the wheelchair positioned, Resident #44 started to slide out of bed. The CNA assisted Resident #44 and she fell forward on top of the CNA. The report further documented Resident #44 gave a different description of the fall, reporting she fell to the ground. When the nurse was notified of the fall, a hematoma [collection of blood under the skin] was noted on the right side of Resident #44's forehead. Resident #44's vital signs were obtained and ice was applied to the slightly swollen, bruising area. Initial interventions included the nurse notified Resident #44's spouse of the fall as well as the rounding provider and Resident #44 was sent to the hospital to rule out internal bleeding due to being on anticoagulants [blood thinners]. She returned the same day with no acute findings. Neurological checks were completed with no further findings. The report documented further interventions included the CNA was provided education on the same day of incident, on timeliness of notifying a Licensed Nurse along with transfer status and following the care plan, although unclear of incident details with investigation. The report documented Resident #44 was healing slowly but had facial bruising due to medication [anticoagulant]. The report further documented Resident #44's pain was at an acceptable pain level at a 5 out of 10 pain scale [0 being no pain and 10 being the worst pain], and tramadol [a narcotic pain medication] helped alleviate the pain. The hospital Emergency Department notes, dated 1/3/24, documented Resident #44 reported she was being moved by staff at the facility and was dropped hitting her head on the ground. She stated she did not have loss of consciousness but was on blood thinning medication. She also reported pain in the chest wall and described her pain as constant, nonradiating, aching pain, and nothing seemed to alleviate or exacerbate her symptoms. A CT scan (an imaging test that helps to detect internal injuries and disease) of Resident #44's Maxillofacial region (bones and tissues of the jaw and lower face), dated 1/3/24, documented, Impression: 1. Hematoma in the right frontal scalp. Soft tissue swelling and hemorrhage of the right superficial face involving the periorbital [around the eye] preseptal soft tissues [eyelid], and the soft tissues overlying the right mandibular ramus/right parotid gland [right jaw area]. 2. Pertinent negatives: No fracture of the face or mandible [jawbone]. No globe rupture or retrobulbar hematoma. Normal temporomandibular joints. During an interview on 6/4/24 at 10:18 AM, Resident #44 stated on the day she fell she remembered a male CNA came into her room, put her on the sit to stand lift, took her to the bathroom, dressed her, and took her back to her bedroom and put her into her wheelchair. Resident #44 stated she remembered being in her wheelchair but does not remember how she got onto her bed, when she fell off her bed onto her face. She stated she did remember the fall. During a phone interview on 6/4/24 at 3:19 PM, Resident #44's husband stated on the day of the incident it was two to three hours after she had fallen before the fall was mentioned to staff. He stated he entered Resident #44's room around 10:23 AM and saw her eye was swollen and closed. He stated he was worried because his wife takes Eliquis (blood thinner). Resident #44's husband stated she was sent out to the hospital. During an interview on 6/5/24 at 10:45 AM, LPN #11, who was the unit manager, stated she did not witness the fall, but she was present the day of Resident #44's fall. LPN #11 stated CNA #2 was getting Resident #44 up for breakfast when CNA #2 walked away from Resident #44's bed and she fell . LPN #11 stated CNA #2 put Resident #44 in her wheelchair. CNA #2 brought Resident #44 out of the room with bruising to her face. LPN #11 asked Resident #44 what happened, and she stated she fell off the bed. LPN #11 further stated CNA #2 was terminated from employment at the facility after the incident. During a phone interview on 6/6/24 at 3:06 PM, LPN #2 stated she remembered Resident #44's incident when she had a fall. LPN #2 stated CNA #2 did not report the fall immediately. LPN #2 stated Resident #44 was up and going into the dining room when she asked her what happened to her face. LPN #2 stated Resident #44's roommate told her what happened, because Resident #44 could not remember. LPN #2 stated she assessed Resident #44, notified the provider and Resident #44's family.

Based on policy review, record review. observation, and resident and staff interview, it was determined the facility failed to ensure a resident's right for self-determination was honored. This was true for 1 of 2 residents (Resident #63) reviewed for choices. This deficient practice had the potential for Resident #63 to experience a decreased sense of well-being, lack of self-worth, and frustration when his preference for bed placement was not accommodated. Findings include: The facility's Resident Rights policy, undated, documented, Self-Determination: You have the right to self-determination through support of your choice, including the right to: make choices about aspects of your life in the facility that are significant to you. Resident #63 was admitted to the facility on [DATE], with multiple diagnoses including morbid (severe) obesity, pressure ulcer of the sacral (tailbone) region, spinal disc degeneration, and major depressive disorder. An MDS assessment, dated 4/9/24, documented was cognitively intact. During an interview on 6/3/24 at 11:18 AM, Resident #63 stated CNA #1 repositioned her bed without her consent. She stated she asked CNA #1 to turn her bed back up against the wall, and CNA #1 stated she repositioned the bed because it was easier for her to provide care for Resident #63. Resident #63 stated she liked her bed up against the wall because she usually leaned to the right side of her bed, and when lying in the bed in its current position she felt she was going to fall out of the bed. Resident #63 stated she told CNA #3 about CNA #1 repositioning her bed. During an interview on 6/4/24 at 2:57 PM, LPN #4 stated residents could have their beds positioned how they wanted in their rooms. LPN #1 stated she was unaware of why the bed was repositioned. LPN #1 stated she would have staff reposition the bed back to the way the resident liked it. During an interview on 6/6/24 at 10:32 AM, the SSD stated a resident had the right to self-determination; it was the staff's responsibility to explain the risk to the resident and family. During an interview on 6/6/24 at 2:42 PM, the DON stated a resident had a right to make their choices about their life while living in the nursing facility. The DON stated staff did not have the right to move a resident's bed without that resident's consent.

asBased on record review, policy review, observation, and resident and staff interview, it was determined the facility failed to implement storage of resident smoking materials as directed by residents' care plans. This was true for 2 of 2 residents (#57 and #67) whose care plans were reviewed for smoking. These failures placed residents in the facility at risk of negative outcomes if smoking materials were not stored safely due to lack of information in their care plan. Findings include: The facility's Smoking Policy, dated 10/15/22, documented Smoking paraphernalia is not permitted to be stored in the resident's room. This includes e-cigarettes and vaping devices/materials. 1. Resident #57 was admitted to the facility on [DATE], with multiple diagnoses including tobacco use. An MDS assessment, dated 4/18/24, documented Resident #57 was cognitively intact. Resident #57's Care Plan, dated 4/7/23, documented Resident #57 was an independent smoker and his smoking paraphernalia was stored in his room or in the nurse's cart. During an interview on 6/3/24 at 11:30 AM, Resident #57 stated he was an unsupervised smoker and had his own smoking products in his room. 2. Resident #67 was admitted to the facility on [DATE], with multiple diagnoses including nicotine dependence and use of cigarettes. An MDS assessment, dated 5/27/24, documented Resident #67 was moderately cognitively impaired. Resident #67's Care Plan, dated 4/7/23, documented Resident #67 a dependent smoker and his smoking paraphernalia was stored at the nursing station, in a locked box outdoors. During an interview on 6/3/24 at 11:30 AM, Resident #67 stated he smoked, and he kept his tobacco and lighter in his room. A red bag with tobacco in it was observed in his room. During an interview on 6/6/24 at 10:16 AM, LPN #5 stated residents that smoked were allowed to keep their smoking material in their rooms. During an interview on 6/6/24 at 10:19 AM, LPN #11 stated residents that smoked were not allowed to have smoking materials in their room. During an interview on 6/6/24 at 10:21 AM, CNA #6 stated if a resident were deemed a safe smoker, they could have smoking materials in their rooms. During an interview on 6/6/24 at 10:23 AM, RN #5 stated residents were not allowed smoking materials in their rooms. During an interview on 6/6/24 at 10:26 AM, RN #3 stated residents were not allowed smoking materials in their rooms and materials were kept somewhere at the nurses' station. During an interview on 6/6/24 at 10:28 AM, CNA #7 stated residents who smoked were not allowed smoking materials in their rooms. During an interview on 6/6/24 at 10:32 AM, the SSD stated he was not sure if residents could have smoking materials in their rooms. He further stated there were lockers outside at the smoking area for residents to keep their smoking materials. During an interview on 6/6/24 at 2:42 PM, the facility Administrator and DON both stated they were not familiar with the facility's smoking policy due to both being hired recently. They both agreed the facility's smoking policy and resident's care plan should be followed.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was true for 2 of 7 residents (#3 and #5) whose records were reviewed for quality of care. Specifically: - Resident #3 experienced harm when she developed a [CONDITION(S)] to her left third toe. - Resident #5 was at risk for undetected neurological changes when his neurological assessments were not completed after unwitnessed falls. Findings include: 1. The facility's policy Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - Perform weekly skin checks to validate there were no unidentified skin concerns. - Address potential new areas of concern, for example, fit of footwear, health of feet, need for a protective sleeve. - Initiate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . - Document the type of injury. - Describe the characteristic of the pressure ulcer or non-pressure skin alterations. This policy was not followed. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound specialist progress note, dated 7/6/21, documented due to trauma of Resident #3's left third toe, he was asked to assess her. The note stated approximately 4 to 5 days ago while Resident #3 was assisted by staff, her left third toe was run over by a wheelchair. The incident resulted in a skin break to the top of Resident #3's left third toe. The note stated Resident #3's injury was treated with a simple dressing since the time of the injury. The wound specialist described the wound as an ulceration (an open wound that develops on the skin as a result of injury, poor circulation, or pressure) that had drying eschar (dead tissue that is hard or soft in texture - usually black, brown, or tan in color found on the surface of the wound) of about 0.7 cm x 0.8 cm to the top of the toe. The wound specialist classified Resident #3's wound as a Wagner 2 [CONDITION(S)] as a result of trauma. The Wound Care Education Institute website, accessed on 9/13/22, defined a Wagner Grade 2 [CONDITION(S)] as a deep ulcer extending through the ligament, tendon, joint capsule, bone, or deep fascia without abscess (swollen area within body tissue containing an accumulation of pus) or [CONDITION(S)] (infection in the bone). Resident #3's record did not include documentation of when her left third toe was injured. There was no documentatin of the incident with the wheelchair or that Resident #3's foot was assessed. Resident #3's record also did not include physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/8/22 at 10:00 AM, the CNO reviewed Resident #3's record and stated Resident #3's record did not include documentation of the description of her wound to her left third toe prior to the wound specialist visit to the facility on [DATE]. The CNO also stated Resident #3's injury to her left third toe should have been monitored and a treatment order placed on her TAR after the incident. On 9/8/22 at 11:06 AM, the Wound Nurse stated Resident #3's wound was not referred to her. The Wound Nurse also stated she was made aware of Resident #3's wound to her left third toe on the morning of 7/6/21, when the former CNO asked her to have the wound specialist see Resident #3's wound. Resident #3 had a wound which worsened to a diabetic ulcer due to lack of assessment and treatment. 2. The facility's policy, Neurological Evaluation, revised 5/17/21, stated a neurological assessment was to be completed upon physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy included a facility-specific standing order for the frequency of the post-fall neurological assessment. The standing orders directed staff to check every 15 minutes for 1 hour, every hour for 4 hours, and every 4 hours for 19 hours. The policy stated neurological assessment documentation included: - Date and time of the assessment - Vital signs - Level of consciousness - Pupil response - Eye signs response - Speech response - Motor response This policy was not followed. Resident #5's quarterly MDS assessment, dated 6/2/22, documented he was moderately cognitively impaired. Resident #5 experienced three unwitnessed falls requiring neurological evaluation. The required documentation was not completed as follows: a. An I&A report, dated 4/30/22 at 5:00 PM, documented Resident #5 had an unwitnessed fall. A nurse's progress note, dated 4/30/22 at 5:53 PM, documented Resident #5 was found kneeling on his knees leaning against his bed and no injury was noted. The note further documented the nurse called Resident #5's family that morning regarding his flat-effect and fixated eyes with extremity stiffness and he had a neurological consult ordered. The note documented Resident #5's sister said he reacted that way when he felt stressed. Resident #5's post-fall neurological assessment flow sheet was not completed as follows: - The area for documenting his pupil response was blank on 4/30/22 at 8:00 PM, 9:00 PM, 10:00 PM, and 5/1/22 at 2:00 AM and 6:00 AM. - The area for documenting his level of consciousness, speech, and motor response were blank on 4/30/22 at 7:00 PM, 8:00 PM, 9:00 PM, 10:00 PM, and on 5/1/22 at 6:00 AM. - The area for documenting his vital signs was blank on 5/1/22 at 6:00 AM. b. An I&A report, dated 12/1/21 at 8:00 PM, documented Resident #5 had an unwitnessed fall. Resident #5 sustained a 4.0 cm by 4.0 cm abrasion to his right forehead. Resident #5's post-fall neurological assessment flow sheet was not completed as follows: - The area for documenting his pupil response was blank on 12/2/21 at 9:00 AM, 1:00 PM, and 5:00 PM. c. An I&A report, dated 5/19/22 at 9:45 PM, documented Resident #5 had an unwitnessed fall. A nurse's progress note, dated 5/19/22 at 11:43 PM, documented Resident #5 was observed to have a bump on his left forehead and an abrasion to the top of his scalp related to the fall. A nurse's progress note, dated 5/20/22 at 9:00 AM, documented Resident #5 was observed to have a hematoma (a collection or pooling of blood outside the blood vessel) above his left eyebrow which started to bruise and an abrasion to the top of his scalp related to the fall. Resident #5's post-fall neurological assessment flow sheet was not completed as follows: - The area for documenting his pupil response was blank on 5/20/22 at 10:45 AM, 2:45 PM, and 6:45 PM. On 9/8/22 at 9:45 AM, the CNO said Resident #5's blank responses on his neurological assessment indicated the task was not completed. The CNO said the neurological assessment should have been completed and documented as the policy stated.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident's Advance Directive was followed. This was true for 1 of 7 residents (Resident #3) reviewed for advance directives. This failure created the potential for harm if Resident #3 was not resuscitated from a life-threatening event per his wishes due to incorrect information in his record. Findings include: The facility's policy for Advanced Directives/Health Care Decisions, dated 10/1/17, defined the following: - Advance Directives: a written instruction recognized by State law (whether statutory or by the courts of the State) relating to the provision of health care when the individual was incapacitated. - Living Will: a document that allows a person to specify ahead of time whether a health care professional was to begin or continue life-sustaining treatment. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's record included a Living Will and Durable Power of Attorney for Health Care, dated 7/5/16, documented, I direct that all medical treatment, care, and procedures necessary to restore my health and sustain my life be provided to me. Nutrition and hydration, whether artificial or non-artificial, shall not be withheld or withdrawn from me if I would likely die primarily from malnutrition or dehydration rather than from injury, disease, illness or condition. An admission evaluation summary note, dated 6/22/21 at 7:53 PM, documented Resident #3 was unable to define her code status or her wishes in regards to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The note also documented Resident #3 stated her sister and niece were her Power of Attorneys. A physician order, dated 6/23/21, documented Resident #3's code status was do not resuscitate (DNR - medical order instructing health care providers not to do cardiopulmonary resuscitation if a patient's breathing stops or if the patient's heart stops beating). Resident #3's record included a POST, which documented her code status was DNR with comfort measures only. The POST form was signed by the physician but the space for the date was blank. The POST form did not include the signature of Resident #3 or her POAs. A Psychosocial Evaluation note, dated 6/24/21 at 2:15 PM, documented Resident #3 had a Living Will and Durable Power of Attorney. The evaluation note documented Resident #3's code status was Do Not Resuscitate. On 9/8/22 at 9:15 AM, the LSW reviewed Resident #3's record and stated Resident #3's code status was DNR. The LSW then reviewed Resident #3's Living Will and stated Resident #3's code status in her Living Will was full code. The LSW stated Resident #3 should have been coded as full code based on her Living Will and not DNR. The LSW also stated the POST form should have the physician's signature and the date it was signed by the physician. The facility's documentation of Resident #3's code status was not according to her wishes as documented in her Advance Directive.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident received foot treatment per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice created the potential for residents to experience ongoing thickening of toenails and callouses or other complications due to a lack of foot treatment. Findings include: The facility's policy Physician Orders, revised 4/4/19, stated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If unable to implement the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This policy was not followed. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #5's care plan for skin alteration, revised 4/24/22, included the following interventions: - Resident #5 was to be seen by the facility podiatrist upon each visit to the facility and the podiatrist was to consult the outside podiatrist and wound care team as needed. - The wound care team and podiatrist were to coordinate care of Resident #5's foot callouses and monitor him for pain and effectiveness of each treatment. A podiatrist progress note, dated 8/26/22, documented Resident #5's toenails were discolored, thickened, yellow, brittle, and crumbly with subungual (situated or occurring under a fingernail or toenail) debris with [CONDITION(S)] (a chalky substance which accumulates under the nail and the nail becomes raised and tender). The podiatrist documented Resident #5 had onychomycosis (a fungal infection of the fingernails or toenails that causes discoloration, thickening, and separation from the nail bed) and debrided (medical removal of dead, damaged, or infected tissue) Resident #5's toenails extensively and removed all surrounding dead tissues and also removed central nodules caused by the fungus. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's record did not include documentation he received kerasal gel for his feet as ordered by the podiatrist on 8/26/22. On 9/8/22 at 10:30 AM, the CNO said the podiatrist's treatment order on 8/26/22 was not entered into the Electronic Medical Record System or administered to Resident #5. The CNO stated the podiatrist's order should have been processed and administered to Resident #5 no later than the next day after the order was received. The facility did not ensure Resident #5 received foot treatment as ordered by the physician.

Based on record review, policy review, medication error investigations, controlled substance inventory record reviews, and staff interview, it was determined the facility failed to ensure medications were administered and recorded in accordance with professional standards of practice. This was true for 7 out of 7 residents (#1, #8, #9, #10, #11, #12, and #13) whose records were reviewed for medications. These failed practices resulted in harm to Resident #1 when she received another resident's medication and experienced adverse affects which resulted in hospitalization , and had the potential to adversely affect all residents should they receive the wrong medication, or if residents did not receive their prescribed medication due to potential diversion of medications by staff. Findings include: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1's physician order [REDACTED]. Resident #1's physician order [REDACTED]. She was prescribed [MEDICATION NAME] (a type of benzodiazepine used to treat anxiety) 0.5 mg twice a day and [MEDICATION NAME] (a synthetic opioid to treat pain) 50 mg every 6 hours. A nursing progress note, dated 9/11/20 at 7:35 PM, documented Resident #1 was alert, verbally responsive, and performing basic daily tasks without difficulty. There were no progress notes in Resident #1's record for 9/12/20. A nursing progress note, dated 9/13/20 at 8:00 AM, documented Resident #1 was difficult to awaken, and her oxygen level was 90 percent while on 2 liters of oxygen (normal oxygen levels are 95-100% without supplemental oxygen). The next nursing progress note, dated 9/13/20 at 9:32 PM, over 13 hours later, documented Resident #1 was transferred to the hospital. An Emergency Department admission note, dated 9/13/20, documented Resident #1 was hypoxemic (low oxygen level in the body) with low respiratory drive (breathing below the normal rate), and she was responsive to [MEDICATION NAME], which is used to reverse the effects of a narcotic overdose, on admission. Resident #1's record included she was taking [MEDICATION NAME] (a synthetic opiod) and [MEDICATION NAME] (a type of benzodiazepine). A urine drug screen from the hospital, dated 9/13/20, documented Resident #1's urine contained opiates (another term for narcotics), benzodiazepines (drug that slows down the central nervous system), and [MEDICATION NAME] (a drug used for pain relief and treatment of [REDACTED]. The Prescibers' Digital Reference website, copyright 2020, accessed 10/1/20, stated [MEDICATION NAME] was contraindicated in people with asthma and people taking [MEDICATION NAME] should be monitored for respiratory depression. It further stated [MEDICATION NAME] may significantly decrease respiratory drive and cause death. The website stated [MEDICATION NAME] had a high rate of serious or fatal respiratory depression in the first 24 hours of medication use. The website also stated [MEDICATION NAME] and central nervous system depressant medication used together may decrease the person's respiratory drive significantly and could cause death. The National Alliance on Mental Illness website, undated, accessed on 10/1/20, stated when benzodiazepines and [MEDICATION NAME] are taken together it may increase the risk of profound central nervous system depression, respiratory rate slowing, and death. It further stated that caregivers must get medical help right away if a person who has taken these medications together does not respond and does not wake up. Resident #1's record from the hospital documented Resident #1 was diagnosed with [REDACTED].#1 was admitted to the ICU. Resident #1 remained in the ICU on the dates the survey was conducted. Resident #1's medication administration records for July through September 2020, did not include orders for [MEDICATION NAME] administration. On 9/18/20 at 12:48 PM, the DON stated there were no orders for [MEDICATION NAME] in Resident #1's record and the facility had an ongoing investigation on how [MEDICATION NAME] could have been given to Resident #1. She stated she received Resident #1's toxicology report and the nurse made a medication error. The DON stated there was only one person in the facility prescribed [MEDICATION NAME] and that person lived across the hall from Resident #1 at the time of the incident. She stated LPN #1 no longer worked at the facility. 2. The facility's policy for the destruction of controlled drugs, dated 11/28/17, stated all controlled substances were destroyed according to Federal and State law. It stated destruction occurred in the presence of two licensed nurses who completed the inventory sheet with the amount of medication destroyed and both nurses signed and dated the log. This policy stated when controlled drugs were destroyed the procedure was as follows: * Two nurses documented the destruction of the controlled substance in the controlled substance logbook. * A product destruction report was created, and the destruction of all controlled drugs destroyed was recorded. * A record of the destruction of controlled drugs were logged into a Controlled Substance Record binder maintained by the DON. This policy was not followed. The United States Drug Enforcement Administration (DEA) website, accessed 10/5/20, stated, The Controlled Substances Act (CSA) places all substances which were in some manner regulated under existing federal law into one of five schedules. This placement is based upon the substance's medical use, potential for abuse, and safety or dependence liability. The website also documented the following: *Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Some examples of Schedule II drugs are [MEDICATION NAME] (contained in [MEDICATION NAME]), [MEDICATION NAME], and [MEDICATION NAME] ([MEDICATION NAME]). [MEDICATION NAME] is also listed as a Schedule II drug in the DEA's alphabetical listing of controlled substances. * Schedule IV drugs, substances, or chemicals are defined as drugs with low potential for abuse and low risk of dependence. Some examples of Schedule IV drugs are [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] ([MEDICATION NAME]). [MEDICATION NAME] is also listed as a Schedule IV drug in the DEA's alphabetical listing of controlled substances. Four controlled substance inventory record books included residents whose narcotic records were signed off incorrectly with only one nurse signing for the disposal or transfer of narcotics, or the signature was blank. Examples include: a. The controlled substance inventory record, unit #1 book #3, documented the following: * Page 0010 of Resident #8's controlled substance inventory record, documented [MEDICATION NAME] was discontinued and there were 4 tablets remaining. There were no signatures for disposal verification by two licensed nurses. * Page 0019 of Resident #8's controlled substance inventory record, documented [MEDICATION NAME] was discontinued and there were 4 tablets remaining. There were no signatures for disposal verification by two licensed nurses. * Page 0047 of Resident #9's controlled substance inventory record, documented 6 [MEDICATION NAME] tablets remained. There were no pages left in the controlled substance inventory record and a note on the inventory record documented the drugs were transferred to another book. There were no signatures for the transfer of the unused drug by two licensed nurses. b. The controlled substance inventory record for unit #1 book #4, documented the following: * Page 0005 of Resident #10's controlled substance inventory record, documented [MEDICATION NAME] was discontinued and there were 2 tablets remaining. There was one signature for disposal verification by one licensed nurse, not two licensed nurses. * Page 0006 of Resident #10's controlled substance inventory record, documented [MEDICATION NAME] was discontinued and there were 28 tablets remaining. There was one signature for disposal verification by a licensed nurse, not two licensed nurses. * Page 0015 of Resident #10's controlled substance inventory record, documented liquid [MEDICATION NAME] was discontinued and there were 27 mls of liquid [MEDICATION NAME] remaining. There was one signature for disposal verification by one licensed nurse, not two licensed nurses. * Page 0028 of Resident 11's controlled substance inventory record, documented [MEDICATION NAME] was transferred to another hall and there were 28 tablets remaining. There were no pages left in the controlled substance inventory record for the [MEDICATION NAME]. There was one signature for transfer verification by a licensed nurse, not two licensed nurses. * Page 0034 of Resident #11's controlled substance inventory record, documented [MEDICATION NAME] was transferred to another hall and there were 84 [MEDICATION NAME] tablets remaining. There were no pages left in the controlled substance inventory record for the [MEDICATION NAME]. There was one signature for transfer verification by a licensed nurse, not two licensed nurses. * Page 0036 of Resident #11's controlled substance inventory record, documented [MEDICATION NAME] was transferred to another hall and there were 18 [MEDICATION NAME] tablets remaining. There were no pages left in the controlled substance inventory record for the [MEDICATION NAME]. There was one signature for transfer verification by a licensed nurse, not two licensed nurses. * Page 0037 of Resident #11's controlled substance inventory record, documented [MEDICATION NAME] was transferred to another hall and there were 30 [MEDICATION NAME] tablets remaining. There were no pages left in the controlled substance inventory record for the [MEDICATION NAME]. There was one signature for transfer verification by a licensed nurse, not two licensed nurses. c. The controlled substance inventory record for unit #3, dated 6/7/20 to 8/25/20, documented the following: * Page 0104 of Resident #12's controlled substance inventory record, documented [MEDICATION NAME] was transferred to another hall and there were 30 tablets remaining. There were no pages left in the controlled substance inventory record for the [MEDICATION NAME]. There was one signature for transfer verification by a licensed nurse, not two licensed nurses. d. The controlled substance inventory record for unit #1, book #4, documented the following: * Page 0005 of Resident #10's controlled substance inventory record, documented [MEDICATION NAME] was discontinued and there were 2 [MEDICATION NAME] tablets remaining. There were no signatures for the disposition of the unused drug by two licensed nurses. * Page 0006 of Resident #10's controlled substance inventory record, documented [MEDICATION NAME] was discontinued and there were 28 [MEDICATION NAME] tablets remaining. There was one signature for disposal verification by one licensed nurse, not two licensed nurses. * Page 0014 of Resident #10's controlled substance inventory record, documented liquid [MEDICATION NAME] was discontinued and there were 26.6 mls of liquid [MEDICATION NAME] remaining. There was one signature for disposal verification by one licensed nurse, not two licensed nurses. * Page 0015 of Resident #10's controlled substance inventory record, documented [MEDICATION NAME] was discontinued and there were 27 mls of liquid [MEDICATION NAME] remaining. There was one signature for disposal verification by one licensed nurse, not two licensed nurses. * Page 0029 of Resident #13's controlled substance inventory record, documented [MEDICATION NAME] was transferred to another hall and there were 13 [MEDICATION NAME] tablets remaining. There was one signature for disposal verification by one licensed nurse, not two licensed nurses. On 9/17/20 at 9:00 AM, RN #1 stated two nurses destroyed controlled medication together in the Rx Destroyer (A chemical compound that liquefies and destroys narcotics) then both nurses documented the destruction by signing the controlled substance logbook. When shown an entry in the controlled substance logbook with one nurse's signature documenting the destruction of a controlled substance, RN #1 stated she was not sure why there was only one nurse's signature. On 9/18/20 at 12:48 PM, the DON stated the facility policy was to have two nurses verify the physical destruction of a controlled medications by using the Rx Destroyer. Those two nurses then signed the controlled substance logbook under disposition of an unused drug. She stated she did not know why there was only one signature on multiple residents controlled substance inventory record disposal entries. The DON stated the facility did not have audit documentation to verify accuracy of the controlled substance inventory records. On 9/18/20 at 12:55 PM, the DON stated the facility had no product destruction reports for verification of controlled medication destruction. She also stated the facility did not keep a controlled substance record binder maintained by the DON, per the facility's policy.

Based on record review, review of medication error investigations, and staff interview, it was determined the facility failed to ensure residents' were free of significant medication errors. This was true for 1 of 7 residents (Resident #1) whose medications were reviewed. This failed practice resulted in harm when Resident #1 experienced a change in condition that resulted in hospitalization due to a [MEDICATION NAME] (a drug that has a high rate of serious or fatal respiratory depression in the first 24 hours of medication use) overdose. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1's physician order [REDACTED]. Resident #1's physician order [REDACTED]. She was prescribed [MEDICATION NAME] (a type of benzodiazepine used to treat anxiety) 0.5 mg twice a day and [MEDICATION NAME] (a synthetic opioid to treat pain) 50 mg every 6 hours a day. A nursing progress note, dated 9/11/20 at 7:35 PM, documented Resident #1 was alert, verbally responsive, and performing basic daily tasks without difficulty. There were no progress notes in Resident #1's record for 9/12/20. A nursing progress note, dated 9/13/20 at 8:00 AM, documented Resident #1 was difficult to awaken, and her oxygen level was 90 percent while on 2 liters of oxygen (normal oxygen levels are 95-100% without supplemental oxygen). The next nursing progress note, dated 9/13/20 at 9:32 PM, over 13 hours later, documented Resident #1 was transferred to the hospital. An Emergency Department admission note, dated 9/13/20, documented Resident #1 was hypoxemic (low oxygen level in the body) with low respiratory drive (breathing below the normal rate), and she was responsive to [MEDICATION NAME], which is used to reverse the effects of a narcotic overdose, on admission. The resident's record documented she was taking [MEDICATION NAME] (a synthetic opiod) and [MEDICATION NAME] (a type of benzodiazepine). A urine drug screen from the hospital, dated 9/13/20, documented Resident #1's urine contained opiates (another term for narcotics), benzodiazepines (drug that slows down the central nervous system), and [MEDICATION NAME]. The Prescibers' Digital Reference website, copyright 2020, accessed 10/1/20, stated [MEDICATION NAME] was contraindicated in people with asthma and people taking [MEDICATION NAME] should be monitored for respiratory depression. It further stated [MEDICATION NAME] may significantly decrease respiratory drive and cause death. The website stated [MEDICATION NAME] had a high rate of serious or fatal respiratory depression in the first 24 hours of medication use. The website also stated [MEDICATION NAME] and central nervous system depressant medication used together may decrease the person's respiratory drive significantly and could cause death. The National Alliance on Mental Illness website, undated, accessed on 10/1/20, stated when benzodiazepines and [MEDICATION NAME] are taken together it may increase the risk of profound central nervous system depression, respiratory rate slowing, and death. It further stated that caregivers must get medical help right away if a person who has taken these medications together does not respond and does not wake up. A review of Resident #1's record from the hospital documented Resident #1 was diagnosed with [REDACTED].#1 was admitted to the hospital's ICU. Resident #1 remained in the ICU on the dates the survey was conducted. Resident #1's medication administration records for July through September 2020, did not include orders for [MEDICATION NAME] administration. On 9/18/20 at 12:48 PM, the DON stated there were no orders for [MEDICATION NAME] in Resident #1's chart and the facility had an ongoing investigation on how [MEDICATION NAME] could have been given to Resident #1. She stated she received Resident #1's toxicology report. She stated the nurse made a medication error. She stated there was only one person in the facility prescribed [MEDICATION NAME] and that person lived across the hall from Resident #1 at the time of the incident. She stated LPN #1 no longer worked at the facility.

Based on record review and staff interview, it was determined the facility failed to immediately notify the physician and the resident's representative when there was a significant change in a resident's condition. This was true for 1 of 1 resident (Resident #1) reviewed for notification of changes in condition. This resulted in the potential for harm to Resident #1 due to delayed care and treatment from lack of notification to the physician and of advocacy and involvement by her representative. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1's physician order [REDACTED]. Resident #1's physician order [REDACTED]. She was prescribed [MEDICATION NAME] (a type of benzodiazepine used to treat anxiety) 0.5 mg twice a day, and [MEDICATION NAME] (a synthetic opioid used to treat pain) 50 mg every 6 hours. A nursing progress note, dated 9/11/20 at 7:35 PM, documented Resident #1 was alert, verbally responsive, and performing basic daily tasks without difficulty. There were no progress notes in Resident #1's record for 9/12/20. A nursing progress note, dated 9/13/20 at 8:00 AM, documented Resident #1 was difficult to awaken, and her oxygen level was 90 percent while on 2 liters of oxygen (normal oxygen levels are 95-100% without supplemental oxygen). The next nursing progress note, dated 9/13/20 at 9:32 PM, over 13 hours later, documented Resident #1 was transferred to the hospital. A document provided by the facility, dated 9/13/20, signed by LPN #1, which was not in Resident #1's record, stated the following: * LPN #1 decided to monitor Resident #1's change in condition because Resident #1 would wake up when she performed a sternal rub (the application of painful stimulus with the knuckles of a closed fist to the center of the chest of a person who is not alert and does not respond to verbal stimuli. The sternal rub is the most common painful stimulus practiced in the field by paramedics and emergency medical personnel). * LPN #1 called Resident #1's Power of Attorney (POA) on 9/13/20 to update her on Resident #1's change in condition. LPN #1 documented, I called her (the POA) and she said when did this start and I told her that we noticed a decline within the last two hours (I did not tell her that it started on the 12th (9/12/20)). I told her I would be getting a hold of the doctor . * LPN #1 documented she planned to call the doctor when the POA asked LPN #1 if she called an ambulance. LPN #1 documented she did not call an ambulance because she was on the phone with the POA. * LPN #1 documented she started to text Resident #1's physician assistant when the emergency dispatch center called for information and she heard the ambulance sirens when it entered the facility grounds. LPN #1 also documented the ambulance arrived about 8:50 PM after talking to the POA. There was no documentation in Resident #1's record Resident #1's physician was notified about her change in condition. On 9/18/20 at 12:48 PM, the DON stated she notified the POA of Resident #1's transfer to the hospital but she did not document the conversation in Resident #1's record.

Based on record review and staff interview, it was determined the facility failed to ensure bed-hold notifications were provided to a resident. This was true for 1 of 2 residents (Resident #1) reviewed for discharges. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's Bed Hold policy, dated 11/28/17, documented residents were provided bed-hold information by written notification, within 24 hours of an emergent transfer, and in cases where the facility was unable to notify the representative, the facility would continue to try to notify the representative and document the multiple attempts to reach the resident's representative. This policy was not followed. A nursing progress note, dated 9/13/20 at 9:32 PM, documented Resident #1 was transferred to the hospital. Resident #1's record did not include documentation Resident #1 received a bed-hold notification. A document provided by the facility, dated 9/13/20, documented LPN #1 asked Resident #1's representative about the bed-hold paperwork and the representative refused to sign it at the time of Resident #1's transfer. The document was not a part of Resident #1's record. There was no further documentation in Resident #1's record the facility attempted to provide Resident #1 or her representative with the bed-hold notification. On 9/18/20 at 15:50 PM, the DON stated Resident #1's representative was told about the bed-hold notification and she refused.

Based on record review and staff interview, it was determined the facility failed to ensure residents' comprehensive care plans were consistent with physician orders. This was true for 1 of 7 residents (Resident #3) whose care plans were reviewed. This failure created the potential for harm should residents receive inappropriate or inadequate care with subsequent decline in health. Findings include: Resident #3 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #3's physician's orders [REDACTED].#3 took all his medications prior to leaving his room by visually inspecting his mouth after medication administration. Resident #3's care plan did not include information directing staff to ensure Resident #3 took all his medications prior to leaving his room by visually inspecting the inside of his mouth after his medications were administered as directed in his physician's orders [REDACTED]. On 9/18/20 at 10:27 AM, the DON said Resident #3's care plan did not include directing staff to ensure Resident #3 took all his medications prior to leaving his room by visually inspecting his mouth after his medications were administered.

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. Two of seven Certified Nursing Assistant (CNA1 and CNA2) did not utilized full personal protective equipment (PPE), specifically eye protection, during cares and interactions within six feet of nine non-masked residents (R5, R7, R8, R9, R10, R11, R12, R13, and R14). Both CNAs worked on Hall 200 where R2 tested positive for COVID-19 eight days prior. The facility was located in a county with a high level of community transmission. The facility also failed to conduct [DIAGNOSES REDACTED]-CoV-2 (severe acute respiratory syndrome coronavirus 2), [MEDICAL CONDITION] that causes COVID-19, testing of all residents and all staff who previously tested negative when the facility had a COVID outbreak. After R17 tested positive for COVID-19, 11 of 12 residents (R14, R9, R2, R13, R11, R12, R18, R19, R5, R10 and R6) on Hall 200, who previously tested negative, should have been tested but were not. R2 later tested positive for COVID-19 on [DATE] after becoming symptomatic requiring transfer to the hospital. After R2 tested positive for COVID-19, 9 of 11 residents (R14, R9, R13, R11, R12, R18, R19, R10 and R6) on Hall 200, who previously tested negative for COVID-19, should have been tested but were not. In addition, 5 of 10 staff (CNA4, CNA5, CNA6, LN3 and LN4) who worked on Hall 200 and previously tested negative for COVID-19 should have been tested but were not. The facility failure to maintain infection control measures to prevent transmission placed all residents and staff in the facility in immediate jeopardy for risk for serious illness and/or death related to COVID-19 and required immediate action. On [DATE] at 4:20 PM the Administrator was informed and emailed Immediate Jeopardy (IJ) determination for 42 CFR §483.80 (F880). On [DATE] at 10:26 AM Administrator was informed of determination that immediacy was removed based on onsite verification that IJ removal plan was implemented. Findings include: During an interview on [DATE] at 8:00 AM Administrator and Director of Nursing (DON) stated that the facility census was 60. The facility currently had 8 COVID-19 positive residents who resided in Hall100 (COVID-19 unit). The facility did not have any resident presumed positive or under investigation outside of the COVID-19 unit. Facility had sufficient inventory of PPE (personal protective equipment) and all staff were required to wear full PPE comprised of mask (N95 on COVID unit and KN95 on non-COVID unit), eye protection, gown and gloves. Full PPE use started on [DATE] when facility had first COVID positive case. The most recent resident who tested positive for COVID was R2. R2 was residing on Hall 200 and became lethargic on [DATE]; therefore, R2 was transferred to hospital and tested positive for COVID-19 on [DATE]. Review of Centers of Disease Control and Prevention (CDC) cases and deaths by county, https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/county-map.html, updated [DATE], accessed [DATE], showed Canyon County (the county where the facility was located) had 2,768 cases per 100,000 indicating a high level of community COVID-19 activity. *CNA1 not wearing PPE Observation on [DATE] between 10:00 AM and 11:00 AM showed CNA1 on Hall 200 entering R9's room. CNA1 wore gown, KN95 mask and glasses but no goggles or face shield. CNA1's glasses were small to medium measuring about 1.5 inches x 2 inches covering the front of her eyes but nothing covering or protecting the sides of her face or eyes. CNA1's glasses were not PPE eye protection. CNA1 stood less than 6 feet away from R9, resident did not wear mask, as the pulse oximeter was placed on R9's finger. After exiting R9's room, CNA1 entered R10's room. CNA1 was not wearing eye protection and stood less than 6 feet from R10, resident did not wear mask, to wrap blood pressure cuff around resident's arm. CNA1 exited R10's room and approached Licensed Nurse (LN)1 at the medication cart. LN1 and CNA1 spoke briefly with CNA1 obtaining hand cuff from LN1. LN1 did not mention to CNA1 that CNA1 was not wearing eye protection. At 10:05 AM, CNA1 entered R8's room with no eye protection and closed the door. After about 15 minutes, CNA1 exited R8's room with two bags of trash and linen. At 10:35 AM, CNA1 stated that she was passing water and ice to all residents on Hall 200. CNA1 still was not wearing eye protection as CNA1 entered several resident rooms. CNA1 entered R7's room and stood less than 6 feet from R7, wiping down bedside table and passing water and ice. R7 did not wear a mask. CNA1 entered R8's room and stood less than 6 feet from R8. R8 did not wear a mask. During interview on [DATE] at 10:40 AM, CNA1 stated that about 30 minutes ago, she changed R8's brief, provided pericare and repositioned resident and she did this before and after breakfast today. CNA1 entered R11's room and stood less than 6 feet from R11 as she passed water and ice and conversed with R11 about misplaced clothing. R11 did not wear a mask. CNA1 entered R12's room and stood less than 6 feet from resident as CNA1 passed water and ice and conversed with resident. Resident did not wear a mask. While in the R12's room, CNA1 asked LN1 to tie the top of her gown and LN1 stood right next to CNA1 and tied gown. LN1 did not mention to CNA1 that CNA1 was not wearing eye protection as both staff were in resident's room. CNA1 then entered R13's, R9's, and R14's room without eye protection and stood less than 6 feet from these residents while passing water and ice and conversing with residents. None of these residents wore a mask. CNA1 stood less than 6 feet from R14, about a foot next to resident, and both were talking for longer than 10 minutes. Observation on [DATE] at 11:40 AM showed CNA1 and CNA2 in R5's room. R5 was sitting in wheelchair and CNA1 stated that plan was to transfer R5 back into bed with hoyer (mechanical) lift, check and change resident's brief and then transfer resident back to wheelchair. CNA1 was not wearing eye protection. R5 had his mouth open about two inches wide and continued to make audible grunting and moaning noises while within 2 feet of both CNA1 and CNA2. R5 then began coughing loudly, cough was moist sounding. CNA1 and CNA2 transferred R5 to bed with hoyer lift. CNA1 was less 6 inches from R5's open mouth and was face-to-face with resident. After R5 was in bed, R5 was rolled onto his side with his face next to CNA1. As R5's brief was changed and pericare was performed, R5 grunted loudly and frequently. After brief change, R5 was transferred back to wheelchair where CNA1 was again face-to-face, about one feet away, from R5's face. R5 laughed in response to conversation with CNAs. R5 could also be heard gurgling with moist sounds and open mouth breathing. CNA2 did not mention to CNA1 that CNA1 was not wearing eye protection and should wear eye protection. During an interview on [DATE] at 11:50 AM CNA1 stated that R5 is high risk for aspiration and we have to make sure he is straight up during feeding. He tends to gurgle a lot and always has his mouth open and grunts often. CNA1 stated that she started shift at 6:00 AM today and provided personal cares to R7, R8 and R9 which involved direct cares as all three residents' required total assistance with personal cares, dressing, mobility, and positioning. CNA1 also stated that she gave a shower to R6 and R7. CNA1 stated that she used the shower hose to spray R6 body and back during shower and washed R6's back and legs during shower. CNA1 stated that she works full time assigned to Hall 200. When asked about COVID amongst residents in Hall 200, CNA1 stated that R2 had COVID and is now in the COVID unit, resident had no symptoms except for diarrhea for ,[DATE] days but no temperature. This happened recently. R3 and R4 also had COVID and went to the COVID unit with R3 just returning back to Hall 200. When asked about use of eye protection such as goggles or face shield, CNA1 stated I'm supposed to wear goggles but it fogs up. I tried the face shield but I couldn't see. When asked if any staff has mentioned to CNA1 that she should be wearing eye protection, CNA1 stated that Administrator told her two weeks ago that she should be wearing goggles. When asked if CNA1 has been wearing goggles since Administrator spoke to her two weeks ago, CNA1 shook her head no and stated that she rarely wears goggles. When asked when CNA1 started her shift, CNA1 responded 6AM. When asked if CNA1 wore eye protection since the start of her shift (6 hours ago) CNA1 said, No. CNA1 did not wear eye protection for the first six hours of her shift on [DATE] (until interview with surveyor) and stated that she rarely wears eye protection despite providing direct resident care within 6 feet of residents on Hall 200 non-COVID unit. Since [DATE], a month ago, 8 residents on Hall 200 tested positive for COVID-19 and the facility did not conduct testing of all residents and all staff after each resident or staff tested positive for COVID-19. In addition, 8 days ago, R2, who resided on Hall 200, tested positive for COVID-19. CNA1 is supposed to wear eye protection and her lack of wearing eye protection consistently for two weeks or more, increased the risk that serious harm or death from COVID-19 is likely to occur. *CNA2 not wearing PPE Observation on [DATE] at 9:23 AM showed CNA2 exit R10's room with goggles on top of her head and not covering her eyes. CNA2 did not have any eye protection. CNA2 held thermometer and pulse oximeter (device to check oxygen level) and began cleaning devices. CNA2 then entered R5's room and stood less than 2 feet away from resident's open mouth, while resident gurgled, grunted and moaned. Resident had device on that supplied oxygen. CNA2 applied pulse oximeter (device to check oxygen level) and scanned resident's forehead with thermometer. CNA2 continued to have goggles on top of her head and did not have any eye protection. CNA2 exited R5's room and cleaned devices and then moved cart with devices to another resident's room, looked at surveyor and then repositioned goggles from top of head to over her eyes. During an interview on [DATE] at 12:10 PM with Infection Preventionist (IP) and DON, when asked about staff providing direct care in close contact with residents without eye protection and the risk of COVID transmission to residents, IP stated that staff would have risk of contracting COVID but if staff was wearing mask and performing hand hygiene, the risk of transmitting COVID to residents are low. When asked to confirm risks are present for transmitting, IP nodded her head. When asked if staff are 100% in hand hygiene and other infection control practices, IP didn't respond. IP and DON stated that they have received from staff texts and reports of staff not wearing PPE. When asked how residents on non-COVID unit are protected from positive COVID staff working, IP stated that if staff are COVID positive they are quarantined for 10 days or they could work on the COVID unit. When asked if COVID positive staff could work on the non-COVID unit, IP stated no. When asked if staff working on non-COVID unit are not wearing eye protection and increasing their risk of getting COVID, how did that differ from not allowing COVID positive staff to work on non-COVID unit, IP stated that the difference was knowing or deliberating knowing COVID positive staff was working with non-COVID unit residents. During an interview on [DATE] at 1:00 PM Administrator stated that he recalled conversation with CNA1 about not wearing eye protection while working. Administrator stated that it was about two weeks ago and he immediately made sure CNA1 put on eye protection. During an interview on [DATE] at 3:10 PM DON stated that eye protection protects staff but when staff wears mask, they are preventing transmission to residents, DON asked how would it get to the residents. When asked if COVID positive staff working in non-COVID unit could transmit COVID to other staff in the break room, if there was a lapse in infection control such as respiratory hygiene, not washing hands appropriately, touching eyes or mouth and not washing hands and then touching resident, resident environment or shared equipment or common area shared by staff or residents, DON responded by stating that eye protection protects staff and not the resident. During an interview on [DATE] at 3:43 PM with DON and Administrator, DON stated that she spoke with CNA1 about not wearing eye protection and CNA1 confirmed that she wears eye protection about 25% of the time and takes eye protection on and off because she can't see and afraid she might fall because she can't see. CNA1 stated that she wants residents to be safe and doesn't feel it's safe to be using hoyer lift if she can't see. DON stated that CNA1 has been suspended today and matter will be investigated before CNA1 can return to work. DON stated that CNA1 did not raise problem of not wearing eye protection because of issues with not seeing and therefore, there was no opportunity to problem solve about alternative eye protection options or other solutions. Administrator and DON stated that it is important that residents need to be protected and safe, staff need to wear PPE. CNA1 knows she's in the wrong and CNA1 apologized for not wearing eye protection. During concurrent interview and record review on [DATE] at 4:04 PM with DON and Administrator, records showed CNA1 received donning and doffing training. DON reviewed facility's policy, Screening and Management of Coronavirus COVID-19, revision date [DATE], with DON confirming that PPE use for staff in Hall 200 was applicable under b. General Population: iv. White Zone: Facility Exposure continuous wear protection: 1. Gown or long sleeve scrub, KN95/respirator, eye protection, and gloves. During an interview on [DATE] between 4:20 PM and 5:30 PM DON and Administrator stated that they would not allow a COVID positive staff to work in non-COVID unit and staff are screened daily but also stated that asymptomatic COVID positive staff could pass the screening process. It was also stated that lack of eye protection increases CNA1 risk of getting infected with COVID-19. CNA1 last COVID-19 test was on [DATE] with negative results. When asked if CNA1 could be asymptomatic COVID positive and working on non-COVID unit, Administrator stated Yes, but that could be the same for any staff. When asked if CNA1 could have been COVID-19 positive but not shedding [MEDICAL CONDITION] enough to yield a positive result on [DATE] or currently COVID positive, Administrator stated it was possible. When asked if mitigation strategies such as staff screening, no visitation, and use of PPE is to keep COVID out of building, Administrator stated Yes. During an interview on [DATE] at 5:45 PM IP stated that CNA1's behaviors of not wearing eye protection puts CNA1 at risk for COVID and want to prevent COVID in non-COVID unit. CNA1 could be asymptomatic with COVID and they could be breaches in infection control. During an interview on [DATE] at about 10:10 AM LN1 stated that she worked primarily on Hall 200 and was not aware CNA1 was not wearing eye protection yesterday. When informed that yesterday CNA1 was observed wearing glasses and not eye protection, LN1 stated that she didn't know CNA1 wore glasses and stated that I just didn't notice, I wasn't aware. Review of facility's LTC (Long Term Care) Respiratory Surveillance Line List, dated [DATE], showed during time period of [DATE] to [DATE], 16 residents and 21 staff tested positive for COVID-19. Out of this total number of residents and staff who tested positive for COVID-19, 7 residents (R4, R15, R8, R16, R3, R17 and R2) resided on Hall 200 and 3 staff member (LN1, LN2, CNA3) was primarily assigned to work on Hall 200. Review of CDC's Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, updated [DATE], accessed [DATE], showed Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens . Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP (health care personnel) is newly identified in the facility; this could also be considered when there is sustained transmission in the community. Review of CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html, updated [DATE], accessed [DATE] showed HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection .They should also: Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays. Review of CDC's Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19, https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html, updated [DATE], accessed [DATE], showed Health care personnel (HCP) who had prolonged close contact with a patient, visitor, or HCP with confirmed COVID-19 who were not wearing eye protection if the person with COVID-19 was not wearing a cloth face covering or facemask should be exclude from work for 14 days after last exposure as well as advise HCP to monitor themselves for fever or symptoms consistent with COVID-19. Review of CDC's Responding to Coronavirus (COVID-19) in Nursing Homes Considerations for the Public Health Response to COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, updated [DATE], accessed [DATE], showed Resident with confirmed COVID-19 .HCP should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents .Maintain Transmission-Based Precautions for all residents on the unit at least until there are no additional clinical cases for 14 days after implementation of all recommended interventions. Review of facility's policy, Screening and Management of Coronavirus COVID-19, revision date [DATE], showed COVID-19 infection can spread very rapidly. Healthcare institutions .are particularly at-risk for outbreaks because of increased person-to-person contact Asymptomatic staff with unprotected exposure to COVID-19 positive individuals, may be excluded from work for 14 days after last exposure. Section 30. Use of Personal Protection Devices showed b. General Population: iv. White Zone: Facility Exposure continuous wear protection: 1. Gown or long sleeve scrub, KN95/respirator, eye protection, and gloves. Review of facility's policy, Transmission-Based Precautions Conventional Plan, revision date [DATE], showed Droplet Precautions: 3. Staff and visitors don a medical mask, gloves and gown when exposure is anticipated or when within 6 feet of the resident's immediate environment. If substantial spraying of respiratory fluids is anticipated, wear goggles or face shield. Review of letter to residents and family members of COVID-19 status, dated [DATE], showed The Orchards has already developed an infection treatment and containment plan to specifically address COVID-19. Our plan contains stringent protocols which were immediately implemented. The protocols include .direct care staff utilizes medical masks, face shields, and gowns for personal protection during care for all residents Record review of R2's progress notes and care plans showed resident was admitted [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at about 8:00 PM, resident was very fatigued, minimally responsive, and unable to swallow medications or drink fluids and had sporadic jerking movements. Resident was transferred to the emergency room . At the emergency room , on [DATE], resident tested positive for COVID-19. Record review of R5's progress notes and care plans showed resident was readmitted [DATE] with [DIAGNOSES REDACTED]. Resident required total assistance with grooming, dressing/ undressing and bathing, [MEDICAL CONDITION] cares and incontinence care, oral care after each meal, staff to have resident up and out of bed for all meals, and required and had suction machine at bedside. Record review of R7's progress notes and care plans showed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident required two person assistant using sit to stand and staff assistance with pericare after each incontinence episode. Record review of R8's progress notes and care plans showed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident required extensive assistance to use the toilet. Record review of R9's progress notes and care plans showed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident required extensive assistance with incontinence care. Record review of R10's progress notes and care plans showed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident required assistance every two to three hours for incontinence care. Record review of R11's progress notes and care plans showed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of R12's progress notes and care plans showed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of R13's progress notes and care plans showed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident required one staff supervision/participation in bathing, personal hygiene, oral care and incontinence care. Record review of R14's progress notes and care plans showed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident required staff participation with incontinence care, bathing, dressing and mobility. *Testing Review of facility's LTC (Long Term Care) Respiratory Surveillance Line List, dated [DATE], showed during time period of [DATE] to [DATE], 16 residents and 21 staff tested positive for COVID-19. Out of this total number of residents and staff who tested positive for COVID-19, 7 residents (R4, R15, R8, R16, R3, R17 and R2) resided on Hall 200 and 3 staff member (LN1, LN2, CNA3) was primarily assigned to work on Hall 200. Record review of R4's progress notes, lab reports, and respiratory surveillance line list showed resident was admitted on [DATE], resided on Hall 200, was almost [AGE] years old, and had symptoms consistent with COVID-19 on [DATE] and tested positive for COVID-19 on [DATE]. Record review of R15's progress notes, lab reports, and respiratory surveillance line list showed resident was admitted on ,[DATE], resided on Hall 200, was over [AGE] years old, and had symptoms consistent with COVID-19 on [DATE] and tested positive for COVID-19 on [DATE]. Record review of R8's progress notes, care plans, lab reports, and respiratory surveillance line list showed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of R16's progress notes, lab reports, and respiratory surveillance line list showed resident was admitted on [DATE], readmitted on [DATE], resided on Hall 200, was over [AGE] years old, and had symptoms consistent with COVID-19 on [DATE] and tested positive for COVID-19 on [DATE]. Record review of R3's progress notes, lab reports, and respiratory surveillance line list showed resident was admitted on [DATE], resided on Hall 200, was over [AGE] years old, and had symptoms consistent with COVID-19 on [DATE] and tested positive for COVID-19 on [DATE]. Record review of R17's progress notes, care plans, lab reports, death report, and respiratory surveillance line list showed resident was admitted on [DATE], readmitted on [DATE], resided on Hall 200, was over [AGE] years old, and had symptoms consistent with COVID-19 on [DATE] and tested positive for COVID-19 on [DATE] and died at the facility on [DATE] with COVID-19 listed as the principle cause of death. Record review of R2's progress notes, care plans, lab reports, and respiratory surveillance line list showed resident was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at about 8:00 PM, resident was very fatigued, minimally responsive, and unable to swallow medications or drink fluids and had sporadic jerking movements. Resident was transferred to the emergency room . On [DATE] at the emergency room , resident tested positive for COVID-19. *R17 tested positive for COVID-19 on [DATE]. Review of Testing events (as of 2020?08?12) document showed first testing event after R17's positive result was [DATE], seven days later. Residents who resided on Hall 200 and previously tested negative for COVID-19 should have been tested at [DATE] testing event after R17's was positive for COVID-19 but these residents were not tested : R14, R9, R2, R13, R11, R12, R18, R19, R5, R10 and R6. R2 later tested positive for COVID-19 on [DATE] after becoming symptomatic requiring transfer to the hospital. There was no documented evidence that these residents refused testing. There was no documented evidence of serial weekly testing of all resident and all staff who resided or worked on Hall 200. *R2 tested positive for COVID-19 on [DATE]. Review of Nursing schedule, dated [DATE] to [DATE] and Point of Care bladder tasks for R2 showed the following staff worked on Hall 200: CNA4 on ,[DATE], ,[DATE] and ,[DATE], CNA5 on ,[DATE], ,[DATE], CNA6 on ,[DATE], ,[DATE], and ,[DATE], LN3 on ,[DATE], and LN4 on ,[DATE]. Review of Testing events (as of 2020?08?12) document showed first testing event after R2's positive result was [DATE]. The above staff, CNA4, CNA5, CNA6, LN3 and LN4, previously tested negative for COVID-19 and should have been tested at [DATE] testing event after R2 tested positive for COVID-19 but wasn't. Review of Testing events (as of 2020?08?12) document showed first testing event after R2's positive result was [DATE]. Residents who resided on Hall 200 and previously tested negative for COVID-19 should have been tested at [DATE] testing event after R2's was positive for COVID-19 but these residents were not tested : R14, R9, R13, R11, R12, R18, R19, R10 and R6. There was no documented evidence that these residents refused testing. During an interview on [DATE] at 8:00 AM Administrator and Director of Nursing (DON) stated that the facility conducted weekly testing for [DIAGNOSES REDACTED]-CoV-2 (severe acute respiratory syndrome coronavirus 2), [MEDICAL CONDITION] that causes COVID-19 for staff who worked in the COVID unit, staff who were symptomatic or staff who wanted testing. The facility also tested staff who were symptomatic. Several staff had previously tested positive for COVID-19, with two nurses who had recovered from COVID-19 and were returning to work this week. During an interview on [DATE] at 11:30 AM IP stated that after R2 tested positive on [DATE], we tested non-verbal residents which would be R5 and R7. R6, R10 and R9 are all verbal so they can report if they are fatigue and how much they are eating so they were not tested . During an interview on [DATE] at 12:10 PM IP stated that the facility has testing every Thursdays and Fridays and we test if residents or staff are symptomatic or had exposure. In addition, COVID unit staff are tested . We use Crush the Curve and get the [MEDICATION NAME] test results within 36 hours. We just got the rapid machine for testing. During an interview on [DATE] at 3:20 PM IP stated that we call staff when they have positive COVID test results and tell them what symptoms they could be experiencing, encourage them to contact others who might have been exposed, offer PPE and sanitizer. Staff do their own notification for contact tracing. When R2 had positive COVID results, we were already watching Hall 200 closely because other residents had already tested positive in that hall. Staff were already aware of COVID positive residents and staff self-refer for testing if they feel they had exposure, staff know which staff they had lunch with or interact with or when they worked. There was no systematic process to ensure all staff and all residents who previously tested negative for COVID-19 and who worked or resided in Hall 200 were tested . Email communications, dated [DATE] at 10:53 AM, from Administrator in response to surveyor request for confirmation or additional information received from interview with IP, showed: *In response to statement Testing is available for staff every Thurs and Friday and staff avail themselves to testing, Administrator wrote Yes this is correct *In response to statement Not all staff and residents are tested whenever any resident or staff tests positive, Administrator wrote We did test the entire facility at first. We assess and look at all residents for signs and symptoms daily. Staff screened daily *In response to statement Testing events (as of 2020?08?12) document provided shows all residents and staff who have been tested (shows testing events on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and results received on ,[DATE]), Administrator wrote Correct, we also tested ,[DATE] and ,[DATE]. Email communications, dated [DATE] at 11:08 AM, showed in response to request for date when entire facility wa(TRUNCATED)

Based on a complaint from the general public, record review, observation, and staff and resident interview, it was determined the facility failed to ensure each resident received adequate supervision and care planned interventions to prevent falls. The facility did not consistently identify hazards; evaluate, analyze, and monitor interventions for effectiveness; or revise interventions as necessary to prevent further falls or injury. This was true for 6 of 10 (#s 4, 6, 9, 11, 12, and 13) sampled residents. Resident #4 sustained a humerus fracture, Resident #6 sustained a hip fracture, and Resident #9 sustained a thoracic spine fracture due to their falls, and all required surgery after their injuries. These injuries constituted harm for Residents #s 4, 6 and 9. Findings included: The facility's Falling Stars policy documented, "Falling Stars are used for residents identified at high risk for falls and/or with a history of falls (past or current). It establishes a common method of communication to remind staff to monitor these residents for fall prevention. It alerts staff to residents at risk for falls and who have approaches or interventions on their care plans to reduce and/or prevent repeat falls." Procedures included, in part: "1. Identify residents that are newly admitted or readmitted with a high-risk falls or have a potential for repeat falls: 2. Assess resident quarterly, annually, and with significant change to identify residents' change in risk status: * Falls Risk Assessment, * Medications Associated with Falls 3. Update and/or implement Falling Stars interventions if the resident is identified at high risk or has a history of falls (past or current).... 5. Communicate to caregivers the initiation of Falling Stars interventions.... 6. Monitor daily for falls and/or lack of falls to determine effectiveness of Falling Stars interventions as identified by no falls. 7. Notify and educate the Resident and/or Family member/responsible party of Falling Stars interventions.... 10. Investigate the cause of the event immediately after emergency care has been given... 12. Update the care plan interventions.... 14. Review resident's needs and remove from Falling Stars, as appropriate. The Interdisciplinary Team makes the decision to keep a resident in Falling Stars or remove a resident from Falling Stars based on the resident's individual needs based on a combination of criteria that may include: a. Review of circumstances under which the fall occurred b. History of falls c. Falls Risk Evaluation d. Resident's Medications e. Safety Judgement f. Potential for Additional Falls g. Review Environmental/Situational Factors" Documentation Guidelines for the Falling Stars policy included: * Document assessments for risk of falls or potential for repeat falls in the resident's medical record and care plan... * Update care plan... * Document fall evaluation and update care plan... * Document root cause analysis and PI Committee's action taken to reduce or prevent falls through the PI Process in the PI minutes. * Document Interdisciplinary Team decision to discontinue resident from Falling Stars Program in the resident's medical record. 1. Resident #4 was initially admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent significant change MDS assessment, dated 11/25/10, documented the following: * Moderate cognitive impairment * Hallucinations and delusions * Rejection of care occurred 4 to 6 days * Behavior status worsened * Extensive assistance of one person for physical assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing * Only able to stabilize with human assistance for moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfers * Occasionally incontinent of urine * Always continent of bowel Resident #4's MDS assessments from 11/17/09 to present all coded the resident as having moderately impaired cognitive skills. In addition, she coded for falls in her 9/2/08 MDS assessment, as well as her 12/7/08 Significant Change Assessment and next three Quarterly assessments. She was not coded for falls on her 11/17/09 Annual MDS Assessment but coded for falls for every quarterly and annual assessment since that date. The resident had previous falls assessments and scored as high risk. She scored a 24 on her 5/25/10 Nursing Partial Quarterly Assessment and a 25 on 8/24/10, both considered high risk. The resident was placed on the Falling Star program as of 1/14/2010. The Comprehensive Care Plan Report, dated 3/12/10, documented some of the following approaches for the problems of fall/safety issues, with a date of problem of 9/07/08: * 9/07/08 Encourage resident to use call light for assistance. * 9/07/08 Encourage to request assist in ambulating. * 9/07/08 Encourage to use recommended device in ambulating. FWW (forward wheeled walker), Assist with O2 (oxygen). * 9/07/08 Use appropriate seating and or devices when out of bed to decrease risk for falls, w/c (wheelchair) for long distances. * 9/07/08 Respond to call light promptly, keep call light within reach. * 4/3/09 Place basket on walker. * 8/31/09 Nonskid mat at bedside. * 1/8/10 Increase supervision NOTE: This approach had a line drawn through it with a date of discontinuation of 5/25/10. * 1/14/10 Falling star. * 1/14/10 Ant (anti) rollback brakes to w/c. * 3/1/10 Smart Mat NOTE: This approach had a line drawn through it with no date of discontinuation. * 3/5/10 Low bed with soft mat. * 3/5/10 Refuses alarms. NOTE: This approach had a line drawn through it with a date of discontinuation of 4/2/10. * 3/11/10 Commode at BS (bedside) at HS (bedtime) * 5/13/10 Room in high traffic area. Staff to check on pt (patient) as walking by. (handwritten) * 5/13/10 Encourage to keep smart mat alarm plugged in. (handwritten) As of the 6/21/10 Comprehensive Care Plan Report, the following changes/additions had been made to the approaches: * 4/2/10 AMPM (days and nights) Q 15 min (every 15 minute) checks (day/pm). NOTE: This entry had a line drawn through it and a discontinuation date of 8/24/10. * 4/2/10 Q 30 min (every 30 minutes) check NOC (at night) (Offer to asst (assist) to toilet or BSC (bedside commode) each time if awake). NOTE: This entry had a line drawn through it and a discontinuation date of 8/24/10 * 5/15/10 Bed, wheelchair, with pressure pad alarms. * 5/15/10 Encourage res (resident) to use call light and walker. * 5/15/10 Ensure call light within resident's reach at all times. As of the 8/26/10 Comprehensive Care Plan Report, the following changes/additions had been made to the approaches: The following approaches all had a line drawn through them with a discontinuation date of 9/8/10- * 9/07/08 Encourage resident to use call light for assistance. * 9/07/08 Encourage to request assist in ambulating. * 9/07/08 Encourage to use recommended device in ambulating. FWW (forward wheeled walker), Assist with O2 (oxygen). * 9/07/08 Use appropriate seating and or devices when out of bed to decrease risk for falls, w/c (wheelchair) for long distances. * 4/3/09 Place basket on walker. The remaining changes/additions were: * 8/31/09 Nonskid mat at bedside had a line drawn through bedside, with "in front of recliner" handwritten, with a start date of 9/8/10. * 9/8/10 Trans(fer) with gait belt and one assist (handwritten) * 9/8/10 Contain O2 (oxygen) tubing to prevent trip hazard. Keep room clutter free. (handwritten) * 5/15/10 Bed, wheelchair, with pressure pad alarms, (handwritten note, adding "and recliner) to approach, dated 9/8/10. * Discontinued approach of "Encourage to keep smart mat alarm plugged in," with no date of discontinuation. As of the 11/09/10 Comprehensive Care Plan Report, the following changes/additions had been made to the approaches: * Discontinued approach of low bed with soft mat, with a line drawn through and a discontinuation date of 11/23/10. * 11/12/10 1:1 (one to one) sitter 24/7 (24 hours a day/7 days a week) to help prevent falls.(handwritten) * 11/23/10 May use BSC at NOC if increased confusion or asst to use BR. * Discontinued approach of commode at BS at HS, with a line drawn through and no discontinuation date. * Discontinued approach of Bed, wheelchair, and recliner with pressure pad alarms, with a discontinuation date of 11/23/10. * 10/15/10 Self releasing alarming seat belt in w/c to remind res to call for asst and alert staff of attempt to self transfer. NOTE: This approach had a line drawn through it and a discontinuation date of 11/23/10. Resident #4 sustained the following falls: * 1/8/10 at 6:15 pm, Post-Event Assessment: "Resident while attempting to ambulate from wc (wheelchair) to BR (bathroom) fell . Resident stated she just got in a hurry." Further documented was that the resident was in a hurry to use the bathroom and did not lock the brakes on her wheelchair when she stood up. There were no alarms in place or sounding documented. No evidence of care-planning for alarms was found in the post event assessmsent. The PI (Performance Improvement) recommendations included the Falling Star program and anti-rollback brakes to the resident's wheelchair. Immediate Corrective Actions Taken were listed as Care Plan Updated and Resident Education. * 1/23/10 at 2:45 pm, Post-Event Assessment: "Res(resident) ambulating with walker. Leaned forward to pick up garbage. Lost balance and fell to floor hitting back on foot board." The resident reported dizziness with event. No alarms were in place and there was no care plan for such items documented on the post event assessmentat that time. The PI recommendations included a physical therapy evaluation and treatment and also orthostatic blood pressure checks for one week, to be sent to the physician for review. Immediate Corrective Actions Taken were listed as Care Plan Updated and Increased Supervision. * 3/1/10 at 3:45 am, Post-Event Assessment: "Resident attempted to locate O2 (oxygen) tubing which had come off and rolled out of bed." It was reported the resident had removed the oxygen tubing and was looking for it when she rolled out of bed, striking her head. No alarms were in place or care-planned. The PI recommendations were to place the resident in a low bed with a soft mat at bedside. There were no Immediate Corrective Actions Taken listed. * 3/8/10 at 5:00 am, Post-Event Assessment: "Resident ambulating back to her bed after using the toilet. Stated she got weak and fell to the ground." No alarms were in place or care planned. There were no PI recommendations. It was further documented in the section, "Why do you think event occurred," that "Resident does not call for assistance when toileting." The IDT (Interdisciplinary Team) event summary documented, "...Res with poor balance but fiercely independent. Has refused alarms in the past or removed them. Recent (increase) in confusion..." There were no Immediate Corrective Actions Taken listed. * 3/8/10 at 6:35 pm, Post-Event Assessment: "(CNA) reported res. fell backward at foot of low bed..." The boxes for "Was alarm in place" and "Was alarm sounding," were checked "yes." There were no PI recommendations after this accident. The IDT event summary documented, "Upon review of fall at foot of bed it appears this res(ident) got up from w/c to walk to BR. Alarm sounded...Will try a BSC (bedside commode) at NOC (night) so res won't try to amb(ulate) all the way to BR...." Immediate Corrective Actions Taken were listed as Alarm and Low Bed. NOTE: The low bed with a soft mat were added to the care plan on 3/5/10 and that the resident refused alarms. The alarms were not added until 5/15/10, per the care plan. * 4/1/10 at 8:30 pm, Post-Event Assessment: "Fall: Res had unassisted fall walking to the bathroom by herself. Aid found res.on bathroom floor laying on Rt (right) hip yelling help. (Alarm's went off)..." In the section, "Describe how event occurred," was documented, "...Res stated she had lit (sic) her call light, but had to get to bathroom right away..." The boxes for "Was alarm in place" and "Was alarm sounding," were left blank, even though it had been documented the alarm was heard sounding. There were no PI recommendations after this accident. Immediate Corrective Actions Taken were listed as Care Plan Updated and Suggestion possible use a 2 hr (hour) toileting program. NOTE: In a 3/12/2010 Comprehensive Care Plan Report, under the Problem, "Fall/Safety Issues..." was the approach of "Smart Mat," dated 3/1/2010. In addition, an approach of "Refuses alarms," dated 3/5/2010, had been crossed through with a handwritten note, "DC (discontinued) 4/2/10." * 4/26/10 at 6:15 am, Post-Event Assessment: "Resident turned bed alarm off and ambulated to bathroom -resident found on floor on R(ight) side had a small emesis -has a large hematoma on back of head...." Under the section, "Describe Event," it was documented, "I saw her trying to get up by herself and I assisted her to the bathroom and once she was settled on the toilet I left her alone and then I heard someone say 'help' and checking I found resident on floor." There were no PI recommendations after this accident. Further documented in the IDT event summary was, "Upon review of fall on 4/26/10 it appears res may have had an orthostatic episode. BP (blood pressure) was low after fall. Ortho BP's done today were 99/66 sitting and 77/49 standing..." Immediate Corrective Actions Taken were listed as Care Plan Updated, Inc.(reased) Supervision, Pain Assessment, and Resident care-planned not to be left unattended while in bathroom. Also put in ADL's not be leave resident unattended in bathroom. NOTE: In a Comprehensive Care Plan Report, dated 3/12/2010, under the Problem titled, "Fall/Safety Issues..." was the approach of, "Q 15 min checks (Day/PM) (every 15 minute checks day and night)," dated 4/2/2010. These were later discontinued on 8/24/10. * 6/25/10 at 10:00 am, Post-Event Assessment: "Res sitting on bed. Res attempted to rise per self. Slid to floor..." Under the section, "Describe event," was documented, "Had taken alarm." There was nothing documented in the sections, "Was alarm in place" or "Was alarm sounding." The PI Recommendations included, "Add PP (pressure pad) alarm to bed and w/c (wheelchair) as res(ident) removes tab alarm." The IDT event summary stated, "Upon review of fall to floor from bed 6/25/10, it appears res. had removed the alarm and attempted to get up... Res is an extremely high falls risk. Very poor safety awareness with occ(asional) ortho(static) BP (blood pressure) and dizziness. Her memory is highly impaired but she is strongly ind.(independent). CP (care plan) is approp.(appropriate). Res room next to nsg (nursing) station with freq.(frequent) staff checks." There were no Immediate Corrective Actions Taken listed. * 8/28/10 at 12:45 pm, Post-Event Assessment: "Resident fell to floor when ambulating. C/O (complains of) R(ight) shoulder and arm pain. Denies hitting head... Deformity felt in R(ight) humerous (sic)." Under the section, "Describe how event occurred," was documented, "...Resident care planned for alarms and there was not an alarm in place on w/c (wheelchair) where resident was sitting." In addition, under the section "Describe event," was documented, "I saw the bed alarm but forgot to move it to w/c when I helped her up." There were no PI recommendations after this accident. The IDT event summary stated, "Upon review of resident fall on 8/28/10, it appears she self transferred from w/c to her recliner at BS (bedside). Res fell to floor next to bed on mat. Res is very non-compliant... Frequently removes alarms. Often gets up and takes self to BR, trx (transfers) to recliner or w/c even with alarms and verbal reminders to ask for asst (assistance)/use call light... Alarms have not prevented res from walking about nor falling. Cont(inue) with Falling Star." Immediate Corrective Actions Taken were listed as Pain Assessment, Staff Education, Res Education and Alarm. According to hospital records, the resident sustained [REDACTED]. The resident had to undergo surgery to correct the injury. NOTE: In a Comprehensive Care Plan Report, dated 3/12/2010, under the Problem titled, "Fall/Safety Issues..." was the approach of, "Q 15 min checks (Day/PM) (every 15 minute checks day and night)," dated 4/2/2010. These were later discontinued on 8/24/10. The resident fell 4 days after the increased supervision was discontinued. * 11/8/10 at 7:30 pm, Post-Event Assessment: "Resident found on floor on R side by dresser. Alarm sounding, resident assisted to bed...." In the section, "Describe how event occurred," was documented, "Alarm sounding, CNA first to respond. No socks (bare foot) R foot, regular sock L(eft) foot. Butter on floor from dinner..." There were no PI recommendations after this accident. The IDT event summary documented, "...Resident was attempting to ambulate across the room to 'lock the door.' Resident is extremely uncompliant (sic) and d/t (due to) increased confusion becomes compulsive and doesn't use call light for safety in transfers or to make needs known... Resident has a hx (history) of falls due to noncompliance and compulsive behavior. Environmental factors include butter that was served at dinner and no nonskid socks in use. To prevent further events, staff should insure proper clean up after dinner and resident has proper footware (sic), insure all alarms are in place, and frequently ask resident what needs are." Immediate Corrective Actions Taken were listed as non skid socks and cleaned floor. * 11/11/10 at 4:45 pm, Post-Event Assessment: "Resident found on floor on R side alarm sounding. C/O hitting head. Lump noted on back of head. Resident confused but pleasant..." Under the section, "Describe how event occurred," was documented, "Resident was found on floor on her R side between window and bottom of bed with head resting on wall below window. Was last on bed; alarm was sounding on bed." There were no PI recommendations after this accident. The IDT event summary documented, "...Res with hx of freq(uent) falls r/t confusion. All precautions for falls were in place and working well. Will initiate a 15 min(ute) monitor and a 1-1 sitter." Immediate Corrective Actions Taken were listed as Inc(reased) supervision, Pain Assessment, Staff Education, Res Education and Alarm. On 12/2/10 at 2:20 pm, the DON was interviewed regarding Resident #4. The DON stated the lack of alarm on Resident #4 would not prevent a fall. She stated the resident knows how to use her call light but refuses to do so. When asked if this could be due to the cognition of the resident and her behavioral issues, she stated they had not discussed trying different psychoactive medications because the psychiatric nurse practitioner didn't want to "drug" the resident for her behaviors. The DON was asked but did not discuss any other preventative measures the facility could have taken to prevent the 11 falls the resident sustained [REDACTED]. The resident had been assessed as a high fall risk and was on the Falling Star program, had poor safety awareness and cognitive impairment; yet the facility continued to rely upon the resident to ask for help and utilize a call light. It was noted the resident had decreased falls with increased supervision and did not have any more falls after a one-to-one staff member was assigned to the resident on 11/12/10. 2. Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident's most recent admission MDS assessment, dated 11/16/10, documented the following: * Short and long term memory problem * Moderately impaired cognitive skills for daily decision making * Inattention and psychomotor retardation behaviors present * Extensive assistance requiring at least two persons for physical assistance for bed mobility, transfers, and toilet use * Extensive assistance requiring at least one person for physical assistance for dressing, personal hygiene, and bathing * Total dependence requiring at least one person for physical assistance for locomotion on and off the unit * Not steady and only able to stabilize with human assistance for moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfers * Functional limitation in range of motion for one side of lower extremities * Wheelchair for mobility * Frequently incontinent of bladder * Continent of bowel On 11/6/10, Resident #6 fell while transferring herself with no assistance from her wheelchair. She sustained a left hip fracture that required surgery and hospitalization . The resident's care plan, dated 10/28/10, (NOTE: The 10/28/10 date had a line drawn through it, and 11/10/10 handwritten to the side.) contained the Problem of Pot. (potential) for Trauma, r/t confusion, r/t recent fall with fx (fracture), and r/t anxiety. Some approaches listed were as follows: * Needs to be anticipated by staff. * Identify behavioral triggers. * Observe for early signs of agitation or increased anxiety and report to LN. It was noted this resident was on the Falling Star program but the date it had been initiated could not be determined. Resident #6's admission nursing assessment, dated 10/28/10, documented the resident's fall risk assessment as a score of 13, moderate risk. A score of 14 would have been considered high risk. Resident #6's Resident Progress Notes contained the following entries: * 10/29/10 at 4:20 am, "...T/O (throughout) the night she has required ii max assist (two person maximum assistance) with toileting...." * 10/29/10 at 8:00 am, "...Pt (patient) up to chair, unresponsive to verbal stimuli. Responsive to painful stimuli. Followed by syncopal episode lasting 3 seconds..." * 10/29/10 at 9:15 pm, "...(Resident) is alert but becomes easily confused esp(ecially) to time and place. At times she is cooperative with cares and other times she becomes resistive..." * 10/30/10 at 9:00 am, "Awake, confused, disoriented...." * 11/1/10 at 11:15 am, "...Pt re-checked. Standing BP (blood pressure) at 10:30 was 90/65...Can request help verbally, however is incapable of remembering to use call light due to dementia, seems scared at times being in her room alone...." * 11/2/10 at 5:00 am, "(Resident) is alert to herself only, she is unaware of time/place. Tonite at HS (bedtime) she became agitated and unable to decide whether she wants her covers on/off..." * 11/2/10 at unknown time, Condition Change Form: "Pt with episodes of dizziness during therapy x (for) past several days. Yesterday BP sitting was 114/80, standing 88/62..." * 11/3/10 at 4:45 am, "(Resident) is alert but very confused and disoriented 2 (secondary) to her dementia...She does not follow requests very well... She requires assist with all ADL's and transfers... She is impulsive and will get OOB (out of bed) unassisted therefore she has a pressure alarm on her bed to alert staff...." * 11/6/10 at unknown time, Condition Change Form, "(Resident)" was admitted on [DATE] to Rm (room number). She fluctuates between being cooperative with cares to being very resistive and agitated. She has had a pressure alarm on her bed and on her wh/ch (wheelchair) since admission 2* (secondary) to her declining safety awareness r/t her dementia. She triggers her wh/ch alarm multiple x's (times) during the evening with attempts to self-transfer/'go for a walk.' She also has a hx of syncopal episodes." A facility Post-Event Assessment, dated 11/6/10 at 6:40 pm, documented the following: * "'(Resident)' was heard screaming and when this nurse entered the room she was lying at the foot of the first bed, she was holding her L(eft) upper leg screaming 'I broke it, I broke it.' It is also noted she has a 1.2 cm (centimeter) by .5 cm open area on her L temple... She c/o (complains of) severely (sic) about her L hip hurting." In the area, "Describe how event occurred," was documented, "Apparently '(Resident)' became agitated in the dining room during dinner. She left the D.R. (dining room) by pushing her own wh/ch into her room. When she got into her room, she attempted to shut the door. The alarm was heard, a loud bang and the pt screaming... Apparently she stood up in her wh/ch with the foot peadals (sic) down and fell over one and twisted landing on her L hip." The DON was interviewed on 12/2/10 at 2:20 pm regarding the accident. She stated the resident had allegedly become upset with the only CNA in the dining room during the evening meal on 11/6/10. She stated the resident was upset that the CNA had to stop assisting a resident to eat and help another resident. She apparently voiced her distress with these actions to the CNA before she wheeled herself from the dining room to her room. The DON stated this occurred during shift change, and all the nursing staff were in report except the CNA who was in the dining room with the other residents. She did not say whether or not the CNA informed the nursing staff of the resident's agitation, nor that the resident had taken herself to her room alone. There was no documentation in the record to indicate the CNA informed other staff of the resident's mental state. Given the documented syncopal episodes, coupled with the resident's cognitive deficits, the facility failed to identify the care-planned behavioral triggers, anticipate the resident's needs for help with transfers, and observe and report the early signs of agitation and increased anxiety for this resident. The resident ultimately fell and sustained a fracture that required surgery and hospitalization . 3. Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 8/27/10 annual MDS assessment coded: * Moderately impaired cognitive skills, with short- and long-term memory problems * Repetitive anxious complaints/concerns, up to 5 days per week, not easily altered * No behavioral symptoms * Extensive assistance by 2 or more staff for bed mobility * Extensive assistance by 1 staff for transfers, walking, and toilet use * Unable to attempt balance test without physical help while standing * Partial physical support during balance test while sitting * Partial loss of range of motion in both legs * Unsteady gait * Mild back pain less than daily * fell with fracture in prior 31-180 days * Physical, Occupational, and Psychological therapy in prior 7 days RAPS associated with the 8/27/10 annual MDS assessment documented: * "Fall on 7/01 d/t (due to) attempt at self transfer. Resulted in compression (fracture) of T12 with kyphoplasty done on 8/11/10." * "Resident requires assistance with all cares d/t balance and mobility defecits (sic). Required (extensive) assist before fall and continues to require (extensive) assist with cares." The resident's 11/11/10 quarterly MDS assessment coded: * Moderately impaired cognition * No signs or symptoms of delirium * Resident reported feeling tired or having little energy half or more of the prior 2 weeks * No thoughts of hurting herself in the prior 2 weeks * No behavioral symptoms * Limited assistance by 2 or more staff for bed mobility, transfer, dressing, personal hygiene, and bathing * Limited assistance by 1 staff for walking * Total dependence by 1 staff for toilet use * Not steady, only able to stabilize with human assistance during balance test * No pain in prior 5 days * 1 fall without injury since admission - NOTE: This was documented in error. The resident was injured with a fracture, when she fell on [DATE]. * Physical and psychological therapy in prior 7 days * Restorative nursing programs for range of motion, transfer, and walking in prior 7 days The resident's 3/10/10 Comprehensive Care Plan included: * "Use gait belt for all transfers unless contraindicated by LN," started 9/15/08 * "Encourage to request assist in ambulating," started 9/15/08 * "Encourage to use recommended device in ambulating. FWW (front wheeled walker) for short distances," started 9/15/08 * "Transfer (with) 1 assist. Encourage to assist (with) transfer," started 9/15/08 * "Use appropriate seating and or devices when out of bed to decrease risk for falls: W/C (wheelchair) for most mobility," started 12/18/08 * A hand written addition, "Falling Star", related to "fall 4/26/10." The resident's 6/8/10 Comprehensive Care Plan included the interventions listed under the 3/10/10 care plan, with the following exception: * "Falling Star," started 5/20/10. A 10/7/10 Care Plan Update documented, discontinue falling star (due to) no falls in 3 months. The resident's 11/16/10 Comprehensive Care Plan included the interventions listed under the 3/10/10 and 6/8/10 care plans, with the following exceptions: * "Allow res (resident) privacy but remain close by when in (bathroom)," started 7/5/10 * "Remind res to use call light (and) wait for (assistance)," started 7/5/10 * No Falling Star program The resident's November 2010 physician's orders [REDACTED]. * Toprol XL 50 mg (milligrams) orally daily for hypertension, started 4/10/09 * Diovan 80 mg orally daily for hypertension, started 10/10/08 * Remeron 30 mg orally at bedtime for depressive disorder, started 6/9/10 * Celexa 40 mg orally daily for depressive disorder, started 10/12/09 * Norco 5/325 mg, 1-2 tabs orally every 6 hours PRN pain, started 8/4/10 NOTE: The Nursing 2010 Drug Handbook by Lippincott Williams and Wilkins documented the following potential adverse reactions to the medications Resident #9 was prescribed: fatigue, somnolence, dizziness, vertigo, syncope, hypotension, orthostatic hypotension, bradycardia, tachycardia, confusion, abnormal thinking, anxiety, agitation, tremors, blurred vision, and dyspnea. The resident's 3/9/10 and 6/3/10 Nursing Quarterly Assessments both documented: * Fall risk score of 30, where a score of 14 or more represented high risk * FWW with 1 assist for ambulation * Disoriented daily * Associated [DIAGNOSES REDACTED]. * "Uses device for transfer/ambulation," and "shuffled gait/balance problems" * "Decreased sensation or coordination in extremities" * "Nocturnal incontinence," "Episodes of sudden weakness, dizziness, unsteadiness (with) position," and "previous falls within 6 months" * "On a med that can cause hypotension, lightheadedness, dizziness, or meds such as hypotensive, psychotropics, diuretics, hypoglycemics" The resident fell on [DATE]. A Post-Event Assessment, dated 4/27/10, documented that the resident fell , "while ambulating from chair to bed via walker" with 1 assist. The CNA's statement included, "I'm sorry to say I didn't have my gait belt on her." In response to the question, "Why do you think event occurred?" the CNA stated, "Resident isn't very steady on feet." The Interdisciplinary Team (IDT) Event Summary concluded: "Upon review of assisted fall on 4/26/10 it appears CNA was assisting res to (transfer) from W/C to bed. Res was using FWW (and) had non skid shoes on. CNA (and) res report she (resident) lost balance when foot did not turn (with) body. CNA was unable to stop fall. CNA did not use gait belt. Will address." A 4/26/10 Condition Change Form (CCF) documented, "Resident had a witnessed fall when transferring from chair to bed via walker (with) assist. Res lost her balance and landed on left side. Assessment done (no) injuries noted. Resident denied any pain or discomfort. (Vital signs within normal limits.)" The middle section of the form was a Care Plan Update, which documented: "(Potential) for trauma. Resident will be free of falls (with) injury. Needs to be anticipated by staff. Assess cause (illegible) of previous falls and act upon (illegible) factors." The