Every finding on record at Raleigh Court Health and Rehabilitation Center

Based on observation, staff interview, and facility document review, facility staff failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings were: Facility staff stacked food storage containers one on top of each other after being washed and remained wet. Facility staff left the ice scoop inside the ice machine. On 08/11/24 at 1:15 p.m. during the initial tour of the kitchen, three (3) stacks of food storage containers were observed wet. A dietary aide who accompanied the surveyor during the tour acknowledged the containers had been washed and stacked, one on top of the other, to dry. The dietary aide unstacked the containers to dry separately. The ice scoop was observed inside the ice machine. The dietary aide removed the scoop, placed it in the holder attached to the wall beside the ice machine and stated, They know not to do that. On 08/14/24 at 4:32 p.m. during an end of day meeting with the assistant administrator, administrator, regional director of clinical services, assistant director of nursing, and regional minimum data set director, the kitchen observations were discussed. The administrator provided two policies. Both policies were from the facility's contracted hospitality services (dietary services), and both read the revision history date was October 2019. The first policy titled, Ware washing and policy 22 read in part, Action Steps 4. The Dining Services Director ensures that all dishware is air dried and properly stored. The second policy titled, Manual Ware Washing and policy 23 read in part, Action Steps 3. The Dining Services Director insures [sic] that all service ware and cook ware are air dried prior and storage [sic]. No further information was provided prior to the exit conference.

Based on staff interviews, clinical record review, and facility document review, facility staff failed to notify the resident representative of a change in condition requiring transfer for 1 of 4 closed records reviewed for the survey (Resident #113) The findings were: The facility staff failed to notify Resident #113's resident representative of the resident's change in condition. The resident was unresponsive and required a transfer to an acute care hospital. The minimum data set with an assessment reference date of 06/15/2023 assigned Resident #113 a brief interview for mental status score a 15 out of 15. The admission record listed the resident was his own responsible party and a family member as the emergency contact #1. The clinical record contained a licensed practical nurse (LPN) change of condition progress note dated 07/11/23 at 9:09 p.m. which read, pt. (patient) notice [sic] to be unresponsive to voice by writer, who attempted sternal rub with no response. vs (vital signs) 101/69 97.8 temp, 106 bpm (beats per minute), and 94% O2 (oximeter). md (medical doctor) was contacted for consultation at 2020 r/t LOC (8:20 p.m. related to level of consciousness) and BP (blood pressure) which read 86/58 approx ten minutes later. pt received IV bolus (intravenous fluids administered quickly) on previous shift, Narcan (opioid antagonist - used to reverse an opioid overdose) administered with little/no change per MD request. 911 contacted at 2030 (8:30 p.m.), sent to ED (emergency department) via ambulance at 2104 (9:04 p.m.). The same LPN wrote a Change of Condition Note on 07/11/23 at 9:20 p.m. which read, pt is own RP (Responsible Party), attempted to call emergency contact at 2119 (9:19 p.m.), busy tone received. A telehealth evaluation note with a date of service reading 07/11/23 at 7:28 p.m. central time (8:28 p.m. eastern time) read in part, Consent for telemedicine/virtual visit obtained from patient/POA: Yes. The LPN was not available for interview. A health status note dated 07/12/23 at 5:06 a.m. read the resident had been admitted to the acute care hospital. A registered nurse' health status note, written on 07/14/23 at 2:26 p.m., read the resident remained in the intensive care unit in stable condition. The regional director of clinical services (RDCS) was interviewed on 08/15/24 at 11:50 a.m. The RDCS acknowledged the clinical record did not include evidence the facility staff successfully contacted Resident #113's emergency contact. The RDCS reported not knowing for sure but felt the reason there was no more attempts to call the emergency contact was that in communication with the hospital, it was determined the hospital had notified the resident's family member. The RDCS discussed the telehealth documentation that read the patient/POA gave consent that since the resident was unresponsive, it would make sense the emergency contact gave consent. The RDCS acknowledged not knowing for sure who gave consent. On 08/15/24 at 2:44 p.m. during a meeting with the assistant administrator, administrator, regional director of clinical services, assistant director of nursing, and regional minimum data set director, the concern of whether Resident #113's emergency contact/resident representative was notified of a significant change with the resident being unresponsive upon transfer was discussed. The administrator reported no further information would be presented prior to the exit conference.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to develop a comprehensive care plan which addressed hypotension for one (1) of 23 sampled current residents (Resident #74). The findings include: Review of Resident #74's comprehensive care plan, on the morning of 8/14/24, fail to reveal evidence the resident was care planned to address low blood pressure (hypotension). Resident #74's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/9/24, was signed as completed on 5/16/24. Resident #74 was assessed as able to make self understood and as able to understand others. Resident #74's Brief Interview for Mental Status (BIMS) summary score was documented as an eight (8) out of 15; this indicated moderate cognitive impairment. Resident #74's clinical record included a medical provider order for midodrine 5 mg tablet dated 6/24/24. This order indicated the resident was to receive one (1) tablet two times a day for low blood pressure. This order indicated the medication should not be administered if the resident's blood pressure was greater than 110/50. On 8/14/24 at 9:10 a.m., the Regional Minimum Data Set MDS) staff member confirmed Resident #74's comprehensive care plan did not address hypotension. The following information was found in a facility policy titled Care Planning (with an effective date of 11/1/19): A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. On 8/15/24 at 2:42 p.m., the survey team met with the facility's Administrator, Assistant Administrator, Assistant Director of Nursing, and Regional Minimum Data Set (MDS) staff member. During this meeting, the surveyor discussed Resident #74's comprehensive care plan not addressing hypotension.

Based on observation, staff interview, and clinical record review, facility staff failed to provide adequate supervision to ensure the resident environment remained free of accident hazards for 2 of 23 current residents in the survey sample (Resident #107 and #62). The findings were: 1. For Resident #107, the facility staff failed to maintain the resident's cigarettes and lighters. The most recent minimum data set with an assessment reference date of 07/17/24 assigned Resident # 107 a brief interview for mental status score a 10 out of 15. The care plan included a focus area which read the resident was a smoker, the goal read the resident will smoke safely. For interventions, the care plan read educate on facility smoking policy, OT referral as needed, smoking apron, smoking assessment as needed. During the initial tour on 08/11/24 at 3:10 p.m., Resident #107 was lying in bed with the overbed table beside the bed. The surveyor observed one (1) pack of cigarettes and two (2) blue lighters on the overbed table. On 08/14/24 at 2:56 p.m., the surveyor observed two packs of cigarettes and a lighter on the over-the-bed table sitting beside the bed. When asked about having the cigarettes and lighter with him, Resident #107 stated the nurses took him to smoke but not always during the designated smoking times. He was not sure of the smoking times and reported there were multiple smoking areas outside. On 08/14/24 at 3:06 p.m., the surveyor notified the administrator of observing Resident #107's smoking paraphernalia (pack of cigarettes and lighters) on overbed table located beside the resident's bed. The administrator did not comment. Resident #107's clinical record contained a smoking assessment dated [DATE] at 11:22 a.m. which assigned the resident a 9.0 score. Within the smoking assessment, a score of 5 or greater, Requires supervision with smoking. The administrator provided policy #1019 titled, Patient Smoking with an effective date of 01/29/2024. The policy read in part, Procedure 7. The center will maintain all smoking paraphernalia for patients who require supervision with smoking On 08/14/24 at 4:32 p.m. during an end of day meeting with the assistant administrator, administrator, regional director of clinical services, assistant director of nursing, and regional minimum data set director, the observations of Resident #107's cigarettes and lighters at the resident's bedside were discussed. No further information was provided prior to the exit conference. 22218 2. For Resident #62, facility staff failed to ensure medications were secured as evidenced by medications left unattended on the resident's tray table. Resident #62 was admitted to the facility with diagnoses which included dysphagia, cognitive deficit after cerebral infarction, type 2 diabetes mellitus, generalized muscle weakness, and major depression. On the most recent Minimum Data Set assessment, the resident scored On 8/11/24 approximately 2:15 PM. A medication cup with 2 pills was on the overbed table. The resident said they leave them a lot. He said he would take them later. There was one chewable ASA 81 mg (milligram) and an oval capsule stamped with G 12 and scored for halving which Drugs.com suggests is metformin 1000 mg from Igneus pharmaceuticals. Clinical record review revealed that the resident had orders for aspirin 81 mg and metformin 1000 mg. On 08/14/24 at 2:30 PM Surveyor spoke with LPN #1, who was responsible for the resident on 8/11. LPN #1 was aware that the resident should be watched while taking medications because he sometimes does not take them. LPN #1 stated she had watched the resident take the noon medications on 8/11/24 (Sunday). The surveyor asked who might have left the medications in the resident's room. LPN #1 did not offer a possible name. ' 08/14/24 03:30 PM Surveyor spoke with ADON and regional director of clinical services about the medications found on the table on 8/11/24. They did not offer an explanation. During a summary meeting on 8/14/2024 which included the administrator, assistant administrator, and assistant director of nursing, the surveyor stated issue remained a concern.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure one (1) of 23 sampled current residents was free from unnecessary medications (Resident #74). The findings include: The facility staff failed to hold Resident #74's midodrine according to the medical provider's ordered parameters. Midodrine is a medication used to treat low blood pressure (hypotension). Midodrine works by constricting blood vessels to increase an individual's blood pressure. Resident #74's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/9/24, was signed as completed on 5/16/24. Resident #74 was assessed as able to make self understood and as able to understand others. Resident #74's Brief Interview for Mental Status (BIMS) summary score was documented as an eight (8) out of 15; this indicated moderate cognitive impairment. Resident #74's clinical record included a medical provider order for midodrine 5 mg tablet dated 6/24/24. This order indicated the resident was to receive one (1) tablet two (2) times a day for low blood pressure. This order indicated the medication should not be administered if the resident's blood pressure was greater than 110/50. Resident #74's Medication Administration Record (MAR) for August 2024 was reviewed on the morning of 8/14/24. It was noted that Resident #74's August 2024 MAR included documentation to indicate the resident's midodrine was administered, 20 times, when the resident's blood pressure would have required the medication to be held (not administered). The following information was found in a document titled General Guidelines for Medication Administration (with an effective date of 9-2018): - Medications are administered as prescribed in accordance with good nursing principles and practices . - Medications are administered in accordance with written orders of the prescriber. On 8/15/24 at 2:42 p.m., the survey team met with the facility's Administrator, Assistant Administrator, Assistant Director of Nursing, and Regional Minimum Data Set (MDS) staff member. During this meeting, the surveyor discussed the findings of facility staff administering Resident #74's midodrine when the parameters indicated it should not have been administered.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that residents are free of any significant medication errors for 1 of 23 sampled residents, Resident #105. The findings included: For Resident #105, the facility staff failed to follow provider orders for the administration of the medication, Cephalexin four times a day for two days as indicated. Cephalexin is indicated for the treatment of patients with certain infections caused by bacteria such as urinary tract infections. Resident #105's diagnosis list indicated diagnoses, which included, but not limited to, Traumatic Subdural Hematoma, Muscle Weakness, Urinary Tract Infection (UTI), Delirium, End Stage Renal Disease, and Dependence on Renal Dialysis. Resident #105's most recent minimum data set (MDS) with an assessment reference (ARD) of 6/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident is moderately cognitively impaired. A provider's order dated 6/7/24, read in part, .Cephalexin Oral Capsule 500 MG (milligrams) (Cephalexin) Give one capsule by mouth four times a day for UTI for 2 (two) days .Start Date 6/7/2024 .End Date 6/9/2024 . Further review of the provider orders read in part, Supply .Date Dispensed 6/7/2024 .Status On Hand . A reviewed of Resident #105's June 2024 MAR (medication administration record) revealed for Cephalexin on 6/7/2024 at 2100 (9:00 PM) and on 6/8/2024 at 0900 (9:00 AM) a code of 9, which indicated to see Other/Progress Note. A review of the progress note dated 6/7/2024 read in part, .pending pharm (pharmacy) delivery . A review of the 6/8/2024 progress note read in part, Orders-Administration Note .Cephalexin Oral Capsule 500 MG Give 1 (one) capsule by mouth four times a day for UTI for 2 Days Rsd (resident) oof (out of facility) at dialysis . According to the provider's orders and the June 2024 MAR, the medication was not given as ordered every four hours for two days. The resident received six doses of Cephalexin and the provider's order indicated the resident should have received eight doses. On 08/14/24 at 2:53 PM, the administrator (ADM#1) informed surveyor the medication was available in the omnicell (an automated medication management system), and the nurse did not pull the medication. ADM#1 did not know the reason why the nurse did not get the medication from the omnicell. This concern was discussed on 8/14/24 at 4:32 PM at the end of day meeting with the administrator, assistant administrator, regional director of clinical services, assistant director of nursing and the regional director of mds and again at the pre-exit meeting on 8/15/24 at 2:41 PM. Surveyor requested and received the facility policy titled, General Guidelines for Medication Administration, which read in part, .Medications are administered as prescribed .I .5. Always employ the MAR during medication administration .if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule .II .2. Medications are administered in accordance with written orders of the prescriber .IV .1 .the person administering the medications reviews the MAR to ensure that necessary doses were administered and documented . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/15/24.

Based on observations, staff interviews, and facility document review, the facility staff failed to ensure the posting of the required daily nurse staffing information. The findings include: On 8/13/24 at approximately 10:25 a.m., the surveyor observed the posted daily nurse staffing information did not include the facility's census. The Assistant Administrator was informed the posting did not include the census. The form used to post the daily nurse staffing information was titled DAILY NURSE STAFFING SUMMARY. This form included the following statements: - Post this document in a prominent place; accessible to patients and visitors. Complete at the beginning of each shift; update any changes to information as needed. - Retain Nursing Staffing Data for 18 months. On 8/13/24 at 10:44 a.m., the surveyor reviewed the facility's retained documentation of posted daily nurse staffing information with the Administrator. These documents were kept in a binder but were not organized by date. The surveyor noted multiple documents were missing some of the required information. The following dates failed to include the facility's census: 2/26/24, 8/20/23, 8/19/23, and September 4, (no year was documented). The following dates only had the day shift (7:00 a.m. - 3:00 p.m.) information documented: 8/8/24, 8/6/24, 8/2/24, 7/29/24, 7/17/24, 7/8/24, 6/28/24, 6/24/24, 6/18/24, 5/21/24, 5/17/24, 4/15/24, 4/4/24, 4/2/24, 1/23/24, 1/16/24, and 11/27/23. On 8/14/24 at 8:46, the surveyor, with the Administrator present, reviewed the facility's retained DAILY NURSE STAFFING SUMMARY documents. The following dates did not have a DAILY NURSE STAFFING SUMMARY document: 8/11/24, 8/9/24, 8/4/24, 8/3/24, 8/1/24, 7/28/24, 7/22/24, and 7/20/24. On 8/15/24 at 2:42 p.m., the survey team met with the facility's Administrator, Assistant Administrator, Assistant Director of Nursing, and Regional Minimum Data Set (MDS) staff member. During this meeting, the surveyor reviewed the concern of the facility's DAILY NURSE STAFFING SUMMARY documents having incomplete and/or missing information.

Based on staff interview and clinical record review, facility staff failed to administer a medication for managing blood pressure (BP) as ordered by the physician/surrogate for 1 of 6 residents in the survey sample (Resident #1). Resident #1 was admitted with diagnoses including diabetes mellitus, essential hypertension, hypotension, vascular dementia, peripheral vascular disease, osteomyelitis, cognitive communication deficit, and primary and secondary malignant neoplasms. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The surveyor obtained the Medication Administration Audit report for 2/10/2024. The report indicated the resident's Midodrine HCl oral tablet 5 mg give 1 tablet three times a day for hypotension, hold for BP above 140/90 scheduled for 9 AM was administered to the resident at 11:07 AM. The administrator and corporate clinical consultant were notified of the concern during a summary meeting on 5/22/2024.

Based on staff interview, family report, and ombudsman interview, facility staff failed to treat the resident with dignity and respect as evidenced by failure to answer calls for assistance within an hour for 1 of 6 residents in the survey sample (Resident #1). Resident #1 was admitted with diagnoses including diabetes mellitus, essential hypertension, hypotension, vascular dementia, peripheral vascular disease, osteomyelitis, cognitive communication deficit, and primary and secondary malignant neoplasms. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During an interview on 5/21/2024, the ombudsman reported investigating a family concern about call bells dating from 2/9 through 2/11/2024. The ombudsman stated that 2 of the 169 calls from the resident's room over that period were answered after more than an hour. This statement was corroborated by the family report dated 5/9/2024 stating that the resident waited over 1 hour during one night and 1.5 hours during another on the same night. The surveyor requested for the resident's room from 2/9 through 2/11/2024. Facility staff were unable to obtain the call response audit report for that time period. The surveyor concluded that the allegations had likely occurred since the ombudsman stated that the reports had supported the family allegation. The administrator and corporate clinical consultant were notified of the concern during a summary meeting on 5/22/2024.

Based on staff interview and clinical record review, facility staff failed to obtain a radiological test ordered by the physician/surrogate for 1 of 6 residents in the survey sample (Resident #1). Resident #1 was admitted with diagnoses including diabetes mellitus, essential hypertension, hypotension, vascular dementia, peripheral vascular disease, osteomyelitis, cognitive communication deficit, and primary and secondary malignant neoplasms. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief Interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The surveyor interviewed the nurse practitioner (NP) on 5/21/2024. The NP reported having entered the order for the Computed tomography (CT) scan and stated the scheduler confirmed the order had been entered. Record review revealed the NP entered an order for a CT of the abdomen on 11/10/2023. During that interview, the administrator stated that the scheduler was no longer working for the facility due to issues with record-keeping, among others. The surveyor concluded the CT scan had not been scheduled per order. The administrator and a corporate consultant were notified of the deficient practice during a summary meeting on 5/22/2024.

Based on staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 1 of 6 residents, Resident #2. The findings included: For Resident #2 the facility staff failed to include an order for oxygen on the physician's order summary and failed to correctly document a physician's order in the nurse's progress notes. Resident #2's face sheet listed diagnoses which included but not limited to chronic obstructive pulmonary disease, unspecified systolic (congestive) heart failure, and major depressive disorder. Resident #2's most recent minimum data set with an assessment reference date of 08/22/23 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicated that the resident was cognitively intact. Section O, Special Treatment, Procedures and Programs coded the resident as receiving oxygen therapy while both a resident of the facility and not a resident of the facility. Resident #2's comprehensive care plan was reviewed and contained a care plan for the resident is a risk for respiratory complications secondary to COPD (chronic obstructive pulmonary disease). Interventions for this care plan included Administer oxygen as ordered and the resident is a risk for weight loss, dehydration, or malnutrition related to chronic diseases . Resident #2's clinical record was reviewed and contained a physician's order summary which read in part, Add humidification to oxygen and Sodium Chloride Intravenous Solution (Sodium Chloride). Use 500 ml (milliliters)/hr intravenously one time only for hyperkalemia, dehydration-total of 500 mls for one day. Surveyor could not locate a physician's order for use of oxygen. Resident #2's nurses' progress notes were reviewed and contained a nurse's noted dated 11/14/23 which read in part, 11/14/2023 15:38 Order Note: edema to left forearm and tricep, new order for NS (normal saline [Sodium chloride]) 500 ml/hr x 500 liters per . (name omitted), NP (nurse practitioner). Surveyor spoke with facility NP on 05/21/22 at 1:20 pm regarding Resident #2. NP stated that was supposed to be on oxygen, they were on home oxygen prior to admission due to COPD (chronic obstructive pulmonary disease). NP stated that resident wore oxygen continuously, as far as I know. NP stated resident received oxygen between 2-4 liters per minute, she could adjust her own, kinda did her own thing. Surveyor asked NP about the sodium chloride order, and NP stated they would not have ordered more than 500 ml total, due to resident having congestive heart failure. The concern of not ensuring an accurate clinical record was discussed with the administrator, assistant director of nursing, and regional nurse consultant on 05/22/24 at 12:30 pm. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to dispose of expired medications on 1 of 2 units (unit 2) ,and failed to secure medications on 2 of 2 units (unit 1 and 2). The findings included: The facility staff failed to dispose of expired medication in the medication room on unit 2 and failed to secure medications in the medication room and on a medication cart on unit 1. 12/13/22 3:05 p.m., the surveyor and Licensed Practical Nurse (LPN) #3 checked the medication room on unit 2. This medication room contained a medication refrigerator that was unlocked. Inside the refrigerator the surveyor observed a clear narcotic box that was unlocked and opened. This narcotic box contained a 30 ml bottle of Lorazepam (ativan). LPN #3 identified the residents name on the bottle as a resident that had been discharged from the facility. A review of the clinical record revealed this resident had been discharged on [DATE]. 12/13/22 3:20 p.m., the surveyor and LPN #1 checked the medication room on unit 1. This medication room included 12 bags of the IV antibiotic Ampicillin with a use by date of 11/26/22. LPN #1 identified this medication as belonging to a discharged resident of the facility. A review of the clinical record revealed that this resident had been discharged on [DATE]. This medication room also included IV Daptomycin (antibiotic) 3 bags with a use by date of 11/30/22, 3 bags with a use by date of 11/27/22, 1 bag with a use by date of 11/24/22 and 3 bags with a use by date of 11/13/22. These IV bags included the name of Resident #55. After checking the medication room, the surveyor checked medication cart #1 with LPN #2. The surveyor observed 2 drinks in the bottom drawer of the medication cart. LPN #2 stated they belonged to them and removed the items from the medication cart. 12/14/22 10:09 a.m., the surveyor observed an unattended, open, and unlocked medication cart on unit 1. The medication cart had an open drawer with the narcotic book laying on top of the drawer, the narcotic keys were observed to be in the narcotic box. The surveyor observed a red pill and white pill in a clear medication cup on top of the cart. The surveyor stayed beside this cart until the nurse returned. When LPN #4 returned to the medication cart they stated they had been assisting a certified nursing assistant (CNA) and identified the medications as Colace and a blood pressure medication. LPN #4 stated they should not have left the medication cart open but did not know what to do. Numerous staff were observed in the hallway and one resident sitting in a doorway near the medication cart. During this observation no staff member acknowledged the open and unattended medication cart. 12/14/22, Regional Nurse Consultant (RNC) provided the survey team with a copy of the facility policy titled, Storage of Medications effective 09/2018. This policy read in part, .Medications and biologicals are stored, safely, securely, and properly .Outdated .medications .are immediately removed from inventory, disposed of according to procedures for medications disposal . The RNC also provided the survey team with a copy of the policy titled, Administration Procedures for All Medications. This policy read in part, .All medication storage areas (carts, medications rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse . 12/19/22 5:11 p.m., the RNC, Regional Minimum Data Set assessment nurse, and Director of Nursing #3 were made aware of the issues regarding the expired medications, unattended medication cart, unlocked medication cart, unsecured narcotics, and personal drinks on a medication cart. No further information regarding this issue was provided to the survey team prior to the exit conference on 12/19/22.

Based on staff interview, clinical record review and facility document review, the facility staff failed to consistently have pharmacy recommendations available for review, and failed to ensure pharmacy recommendation were followed up on by the provider for 1 of 5 resident's sampled for unnecessary medications. Resident #54. The findings included: 1. The facility staff failed to ensure pharmacy recommendations were consistently available for review. During the clinical record review, the surveyors were unable to consistently locate pharmacy recommendations in the clinical record. On 12/19/22 at 1:03 p.m., Regional Nurse Consultant (RNC) stated the pharmacy recommendations should have been uploaded into the clinical record and it was ultimately the responsibility of the Director of Nursing (DON) to ensure they were addressed and uploaded. On 12/19/22 at 3:00 p.m., the facility provided the surveyor with a copy of their policy titled, Medication Regimen Review, effective 08/20/20. This policy read in part, .The consultant pharmacist reviews the medication regimen of each resident at least monthly .The findings are phoned, faxed or e-mailed within 24 hours, or in accordance with facility policy, to the Director of Nursing or designee, and are documented and stored with the other consultant pharmacist recommendations in the resident's active record . 12/19/22 5:11 p.m., the RNC, Regional Minimum Data Set Assessment (MDS) nurse, and DON #3 were made aware of the issue regarding the pharmacy recommendations. No further information regarding this issue was provided to the survey team prior to the exit conference on 12/19/22. 2. The facility staff failed to ensure that pharmacy recommendations were reviewed by the attending physician regarding what, if any, action was to be taken regarding Lorazepam 0.5mg tid (three times a day) for Resident #54. Resident #54's admission record listed diagnoses information to include, myocardial infarction, type 2 diabetes mellitus, Cushing's syndrome, major depressive disorder, anxiety disorder, and Crohn's disease. On the minimum data set with an assessment reference date of 11/21/2022, the resident scored a 12 out of 15 on the brief interview for mental status. A document titled, Consultant Pharmacist Recommendation to Physician signed by the consultant pharmacist and dated 11/28/2022 was provided by the Regional Nurse Consultant who was acting in place of the facility's director of nursing (DON) who was absent for most of the survey. The document read in part, 12.19.22 This resident has been taking Lorazepam 0.5mg TID since 5/5/2022 without a GDR [gradual dose reduction]. Could we attempted a dose reduction at this time to perhaps Lorazepam 0.5mg BID [twice a day] to verify this resident is on the lowest possible dose? If not, please indicate response below. There was no written response from the physician. The nurse consultant acknowledged there was no provider acknowledgement and/or instruction on the form. Resident #54's medication administration record (MAR) for December 2022 was reviewed on 12/19/2022. Lorazepam 0.5mg 1 tablet by mouth three times a day for anxiety was noted with the medication documented as administered three times a day through the second dose on 12/19/2022 at 2:00 p.m. The nurse consultant acknowledged the medication continued being given three times a day after the pharmacy recommendation to change to twice a day on 11/28/2022 without documented guidance from the provider regarding whether or not to accept recommendations. No further information was provider prior to exit conference. 28567

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for 1 of 24 residents, Resident's #209 and failed to initiate physician orders following an office visit for 1 of 24, Resident #100. The findings included: 1. The facility nursing staff failed to administer Resident #209's Miramax powder per the providers order. Resident #209's diagnoses included, but were not limited to, diabetes and muscle weakness. There was no completed minimum data set assessment on this resident. The clinical record included an admission/readmission nursing collection tool completed on 12/09/22 that indicated Resident #209 was orientated to person, place, time, and situation. Resident #209's clinical record included a provider order for Miralax powder 17 grams give 1 scoop by mouth one time a day for constipation. Date of order 12/09/22. The scheduled time for administration was documented as 9:00 a.m. 12/14/22 8:15 a.m., the surveyor observed Licensed Practical Nurse (LPN) #4 prepare and administer Resident #209's morning medications. The surveyor did not observe LPN #4 administer Miralax to this resident. 12/14/22 10:09 a.m., LPN #4 stated they had poured Miralax in Resident #209's water and administered the Miralax to Resident #209. 12/14/22 10:30 a.m., Resident #209 stated they could taste the Miralax in their water and they did not taste it this morning. The Administrator and Regional Nurse Consultant were made aware of the medication error during an end of the day meeting with the survey team on 12/14/22 at 4:00 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference on 12/19/22. 22218 Based on observation, resident interview, staff interview, clinical record review, the facility staff failed to ensure the highest practicable well being for one of 24 residents, Resident's #209, and failed to initiate physician orders following an office visit for one of 24. (Resident #100). 2. Resident #100 was admitted to the facility with diagnoses including fractures of lower limb, ribs, and spine, essential hypertension, major depression, anxiety, and degenerative disease of the nervous system. On the Minimum Data Set assessment, with assessment reference date 10/20/22, the resident scored 15/15 on the brief interview for mental status, and was assessed as lacking signs of delirium, psychosis, or behaviors affecting care. The resident was assessed as requiring the limited assistance of 2 persons for personal hygiene, and total dependence on 2 or more persons for bathing. Staff documented that the resident required nursing care after recent orthopedic surgery. On 12/19/22, Resident #100 told the surveyor that the resident had visited a physician office on 11/30/22. Upon return to the facility, the resident gave the nurse paperwork from the physician. The nurse copied the paper and gave the resident the copy. The resident checked the paper on 11/19 to see what time the follow-up appointment was and discovered there were new orders for wound care. The surveyor reviewed the consultation report and agreed that there were new wound care orders. Under the physician signature, a physician assistant who works with the medical director wrote 'please initiate orders', and signed it on 12/6/22. The surveyor interviewed the unit manager, who stated the resident had gone to a specialist office on 11/30/22. The unit manager was unaware of the physician assistants' directive to initiate the orders. The orders were initiated on 11/19/22. On 12/19/22, the surveyor reported the ongoing concern with following physician orders to the regional nurse consultant (covering for the administrator, DON, ADON, and staff development coordinator).

Based on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to provide activities of daily living care for 4 of 24 residents, Residents #109, #79, #100, and #209. The findings included: 1. For Resident #109, the facility staff failed to complete activity of daily living (ADL) care for a dependent care resident. This was a closed record review. Resident #109's diagnoses included, but were not limited to, plantar fascial, fibromatosis, obstructive sleep apnea, diabetes, chronic pain, pain in right foot, non-displaced fracture of proximal phalanx of right great toe, and morbid obesity. The clinical record included an Admission Assessment/Screening dated 05/08/21 that indicated the resident was alert and orientated to person, place, time, and situation. The portion of the admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/15/21 did not include a cognitive score. Section G (functional status) was coded 3/3 (extensive assist of two persons) for personal hygiene and 4/2 (totally dependent on 1 person) for bathing. Resident #109's comprehensive care plan included the following focus areas-Activities of daily living (ADL) self-care performance deficit. Interventions included, but were not limited to, AM routine, bathing/showering, bed mobility, dressing, eating, personal hygiene, toilet use, transfers resident is able to assist PRN (as needed), allow the resident to make decisions about treatment regimen to provide sense of control. A review Resident #109's bathing documentation for the months of May and June 2021 indicated Resident #109 received a shower on June 3, 2021, no other showers were documented. For May 2021 bed baths were documented on May 13, 20, 24, and 31. The facility nursing staff had documented the resident had received a bath/shower/bed bath on May 10, 2021. For June 2021 bed baths were documented on June 14, 21, 24, and 28. Refusals were documented on May 17 and June 17, 2021. The facility provided no further documentation regarding bathing. 12/14/22 2:07 p.m., therapy staff #2 stated they had a shower bench and a shower stretcher that certified nursing assistants (Cans) could utilize for bathing if needed. 12/14/22 3:24 p.m., Physical Therapy (PT) staff #1 stated this resident was receiving therapy services for self-care. However, billing of self-care was not always for bathing it could be dressing. The OT (occupational therapy) plan of care was bathing and hygiene etc . Self-care was billed for the month of May 2021-12 times between 05/10 and 05/31 and for June-June 1, 2, and 3. Resident #109 was discharged from therapy on June 4, 2021. 12/14/22 4:00 p.m., end of the day meeting with the Administrator and Regional Nurse Consultant (RNC). The RNC stated the expectation for bathing is the resident should receive a bath/shower 2 times a week based on regulations and bed bath everyday if not bathed/showered. The RNC added CNA's were responsible for giving baths. 12/15/22 8:55 a.m., CNA #1 stated they did not believe Resident #109 was able to get a shower as they were a slide board transfer. But they did see this resident get a bed bath and they gave a few. 12/15/22 CNA #2 stated this resident received a lot of bed baths. 12/16/22 CNA #7 stated they did not remember this resident. However, CNA #7 stated they gave their showers, they worked together, if the resident did not get a shower, they gave a good bed bath and they would stay over if they needed to. 12/19/22 5:11 p.m., the RNC, Regional MDS nurse, and Director of Nursing #3 were made aware of the issue regarding Resident #109 and ADL care. No further information regarding this issue was provided to the survey team prior to the exit conference on 12/19/22. This is a complaint deficiency. 22218 Based on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to provide activities of daily living care for four of 24 residents, Residents #109, 79, 100, 209. 2. Resident #79 was admitted to the facility with diagnoses which included multiple sclerosis, local infection of skin, right hip pressure ulcer, hypertension, and major depression. On the quarterly Minimum Data Set assessment with assessment reference date 11/17/22, the resident scored 12/15 on the brief interview for mental status, indicating the resident's cognitive status was essentially intact, and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The resident required extensive assistance of 1 person for personal hygiene and was totally dependent on 1 person for bathing. During initial tour on 12/13/22, the resident reported to the surveyor that the facility was chronically short of staff. The staff shortage resulted in long waits for incontinence care, not being bathed, and missed wound treatments. The surveyor asked the resident why the resident believed the care issues were the result of staff shortages and the resident responded that is the reason staff give when asked. State nursing home regulations require residents be offered 2 shower baths per week or daily bed baths. The resident's clinical record indicated the resident received no showers from 12/1/22 through 12/13/22, when the surveyor raised the issue with facility administration, and 1 shower on 12/13 and 12/16/22 during the survey. The ADL bed bath record documented bed baths on December 3rd (21:33 PM), 4th (9:40 AM), 5th (00:28 AM), 6 (10:11 AM), 7 (20:38 PM), 9 (9:58 AM), 10 (14:59 PM), 13 (6:40 AM), 13 (21:25 PM). The surveyor asked the resident about the documented bed baths. The resident reported nursing assistants only cleaned what was needed after incontinence episodes. The resident's comprehensive care plan did not address the resident's need for bathing assistance. During a summary meeting on 12/14/22 at 4 PM, surveyors reported a concern with bathing to the administrator and corporate nursing consultant and asked about the facility bathing policy. The consultant stated there was no corporate policy, but that the expectation based on regulations was that residents would have 2 showers or bed baths per week. The administrator stated no one had told him they were not getting showers. A staff member who asked not to be identified to management, Other #4, reported during an interview that the issue with showers was known. In Other #4's opinion, the large number of agency staff leads to showers not being offered on schedule. Residents report that showers have not even been offered and that bed baths are not offered as an alternative to showers. Some residents have told regular staff members that aids tell them that therapy is responsible for bed baths. On 12/19/22, the surveyor reported the ongoing concern to the regional nurse consultant (covering for the administrator, DON, ADON, and staff development coordinator). 3. Resident #100 was admitted to the facility with diagnoses including fractures of lower limb, ribs, and spine, essential hypertension, major depression, anxiety, and degenerative disease of the nervous system. On the Minimum Data Set assessment with assessment reference date 10/20/22, the resident scored 15/15 on the brief interview for mental status and was assessed as lacking signs of delirium, psychosis, or behaviors affecting care. The resident was assessed as requiring the limited assistance of 2 persons for personal hygiene and total dependence on 2 or more persons for bathing. Staff documented the resident required nursing care after recent orthopedic surgery. The resident reported not receiving shower baths on a regular basis. On 12/14/22 at 1:49 PM, the resident reported to surveyor that one night she had diarrhea and waited 2 hours after calling for help. No nursing staff came, but the therapist came for the scheduled therapy session and cleaned her and changed her clothes. The occupational therapist confirmed that the resident reported calling for staff to change bedding and provide incontinent care for 2 hours before COTA arrived. The resident's ADL shower report documented December showers on 12/6, 12/13, and 12/16. The ADL bed bath report indicated that the resident received bed baths on December 3, 4, 5, 6 (at the same time as the shower), 7, 8, 13, 14 (two on this date), 16 (two on this date, one at the same time as the shower), 17, and 18. During a summary meeting on 12/14/22 at 4 PM, the surveyor reported a concern with bathing to the administrator and corporate nursing consultant and asked about the facility bathing policy. The consultant stated there was no corporate policy, but that the expectation based on regulations was that residents would have 2 showers or bed baths per week. The administrator stated that no one had told him they were not getting showers. A staff member who asked not to be identified to management, Other #4, reported during an interview that the issue with showers was known. In Other #4's opinion, the large number of agency staff leads to showers not being offered on schedule. Residents report that showers have not even been offered and that bed baths are not offered as an alternative to showers . Some residents have told regular staff members that aids tell them that therapy is responsible for bed baths. On 12/19/22, the surveyor reported the ongoing concern to the regional nurse consultant (covering for the administrator, DON, ADON, and staff development coordinator). 4. Resident #209 was admitted to the facility with diagnoses including acute osteomyelitis, orthopedic surgical aftercare, rheumatoid arthritis, type 2 diabetes mellitus, chronic ulcer of foot, hypertensive heart disease with heart failure, and Charcot's joint, ankle, and foot. Facility staff had not completed a Minimum Data Set assessment at the time of the survey. Surveyors determined that the resident was capable of answering questions concerning care. Review of the residents' clinical record revealed that no showers were provided from 12/9/22 through 12/19/22. Bed baths were documented 12/10, 13, 15, and 16. During a summary meeting on 12/14/22 at 4 PM, surveyors reported a concern with bathing to the administrator and corporate nursing consultant, and asked about the facility bathing policy. The consultant stated there was no corporate policy, but that the expectation based on regulations was that residents would have 2 showers or bed baths per week. The administrator stated no one had told him they were not getting showers. On 12/19/22, the surveyor reported the ongoing concern to the regional nurse consultant (covering for the administrator, DON, ADON, and staff development coordinator).

Based on clinical record review, staff interview, and facility document review, and during the course of a complaint investigation the facility staff failed to provide notice of room change for one of 24 residents in the survey sample, Resident #108. The findings include: The facility failed to provide the resident with any notice, written or verbal, prior to moving her to another room. Resident #108 was admitted to the facility on [DATE]. Diagnosis included but were not limited to Wernicke's encephalopathy, bipolar disorder, suicidal ideations, major depressive disorder, homelessness, alcohol dependency. This was a closed record review and surveyor was not able to interview this resident. According to the census in the electronic medical record, resident #108 was moved to different rooms on 7/13/21, 7/14/21 and 8/4/21. There is no indication that the room moves were discussed with them for the 7/14/21 and 8/4/21 moves. A progress note dated 7/13/21 at 11:59 am read, PT (patient) moved from room [ROOM NUMBER] A due to clinical need. PT is own RP (responsible party). On 12/13/22 3:15 pm surveyor met with social worker/discharge planner and assistant. Neither were employed at the facility in 2021 and are not familiar with resident #108 and had no documentation to indicate the resident was notified of the room changes. Surveyor Requested and received a policy entitled, Bed management/room changes with an effective date of 9/30/22 that read in part, Social worker and discharge planning staff, in conjunction with the interdisciplinary team will strategically evaluate and internally manage placement of skilled and extended care patients to enhance quality of care and services, and Provide timely and efficient room changes through internal transfers with proper documentation using the Room Change Assessment Notification form. During a meeting on 12/14/22 at 4:06 pm with the regional nurse consultant, the surveyor discussed this matter and asked if there were any documents to support resident #108 was notified of the room changes. Nurse consultant indicated that there were no documents. This concern was discussed again on 12/19/2022 at 5:46 pm with the regional nurse consultant and regional MDS consultant. No further information was provided to the survey team prior to exit.

Based on family interview, staff interview, and clinical record review, facility staff failed to notify the RP and/or physician with significant changes to resident status for one of 24 current residents in the survey sample (Resident #85). On the Minimum Data Set assessment with assessment reference date 9/14/22, Resident #85 scored 11/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The residents' diagnoses included chronic venous insufficiency, cerebral infarct, diabetes mellitus with peripheral angiopathy, atrial fibrillation, heart failure, chronic kidney disease, essential hypertension, morbid obesity, bacterial pneumonia, and chronic pain. On 12/19 at 9:30 AM, the surveyor interviewed the residents' Power of Attorney (POA) at his request. The POA stated that the administrator said that the POA was not empowered to make decisions for the resident. The POA is not always notified when changes occur in the residents' status and the resident has been sent to medical appointments without the POAs knowledge. The POA is not notified when the resident does not receive care or treatments. The POA has requested that staff call when the resident refuses care, treatment, or feeding so that a family member can convince the resident to accept treatment or eat meals. The POA stated the administrator told him that he was not empowered to make decisions for the resident. Clinical record review revealed the resident was listed as the responsible party under the Contact list with the POA spouse as emergency contact #1 and the POA as emergency contact #2. The surveyor noted a physician order dated 12/16/22 for STAT X-ray of cervical spine 3 view d/T pain. Mobile imaging d/T inability to transfer and a second order dated 12/18/22 for STAT X-ray of cervical spine 3 view d/T pain. Mobile imaging d/T inability to transfer one time only for 1 day. Progress notes did not mention an order for the X-ray on 12/16/22. A note dated 12/16/22 11:56 AM Late Entry: Resident had an X-ray of neck this shift. A progress note dated 12/18/11 at 12:38 PM noted the imaging service reported that the resident refused to allow the technician to perform the X-rays on 12/16. The resident's' #1 emergency contact was notified the X-ray was not performed and the contact stated the resident was not able to refuse treatment. A note dated 12/18 at 11:11 AM documented the physician ordering the X-ray and lab work stat (repeating the order from 12/16/22). The surveyor concluded the physician had not been notified when the STAT X-ray and lab order was not completed on 12/16/22. Other progress notes indicated treatment refusal without notification of POA or physician were written on 12/18 at 6:19 AM, PT refused CPAP, and on 12/17 20:58 and 22:02 PM Resident #85 refused X3. Education was provided. On 12/19/22 at 3:25 PM, the surveyor reported the concern to the regional nurse consultant (covering for the administrator, DON, ADON, and staff development coordinator). Staff acknowledged that the responsible party and physician were not always informed of changes in the residents' condition or when ordered treatments were not performed.

Based on observations, staff interviews, and resident interview the facility staff failed to maintain a clean and homelike environment in one of two shower rooms (Unit 1 Shower Room). The findings: On 12/19/22 at approximately 1:00 p.m., a resident, who was not included in the sample, reported the shower room on Unit 1 had black mold in the shower. LPN #1 (licensed practical nurse) accompanied one surveyor to the Unit 1 Shower room for observation 12/19/22 at 1:08 p.m. A black substance was noted in the grout, not on the tile, of the shower. There was no odor noted. LPN #1 applied a glove and attempted to scratch one of the discolored areas on the grout. The nurse's glove remained clean after attempting to scratch the black substance. LPN #1 stated she would notify maintenance. The Regional Nurse Consultant who was acting in place of the director of nursing (DON) as well as acting in place of the administrator due to both of their absences during the survey, was informed of the shower room observation on 12/19/22 at 1:15 p.m. At approximately 2:30 p.m. on 12/19/22, the maintenance director reported (after observing the shower room) the black substance was mildew, not mold, and only in the grout of the shower, not on the tile itself. The director explained that although the shower rooms were on a list of interior places to inspect daily, it often gets missed when the shower was being used at the time of the inspection. He stated he should return to inspect the shower room when it was unoccupied. The maintenance director stated soap scum sits on the walls and should be scrubbed routinely. The director met with the housekeeping director and developed a plan for routine cleaning. No further information was provided prior to the exit conference.

Based on personnel record review, facility staff failed to obtain a criminal background check prior to employment for one of 25 staff members reviewed. Facility Policy Number 702 titled Abuse/Neglect/Misappropriation/Crime Prevention/Screening/Training states under PROCEDURE: 1. Criminal background and reference checks are performed on all employees. The surveyor reviewed the employment records of 25 employees hired since the last standard survey. One non-clinical employee's record did not contain a criminal background check. The surveyor informed the regional nurse consultant (acting as director of nursing and administrator) of the issue on 12/16/22. A background check dated 12/19/22 revealed several convictions. The surveyor reviewed the convictions with the nurse consultant and concluded none were barrier offences. On 12/19/22 at 3:25 PM, the surveyor reported the concern to the regional nurse consultant (covering for the administrator, DON, ADON, and staff development coordinator).

Based on family interview, clinical record and staff interview the facility staff failed to honor the legal Power of attorney (POA) for one of 24 residents sampled (Resident #85). On the Minimum Data Set assessment with assessment reference date 9/14/22, the Resident #85 scored 11/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The resident's diagnoses included chronic venous insufficiency, cerebral infarct, diabetes mellitus with peripheral angiopathy, atrial fibrillation, heart failure, chronic kidney disease, essential hypertension, morbid obesity, bacterial pneumonia, and chronic pain. On 12/19 at 9:30 AM, the surveyor interviewed the resident's Power of Attorney (POA) at his request. The POA stated that the administrator has said that the POA was not empowered to make decisions for the resident. The POA is not always notified when changes occur in the resident's status and the resident has been sent to medical appointments without the POA's knowledge. The POA is not notified when the resident does not receive care or treatments. The POA has requested that staff call when the resident refuses care, treatment, or feeding so that a family member can convince the resident to accept treatment or eat meals. The POA stated the administrator told him that he was not empowered to make decisions for the resident. The resident's POA provided the surveyor with a copy of the durable power of attorney filed with the court, a notarized medical advance directive naming the POA as decision-maker, and an assessment of capacity dated 7/14/21 signed by the facility's medical director stating the resident lacked capacity to understand his medical condition and make decisions concerning treatment. Clinical record review revealed the three forms were present in the resident's record filed under the miscellaneous tab. The resident was listed as the responsible party under the Contact list with the POA spouse as emergency contact #1 and the POA as emergency contact #2. On 12/19/22 at 3:25 PM, the surveyor spoke with the regional nurse consultant (covering for the administrator, DON, ADON, and staff development coordinator) stated she had spoken with the administrator who reported he had told the POA that he was not empowered to make decisions for the resident, but had been unaware the physician had deemed the resident incompetent.

Based on family interview, staff interview, complainant interview, clinical record review and facility record review, and during a complaint investigation, facility staff failed to provide assessment and treatment as evidenced by failure to treat and assess a non-pressure skin wound as it progressed to a full thickness wound for 1 of 3 residents in the survey sample (Resident #1). Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. 8/11/2020), tinea pedis (dx. 8/11/2020), diabetes mellitus with diabetic [MEDICAL CONDITION] and diabetic ophthalmic complication, presence of cardiac pacemaker, [MEDICAL CONDITION], and [MEDICAL CONDITION]. On the minimum data set assessment with assessment reference date 8/12/2020, the resident scored 9/15 on the brief interview for mental status and was assessed as vision and hearing impaired, and without signs of [MEDICAL CONDITIONS], or behaviors affecting care. The resident was assessed as having no venous or arterial ulcers and with an infection of the foot. The surveyor spoke with the resident's responsible party (RP) by phone on 12/2/2020. The RP repeated the complainant's allegations that the resident had been admitted to the hospital with [REDACTED]. The RP stated the nurse assigned to the resident on 11/21 told the RP that Resident #1's condition was not an emergency and the resident could not be sent to the hospital. The RP stated that the resident was allowed to go to the hospital after she insisted and called 911. Hospital admission records documented that the resident arrived at the hospital with EMS on 10/21/2020 at 18:04. Notes indicated EMT had reported during transport a BP 70/0 at transport and had been told to administer 1 liter NS bolus. Hospital ED notes documented the resident's blood pressure on 10/21 at 18:13 was 119/56. The resident was documented to have toe wounds with odorous, purulent drainage and visible bone. The resident's left 2nd and 3rd toes were amputated on 10/22/2020 and the resident was treated for [REDACTED]. The surveyor noted a physician order [REDACTED]. WRAP IN KERLIX, WRAP IN ACE. weeping left foot and left toes related to CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE. The treatment administration record recorded administration of the treatment twice per day from 8/5/2020 through 10/5/2020 with the exception of 9/9 day shift and 9/15 evening shift. No descriptions of the foot and toes or wounds were documented in progress notes, wound care notes or skin assessment notes in the clinical record. The surveyor noted a physician order [REDACTED]. Apply Santyl, NAD, and Wrap with Kerlix then ACE Wrap every day shift for wound care. Again, there was no description of the foot and toes or any wounds on the foot and toes. Clinical record review revealed multidisciplinary progress notes documented no foot [MEDICAL CONDITION] prior to 8/11/20, when left lower limb [MEDICAL CONDITION] and tinea pedis were diagnosed . There were no nursing notes between 8/3/20 and 8/11/20. The 8/11/20 Medical (MD, NP,PA)note documented the resident was seen for nursing concern of warmth and drainage to left foot. The physical exam note by PA yeasty rash along dorsal side of left toes, weeping and crusting over, between toes bilaterally is [DIAGNOSES REDACTED]tous and moist with odor noted. There is [DIAGNOSES REDACTED] (dorsal side of left foot warm and tender to touch) .Tinea pedis of both feet, [MEDICAL CONDITION] of left foot, start [MEDICATION NAME] AF powder to bilateral toes and in between toes bid X 4 weeks, start keflex 500 mg q6 hours X 10 days. Nursing notes document treatment of [REDACTED]. Notes continued to indicate treatment for [REDACTED]. No description of the condition of the wound or drainage characteristics were documented. No nursing notes were documented between 8/21 and 9/5. The next nursing note to mention foot or toes was a nursing order note dated 10/5/2020 cleanse left 2nd and 3rd toes with NS (normal saline), apply Santyl, NAD, and wrap with Kerlix then ACE wrap every day shift for Wound Care. This note did not document the appearance of the foot, toes, or wound. No physician/nurse practitioner/physician assistant visit was associated with the order. The Medical Note (MD,NP, PA) dated 10/7/2020 documented [MEDICAL CONDITION] (trace [MEDICAL CONDITION] bilateral lower extremities) present. No tenderness. The note did not mention wounds, debridement, or dressing to lower extremities. The next mention of the resident's foot in notes was a nursing note dated 10/17/2020 at 12:53 'this nurse changed dressing to rsd left foot, vascular wounds to top of foot noted to have increased drainage, green discharge, slough present, strong odor noted. this nurse cleaned wound, applied santyl as ordered and wrapped with kerlix, notified (sic) NP who placed a N. O. for Keflex 500 mg Q 8 hours x 10 days. RP made aware. Nursing notes documented the resident on antibiotics for wound infection without mention of wound appearance on 10/17 at 18:19, 10/18 at 06:26, 10/18 at 21:17, and 10:19 at 06:33. The next progress note after the 10:19 note was 10/21/2020 at 13:09 concerning ear wax treatment. A nursing note dated 10/21/20 at 14:22 documented the facility wound physician ordered a vascular surgery consultation and new wound treatment and that medical director and RP were aware. The 10/21/2020 visit was the only time the wound care physician saw the resident. A note dated 10/21/2020 at 18:26 titled Infection Note documented Rsd still on ABX for wound infection on her left 2nd and 3rd toes. She tolerated the pill without any complications. No s/s of adverse reaction noted. No c/o of pain noted or voiced. VS 131/71, 97.3, 17, 60, 92%. (* See reference below) A note dated 10/21/2020 at 19:05 titled Health Status Note (responsible party name) wants pt sent to Lewis Gale Salem for wound/vascular surgery evaluation. Order from (medical director name) to send pt out per family request. (* See reference below) A note dated 10/21/2020 at 22:47 titled Health Status Note Resident admitted to LGH hospital. A late entry for discharge planning was made on 10/21/2020 at 11:18 (PM) Discharge Planning Progress notes Late entry: Resident D/C to hospital on [DATE]. RP made aware of transport. The surveyor reviewed weekly skin assessments from 7/31/21 through discharge on 10/21/20. A McGeer assessment dated [DATE] at 13:14 did not name a wound site, but the following items were checked A: pus present at wound, skin, or soft tissue and B: 2. Redness at the affected site, 3. Swelling at the affected site and C: a. Resident meets criteria for [MEDICAL CONDITION], SSTI, wound infection. The 9/11/2020 Weekly Skin Evaluation documented the skin was intact without impairment and there were no wounds present. Under 5. Notes, the nurse documented weeping left foot and toes. area wrap with 10/1/2020 documented and described a right lower leg skin tear and a left upper arm skin tear. Both skin tears were described under the Wound section of the form. Observations 5. Notes documented weeping left foot and toes. area wrap with kerlix and ACE wrap. The surveyor requested the policies concerning skin assessments. Facility staff provided Policy #2401 titled Skin Assessments. The policy stated that skin assessments will be completed for all patients. Procedure: 1- licensed nurse to conduct skin risk assessments on admission and quarterly, 2-skin risk assessment on readmission, 3- weekly skin assessment, 4- care plan based on skin risk assessment and individual needs. The surveyor discussed the findings by phone with the facility administration team (Administrator and Director of Clinical Services) on 12/10/2020. The surveyor described the failure to document the condition of the resident's foot prior to initiation of treatment on 8/4/20 and failure to document condition of the foot either in nursing progress notes or in weekly skin assessment notes. When asked, the director of clinical services (DCS) did say descriptions of wounds at treatment were expected. The only physician note addressing the wounds was the one dated 8/11/20. The one subsequent physician note did not address the wounds to the feet. ** Per clinical documentation, facility staff were unable to report when the resident left the facility or what her condition was when she left. Nursing staff were documenting the resident's status as if the resident was still in the building after the resident had been admitted to the hospital ED. The surveyor reported that the EMS low blood pressure was a concern, particularly when the facility clinical record did not document the resident's status at discharge. The surveyor expressed concern that the resident's foot was not assessed by a physician between 8/11/2020 and 10/21/2020. The administrator stated that the EMT low blood pressure was likely an error in light of the blood pressure obtained at admission to the ED. A wound physician assessment note that was not in the clinical record at the time of the review was forwarded to the surveyor. That note was dated 10/21/2020. The time of assessment was not documented, but the assessment described both toes in question and ordered a vascular surgery consultation. The surveyor concluded that the time gap between the first physician assessment documenting the foot wounds on 8/11/20 and the next physician assessment on 10/21/20 (exacerbated by the failure of the physician to assess the wounds on 10/7/20) contributed to the resident being transferred to a higher level of care and a delay in treatment. In addition, facility staff's failure to regularly document the condition of the resident's foot wounds, either in nursing progress notes or in periodic skin assessment notes made it impossible to determine when the wounds formed and the resident's condition deteriorated. The surveyor was unable to determine who ordered the wound physician consultation, when it was ordered, or what the resident's condition was at the time. The surveyor concluded that these failures constituted neglect of the resident that resulted in harm to the resident. The facility administrative team were notified of the surveyor's conclusions during a phone conference call on 12/14/2020. This is a complaint deficiency.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure 1 of 28 residents (Resident #99) was free of accident hazards as evidenced by failure to ensure the resident was transferred with the correct size sling when using the mechanical lift, which resulted in resident injury. The findings included: Resident #99 was transferred with the incorrect sling when being transferred with the Hoyer lift. This resulted in the sling breaking and the resident fell to the floor. Resident #99 was evaluated at a local hospital and was diagnosed with a closed reduction (dislocation) left shoulder. This was a closed record review due to an FRI (facility reported incident) that was reported to the OLC (Office of Licensure and Certification). The face sheet in the EHR (electronic health record) included the diagnoses cerebral infarction, essential (primary) hypertension, and morbid (severe) obesity. Section C (cognitive patterns) of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 05/12/2019 included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. Section G (functional status) was coded to indicate the resident required extensive assistance of two people (3/3) for bed mobility and transfers. Walk in room/corridor was coded (8/8) indicating this activity did not occur. The resident was coded as having functional limitation in range of motion in the upper and lower extremities on one side (1/1). For mobility devices, the resident was coded as using a wheelchair. The resident's comprehensive care plan included the focus area resident has an activities of daily living self-care performance deficit. Interventions included Hoyer lift with 2-person assist. Resident #99's height located under the vital sign tab in the EHR was documented as 65 inches. There was no documented weight for 07/2019. On 06/06/2019, the residents weight was documented as 260.4 pounds for 08/01/2019 the residents weight was documented as 261 pounds. The clinical record included the following progress note dated 07/08/2019 at 2:37 p.m., This nurse alerted to resident's room by CNA (certified nursing assistant), observed resident on the floor beneath the Hoyer lift, lying on left side. Resident stated, I fell from the lift. CNA's reported that lift pad had ripped while resident was in the air .Assessed resident from head to toe., VS (vital signs) BP (blood pressure) 195/85, temp 97.7, O2 (oxygen) 93, Notified Dr.____ MD, order to send to ED (emergency department) for eval. RP (responsible party) _____ aware . The facility provided the surveyor with a copy of the ED (emergency department) report dated 07/08/2019. This ED report read in part, .presents to _____ ED via EMS (emergency medical service) from ______ (facility) with chief complaint of shoulder pain s/p (status post) fall. Friend at bedside reports patient as being lifted in a Hoyer lift into bed today, however at the highest point above the height of the bed, one side of the lift broke, causing pt (patient) to fall onto the hard ground and onto .left side .did hit .head, for which .complains of a generalized headache, but denies any LOC (loss of consciousness) .Xrays have processed. Left shoulder is dislocated .Performing nerve block to the left shoulder at bedside .Attempting closed shoulder reduction at bedside. Reduction unsuccessful. Will prep for conscious sedation .Performed conscious sedation and closed reduction at bedside .Medications administered in ED .[MEDICATION(S)] (LOPRESSOR) tablet 100 mg .[MEDICATION(S)] .0.1 mg .[MEDICATION(S)] .2 mg Intravenous .Procedures: Nerve Block .Conscious Sedation .The patient was given [MEDICATION(S)] .CLOSED REDUCTION (DISLOCATION)-Left shoulder .the patient will be discharged back to nursing facility .Care Timeline 1505 Arrived .2316 discharged . New orders transcribed on 07/09/2019. [MEDICATION(S)] 50 mg give 1 tablet by mouth every 6 hours for pain until 07/14/2019. Acetaminophen 500 mg every 6 hours for pain until 07/19/2019 give with [MEDICATION(S)]. Sling to left arm to remain in place every shift for dislocated left shoulder for 3 days. The resident had a previous prn (as needed) order for [MEDICATION(S)] that was put on hold when the scheduled order was obtained. The facility nursing staff documented they administered this on 07/09/2019 at 7:54 a.m. for a pain level of 8. The facility staff documented this medication was effective. The office of OLC received a fax from the facility indicating that on 07/08/2019 the Resident fell to floor from Hoyer lift. Lift pad ripped while in air. The facility sent the office of OLC a follow-up to this incident on 07/10/2019 that read in part, This letter is in regards to a Facility Reported Incident submitted on 7/8/2019. On 7/8/2019, ______ (Resident #99) fell to the ground from the hoyer lift. The hands on the pad used to lift her, ripped while 2 CNA's (certified nursing assistants) had .suspended in the air .sent to the hospital for evaluation immediately following the incident and returned several hours later with a dislocated left shoulder, and no other injuries. Staff education is being completed related to using the hoyer lift. Our investigation concludes that no abuse or neglect occurred. There is no follow up needed at this time . The facility administrator had signed this letter. 03/11/2020 3:05 p.m., during an interview with the DON (director of nursing) the DON provided the surveyor with a typed statement that revealed the resident had fell from the lift when 2 CNA's (CNA #1 and CNA #2) were using the wrong size lift pad, the pad broke, and the resident fell to the floor incurring a left shoulder dislocation. This statement read in part, On July 8, 2019, ______ (Resident #99) fell from the hoyer lift, while .suspended in the air. Several staff members assisted resident back into the bed. The physician was notified and we received an order to send .to the hospital. _____ CNA #2 and _____ CNA #1 were the CNA's using the lift pad to transfer ____ (Resident #99). They were interviewed and stated while lifting .from chair to bed, one of the straps broke . (Resident #99) fell to the floor. The lift pad was observed and rip confirmed in one of the straps. We removed it from floor and discarded it. All other pads were reviewed to ensure integrity of the straps. Further investigation revealed it was not the proper pad .the CNA's used a pad that was too small. The CNA's were both educated and provided with disciplinary action. The resident returned from the hospital the same day, with a diagnosis of closed dislocation of the left shoulder. Reduction was successful in the ED and her pain was controlled. We educated staff on how to choose the proper hoyer pad. We completed an audit on all residents who require use of mechanical lift to ensure they had the proper hoyer pad. Our investigation determined that no intentional abuse occurred. This typed letter was unsigned. Per the DON, CNA's #1 and #2 were no longer employed at the facility. The Nurse Consultant and DON verbalized to the surveyor that they had completed a plan of correction and provided a copy of this to the survey team. This plan of correction was dated 07/08/2019 and did not include The title of the person responsible for implementing the acceptable plan of correction as per the CMS (Centers for Medicare & Medicaid Services) S&C (Survey and Certification) letter dated June 16, 2017. When the DON was asked who was responsible for implementing the acceptable plan of correction the DON stated myself. 5 Step Plan-Mechanical Lifts 7/8/2019 1. Failure to utilize proper lift pad when transferring resident using a mechanical lift. 2. Current residents requiring use of mechanical lifts were reviewed by nursing leadership and therapy. Patients were measured per manufacturer guidelines, and correct lift pads ordered for all current residents who require use of the mechanical lift. 3. Current nursing staff were educated on procedures for using a mechanical lift, and selecting the appropriate lift pad, with return demonstration. Mechanical lift transfers will be reviewed and observed with new nursing staff during orientation period. SDC (staff development coordinator) or designee will randomly review three lift transfer weekly X4 to ensure standard procedures are being followed. 4. Process will be reviewed in next quarterly QA (quality assurance). 5. 8/2/19. The surveyor asked the DON to provide the survey team with credible evidence regarding the above 5-step plan. The DON provided the surveyor with a copy of an Inservice/Education record dated 07/11/2019 and a copy of the staff that would have been employed at the facility during that timeframe that would have been responsible for patient care. These two lists were compared. There were numerous discrepancies between the two lists indicating that step 3 was incomplete. 03/11/2020 3:57 p.m., meeting with the Administrator, DON, Nurse Consultant, and ADON (assistant director of nursing). The DON verbalized that this resident had fell from the lift during a transfer when the wrong lift pad was being used. The DON stated part of the training on hire was the Hoyer lift and there was a skill check off. The DON stated the resident had an assigned pad and they ended up finding it in laundry that day so the staff had just grabbed another pad. The facility provided the surveyor with copies of skills competency validation records to indicate CNA #1 and #2 had been trained on demonstration of Hoyer lift with no less than 2 people and proper transfer techniques. Both of these were dated prior to the incident on 07/08/2019. 03/12/2020 8:24 a.m., during a meeting with the Administrator, DON, and Nurse Consultant the DON verbalized to the survey team that the wrong lift pad had been used when transferring Resident #99. The DON stated that prior to the incident with Resident #99, the lift pads were stored in a bin and the CNA's would just get what they needed at their own discretion. 03/12/2020 8:53 a.m., the surveyor requested the facility copy of the FRI. After reviewing the FRI the surveyor stated this FRI does not mention that the wrong pad was being used during the transfer. The DON replied, that is correct. 03/12/2020 9:16 a.m., the DON and Nurse Consultant were notified that they had discrepancies between the inservice list and the employee list. The DON verbalized to the surveyor that they sent an email to the other employees. Copies of emails were provided to the surveyor which included an email to the laundry staff dated 07/15/2019 indicating they needed to get together to .discuss the process for washing the hoyer lift pads An email to the unit managers dated 07/09/2019 stated, I need a complete sweep of both your units complete today for any hoyer lift pads. I also need a list of our residents we currently use the hoyer lift on. We need to make sure each patient has an assigned lift pad-let me know if this is not the case. An email addressed to the team dated 07/25/2019 reflected that they had ordered four new hoyer lift pads and assigned them to identified long term care residents which included Resident #99. They were labeled with resident names in multiple places on the pad, and were given out. They were measured to fit the residents per manufacturer guidelines. The email reflected the facility went through a lot of other hoyer pads and discarded old ones or ones that were not compatible with their machine and if a pad was needed for another resident, nursing management would need to know to ensure the correct pad was selected. The email reflected the pads would no longer be stored in the clean linen rooms. Formal training would be conducted on lift machines and pads by the vendor who supplies them on Wednesday, August 7th . 03/12/2020 9:25 a.m., RN (registered nurse) #1 verbalized to the surveyor that they would have expected the staff to know what kind of sling to use for a resident. They received training on using the Hoyer lift, they have preceptors on hire, and they thought each patient had their own sling. The DON provided the surveyor with a copy of an Inservice/Education record completed by an outside vendor. This document was dated 08/07/2019, which would have been after the date on the 5 step plan provided to the survey team. The surveyor requested the facility policy on the Hoyer lift. On 03/12/2020 at 10:05 a.m., the MDS coordinator provided the surveyor with a copy of their policy titled, Mechanical Lift with an effective date of 11/01/19 and this policy read in part, POLICY: A mechanical lift may be used to enable staff to lift and transfer a patient safely. The surveyor requested the manufactures instructions regarding the sling and use of the Hoyer lift. On 03/12/2020 at 10:15 a.m., the DON provided the surveyor with a copy of document titled, ProCare Medical this document read in part, .Sizing UNI-FIT SLINGS should be long enough to fit from the bottom of the patient's coccyx to the top of, or a few inches above, the patient's head and wide enough for sling fabric to extend at least two inches in front of the patient's anterior shoulder .Measurements are from the top of the head support to the bottom of the horseshoe area . 03/12/2020 11:14 a.m., during a meeting with the Administrator, DON, and Nurse Consultant, the staff were asked if they had any further information regarding this resident and the incident on 07/08/2019. The staff verbalized they did not have any further information.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to accurately assess 1 of 25 residents (Resident #22). Staff interviews revealed that Resident #22 required a two person assist during showers and only one staff provided assistance which led to Resident #22 receiving a femur fracture. The findings include: Facility staff failed to ensure Resident #22 was transferred according to her ability to stand. Resident #22 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 10/19/11, a review of Resident #22 ' s clinical record was completed. Her minimum data set (MDS) with a resident assessment reference date (ARD) of 8/28/11 revealed in Section G that the resident was totally dependent on one person physical assist for transfers. She was also totally dependent - full staff performance every time during entire 7-day period for dressing and personal hygiene. Also in Section G. Balance During Transitions and Walking, she was coded for surface to surface transfer (transfer between bed and chair or wheelchair) as a 2-not steady, only able to stabilize with human assistance. Continuation of the resident ' s clinical record revealed her care plan with a reference date of 6/14/11 had her as being a fall potential. On 9/13/11, the care plan revealed that she had had a fall with femur fractures. Review of the nurse ' s notes for 9/13/11 revealed the following: A nurse ' s note at 3:48 pm read in part: " CNA had resident ' s in the shower with resident holding onto railing while CNA pulled up brief. Resident started to buckle. CNA caught resident. Lowered her to the floor. CNA states knees slid down the wall. No other injuries. Right knee has a small bruise. Left knee has a small scrape. Resident complained of right knee pain. Neuro checks started. Will continue to monitor. No mental status changes noted. X-Ray of the right knee ordered. Responsible party (self) notified as well as POA. Physician notified. " Another nurse ' s note at 3:42pm read in part: " Physician notified of results of x-ray to right knee, resident with femur fracture. New orders to send resident out to hospital and [MEDICATION NAME] 5/500 mg po (by mouth) x 1 dose for pain. Resident is her own responsible party (RP). Informed resident that they had a fracture and that the physician thought it be best to send her out to the hospital, resident said yes (witnessed by another nurse). Resident POA also notified of results and agreed that resident be sent to hospital ... POA wanted to know what they would do, educated her that an orthopedist would have to determine her options. Resident in room and appeared to be in no distress. " The surveyor continued to review clinical record and could not locate a current fall nursing assessment form. On 9/24/11, the surveyor requested of the director of nurses (DON) and regional corporate nurse (RN #1) a fall risk assessment done previous to the 9/13/11 fall. A copy of a fall risk assessment for Resident #22 with a date of 9/13/11 was provided to the surveyor. However, the regional nurse consultant and DON said it was pulled from the previous admission nursing assessment form dated 6/21/10. This indicated that no fall risk assessment/admission nursing assessment form had been done for Resident #22 after 6/21/10. A copy of fall risk assessment/falls was requested by the surveyor of the DON. On 10/24/11, a copy of the requested documentation was provided by the DON. The policy and procedure for falls was titled Falls Management Program. Under PROCEDURE, it read in part: " 1. A Fall Risk Assessment will be completed upon admission, readmission, quarterly, and significant change of condition.2. Incorporate identified interventions into the Comprehensive Care Plan as applicable.3. Discuss fall risks and interventions with resident/RP with supporting documentation.4. Review and re-evaluate initial fall risk assessment and Device Assessment during the initial weekly fall meeting and the initial care plan meeting after admission.5. Refer the resident to PT/OT for screening, evaluation, and treatment as indicated.6. Consult Maintenance personnel for any necessary adaptations (i.e., wheelchair height adjustment, handrail placement, lighting, etc.). " The Illustrated Manual of Nursing Practice, second edition states, " If the patient is found on the floor or reports falling, don ' t move him until his status is evaluated. Relieve his anxiety as you rapidly assess his vital signs, mental status, and functional capacity. Note any signs and symptoms, such as confusion, tremors, weakness, pain or dizziness. Take steps to control bleeding, if indicated, and obtain an X-ray if a fracture is suspected. Observe and monitor the patient ' s status for the next 24 hours. " On 10/19/11 at 8:45am, CNA #2 was interviewed regarding Resident #22 ' s fall. CNA #2 stated, " I was not working that day and was not the CNA with her. " The CNA was then asked if the resident could transfer with one person. The CNA responded, " She did not walk but could pivot with one person. She needed only one to transfer unless you needed to pull up her brief. " On 10/20/11 at 12:25pm, LPN #1 was asked if she could give an account of what occurred the day Resident #22 fell . The LPN responded, " I had just finished my medication pass. Another nurse asked me how Resident #22 took her shower. LPN #2 (a new nurse) was in the shower room with Resident #22. Resident #22 was sitting on the floor. The CNA who had given Resident #22 her shower was with her in the shower room and asked me why I had put her on the list to take a shower with the resident. " LPN #1 then stated, " The CNAs know who can have individual showers. Resident #22 was a two person assist for a shower. She was unable to stand by herself. They have always used two people. I made the assignments. I did not know she needed two people to shower her. CNA #7 refused to ask for help. She told the supervisor that no one would help her. " On 10/20/11 at 1:18pm, LP N #3 was asked to give her account of Resident #22 ' s fall. LPN #3 was asked if she had ever worked with the resident in the shower and to explain how she transferred and how much assistance was needed. She then said, " Resident #22 was alert but confused. She required one person to assist her with transfers and ADLs (Assistance for Daily Living). But she could not stand alone for any period of time or with assistance. What we do if it ' s a person who is a one person transfer, we use two to do the shower to help pull up her clothes. You need to ask for help with Resident #22. The CNA who had her the day she fell was a floater. We had to tell her that we had to work together. " LPN #2 was interviewed at 1:50pm on 10/20/11. She showed the surveyor the shower room where Resident #22 fell . LPN #2 ' s statement indicated that Resident #22 was sitting with her back to the door of the shower, facing the wall although approximately a foot away from the wall. LPN #2 said, " I was new and was unfamiliar with the resident. " She stated, " The CNA that was showering Resident #22 did not ask for help. I would ' ve come in to help, but she did not ask. " On 10/20/11 at 1:37pm, CNA #3 was asked if she had ever showered Resident #22. She responded, " I called for help. She could not stand. She could not hold onto the rail with a good grip. I wouldn ' t try it. She was an easy transfer from the wheelchair to the bed. You had to get help to stand her. It could ' ve been prevented. It is common sense to ask for help with her. That CNA said no one would help her. She is her own person. The first thing the CNA said was, ' I didn ' t know she couldn ' t stand. ' Sometimes the CNA would ask for help, but she was nasty to the people and got into it with them. On the day Resident #22 fell , before I went to lunch, I stood in the shower room doorway until the CNA went to get towels. I went to lunch and when I came back, it had already happened. Resident #22 was in her bed and it looked like she was in pain. Stress on her forehead and eyebrows. " On 10/20/11 at 1:00pm, the Unit Manager (RN #3) was asked to give her account of what occurred when Resident #22 fell . She stated, " My office is beside the shower room. CNA #7 took her to the shower and alerted me when she had fallen. " RN #3 was asked if one person could transfer her and pull up a brief. She stated, " I wouldn ' t do it myself. I didn ' t know it took two to shower her. CNA #7 was terminated for behavior. She had a problem working with other CNAs. " On 10/24/11 at 10:10am, CNA #1 was asked if she was the CNA who gave regular care to Resident #22. She stated, " Unless I was off, I took care of her most of the time. " She was asked how many people it took to shower Resident #22. She responded, " Sometimes I use two people. Most of the time, she stands for me. When you have someone for a long time, I knew what she could do and could not do. Sometimes her legs are shaky. When she ' s shaking, I use two people. " On 10/24/11 at approximately 11:20am, the director of nurses and regional nurse consultant were informed of the above information. Prior to exit, no other information was provided to the surveyors regarding Resident #22 ' s fall. Complaint deficiency. Cross reference to F281 and F323.