Every finding on record at Regency Hermiston Nursing & Rehab Center

Based on observation, interview and record review it was determined the facility failed to maintain a medication administration error rate of less than five percent. There were 4 errors in 29 opportunities resulting in a 13.79 percent error rate. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 3 admitted to the facility in 11/2019 with diagnoses including seizures and multiple sclerosis. A 2/22/2025 quarterly MDS revealed Resident 3 had a BIMS score of three which indicated the resident had severe cognitive impairment. Resident 3's 2/2025 provider orders indicated Metoprolol Tartrate 25mg (a blood pressure medication) was to be given as 12.5mg twice daily with instructions to hold the medication for systolic blood pressure (top number in a blood pressure reading) below 110. Resident 3's provider orders indicated potassium chloride extended release 20meq (a supplement) was to be given one time a day with instructions to swallow whole, do not crush or chew, and do not allow to dissolve in the mouth. During an observation of medication administration for the 200-hall on 4/9/25 at 8:30 AM, Staff 11 (CMA) administered Metoprolol 12.5mg to Resident 3 after their blood pressure was recorded as 102/61. Staff 11 placed a potassium chloride 20meq tablet in a cup and poured a small amount of water on the pill which caused it to dissolve prior to administering it to Resident 3. A 4/9/25 review of Resident 3's health record revealed no indication the potassium chloride was ordered to be dissolved in water prior to administration. On 4/10/25 at 12:04 PM, Staff 2 (DNS) stated the expectation for administering blood pressure medications was for staff to take the blood pressure reading prior to administration and not administer the medication if the reading was outside the ordered parameters. She stated Resident 3's potassium chloride order did not indicate the pill was to be dissolved prior to administration. On 4/11/25 at 9:37 AM, Staff 22 (LPN Registered Care Manager) stated dissolving potassium chloride in water prior to administration was not the correct method and Resident 3's order for potassium chloride had no indication for it to be dissolved prior to administration. 2. Resident 16 admitted to the facility in 4/2023 with diagnoses including diabetes and difficulty breathing. A 1/31/2025 quarterly MDS revealed Resident 16 had a BIMS score of 15 which indicated the resident was cognitively intact. During an observation of medication administration for the 500-hall on 4/9/25 at 9:08 AM, Staff 17 (CMA) noticed a small round brown pill on Resident 16's bedside table while administering medications and discarded it in the resident's trashcan. She stated she did not know what pill it was or when it was given to the resident. On 4/10/25 at 12:04 PM, Staff 2 (DNS) stated the expectation for unidentified medications found in resident's rooms was for staff to bring the medication to a nurse or management for identification and destruction in the drug buster (liquid in a jug used to dissolve medications). On 4/11/25 at 9:37 AM, Staff 22 (LPN Resident Care Manager) stated the expectation for unidentified medications found in resident's rooms was for staff to bring her the pill for identification and destruction. 3. Resident 30 admitted to the facility in 12/2024 with diagnoses including right leg fracture and diabetes. A 4/2/2025 comprehensive MDS revealed Resident 30 had a BIMS score of 14 which indicated the resident was cognitively intact. During an observation of medication administration for the 400-hall with Staff 30 (LPN) on 4/9/25 at 5:35 PM, a tube of Orajel (gel medication for tooth pain) was observed on Resident 30's bedside table. A 4/9/25 review of Resident 30's health record revealed no provider order for Orajel, and no self-administration assessment for Orajel. On 4/10/25 at 12:04 PM, Staff 2 (DNS) stated she was not aware of the Orajel in Resident 30's room. She stated the expectation for an over-the-counter medication at a resident's bedside was for an order to be placed and a self-administration assessment to be completed prior to the resident having the medication at their bedside. On 4/11/25 at 9:37 AM, Staff 22 (LPN Resident Care Manager) stated she was not aware Resident 30 had Orajel at their bedside. She stated an over-the-counter medication at a resident's bedside required a provider's order and a self-administration assessment prior to the resident having the medication.

Based on observation, interview and record review it was determined the facility failed to ensure resident medications were not expired for 2 of 2 medication storage rooms and 2 of 3 medication carts reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include: The facility Medication Storage In The Facility policy, revised July 2021, indicated expiration dates on all medications were to be checked prior to administration, no expired medications were to be administered, and all expired medications were to be removed from the active supply and destroyed in the facility. During an observation of the 400-hall medication cart on 4/8/25 at 3:52 PM, the following were found: - One bottle of Geri Dryl 25mg tablets with an expiration date of 9/2024. - One bottle of ASA 81mg tablets with an expiration date of 8/2024. - One bottle of calcium 500mg + D 500mg tablets with an expiration date of 12/2024. - One bottle of melatonin 1mg tablets with an expiration date of 3/2025. - One bottle of acid reducer 10mg tablets with an expiration date of 3/2025. - One bottle of calcium 600mg +D3 10mcg tablets with an expiration date of 2/2025. - One bottle of Rena Vite tablets with an expiration date of 12/2023. - One bottle of ocular vitamin tablets with an expiration date of 1/2025. - One bottle of zinc 50mg tablets with an expiration date of 3/2025. - One bottle of calcium 600mg +D 5mcg tablets with an expiration date of 8/2024. - Two bottles of ASA 325mg tablets with an expiration date of 12/2024. - One bottle of prenatal vitamin tablets with an expiration date of 9/2024. - One bottle of ferrous gluconate 240mg tablets with an expiration date of 2/2025. - One bottle of acetaminophen 500mg/15ml liquid with an expiration date of 1/2025. - One box of Pepto Bismol chewable tablets with an expiration date of 3/2025. - Two bottles of Multi Vite liquid with an expiration date of 1/2025. - One bottle of pink bismuth 525mg/30ml liquid with an expiration date of 2/2025. - One bottle of flaxseed 1,000mg tablets with an expiration date of 1/2025. On 4/8/25 at 4:12 PM, Staff 29 (CMA) stated the expectation for expired medications was they would be removed from the cart and destroyed. During an observation of the 500-hall cart on 4/8/25 at 4:17 PM, the following were found: - One bottle of Levetiracetam 100mg/ml liquid with an expiration date of 4/1/2025. - One bottle of acid reducer 10mg tablets with an expiration date of 3/2025. On 4/8/25 at 4:25 PM, Staff 3 (Assistant Director of Nursing) stated the expectation for expired medications was for them to be removed from the cart and discarded. During an observation of the 200/300/400-hall medication storage room on 4/8/25 at 4:35 PM, the following were found: - One bottle of acid reducer 10mg tablets with an expiration date of 3/2025. - Three bottles of ASA 325mg tablets with an expiration date of 12/2024. - Two bottles of ferrous gluconate 27mg tablets with an expiration date of 2/2025. - One bottle of ASA 325mg tablets with an expiration date of 2/2024. On 4/8/2025 at 4:47 PM, Staff 2 (DNS) stated the expectation for expired medications was for them to be destroyed and reordered. During an observation of the 100/500-hall medication storage room on 4/8/25 at 4:52 PM, the following were found: - Eight bottles of ASA 325mg tablets with an expiration date of 12/2024. - One bottle of ASA 325mg tablets with an expiration date of 2/2024. - Two bottles of ASA 325mg tablets with an expiration date of 4/2024. - One bottle of acid reducer 10mg tablets with an expiration date of 3/2025. - One bottle of Dakin's solution with an expiration date of 11/2023. - One tube of Ayr saline nasal gel with an expiration date of 1/2025. On 4/8/25 at 5:16 PM, Staff 2 (DNS) stated the expectation for expired medications was for them to be destroyed and reordered.

Based on observation, interview and record review it was determined the facility failed to store food in a manner to prevent spoilage in 1 of 1 kitchen reviewed for sanitary practices. This placed residents at risk for foodborne illness. Findings include: The facility's Food Safety and Sanitation Policy and Procedure dated 2023 indicates: -All time and temperature control for safety foods should be labeled, covered and dated when stored; and -Perishable foods should be used prior to the use by date on the package. On 4/7/25 at 10:06 AM during a tour of the facility's Kitchen, the following was observed in the walk-in refrigerator: -a plastic container labeled, chicken noodle - use by 4/5; -a plastic container labeled, rice prep - use by 4/6; -a one-quart container of sauerkraut labeled, expires 4/4; and -two unlabeled and undated trays containing multiple prepared beverage cups: 28 cups of milk and 6 cups of apple juice. On 4/7/25 at 10:06 AM Staff 5 (Dietary Manager) acknowledged the items should not be in the refrigerator past their use by dates and should be thrown away. Staff 5 stated she expected trays of beverages to be labeled at the time they were placed in the refrigerator to avoid any confusion and maintain their freshness. On 4/7/25 at 10:28 AM an undiscernible and unlabeled piece of meat was observed wrapped in plastic on a shelf in the walk-in freezer. The meat was dark brown and had layers of ice under the plastic wrapping. Staff 5 acknowledged the item, stated it looked like a ham with freezer burn. Staff 5 stated she expected items to be thrown away before they reached that stage so the residents were served fresh meals. On 4/11/25 at 11:41 AM Staff 2 (DNS) stated she expected foods to be discarded in timely manner to ensure food safety and prevent food-borne illness. She also stated she expected food in freezer to be free from freezer burn.

Based on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual and physical abuse by other residents for 4 of 5 sampled residents (#s 12, 29, 128 and 279) reviewed for abuse. This placed residents at risk for mental anguish and abuse. Findings include: Review of the facility's revised 10/2022 Abuse/Neglect/Misappropriation/Exploitation Policy and Procedures revealed the purpose of the policy was to define how the facility will prevent, identify, report and investigate abuse. Sexual abuse was defined as any form of non-consensual contact including unwanted or inappropriate touching. The facility must evaluate whether the resident has the capacity to consent to sexual activity. Physical abuse included hitting, slapping, pinching, striking with an object and shoving. 1. Resident 12 admitted to the facility in 2020 with a diagnoses including dementia with behavioral disturbance. Resident 12's 7/6/24 Quarterly MDS revealed, Resident 12 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Resident 22 admitted to the facility in 2019 with diagnoses including schizophrenia (mental disorder that affects a person's ability to think, feel and behave clearly), sexual disorders and depression. Resident 22's 9/15/24 Quarterly MDS revealed, Resident 22 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. A 9/19/24 at 1:00 PM Alleged Abuse incident report written by Staff 2 (DNS) revealed Staff 19 (CNA) observed Resident 22 in Resident 12's room. Resident 22 sat in her/his wheelchair at Resident 12's bed side. Staff 19 saw Resident 22's hands on Resident 12's breasts and over her/his clothing. The residents were immediately separated and neither recalled the incident minutes later. A 9/19/24 at 1:34 PM Progress note revealed Staff 4 (Resident Care Manager/LPN) spoke with Resident 12 related to Resident 22's physical contact with her/him and she/he could not recall anyone coming into her/his room. On 4/7/25 at 11:55 AM Resident 12 was observed in her/his room in bed coloring. Resident 12 was able to state some needs, but she/he was not able to recall ever being abused or touched by another resident. On 4/7/25 at 6:49 PM Staff 19 stated when staff walked down the facility hallways, they always looked into resident's room to ensure residents were safe. Staff 19 stated she recalled when she walked past and looked into Resident 12's room she observed Resident 12 in bed while Resident 22 sat in her/his wheelchair at the head of Resident 12's bed. Resident 22's hands were grabbing and touching all over Resident 12's breasts. Staff 19 removed Resident 22 from Resident 12's room and told management staff. On 4/9/25 at 11:15 AM Staff 4 confirmed she wrote the 9/19/24 at 1:34 PM progress note and she interviewed Resident 12 after the incident. Staff 4 stated Resident 12 was on alert charting, did not recall the physical abuse and did not experience any changes in behavior after the incident. On 4/9/25 at 11:27 AM Staff 2 confirmed she wrote the 9/19/24 at 1:00 PM Alleged Abuse incident report for Resident 12 and Resident 22. Staff 2 confirmed Staff 19 reported she witnessed Resident 22 with her/his hands on Resident 12's breast and the facility investigation confirmed abuse. Staff 2 acknowledged both residents were assessed as severely cognitively impaired, both were often confused and neither resident recalled the incident after it occurred. 40774 2. Resident 29 was admitted to the facility in 3/2022 with diagnoses including personality disorder (long-term pattern of thoughts, feelings, and behaviors that are unhealthy) and anxiety. Resident 29's 8/29/23 Annual MDS revealed she/he had moderate cognitive impairment and was able to understand others. Resident 128 was admitted to the facility in 6/2024 with diagnoses including dementia and anxiety. Resident 128's 6/9/24 Admission MDS revealed she/he had moderate cognitive impairment. The facility's incident investigation completed on 11/29/24 by Staff 18 (Former Administrator in Training) indicated Resident 128 struck Resident 29 twice as the resident moved past her/him. Resident 29 grabbed Resident 128's right forearm with both hands, shook her/him and stated, Don't hit me. Staff intervened and separated the residents. Staff 17 (CNA) witnessed Resident 29 and Resident 128 strike each other and assisted in separating them. On 4/10/25 at 8:25 AM Staff 17 stated both residents had a history of hitting other residents. On 4/10/25 at 8:55 AM Resident 29 stated she/he did not remember the incident. On 4/11/25 at 11:04 AM Staff 2 (DNS) acknowledged the physical interaction between Resident 29 and Resident 128. Staff 2 stated both residents were monitored and kept at a distance to prevent this type of incident from occurring. 46053 3. Resident 279 was admitted to the facility in 8/2019 with diagnoses including heart attack and a fracture of the left tibia (broken shin). Resident 279's 8/29/23 Annual MDS revealed she/he had moderate cognitive impairment, had adequate hearing and was able to understand others. Resident 29 was admitted to the facility 3/2022 with diagnoses including type 2 diabetes mellitus and heart disease. Resident 29's 7/7/23 Quarterly MDS revealed she/he had moderate cognitive impairment, had adequate hearing and was able to understand others. The facility's incident investigation completed on 10/5/23 by Staff 1 (Administrator) indicated Resident 279 entered Resident 29's room on 10/5/23 and did not leave when Resident 29 asked her/him to leave. Staff 16 (LPN) witnessed Resident 29 hit Resident 279's arm and then separated the residents. On 4/9/25 at 9:16 AM Resident 29 stated she/he did not remember the reported incident but stated facility staff placed a stop sign across her/his door to discourage other residents from coming in. On 4/10/25 at 8:10 AM and 4/17/25 at 12:14 PM Staff 16 stated he heard Resident 29 yelling in her/his room on 10/5/23. Staff 16 stated he went to Resident 29's room to investigate and observed Resident 29 hit Resident 279's arm. On 4/10/25 at 9:43 AM Staff 2 (DNS) stated she considered abuse to include willful hitting or physical contact between residents. Staff 2 confirmed the incident occurred on 10/5/23, revealing Resident 29 hit Resident 279 because Resident 29 did not want Resident 279 in her/his room. Staff 2 stated Resident 29 should not have hit Resident 279 and emphasized it was the facility's responsibility to protect residents from abuse.

Based on observation, interview, and record review it was determined the facility failed to develop comprehensive care plans for 1 of 1 sampled resident (#40) reviewed for vision. This placed resident at risk for lack of visual care needs. Findings include: Resident 12 admitted to the facility in 2020 with a diagnoses including dementia with behavioral disturbance. Resident 12's 1/6/25 Quarterly MDS revealed the resident had vision impairment and her/his BIMS score was 5 which indicated a severe cognitive impairment. The resident's required substantial/maximal assistance with a helper completing more than half of the effort. On 4/7/25 at 11:55 AM Resident 12 was observed without eyeglasses, in bed coloring. Resident 12 stated she/he was worried about her/his eyeglasses and said they were missing. The surveyor looked around on Resident 12's bed and bedside table and no eyeglasses were visible. Resident 12 was observed to not have worn eyeglasses on the following dates and times: -4/7/25 at 10:28 AM and 11:55 AM; -4/8/25 at 8:08 AM, 9:26 AM, 12:39 PM and 2:23 PM; -4/9/25 at 7:41 AM. Record review of Resident 12's care plan revealed no indication she/he wore eyeglasses or that staff were to assist her/him with eyeglasses. On 4/9/25 at 8:52 AM Staff 9 (CNA) stated they obtained information to care for Resident 12 from her/his care plan. Staff 9 stated they were not sure if Resident 12 had prescription eyeglasses but the resident did wear eyeglasses when she/he colored. On 4/9/25 at 8:58 AM Staff 20 (CNA) stated they obtained information to care for Resident 12 from the care plan. Staff 20 stated Resident 12 wore eyeglasses to see better especially when she/he colored and did puzzles. On 4/9/25 at 11:15 AM Staff 4 (Resident Care Manager/LPN) stated she was aware Resident 12 wore eyeglasses sometimes. Staff 4 confirmed Resident 12 required staff assistance to complete many ADLs, staff needed to assist the resident with her/his eyeglasses and often needed assistance to find the eyeglasses to wear. Staff 4 confirmed the care plan did not include information about eyeglasses. On 4/9/25 at 11:27 AM Staff 2 (DNS) stated she expected Resident 12's care plan to include direction for staff to assist her/him with eyeglasses as needed or requested by the resident.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 4 sampled residents (#s 11 and 40) reviewed for ADLs. This placed residents at risk for a lack of personal hygiene and loss of dignity. Findings include: 1. Resident 11 admitted to the facility in 12/2024 with diagnoses including weakness and kidney disease. A 4/4/25 quarterly MDS revealed Resident 11 had a BIMS score of three which indicated severe cognitive impairment and was dependent on staff for grooming. A review of Resident 11's 3/13/25 through 4/10/25 health record revealed CNA staff documented grooming was completed daily, a shower was provided six times, and the resident refused a shower two times. Random observations from 4/7/25 through 4/11/25 revealed Resident 11 had long white hairs hanging approximately two inches from her/his chin in multiple locations. On 4/10/25 at 2:42 PM, Staff 28 (CNA) stated she was not sure if Resident 11 had long chin hairs. She stated grooming for residents occurred at least twice a day and included shaving. She stated shaving was offered to residents during showers but was not sure if Resident 11 was offered during her/his showers. On 4/10/25 at 2:50 PM, Staff 4 (Resident Care Manager/LPN) stated she did not know Resident 11 had long chin hairs and acknowledged it was not proper ADL care. She stated the expectation was for residents to be offered shaving twice daily, with showers, and as needed. 38140 2. Resident 40 admitted to the facility in 2022 with diagnoses including Type 2 Diabetes (body's trouble with blood sugars) and vascular disease (body's circulatory system). Resident 40's 2/26/25 Quarterly MDS revealed Resident 40 had a BIMS score of 10 which indicated moderate cognitive impairment. The resident was dependent on staff to complete personal hygiene Review of Resident 40's health care record revealed the following: -From 3/12/25 through 4/8/25 indicated the resident received assistance from staff with personal hygiene daily. -From 3/13/25 through 4/9/25 no evidence was found indicating whether the resident was offered or refused assistance to trim chin hair. On 4/8/25 at 9:23 AM Resident 12 used her/his left hand, rubbed her/his chin, pulled the hairs together into a point and stated she/he wanted the chin hairs cut. Resident 12 was observed with long chin hairs, about two inches long, on the following dates and times: -4/8/25 at 9:23 AM and 2:20 PM; -4/9/25 at 7:45 AM and 5:12 PM. On 4/10/25 at 4:13 PM Staff 10 (CNA) acknowledged Resident 40 required assistance with her/his ADLs. Staff 10 stated they were aware of Resident 40's long chin hairs and the resident asked several times in the past to get them cut. On 4/10/25 at 4:16 PM Staff 4 (Resident Care Manager/LPN) stated she was aware of Resident 12's long chin hairs. She expected staff to offer Resident 12 to shave her/his chin hairs PRN, at least two times a week during bathing and if she/he refused it should be documented as refused in her/his medical record.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for skin assessments and monitoring for 2 of 2 residents (#s 27 and 40) reviewed for non-pressure skin conditions. This placed residents at risk for delayed treatment and skin breakdown. Findings include: The facility's revised 4/2018 Skin at Risk Program Overview Policy indicated the Skin at Risk Program was based on the nursing process and included identification of residents at risk for skin breakdown, care plan developed to prevent skin breakdown, implementation of care plan interventions, to evaluate and monitor interventions for skin. 1. Resident 27 admitted to the facility in 2019 with diagnoses chronic pain and depression. Resident 27's physician order, start date on 10/21/23, directed staff to check her/his skin and indicate if a new condition was present. If a new condition was present staff were to document a progress note and initiate a skin documentation form. Resident 27's 2/25/25 Quarterly MDS revealed the resident had a BIMS score of 11 which indicated a moderate cognitive impairment. On 4/7/25 at 11:13 AM Resident 27 was observed with a bruise about the size of a quarter on her/his right upper forearm. Resident 27 stated she/he did not know where the bruise came from. Resident 27 was observed with the bruise on her/his right upper forearm on the following dates and times: -4/8/25 at 3:28 PM; -4/9/25 at 7:41 AM, 4:00 PM, 5:18 PM; -4/10/25 at 9:50 AM and 12:15 PM. Review of Resident 27's health record reveal no indication an assessment, monitoring or progress note were completed for any bruise. On 4/10/25 at 4:26 PM Staff 4 (Resident Care Manager/LPN) confirmed Resident 27 had a bruise to her/his right upper forearm. Staff 4 confirmed Resident 27's health record had no information regarding the bruise and she expected staff to provide appropriate documentation when a new skin condition occurred. On 4/11/25 at 11:39 AM Staff 2 (DNS) acknowledged Resident 27's bruise was not assessed, monitored or documented. She stated she expected staff to assess, monitor and document any new skin condition. 2. Resident 40 admitted to the facility in 2022 with diagnoses including Type 2 Diabetes (body's trouble with blood sugars) and vascular disease (body's circulatory system). Resident 40's physician order, start date on 10/19/23, directed staff to check her/his skin and indicate if a new condition was present. If a new condition was present staff were to document a progress note and initiate a skin documentation form. Resident 40's 2/26/25 Quarterly MDS revealed the resident had a BIMS score of 10 which indicated moderate cognitive impairment. On 4/8/25 at 9:58 AM Resident 40 was observed in bed with her/his feet sticking out from under the sheet. Resident 40's left foot was discolored with hues of blue and green and the ankle towards the calf was covered in a white mesh wrap with scabs visible under it. A review of Resident 40's health record revealed no indication an assessment, monitoring or progress note were completed for her/his left foot scabbing and discoloration. On 4/10/25 at 4:16 PM Staff 4 (Resident Care Manager/LPN) stated Resident 40 had scabs on her/his left foot from scratching her/himself and the discoloration of the foot was from an infection. Resident 4 acknowledged she was not able to find any documentation for Resident 40's left foot. On 4/11/25 at 11:29 AM Staff 2 (DNS) stated she expected Resident 40's left foot to be assessed, monitored and documented. Staff 2 was unable to provide any additional information.

Based on observation, interview and record review it was determined the facility failed to ensure accurate communication occurred between the facility and the dialysis provider, ensure the residents care plan and physician orders were followed for fluid restriction for 1 of 1 sampled resident (#69) reviewed for dialysis. This paced residents at risk for lack of communication with the dialysis center and fluid overload. Findings include: Resident 69 admitted to the facility in 3/2025 with diagnoses including heart failure and ESRD (end stage kidney disease). The facility's Dialysis Policy revised on 3/2024 indicated the following: -Licensed nurses were to complete the Pre and Post-dialysis assessments with each dialysis visit. -The licensed nurse are to ensure the Dialysis Communication form were completed and special instructions/orders were implemented. a. A 3/3/25 physician order indicated staff were to follow the dialysis flow sheet protocol every day shift every Tuesday, Thursday and Saturday. A review of the Dialysis Communication form revealed the following: The 3/4/25, 3/25/25, and 4/1/25 revealed: The post dialysis section had no documentation related to vitals, dialysis cite assessment and condition, pertinent information, nurse signature and date or time. The 3/8/25, 3/11/25, 3/13/25, 4/5/25 and 4/8/25 Dialysis Communication forms did not include the following: The post dialysis section had no documentation related to vitals, dialysis cite assessment and condition, pertinent information, no nurse signature and date or time. No documentation was found in the resident's clinical record to indicate staff completed the Dialysis Communication forms or notified the dialysis center. On 4/9/25 at 9:49 AM Witness 1 (Dialysis RN) stated the facility was required to complete the Pre-dialysis section prior to sending Resident 69 to dialysis; however, there had been instances when the facility did not send the form or the form was sent incomplete. Witness 1 stated it was important the forms were complete because the information was used to determine the type of care the resident received during dialysis treatment. On 4/9/25 at 11:27 AM Staff 23 (LPN) stated nurses were expected to fill the Pre and Post Dialysis Communication form before and after Resident 69 went to dialysis and staff were to ensure the Dialysis Center Report was completed by the dialysis center. Staff 23 further stated it was the nurse's responsibility to ensure the forms were complete. On 4/9/25 at 11:53 PM Staff 22 (Resident Care Manager/LPN) stated nurses were expected to complete the Dialysis Communication forms and send with the resident to dialysis. Staff 22 stated staff were expected to ensure the Post Dialysis Assessment forms were completed after the resident returned from dialysis. Staff 22 reviewed the residents Dialysis Communication forms dated 3/4/25, 3/8/25, 3/11/25, 3/13/25, 3/25/25, 4/1/25, 4/5/25 and 4/8/25 and confirmed they were incomplete and was an ongoing problem. On 4/10/25 at 11:46 AM Staff 2 (DNS) and Staff 3 (Assistant DNS) confirmed nurses were expected to complete the Dialysis Communication forms and send with the resident to dialysis. Staff were expected to ensure the Post Dialysis Assessment forms were completed after the resident returned from dialysis. Staff 2 reviewed the residents Dialysis Communication forms dated 3/4/25, 3/8/25, 3/11/25, 3/13/25, 3/25/25, 4/1/25, 4/5/25 and 4/8/25 and confirmed they were incomplete. Staff 2 further stated the facility had not provided staff training related to dialysis. b. The 3/3/25 care plan indicated Resident 69 had acute edema (swelling caused by excess fluid trapped in the body's tissue) to her/his lower extremities. Staff to monitor and report any issues related to fluid overload to the nurse and physician. Staff not to leave a pitcher of water at Resident 69's bedside. The 3/4/25, 3/6/25 and 3/27/25 Dialysis Communication form instructed staff to limit Resident 69's fluid to 16 ounces a day. A 3/27/25 physician order indicated Resident 69 required a 1000 ml fluid restriction. The order instructed kitchen staff to provide 700 ml. The nursing staff was to provide 120 ml during the morning, evening shift and night shift was to provide 60 ml. The order instructed staff to notify the Resident Care Manager, DNS and provider each shift when the resident did not adhere to the ordered fluid restriction. The 3/29/25 Dialysis Communication form indicated Resident 69 required 1000 ml fluid restriction. The 3/2025 LNAR (Licensed Nurse Administration Record) related to fluid intake revealed Resident 69 consumed the following: Morning shift 3/31/25 950 ml Evening shift 3/29/25 480 ml 3/30/25 460 ml 3/31/25 240 ml Night shift 3/29/25 480 ml 3/31/25 1200 ml total No documentation was found in the resident's clinical record to indicate staff notified the Resident Care Manager, DNS or provider related to the resident not adhering to fluid restrictions. There was no evidence found to indicate an assessment was completed or staff were monitoring Resident 69's fluid overload. A 4/1/25 nursing note created by Staff 22 (Resident Care Manager/LPN) indicated Resident 69 required a additional dialysis appointment due to fluid overload. A 4/1/25 nursing note indicated staff posted a sign in Resident 69's room related to appropriate fluids for a renal diet. The 4/2025 LNAR fluid intake revealed Resident 69 consumed the following: Morning shift 4/1/25 360 ml 4/2/25 960 ml 4/3/25 480 ml 4/4/25 480 ml 4/5/25 240 ml 4/6/25 240 ml 4/7/25 240 ml 4/8/25 240 ml Evening shift 4/1/25 240 ml 4/4/25 640 ml 4/5/25 480 ml 4/6/25 180 ml 4/7/25 460 ml Night shift 4/1/25 120 ml 4/2/25 120 ml 4/3/25 120 ml On 4/7/25 at 10:27 AM Resident 69 was observed in her/his room. The resident stated she/he attended dialysis three days a week but sometimes went more often due to fluid overload. Resident 69 stated she/he was on 1000 ml fluid restrictions. Multiple beverages were observed on the resident's bedside table, including a 600 ml cup of ice water. The resident stated she/he always kept a pitcher of ice water at her/his bedside and after the ice melted, would ask staff to refill it. No sign was posted in the resident's room to indicate she/he was on a fluid restriction. A 4/8/25 nursing note indicated Resident 69 returned from dialysis and needed to return to dialysis the following day due to fluid overload. A 4/9/25 physician order instructed staff to apply compression socks in the AM and remove them in the PM related to ESRD. On 4/8/25 at 9:05 AM Staff 24 (CNA) stated the resident went to dialysis three days a week but was unsure if the resident was on a fluid restriction. Staff 24 stated she would bring the resident water whenever she/he requested. On 4/8/25 at 2:33 PM Staff 25 (Lead CNA) stated Resident 69 attended dialysis three days per week and when she/he returned from dialysis she provided her/him 240 ml of fluid and an additional 240 ml at dinner. Staff 25 stated she did not monitor the resident legs for swelling and did not know if she/he was supposed to wear compression stockings (socks that apply gentle pressure to legs and ankles to help reduce swelling). Staff 25 stated she believed the resident was on an 1800 ml fluid restriction. On 4/8/25 at 4:30 PM Staff 26 (CNA) stated Resident 69 attended dialysis three days a week. Staff 26 stated she was not aware if the resident was on fluid restrictions or the specific amount of fluids the resident was permitted to consumed during the shift. Staff 26 stated if the resident requested fluids during her shift, she would provide fluids to the resident and document the amount consumed. On 4/8/25 at 4:28 PM Resident 69 stated she/he attended dialysis in the morning and had to have 2.7 liters of fluid removed. The resident further reported she/he was scheduled to return to dialysis the following day due to fluid overload. Resident 69 stated she/he did not have compressions socks on to help with the swelling. Resident 69 further stated she/he had a significant amount of fluid removed over the past few days. The following fluids were observed on the resident's bedside table: -one almost empty 120 ml cup of water -120 ml cup of fluid; -120 ml cup of fluid approximately half drank and; -600 ml cup of ice water with approximately 500 ml remaining. On 4/9/25 at 8:18 AM Resident 69 stated she/he had a shower but staff did not put on her/his sock or shoes. The resident's feet were observed to be red and swollen. The resident stated she/he did not have any socks in her/his room. Resident 69's breakfast tray had the following fluids: -600 ml pitcher of water; -120 ml apple juice; -Two 120 ml cups of water and; -8 oz of silk (soy) milk. On 4/9/25 at 11:27 AM Staff 23 (LPN) stated Resident 69 received dialysis three days a week. The resident was on 1000 ml fluid restriction, and staff were instructed not to leave a water pitcher on her/his bedside table. Staff 23 observed a 600 ml water cup on the resident's bedside table and noted there was no sign in the resident's room regarding her/his fluid restriction. Staff 23 acknowledged the picture of water on Resident 69's bedside table. On 4/9/25 at 11:53 PM Staff 22 (Resident Care Manager/LPN) indicated Resident 69 developed edema. Staff 22 stated nurses were expected to assess and monitor the resident's edema, but was unable to provide documentation indicating the resident was assessed or monitored. Staff 22 confirmed the resident's care plan indicated staff were not to leave water at the resident's bedside and acknowledged staff did not follow the care plan. Staff 22 reviewed the resident physician orders which instructed staff to notify the physician, DNS and Resident Care Manager per shift if the resident did not adhere to fluid restrictions. The following fluids were observed on the resident's bedside table: -800 ml cup ice water -120 ml cup of juice On 4/10/25 at 11:46 AM Staff 2 (DNS) reviewed the resident's physician orders and confirmed staff were not notifying the physician when the resident did not adhere to fluid restrictions. Staff 2 confirmed staff were not following fluid restrictions and did not monitor the resident's edema.

Based on interview and record review it was determined the facility failed to ensure narcotics were administered according to physician's orders for 1 of 4 sampled residents (#1) reviewed for medication errors. This placed residents at risk for adverse medication consequences. Findings include: On 3/21/24 a concern was received by the State Survey Agency (SSA) which alleged Resident 1 was given an additional dose of the narcotic Oxycodone. Resident 1 was admitted to the facility in 2022, with diagnoses including a fractured leg and dementia. Resident 1's 3/2024 signed physician orders revealed she/he was to be administered an Oxycodone 5 mg tablet by mouth every eight hours for pain. A review of Resident 1's 3/2024 MAR revealed on 3/20/24 Resident 1 was given Oxycodone 5 mg at 6:00 AM, 2:00 PM and 10:00 PM. On 3/20/24 at 9:00 PM, Staff 9 (CMA) and Staff 10 (CMA/CNA) counted the narcotics for Resident 1 and discovered there was a missing Oxycodone tablet. Staff 9 stated she had accidentally given Resident 1 an extra dose of 5 mg Oxycodone. Staff 9 and Staff 10 informed the charge nurse, a medication error form was filled out and Resident 1 was closely monitored. On 6/4/24 at 9:20 AM, Staff 9 stated on 3/20/24 she accidentally gave Resident 1 two 5 mg tablets of Oxycodone instead of one 5 mg tablet of Oxycodone per the MAR and physician order. On 6/4/24 at 3:17 PM, Staff 2 (DNS) acknowledged Staff 9 did not follow the physicians' orders for Resident 1's Oxycodone administration. Staff 2 stated she expected staff to follow physician orders when administering medications.

Based on observation, interview, and record review it was determined the facility failed to ensure the environment remained free from accident hazards related to mechanical lift transfers for 3 of 3 sampled residents (#s 4, 15 and 18) reviewed for accidents. This failure resulted in Resident 15 sustaining a hip fracture which required surgical intervention. Findings include: Resident 15 was admitted to the facility in 2018 with diagnoses including pain in her/his lower legs. Resident 15's [DATE] Annual MDS indicated the resident had no cognitive impairment. Resident 15 required the assistance of two-persons using a mechanical lift for transfers. An [DATE] 7:21 AM Fall Investigation revealed Resident 15 fell during a mechanical lift transfer because staff were unable to turn the mechanical lift which resulted in the mechanical lift tipping over and the resident landing on her/his right side. Resident 15 complained of pain to her/his right leg and shoulder and was sent to the hospital. A witness statement indicated multiple staff complained the wheels on the mechanical lift were getting stuck, nothing had been done and the lift was unsafe. The investigation concluded that the staff were in error and education and competencies would be completed. An [DATE] Hospital Discharge Summary revealed Resident 15 was admitted to the hospital on [DATE] for surgical intervention of a right hip fracture which was sustained after the resident was dropped from a mechanical lift. On [DATE] at 1:51 PM Staff 2 (DNS) was requested to provide mechanical lift education and competencies for the following staff on duty [DATE]: Staff 5 (RN), Staff 6 (CNA), Staff 7 (CNA), Staff 8 (CNA), Staff 12 (CNA), Staff 20 (CNA), Staff 21 (CNA), Staff 22 (CNA) and Staff 23 (CNA). The following competencies were provided: -Staff 6 completed on [DATE]; -Staff 7 completed on [DATE] and -Staff 23 completed on [DATE]. Staff 2 was unable to provide education and competencies for the remaining requested staff. The [DATE] through [DATE] monthly maintenance reports were provided for one of the five mechanical lifts. There was no additional evidence provided that monthly maintenance was completed on the additional four mechanical lifts. On [DATE] at 12:58 PM a mechanical lift was observed outside of Staff 11's (Maintenance Director) office. The wheels on the mechanical lift did not turn properly. When the mechanical lift was pushed it did not steer or turn in the direction being pushed. On [DATE] at 3:24 PM Resident 15 stated staff were getting her/him up using the pumperoo type mechanical lift when part of the mechanical lift broke which caused her/him to fall. Resident 15 stated she/he injured her/his chest and broke her/his leg. On [DATE] at 4:11 PM Staff 4 (CNA) stated on [DATE], she and Staff 10 were getting Resident 15 up for breakfast. Staff 4 stated as she attempted to drive the mechanical lift the wheels became jammed. Staff 4 stated the mechanical lift could only move with the front wheels, the lift was not budging and with the momentum and the weight of the resident, the lift tipped over and Resident 15 fell on to the floor. Staff 4 stated the mechanical lift was taken off of the floor but the administration and maintenance said there was nothing wrong with the mechanical lift. On [DATE] at 4:35 PM Staff 10 (CNA) stated the mechanical lifts were wobbly and jiggly, the wheels got stuck and were difficult to turn. Staff 10 stated on [DATE] she attempted to transfer Resident 15 with Staff 4 (CNA). Staff 10 stated Staff 4 turned the mechanical lift, the legs and back wheels became stuck and the lift immediately stopped moving. Staff 10 stated Staff 4 tried to get the mechanical lift to move but the mechanical lift tipped over and Resident 15 fell to the ground. On [DATE] at 12:06 PM Staff 7 (CNA) stated the mechanical lifts did not always work. Staff 7 stated she brought her concerns to Staff 1 (Administrator) and Staff 11 and they just blame it on us. On [DATE] at 12:58 PM Staff 5 (RN) stated she told management on several occasions that the mechanical lifts were not operating properly and someone was going to get hurt. Staff 5 stated in ,d+[DATE], Resident 15 fell from the mechanical lift because the lift was not working properly and tipped over. Staff 5 stated earlier today, she attempted a mechanical lift transfer of a resident with Staff 12 (CNA) assisting and the mechanical lift nearly tipped over. Staff 5 stated as she took the mechanical lift down the hallway it would barely roll. She placed the lift outside of Staff 11's office. Staff 5 stated the batteries needed to operate the mechanical lifts were always dead or died in the middle of a transfer despite being on the battery charger all day. On [DATE] at 1:10 PM Staff 12 (CNA) stated often the wheels on the mechanical lifts did not move properly and got stuck. On [DATE] at 7:03 PM Staff 3 (CNA) stated the mechanical lifts were horrible. Staff 3 stated frequently there were mechanical lifts out of commission. Staff 3 stated the mechanical lifts were hard to push, difficult to steer and barely turned. On [DATE] at 7:09 PM Staff 17 (CNA) stated the wheels on three of the mechanical lifts got stuck and the legs did not move well. Staff 17 stated in the past, the pump mechanical lift locked at the top and the lift collapsed. Staff 17 stated at least one mechanical lift needed to be serviced every week. On [DATE] at 6:39 AM Staff 5 stated two malfunctioning mechanical lifts were taken off of the floor and new ones replaced them. On [DATE] 2:29 PM Staff 1 stated the issues with the mechanical lifts had been going on for a long time. Staff 1 stated staff brought the mechanical lifts to the maintenance department and every time they were looked at by Staff 11, there was nothing wrong with them. Staff 1 stated Staff 11 was unable to recreate the issues. Staff 1 stated staff concerns with the mechanical lifts had been going on for months because the staff did not know how to use the mechanical lifts properly. On [DATE] 11:09 AM Witness 2 (Resident Advocate) reported she discussed concerns regarding the mechanical lifts with Staff 1 over a year ago and felt the concerns were minimized and there was no follow through. In addition, Witness 1 stated when concerns were brought forward to Staff 1, Staff 1 tended to minimize or say there was no problem thus concerns were usually not addressed. 43691 2. Resident 18 was admitted to the facility with diagnoses including hemiplegia (limited or no ability to move a side of the body). Resident 18's ,d+[DATE] Care Plan included the use of a mechanical lift for all transfers. On [DATE] at 3:34 PM Staff 16 (CNA) stated the mechanical lifts were difficult to use and dangerous. Staff 16 stated after the resident was raised in the air, the wheels lock and it is very difficult to push the mechanical lift for repositioning . I've had residents swing so much when we are trying to move them in it that I've had to catch the resident to prevent them from falling. On [DATE] at 7:03 PM Staff 3 (CNA) stated Resident 18 experienced a malfunctioning mechanical lift when she/he was transferred from a wheelchair to her/his bed in ,d+[DATE]. Staff 3 stated Resident 18 was being supported by the mechanical lift when it gave out and Staff 36 (CNA) was required to catch the resident who was halfway out of the mechanical lift sling, six inches from the floor. On [DATE] at 7:09 PM Staff 36 (CNA) stated she assisted Staff 3 when the mechanical lift malfunctioned. Staff 36 stated Resident 18 was being transferred with a mechanical lift when the lock disengaged and the mechanical lift collapsed which dropped Resident 18 towards the ground. Staff 36 stated she had to catch Resident 18 to prevent her/him from striking the ground. Staff 36 recalled Resident 18 having been afraid after the incident and stated Resident 18 has had a continued fear of mechanical lift transfers since. On [DATE] at 7:13 PM Resident 18 stated she/he experienced a near injury as a result of a faulty mechanical lift. Resident 18 reported the mechanical lift gave out and she/he was dropped from being fully raised to being six inches from the floor. Resident 18 stated they were not even touching it when the drop happened so it wasn't user error. Resident 18 stated she/he has felt afraid during transfers since she/he was nearly dropped to the floor. Resident 18 stated I don't feel [mechanical lifts] are safe for anyone. Still when they use [a mechanical lift] I wonder: Is it going to fall? Is it going to happen again? I am afraid it will happen again every time they use one. On [DATE] at 10:16 AM Staff 2 (DNS) stated she was unaware of the incident with Resident 18 but confirmed unsafe mechanical lifts should not be used for any transfers. On [DATE] 2:29 PM Staff 1 (Administrator) stated the issues with the mechanical lifts had been going on for a long time. Staff 1 stated staff brought the mechanical lifts to the maintenance department and every time they were looked at by Staff 11 (Maintenance Director), there was nothing wrong with them. Staff 1 stated staff concerns with the mechanical lifts had been going on for months because the staff did not know how to use the mechanical lifts properly. 3. Resident 4 was admitted to the facility with diagnoses including obesity and difficulty walking. Resident 4's ,d+[DATE] Care Plan included the use of a mechanical lift for all transfers. On [DATE] at 3:34 PM Staff 16 (CNA) stated the mechanical lifts were difficult to use and dangerous. Staff 16 stated after the resident was raised in the air, the wheels lock and it is very difficult to push the [mechanical lift] for repositioning . I've had residents swing so much when we are trying to move them in it that I've had to catch the resident to prevent them from falling. On [DATE] at 3:38 PM Resident 4 was observed receiving mechanical lift transfer assistance from Staff 16 (CNA) and Staff 3 (CNA). After Resident 4 was raised out of her/his wheelchair, Staff 16 and Staff 3 began to attempt to reposition the mechanical lift. The movements made were jerky and the resident began swinging back and forth while supported with the mechanical lift sling. Staff 16 and Staff 3 both were required to bend over and move the bottom portion of the mechanical lift when the wheels became stuck on the flat, smooth and unobstructed ground. On [DATE] at 3:45 PM Resident 4 stated the observed transfer was consistent with previous mechanical lift transfers. Resident 4 stated she/he did not feel safe with the use of the facility's mechanical lifts because the wheels often jammed and staff had to make adjustments to the mechanical lift for it to move, rather than focusing on the resident. On [DATE] at 10:16 AM Staff 2 (DNS) stated mechanical lifts should not require staff to bend over to allow for wheel movement. Staff 2 confirmed a mechanical lift requiring this practice should no be used. On [DATE] 2:29 PM Staff 1 (Administrator) stated the issues with the mechanical lifts had been going on for a long time. Staff 1 stated staff brought the mechanical lifts to the maintenance department and every time they were looked at by Staff 11 (Maintenance Director), there was nothing wrong with them. Staff 1 stated staff concerns with the mechanical lifts had been going on for months because the staff did not know how to use the mechanical lifts properly.

Based on observation and interview it was determined the facility failed to ensure food was labeled and stored in a manner to minimize spoilage and proper food handling practices were followed to prevent cross contamination in 1 of 1 kitchen reviewed for food safety. This placed residents at risk for foodborne illness and unappetizing meals. Findings include: 1. On 11/13/23 at 10:56 AM the following observations were made regarding dry food storage: -Three undated containers of pasta; -One undated container of croutons; and -One undated container of rice. On 11/13/23 at 11:13 AM Staff 33 (Cook) stated dry food containers were not dated. When questioned, Staff 33 was unable to say specifically how long they have had the dry foods. On 11/15/23 at 12:05 PM Staff 35 (Dietary Manager) confirmed all food should be dated. 2. On 11/15/23 at 11:39 AM Staff 34 (Cook) was observed preparing and plating lunch with no hairnet. On 11/15/23 at 12:05 PM Staff 35 (Dietary Manager) stated staff were to wear hairnets anytime they were in the kitchen area. Staff 35 confirmed Staff 34 was not wearing a hairnet when preparing and plating food. 3. On 11/15/23 at 11:40 AM the wall directly above the food plating area contained grease and food scraps. On 11/15/23 at 12:05 PM Staff 35 (Dietary Manager) stated staff were to maintain cleanliness of all areas of the kitchen, especially the area surrounding food plating. Staff 35 confirmed the grease and food on the wall was unacceptable.

Based on interview and record review it was determined the facility failed to have a system in place to track annual nurse aide training (required 12-hour minimum every year) for 5 of 5 randomly sampled CNAs (#s 7, 8, 12, 30 and 31) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 11/16/23 at 12:02 PM the following CNA staff training logs were requested and received from Staff 2 (DNS): -Staff 7 (CNA): received 0 hours of annual training; -Staff 8 (CNA): received 0 hours of annual training; -Staff 12 (CNA): received 0 hours of annual training; -Staff 30 (CNA): received 0 hours of annual training and -Staff 31 (CNA): received 0 hours of annual training. On 11/16/23 at 12:26 PM Staff 2 acknowledged the required 12 hours of annual in-service training was not completed for Staff 7, Staff 8, Staff 12, Staff 30 and Staff 31.

Based on observation and interview it was determined the facility failed to ensure contact information for pertinent State agencies was posted and available to residents for 1 of 1 facility observed for required postings. This failure placed residents at risk for lack of information about how to file a complaint. Findings include: Review of the facility's required postings on 11/16/23 revealed a poster with State agency information on reporting a complaint was not posted in the facility. On 11/16/23 at 10:16 AM Staff 2 (DNS) stated the facility previously had a poster up with contact information for the pertinent State agencies, but the poster was removed a week ago. Staff 2 acknowledged no contact information for the pertinent State agencies was currently posted.

Based on observation and interview it was determined the facility failed to ensure survey results were readily accessible for 1 of 1 facility reviewed for resident rights. This placed residents and the public at risk for not being informed of the facility's survey history. Findings include: On 11/14/23 at 10:30 AM a binder containing the facility's survey results was observed lying flat on the counter adjacent to a closed roll-up window on the south side of the building. The binder was oriented away from the room and the label of the binder was not visible when observed from wheelchair height. A sign was observed on the outside of the door which read, PUBLIC ACCESS TO FACILITY IS LOCATED ON THE [north] SIDE OF THE BUILDING. On 11/14/23 at 10:33 AM Staff 9 (Activities Director) stated the south side of the building was the facility's back door. She stated the main entrance was located on the north side of building and residents and guests entered and exited through the north side doors. On 11/17/23 at 11:05 AM Staff 5 (RN) reported she knew the binder existed but did not know where it was. She stated I don't think residents even know about it, to be honest. On 11/17/23 at 11:50 AM Staff 1 (Administrator) confirmed the current location of the survey binder and stated That's where it's always been. From COVID this side was locked and was not a public entrance. He stated nursing stations are the most central locations where residents would be more likely to find the binder.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 11/13/23 through 11/17/23 identified the following issues: -The 100 hall shower room was missing the threshold from the shower room to the hallway and was not cleanable. The tiles in the shower stall were worn down and chipped. The flooring was discolored. The overhead light was dirty and had a cracked plastic covering. -The skilled floor dining room had black marks along the wall under the window and black shoe prints on the wall near the sink. -room [ROOM NUMBER] had gouges in the wall above the bed and along the wall next to the bathroom. The heater was also gouged and had areas of missing paint. -room [ROOM NUMBER]'s bathroom light covering had come off and was on the floor by the toilet. In the corner of the room, the wall had gouges approximately five feet long. The wall under the window had numerous black markings. The wall edges where the corner of the wall met were gouged and needed repair. -room [ROOM NUMBER] had long dark marks on the wall entering the room, dark marks above the bed and along the wall near the head of the bed. The bathroom wall had several areas that needed repair. -room [ROOM NUMBER]'s wall had gouges near the head of the bed, the bathroom door with missing a chunk of wood and was scraped along the bottom of the door. The corner of the wall was gouged and needed repairs. -room [ROOM NUMBER]'s windows were dirty and hard to see out of. There were gouges near the head of the bed and along the wall, entering the room there were gouges on approximately four feet of the wall. The wall on the right side of the room was gouged and scraped. -room [ROOM NUMBER] had large black gouges in the floor and the window was dirty and hard to see out of. -room [ROOM NUMBER]'s window was dirty and hard to see out of. There were long gouges on the wall behind the bed and other walls that needed to be painted. The dresser and closet were scraped up. The bed protector on the wall was broken the entire length of the wall behind the bed. -room [ROOM NUMBER], when entering the room the wall had long gouges the length of the wall, the wall was scraped by the headboard, the dresser was scraped up, and there was missing plaster on the corner wall that needed to be repaired. 11/17/23 at 9:57 AM Staff 11 (Maintenance Director) acknowledged the identified rooms were not homelike and the identified maintenance concerns needed to be repaired.

Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for unmet care needs and lengthy call light response times. Findings include: On 11/13/23 the facility had a census of 72 residents. On 11/15/23 Staff 2 (DNS) provided a list of residents who: -Required two-person mechanical lift transfers: 24. -Were considered to be bariatric (obese) with a body mass index over 40: 9. -Had behavioral healthcare needs: 13. -Required frequent checks: 3. -Were determined to be at a high fall risk: 26. -Were dependent on staff for showers: 57. -Were dependent on staff for toileting: 44. -Required one-to-one assistance with eating: 6. The 1/2023 through 11/2023 Resident Council Meeting notes revealed residents' voiced concerns regarding long call light response times during every Resident Council meeting this year. Observations from 11/13/23 through 11/16/23 from the hours of 6:30 AM to 9:30 PM revealed the following concerns: -11/14/23 at 1:40 PM the resident in room [ROOM NUMBER] was yelling help me; -11/14/23 at 1:48 PM the call light in room [ROOM NUMBER] was activated for 35 minutes and the call light in room [ROOM NUMBER] was activated for 32 minutes; -11/14/23 at 3:21 PM the call light in room [ROOM NUMBER] was activated for 35 minutes; -11/15/23 at 10:13 AM the call light in room [ROOM NUMBER] was activated for 30 minutes; -11/15/23 at 2:50 PM Resident 28, identified to be at a high fall risk, attempted to self-transfer using a transfer pole and was unable to get to a standing position. No staff were observed in the hallway; and -11/16/23 at 11:16 AM a resident on the 200 hallway was yelling somebody help me. Interviews with staff revealed the following: On 11/13/23 at 3:35 PM Staff 16 (CNA) stated she typically was assigned 11 residents on evening shift and reported during the first week of 11/2023, there was a day when she was the only licensed CNA on the unit. Staff 16 stated it was very difficult because she was told she had to get all of the residents up for dinner and then change all of the residents' bedsheets. Staff 16 stated this was an impossible task. On 11/15/23 at 8:28 AM Staff 4 (CNA) stated staffing on the weekend was awful and Saturdays were consistently short one staff. Staff 4 stated because of low staffing, residents had falls and staff were unable to get residents up for meals because there were so many residents that require two-person mechanical lift transfers. Staff 4 stated the residents often did not get showered or toileted in a timely manner and residents did not receive restorative therapy at times because the restorative aid was pulled to the floor to work as a CNA. On 11/15/23 at 9:57 AM and 7:26 PM Staff 5 (RN) stated the long-term hallways had very heavy care residents. She stated many residents required two-person mechanical lift transfers, there were several residents with behaviors and it took at least one hour to provide routine care for one resident. Staff 5 reported the facility staffed to the state minimum ratios but that was not adequate based on the needs of the residents. Staff 5 stated the facility was short CNA coverage all the time and there were staff that frequently called in. Staff 5 reported as a result of the facility being short staffed, many residents had skin issues, recently a resident had a choking incident, showers were missed and the CNAs were unable to take breaks and had to stay past their shift in order to get their charting done. On 11/15/23 at 10:45 AM Staff 6 (CNA) stated the weekends were consistently incredibly short staffed. Staff 6 stated there were many new CNAs and NAs which made it hard for the veterans because the newly hired staff did not get enough training. Staff 6 stated due to low staffing, sometimes residents did not get showered and the CNAs did not take breaks or lunches at times. On 11/15/23 at 12:06 PM Staff 7 (CNA) stated the facility was typically short staffed. Staff 7 stated when the facility was short staffed the residents did not get showered and they got upset, wondering when they would receive a shower. Staff 7 stated if the facility was staffed over the state minimum ratios then staff got sent home. On 11/15/23 at 12:17 PM Staff 8 (CNA) stated staffing may look good on paper but there were not enough staff to meet the acuity needs of the residents. Staff 8 stated training of NAs was a big problem because they were not provided adequate training. Staff 8 stated the CNA staff were in a lose/lose situation due to inadequate staffing. Staff 8 stated residents did not get washed properly, their dentures did not get taken out and cleaned at night and skin care was not getting done. On 11/15/23 at 1:10 PM Staff 12 (CNA) stated in general the facility was short staffed almost every day. Staff 12 stated the new NAs were not adequately trained which took a lot of time from the experienced CNAs. Staff 12 stated when the facility was short staffed residents had to stay up longer than they should, were left in bed for meals, showers were missed and denture/oral care was not completed. Staff 12 stated CNAs had to work longer than their scheduled shift in order to get their charting completed. On 11/15/23 at 7:03 PM Staff 3 (CNA) stated evening shift CNAs often had 10 to 12 assigned residents. Staff 3 stated the facility had many residents who required two-person mechanical lift transfers which made it hard on the staff. Staff 3 stated often the staff had to bump showers and residents had to sit up in their chairs for long periods of time because staff did not have time to put the residents back to bed. On 11/16/23 at 10:52 AM Staff 9 (Activities Director) stated she participated in monthly Resident Council meetings and long call light times were a problem brought up by the residents' throughout the entire year. On 11/16/23 at 1:06 PM Staff 2 stated staffing was determined based on the state minimum staffing ratios. Staff 2 stated staff came to her stating the facility was short staffed and she told them the facility was staffed based on the state minimum staffing ratios so staffing was fine. Staff 2 acknowledged that the facility was supposed to staff according to the acuity needs of the residents but stated they had no acuity tools to use. Staff 2 stated the facility was not completing annual licensed staff competencies and she needed to get those going. On 11/17/23 at 11:09 AM Witness 2 (Resident Advocate) stated she brought staffing concerns to the attention of Staff 1 (Administrator) and the concerns were minimized. Witness 2 stated during visits in 9/2023 and 10/2023, call light times were over 40 minutes and residents frequently reported call light response times between 30 minutes to one hour. Witness 2 stated staffing issues lead to residents sitting in urine soaked clothing for long periods of time. Witness 2 stated staffing concerns continued to be an ongoing issue with the facility.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 2 of 5 sampled CNA staff (#s 7 and 31) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: On 11/16/23 at 12:10 PM a review of the facility staff training records for CNAs employed over one year revealed the following: -Staff 7 (CNA), hire date 7/17/22; had no annual performance review documentation on file. -Staff 31 (CNA), hire date 10/1/21; had no annual performance review documentation on file. On 11/16/23 at 1:09 PM Staff 2 (DNS) confirmed she was unable to provide annual performance review documentation for Staff 7 and Staff 31.

Based on observation and interview it was determined the facility failed to ensure the garbage area dumpsters were covered and free from debris for 3 of 3 facility dumpsters reviewed for sanitation. This placed residents at risk for exposure to pests and rodents. Findings include: On 11/15/23 at 12:06 PM three dumpsters were observed, all with lids open. Two used medical gloves and one wet-wipe were observed around the two south dumpsters. On 11/16/23 at 9:25 AM three dumpsters were observed, all with lids open. Three used medical gloves were observed on the ground around the outside of the south dumpsters. Two medical gloves were observed on the ground around the outside of the north dumpster. On 11/16/23 at 10:10 AM the north and south dumpster areas were reviewed with Staff 11 (Maintenance Director). Staff 11 confirmed the dumpster lids were to be closed and used medical equipment was to be in the containers, not on the ground around the containers.

Based on observation, interview and record review it was determined the facility failed to ensure dignity for 1 of 2 sampled residents (#40) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include: Resident 40 was admitted to the facility in 2021 with diagnoses including stroke. A review of Resident 40's 9/27/23 Annual MDS Assessment revealed she/he had moderate cognitive impairment. Resident 40's Care Plan revised on 10/8/21 revealed she/he required extensive assistance from one staff member twice a week and as necessary to complete bathing tasks. Resident 37 was admitted to the facility in 2022 with diagnoses including muscle wasting and atrophy. A review of Resident 37's 10/7/23 Quarterly MDS Assessment revealed she/he had moderate cognitive impairment. On 11/14/23 at 1:42 PM Resident 40 was observed in a shower chair and partially covered by a bath blanket while Staff 17 (CNA) transported her/him to the 400 hall shower room. Resident 40's left buttock and left leg were completely exposed. On 11/14/23 at 1:44 PM Resident 37 was observed sitting in her/his wheelchair near the 400 hall shower room. She/he stated, Did you see that? That man was completely naked and they just rolled him down the hall naked for his shower. Resident 37 stated residents are frequently transported to and from the shower without being completely covered. She/he stated she/he thought it was not right to be transported naked. On 11/14/23 at 2:13 PM Staff 17 stated she did not notice Resident 40's buttock and leg were uncovered when she prepared her/him for her/his shower. She stated, Maybe I should have made sure [she/he] was more covered. On 11/16/23 at 11:57 AM Staff 18 (RN) stated CNAs and shower aides prepared residents for showers in the shower room or in the residents' rooms. She stated staff members were expected to make sure residents were completely covered while going between their rooms and the shower room. On 11/17/23 at 11:57 AM Staff 2 (DNS) stated when going to and from the shower room she expected residents to be covered completely for everyone's dignity and privacy.

Based on observation, interview and record review it was determined the facility failed to assess a resident for safe self-administration of medication for 1 of 2 sampled residents (#41) reviewed for medication self-administration. This placed residents at risk for unsafe medication administration. Findings include: Resident 41 was admitted to the facility in 2022 with diagnoses including asthma. A Physician Order from 3/17/23 instructed Resident 41 to inhale 2 puffs of albuterol 90 mcg for shortness of breath. The order included instructions the medication was to be administered by a clinician. On 11/13/23 at 3:38 PM an albuterol inhaler was observed on the residents bedside table. Resident 41 stated she/he had been assessed and approved to use the inhaler independently. On 11/15/23 at 8:43 AM Staff 32 (RNCM) stated a resident must have physician orders and an assessment for safety with self-administration of any medication. Review of Resident 41's orders with Staff 32 revealed Resident 41's albuterol medication was to be administered by a clinician and should not be left in her/his room. Staff 32 also confirmed a self-administration assessment was not performed on Resident 41 regarding self-administration of albuterol. Upon visit of Resident 41's room, Staff 32 confirmed Resident 41 had an albuterol inhaler by her/his bedside and removed the inhaler from Resident 41's room.

Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse by Resident 2 for 1 of 3 sampled residents (#1) reviewed for abuse. This failure resulted in Resident 1 experiencing pain and fear. Findings include: The facility's Abuse/Neglect/Misappropriation/Exploitation Policy and Procedure revised 10/2022 revealed the following information: - It is the policy of this facility to protect residents from mistreatment, neglect, abuse, exploitation, involuntary seclusion and misappropriation of property by implementing procedures designed to prevent, identify, report and investigate potential instances of abuse, neglect and exploitation. - Physical Abuse - Includes, but is not limited to hitting, slapping, pinching, choking, striking with an object, kicking, shoving, prodding, corporal punishment or the use of chemical or physical restraints unless indicated by the resident's condition. Resident 1 was admitted to the facility in 2022 with diagnoses including a history of stroke and chronic kidney disease. Resident 1's 5/2023 Quarterly MDS revealed a BIMS score of 10 (moderate cognitive impairment) and a history of behavioral symptoms not directed toward others (hitting, rummaging and disruptive sounds four to six days per week). Resident 2 was admitted to the facility in 2022 with diagnoses including diabetes and chronic pain syndrome. Resident 2's 7/2023 Quarterly MDS indicated a BIMS score of 15 (cognitively intact) and a history of verbal behavior symptoms directed toward others (threatening, screaming or cursing at others on a daily basis). Resident 1's medical record revealed there was a resident-to-resident incident between her/him and Resident 2 on 4/13/23. Resident 1 was in the hall outside Resident 2's room. Resident 2 became upset because Resident 1 would not stop making noise. The incident was investigated and there were no injuries or abuse found. Resident 1 was moved to a room in a different hall away from Resident 2's room. A 7/4/23 progress note revealed Resident 1 was observed by Staff 4 (CMA) in the hall near Resident 2's room. Staff 4 stated Resident 2 yelled get out of here you [expletive] thief and she/he hit Resident 1. Resident 1 stated Resident 2 slapped her/him on the left side of her/his face. The left side of her/his face had a red mark and she/he complained of pain. A 7/5/23 progress note indicated Resident 1 complained of pain and tenderness to the left side of her/his face. On 7/10/23 two public complaints were received by the State Agency regarding allegations of physical abuse between two residents. Resident 2 was observed by facility staff to slap Resident 1 in the face. On 7/12/23 at 4:45 PM Resident 1 was observed in her/his wheelchair in the hall by the nurses station. She/he was alert and interacting with another resident. On 7/12/23 at 4:50 PM Resident 2 was observed in her/his room sitting by the doorway. Resident 2 declined to talk with the surveyor. On 7/13/23 at 12:03 PM Staff 3 (LPN) stated Resident 1 was oriented only to self and had behaviors of repetitive crying, moaning and wandering around the facility in her/his wheelchair. Staff 3 stated between April 2023 and July 2023 there were incidents of yelling between Resident 1 and Resident 2. Staff 3 indicated Resident 1 did not cause any harm or problems with other residents. Staff 3 stated Resident 1 reported Resident 2 slapped her/him and pointed to her/his left cheek where it was warm and red. Staff 3 indicated the resident appeared scared and was teary eyed. On 7/17/23 at 7:00 PM Witness 1 (Complainant) indicated Resident 1 was very scared and her/his left cheek was red and puffy after the incident with Resident 2. On 7/19/23 at 10:42 PM Staff 5 (LPN) stated Resident 1 did not enter Resident 2's room on 7/4/23 and Resident 2 had a history of aggressive behavior toward Resident 1. Staff 5 revealed Resident 2 displayed aggressive behaviors toward other residents in the past. Staff 5 stated a Stop sign was placed on Resident 2's door as the intervention after her/his incident with Resident 1. On 7/21/23 at 12:51 PM Staff 1 (Administrator) and Staff 2 (DNS) reviewed the 7/4/23 incident between Resident 1 and Resident 2. Staff 1 stated the incident was not reported as abuse initially and the whole story was not documented. On 7/28/23 at 1:38 PM Staff 1 and Staff 2 acknowledged the findings related to the 7/4/23 incident. No additional information was provided.

Based on interview and record review it was determined the facility failed to prevent the worsening of pressure ulcers for 1 of 2 sampled residents (#17) reviewed for pressure ulcers. This resulted in Resident 17 developing a worsened pressure ulcer. Findings include: The 10/21/22 State Operations Mannual indicated the following: Nutrition and Hydration: Adequate nutrition and hydration are essential for overall functioning. Nutrition provides vital energy and building blocks for all of the body ' s structures and processes. Any organ or body system may require additional energy or structural materials for repair or function. Weight reflects a balance between intake and utilization of energy. Significant unintended weight loss may indicate under-nutrition or worsening health status. Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated [CONDITION(S)], intertriginous [CONDITION(S)] (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, [CONDITION(S)], abrasions). The National Pressure Ulcer Advisory Panel defined the following pressure injury stages: Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damages varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining the tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury Resident 17's 7/1/22 Care Plan revealed Resident 17 was at risk for nutritional problems including a potential for decreased intake and weight loss due to dementia and diabetes. Facility was to educate caregivers on the importance of good nutrition to avoid skin breakdown and promote healing of pressure wounds. Care staff were to attempt alternative methods during issues of non-compliance and refer to the Registered Dietician as needed. A 7/19/22 Medication Administration Note revealed Resident 17 acquired a Stage 2 Left Buttock Pressure Ulcer. Review of Resident 17's 7/2022 clincial record revealed no additional information about the wound or how it was aquired. Resident 17's weight summary reviewed from 7/2022 through 9/2022 revealed the following: - 203.6 lbs on 7/19/22; - 181.4 lbs on 8/16/22; - 180.5 lbs on 8/30/33 and - 178.1 lbs on 9/6/22 (This was a 25.5 lbs (12.5%) weight loss between 7/19/22 through 9/6/22). Resident 17's Meal Intake Monitor reviewed from 7/2022 through 8/2022 revealed the following: - 12 of 31 days showed missing meal intakes for breakfast, lunch an dinner for the following days (8/5/22, 8/9/22, 8/10/22, 8/11/22, 8/15/22, 8/17/22, 8/18/22, 8/21/22. 8/24/22, 8/25/22, 8/26/22); - 12 of 31 days showed staff documented that resident refused meal intake (8/1/22, 8/6/22, 8/7/22, 8/8/22, 8/9/22, 8/12/22, 8/13/22, 8/19/22, 8/28/22, 8/31/22); - 18 of 31 days showed staff documented resident meal intake was between 25 to 50% (8/1/22, 8/2/22, 8/7/22, 8/8/22, 8/9/22. 8/12/22, 8/13/22, 8/15/22, 8/17/22, 8/19/22, 8/22/22, 8/23/22, 8/24/22, 8/26/22, 8/28/22, 8/29/22, 8/30/22, 8/31/22). Resident 17's clinical record reviewed from 7/2022 through 10/2022 revealed no Physician or Registered Dietician was notified or residents weight loss or low meal intake. There was no new inventions were documented since 9/13/22. An 11/1/22 Medication Administration Note revealed Resident 17 received pain medication administration every 6 hours for pain due to Stage 3 pressure ulcer of the left buttock. On 11/1/22 at 10:22 AM and 10:36 AM Witness 1 (family) stated family often came in to assist Resident 17 with eating as the facility did not encourage the resident to eat. Witness 1 stated due to the facility's lack of encouragement with eating, Resident 17 went from 203 lbs on 7/19/22 to 181 lbs on 8/16/22. Family indicated as a result of the weight loss, Resident 17's wound had worsened. Witness 1 (Family) further indicated that the wound on Resident 17's left buttock had increased to the size of quarter. On 11/2/22 at 9:07 AM Staff 10 (CNA) stated Resident 17 required frequent encouragement to eat due to residents non-compliance. Staff 10 stated when Resident 17 became non-compliant with eating the care staff would leave her/him alone. Staff 10 stated staff would rely on family to get Resident 17 to eat. Staff 10 revealed that Resident 17's pressure ulcer on the residents left buttock had worsened from a red spot to a stage 3 pressure ulcer. Staff 10 stated as a result, Resident 17 often complained of pain due to the wound and required pain medication before care. On 11/02/22 at 11:27 AM Staff 12 (LPN - Wound Nurse) confirmed Resident 17's wound had worsened and developed into a Stage 3 pressure ulcer due to a lack of proper nutrition. Staff 12 stated staff wound encourage Resident 17 to eat but stopped trying to assist the resident with eating due to the residents combativeness. Staff 12 stated the staff often relied on Resident 17's family to encourage and assist with eating.

Based on interview and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for 1 of 2 sampled residents (#17) reviewed for nutrition. As a result, Resident 17 had severe weight loss of greater than 10% in a month. Findings include: Resident 17 admitted to the facility in 7/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 17's 7/1/22 Care Plan revealed Resident 17 was at risk for nutritional problems including a potential for decreased intake and weight loss due to dementia and diabetes. Facility was to monitor and report any significant weight loss or gains to the Physician and Registered Dietician. On 11/1/22 at 10:22 AM Witness 1 (family) stated family often came in to assist Resident 17 with eating as the facility did not encourage the resident to eat. Witness 1 stated due to the facility's lack of encouragement with eating, Resident 17 went from 203 lbs on 7/19/22 to 181 lbs on 8/16/22. On 11/2/22 at 9:03 AM Staff 10 (CNA) stated the resident required frequent encouragement to eat and often times required staff to feed the resident due to non-compliance. Staff 10 stated that when Resident 17 became non-compliant with eating that care staff would leave her/him alone. Resident 17's weight summary reviewed from 7/2022 through 9/2022 revealed the following: -203.6 lbs on 7/19/22; -181.4 lbs on 8/16/22; -180.5 lbs on 8/30/22 and -178.1 lbs on 9/6/22 (This was a 25.5 lbs (12.5%) weight loss between 7/19/22 through 9/6/22). Resident 17's Meal Intake Monitor reviewed from 7/2022 through 8/2022 revealed the following: - 12 of 31 days showed missing meal intakes for breakfast, lunch and dinner for the following days (8/5/22, 8/9/22, 8/10/22, 8/11/22, 8/15/22, 8/17/22, 8/18/22, 8/21/22, 8/22/22, 8/24/22, 8/25/22, 8/26/22); - 12 of 31 days showed staff documented that resident refused meal intake (8/1/22, 8/2/22, 8/6/22, 8/7/22, 8/8/22, 8/11/22, 8/12/22. 8/13/22, 8/19/22, 8/28/22, 8/31/22); - 18 of 31 days showed staff documented resident meal intake was between 25 to 50% (8/1/22, 8/2/22, 8/7/22, 8/8/22, 8/9/22, 8/12/22, 8/13/22, 8/15/22, 8/17/22, 8/19/22, 8/22/22, 8/23/22, 8/24/22, 8/26/22, 8/28/22, 8/29/22, 8/30/22, 8/31/22). Resident 17's clincial record reviewed from 7/2022 through 10/2022 revealed no Physician or Registered Dietician was notified of resident's weight loss, refused meal intake, or low meal intake. No new interventions were implemented. On 11/2/22 at 11:27 AM Staff 12 (LPN - Wound Nurse) confirmed the findings and stated a lack of eating and proper nutrition directly caused Resident 17 to lose weight. Staff 12 stated staff would encourage Resident 17 to eat but stopped trying to assist the resident with eating due to the resident's combativeness. Staff 12 stated the staff often relied on Resident 17's family to encourage and assist with eating.

Based on observation, interview and record review it was determined the facility failed to appropriately assess and prevent new and worsening facility acquired pressure ulcers for 6 of 12 sampled residents (#s 3, 10, 29, 31, 36 and 42) reviewed for skin and pressure ulcers. This failure resulted in all six residents acquiring new or worsening pressure ulcers. Findings include: 1. Resident 3 was admitted to the facility in 2/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 10/29/19 MDS Pressure Ulcer CAA indicated, Resident 3 admitted to the facility for therapy and wound care after being in the hospital with a left femur fracture. Resident 3 needed extensive assistance with transfers and bed mobility which placed her/him at risk for pressure ulcers. Resident 3 was alert and oriented and aware of her/his need to change positions frequently to decrease the risk for pressure ulcers. Resident 3 had limited mobility which increased her/his risk because she/he could not change position and Resident 3's incontinence could lead to maceration and pressure ulcers due to her/his skin being exposed to moisture for extended periods of time. The assessment indicated to provide interventions to decrease the residents risk for pressure ulcers and monitor for signs and symptoms of skin breakdown. The 4/2/19 care plan indicated Resident 3 had potential alteration in skin integrity and pressure ulcers related to weakness, limited mobility and surgical incision. Interventions included: -Educate the resident, family and care givers to the cause of skin breakdown, including: transfer, positioning, good nutrition and the importance of repositioning. -Encourage the resident to float and offload heels. -If the resident refused treatment, confer with the interdisciplinary team and family members to try alternative methods to gain compliance. -Keep skin clean and dry and protect from injury. -Monitor dressing sites to ensure they are clean, dry and intact. -Skilled boot to both feet at all times as the resident will allow, float heels as the resident will allow. -Resident 3 needed reminding and assistance to turn and reposition at least every two hours or more often as needed or requested. -Resident 3 used a pressure relieving wheelchair cushion. On 11/14/19 Resident 3 was noted to have a facility acquired unstageable (full thickness tissue loss covered by slough [yellow, tan, gray, or brown] tissue or eschar [tan, brown or black] in the wound bed) pressure ulcer to her/his left toe and left heel. An Incident Report Completion Form dated 11/14/19 indicated: -Occupational Therapy called nurse to shower room and noted drainage from Resident 3's left heel as well as necrosis to the great left toe. -The investigation indicated Resident 3 had her/his last skin check on 11/14/19 and no skin issues were noted. -the care plan was updated to include: heel pressure relieving boots to both feet at all times, float heels when boots were not in place and educate the resident about the importance of changing positions as the resident preferred to lay on her/his back while in bed. A physician's note dated 11/26/19 did not mention Resident 3's pressure ulcers. On 12/10/19 Resident 3 developed a facility acquired unstageable pressure wound to her/his malleolus (the bony prominence on either side of the ankle) and necrotic tissue to the left second great toe. An Incident Report Completion Form dated 12/10/19 indicated: -Therapy had informed the treatment nurse Resident 3 had SDTI (suspected deep tissue injury) to left malleolus and necrosis to second great toe. -The investigation indicated the resident had been last seen 45 minutes prior to finding the wounds and the CNA was not aware of the wounds. -Resident 3's last skin check was 12/5/19 and the area were not noted. -Resident 3 had used a CPM (continuous passive motion) machine for several hours through the day to her/his left leg fracture. The pressure injuries most likely occurred due to the pressure to her/his left foot from the the CPM machine. CPM machine was placed on hold until the orthopedic physician clarified it the resident should continue the CPM machine. -The care plan indicated Resident 3 needed reminding and assistance to turn or reposition at least every two hours. On 1/7/20 Resident 3 developed a facility acquired unstageable pressure wound to her/his left third toe and on the outside of the ankle. Resident 3 had necrosis to the left third and forth toes. An Incident Report Completion Form dated 1/7/20 indicated: -During wound care services Resident 3 was noted with necrotic tissue to third and fourth toes along with SDTI to lateral malleolus. Area was non-tender to the touch and Resident 3 was able to move her/his toes when prompted. -The investigation indicated; -The resident had been toileted 30 minutes prior to the wounds being found, CNA was not aware of the wounds. -Last wound check was on the morning of 1/2/20 and the areas were not noted. A progress note dated 1/16/20 indicated Resident 3 was noted with foul odor to the wounds on the left foot along with grimacing and vocal expression of discomfort when toes were touched. All of Resident 3's left toes were necrotic and no longer showing signs of movement, Resident 3 was set to see a surgeon on 1/17/20 and was sent to the hospital for evaluation. On 1/16/20 Resident 3 was at [CONDITION(S)] and the [CONDITION(S)] center called the vascular surgeon to make an appointment. On 1/17/20 Resident 3 was admitted to the hospital for a left above the knee amputation. On 6/1/22 at 2:33 PM Staff 7 (RN) stated the physician should have assessed Resident 3 right away because Resident 3 had a change of condition and it was unusual the physician did not come in and a vascular physician was not called. Staff 7 stated as the foot deteriorated Resident 3 should have been seen by a physician. Staff 7 stated the resident used a CPM machine on the left leg due to a leg fracture but should not have used the machine with necrotic toes. Staff 7 stated Resident 3 did not refuse care from staff. On 6/1/22 at 2:58 PM Staff 27 (RN) stated Resident 3 did not refuse care from staff. Staff 27 stated Resident 3 needed an interpreter but the facility had Spanish speaking staff to help translate. Staff 27 stated if Resident 3 had necrotic tissue on her/his foot she would have asked a therapist about using the CPM machine. Staff 27 stated the wounds and the CPM machine were not on the care plan. On 6/6/22 at 2:53 PM Staff 49 (CNA) stated the nurses put the CPM machine on Resident 3. Staff 49 stated staff would tell the nurses to take it off because it had been on all day but they would not listen. Staff 49 stated she tried to ask the nurses to let her give her/him a shower so she could remove the CPM machine but that did not happen. Staff 49 stated she had not seen a physician come in to look at the wounds. Staff 49 stated nurses did not watch the wounds close enough and the wounds worsened and Resident 3 ended up with an amputation. Staff 49 stated Resident 3 did not refuse care but at times staff would have to re-approach her/him and then she/he would agree to care being provided. On 6/6/22 at 10:10 AM Staff 3 (CNA) stated Resident 3 would sometimes refuse care but staff re-approached Resident 3 and she/he would let them provide cares. Staff 3 stated Resident 3 did not refuse to be repositioned. On 6/8/22 at 12:53 PM Staff 24 (LPN) stated Resident 3 did not refuse care from staff. On 6/8/22 at 2:37 PM Staff 42 (RN) stated Resident 3's wounds were found on 11/14/19. The physician came in on 11/26/19 (11 days later) but did not mention the wounds. Staff 42 stated on 1/15/20 while Resident 3 was at [CONDITION(S)] the [CONDITION(S)] staff called a vascular surgeon due to the necrotic wounds. Staff 42 stated the facility did not send the resident to the vascular surgeon right away because the facility would try to heal the wounds first. Staff 42 acknowledged the initial wound started on 11/4/19 and on 12/10/19 the wound had deteriorated and then worsened further on 1/7/20. Staff 42 stated Resident 3 was sent to the hospital on 1/9/20. Staff 42 stated an order was received which indicated Resident 3 had a vascular referral for 1/20/20. Staff 42 stated the toes definitely deteriorated and worsened and she was not sure why nothing was done sooner. On 6/15/22 at 11:21 AM Staff 2 (DNS) stated she did not have an answer as to why it was the [CONDITION(S)] center who called the vascular surgeon. Staff 2 stated when the toes became worse she called the vascular surgeon on 1/16/20 and the resident was sent out to the hospital for an amputation. Staff 2 stated she could not provide further documentation from Resident 3's surgeon, hospital or physician. 2. Resident 10 was admitted to the facility in 4/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 10's care plan dated 4/7/20 instructed staff to turn, reposition and check and change the resident every two hours or more as needed or requested. The care plan did not include any of the pressure wounds. A Pressure Ulcer CAA dated 4/14/20 indicated the resident was at risk for pressure ulcers due to needing assistance with transfers, bed mobility, being incontinent and having current skin breakdown. The resident had an air mattress, a cushion in her/his wheelchair and was on a turning schedule to help her/his current pressure ulcers heal and decrease her/his risk for new pressure ulcers. Resident 10 had frequent pain which could lead to pressure ulcers if she/he refused to change positions. Resident 10 had to be reminded and assisted to change positions. A FRI dated 5/15/20 revealed the following: -Staff 56 (Former CNA) left Resident 10 on a bedpan for several hours. -On 5/18/20 Staff 55 (CNA) reported to Staff 57 (Former RN) Resident 10 had an open area to her/his gluteal split. -The pressure ulcer was a previous site of injury that Resident 10 had admitted with which put Resident 10 at greater risk for re-injury of the gluteal split. A 5/18/22 Incident Witness Statement indicated Resident 10 had a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 57 (Former RN) noted a Stage 2 pressure ulcer to the top of the gluteal split. The area measure 2 x 0.2 cm. Staff 57 indicated the ulcer is a previous site the resident had admitted with. The previous injury was a Stage 3 and had resolved 5/5/20. Staff 57 indicated having a previous Stage 3 pressure ulcer put the resident at risk of reinsuring the skin. On 5/27/22 at 11:08 AM Staff 44 (CNA) stated Resident 10 used a bedpan and was incontinent of bowel and bladder. Staff 44 stated she/he was to be repositioned and toileted every two hours but this did not always occur. On 6/1/22 at 3:30 PM Staff 50 (CNA/CMA) stated staff did not always document if Resident 10 was turned or toileted every two hours. Staff 50 stated the turn and toilet schedule was based on the honor system. On 6/7/22 at 1:57 PM Staff 19 (RNCM) stated she expected CNAs to reposition and toilet Resident 10 every two hours. Staff 19 stated she assumed staff were doing their jobs and the CNAs could not be supervised 100 percent of the time. Staff 19 further stated Resident 10 did have a previous gluteal split which had healed. Staff 19 stated Resident 10 had a gluteal split three days after the 5/15/20 bed pan incident which could have definitely been from the bedpan due to the previous injury. 3. Resident 29 was admitted to the facility in 11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pressure Ulcer CAA dated 11/17/21 indicated Resident 29 needed assistance with transfers and bed mobility due to not being able to change positions independently which placed the resident at risk for pressure ulcers. The resident was alert and oriented and aware of her/his need to change positions frequently to decrease her/his risk of pressure ulcers. The resident had a cushion in her/his wheelchair to decrease pressure areas. The resident was experiencing occasional incontinence which placed her/him at risk for pressure ulcers and maceration due to her/his skin being exposed to moisture for extended periods of time. The assessment indicated to proceed to care plan to provide interventions to decrease the resident's risk for pressure ulcers and monitor for skin breakdown. Resident 29's care plan dated 11/25/21 instructed staff to educate the family, resident and care givers as to the causes of skin breakdown including: -transfers, positioning, importance of taking care during ambulating, mobility and frequent repositioning. -teach resident and family the importance of changing position/turning for prevention of pressure ulcers. Encourage small frequent turning/position changes. A FRI dated 1/3/22 revealed the following: -Staff 16 (RNCM) found Stage 2 (partial thickness loss skin) pressure ulcers to the coccyx (tailbone) and the buttocks. The 1/3/22 Initial Skin Ulcer Assessment indicated Resident 29 had a facility acquired Stage 2 pressure ulcer to the coccyx and the buttocks. On 6/1/22 at 3:41 PM Staff 50 (CMA) stated the resident had facility acquired pressure ulcers due to not being turned as often as she/he should have been. Staff 50 stated staff tried to be quick and get Resident 29 changed right away but this did not always occur due to being short staffed. On 6/3/22 at 12:46 PM Staff 22 (CNA) stated she worked with Resident 29 the day the pressure ulcers were found. Staff 22 stated she was not always able to change the resident every two hours or reposition her/him due to not having enough staff. Staff 22 stated Resident 29 did not refuse care. On 6/15/22 at 11:34 AM Staff 2 (DNS) stated Resident 29 should have been offered toileting and helped with bed mobility every hour. Staff 2 indicated on 1/3/22 the resident was toileted at 6:00 PM and the pressure ulcer was found at 9:00 PM which indicated Resident 29 was not offered toileting or repositioned every one to two hours. 4. Resident 31 was admitted to the facility in 1/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 1/30/22 Annual MDS Pressure Ulcer CAA indicated Resident 31 needed extensive to total assistance with transfers, bed mobility, had cognitive deficits and incontinence which placed her/him at risk for pressure ulcers. Resident 31 spent most of her/his day in her/his wheelchair which could lead to pressure ulcers if she/he was not repositioned to relieve pressure. the assessment indicated to proceed to care plan to provide interventions to decrease her/his risk for pressure ulcers and monitor for signs and symptoms of skin breakdown. Resident 31 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/28/21 care plan revised on 6/2/22 indicated Resident 31 had potential/alteration in skin integrity/pressure ulcers related to diabetes, muscle weakness, dementia with behavioral disturbances, muscle weakness, heart disease, pain and bowel and bladder incontinence. Resident 31 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 31 had a current left heel pressure ulcer. Interventions included: -Air mattress with bolsters related to skin integrity, ensure mattress is working properly every shift. -Educate the resident, family and care givers to the causes of skin breakdown including; transfer, positioning, good nutrition and frequent repositioning. -Keep the resident off her/his coccyx, turn side to side every two hours, up for meals then lay back down. -Encourage the resident to offload or float heels. -Boots to both feet at all times as the resident will allow. A 2/9/22 Incident Report Completion Form indicated Resident 31 had a facility acquired Stage 3 (full thickness tissue loss, fat may be visible but bone and tendon are not) pressure wound to both sides of the buttocks. Resident 31 was confused and not able to give a statement regarding the wound. The 2/9/22 Investigation indicated Resident 31 was dependent on staff for all cares. Resident 31 received her/his air mattress which was backordered. On 5/19/22 at 3:16 PM Staff 33 (CNA) stated Resident 31 had pressure ulcers to her/his buttocks and heel. Staff 33 stated Resident 31 was not always turned as often as she/he should have been due to not being able to find another staff member to assist. On 6/1/22 at 3:49 PM Staff 50 (CMA) stated Resident 31 developed a pressure ulcer in the facility and also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 50 stated Resident 31 spent most of her/his time in her/his bed not in the wheelchair. On 6/4/22 at 1:46 PM Staff 25 (CNA) stated Resident 31 had an air mattress but it was removed because the facility did not have enough to go around and then she/he developed pressure ulcers. On 6/7/22 at 2:15 PM Staff 19 (RNCM) stated there was a shortage of air mattresses at the time Resident 31 developed pressure ulcers. Staff 19 stated they did remove her/his air mattress because Resident 31 did not have a pressure ulcer at that time. Staff 19 acknowledged as soon as the air mattress was removed Resident 31 developed a pressure ulcer. 5. Resident 36 was admitted to the facility in 1/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 1/6/22 care plan indicated Resident 36 had potential alteration in skin integrity and pressure ulcers related to muscle wasting, kidney disease, heart disease, limited mobility, weakness, refusals of care, intermittent refusals of turning, repositioning and unavoidable skin breakdown. Resident 36 had a current coccyx pressure ulcer Stage 4 and current left heel deep tissue injury. Interventions included: -Air mattress -Apply heel protectors to both feet at all times. -Educate the resident, family and care givers to the cause of skin breakdown including good nutrition and frequent repositioning. -If the resident refused treatment confer with the resident, interdisciplinary team and family to determine why. Try alternative methods to gain compliance The 1/13/22 Admission MDS indicated Resident 36 was at risk for developing pressure ulcers. Resident 36 had a pressure relieving device in her/his wheelchair. There was no pressure reducing device for the bed and no turning or repositioning program. The Pressure Ulcer CAA indicated Resident 36 admitted to the facility for therapy and wound care after surgical repair of her/his right hip fracture. Resident 36 was at risk for pressure ulcers due to the need for assistance with transfers, bed mobility, experiencing incontinence, and having cognitive deficits. Having limited mobility can lead to pressure ulcers due to not being able to change positions independently. Resident 36 was experiencing cognitive problems which decreased her/his ability to remember to change positions. Being incontinent placed her/him at risk due to skin being exposed to moisture for extended periods of time. The assessment indicated to proceed to care plan to provide interventions to decrease the resident's risk for pressure ulcers and monitor for signs and symptoms of skin breakdown. A 2/8/22 Incident Report indicated during routine care Resident 36 was found to have a Stage 3 (full-thickness skin loss) pressure ulcer to her/his coccyx. The investigation indicated the incident most likely occurred due to the resident's limited mobility and non-compliance with rotating and pressure relief. Resident 36 was turned frequently by staff, however, at times she/he refused or was found in a different position when aides return to the room. Resident 36 and family had been educated. Resident 36 continued to work with therapy on strengthening, bed mobility and transfers. The report indicated for staff to continue current interventions and add to the care plan to remind the resident to turn and reposition at least every two hours or more often as needed or requested. A 3/11/22 Incident Report indicated Resident 36's Stage 3 pressure ulcer had deteriorated to a Stage 4 (deep wound reaching into muscle and bone) pressure ulcer. The wound had undermining and increased depth. A surgeon was notified for a follow-up appointment for debridement (the removal of damaged tissue from a wound). The investigation indicated the incident most likely occurred due to the resident's resistance to turning, repositioning, poor nutrition, weight loss and co-morbidities associated with decreased wound healing. The report indicated to continue current interventions, wound care completed at the wound clinic and the resident was scheduled for a surgical debridement. An 4/7/22 Incident Report indicated Resident 36 was found to have an unstageable (full thickness tissue loss covered by necrotic tissue or by eschar) wound to her/his left heel. The investigation indicated the incident most likely occurred due to the resident's resistance to turning, repositioning, poor nutrition, weight loss, advanced age and co-morbidities. Resident 36 was on comfort care. Revisions to her/his care plan included place heel protector boots on the resident at all times as she/he will allow. On 6/1/22 at 3:53 PM Staff 50 (CMA) stated Resident 36 did not mind to be repositioned most of the time. Staff 50 stated Resident 36 had chronic pain and at times did not want to move much until she/he received her/his pain medication. Staff 50 stated she tried to get staff to get to Resident 36 quicker to provide care but it was difficult due to being short staffed at the facility. On 6/4/22 at 1:48 PM Staff 25 (CNA) stated staff were to document Resident 36 was checked and changed every two hours and as needed for incontinence care. Staff 25 stated charting was not always completed due to being short staffed. Staff 25 stated when she found a wound she would notify a nurse right away but the nurses would not always get to the wound because they were too busy. On 6/6/22 at 3:02 PM Staff 22 (CNA) stated Resident 36 did not have an air mattress when she/he first admitted but thought she/he received one after the pressure ulcer. Staff 22 stated Resident 36 did not refuse care. Staff 22 stated the facility was short staffed often and staff were not able to get their work completed as well as they would like. Staff 22 stated she did not have time to get to know the residents, provide cares or chart and sometimes had to stay late to complete her charting. On 6/7/22 at 3:08 PM Staff 15 (RNCM) stated Resident 36 did not receive an air mattress for her/his bed until 3/1/22. Staff 15 stated she did not go straight to an air mattress but would try other interventions first. Staff 15 stated the facility did not have a lot of air mattresses to go around. Staff 15 stated she did not send the resident to the wound clinic because the facility had everything they needed to treat the wound and on 3/2/22 the resident's family demanded a referral to the wound clinic which was made. Staff 15 stated they sent Resident 36 to the wound clinic and the wound clinic ordered wound care in the facility and to follow-up weekly. Staff 15 stated the wound clinic recommended a referral to a surgeon for debridement. Staff 15 stated on 3/10/22, 3/17/22 and 3/23/22 Resident 36 refused to go to the wound clinic. On 3/24/22 a pre-op phone call was made with the physician and he was informed Resident 36 had been refusing care and dressing changes and refused her/his wound clinic appointment on 3/23/22. Resident 36 was oriented to self at this point. The physician canceled the debridement. No documentation was found in the clinical record or provided by staff regarding the 3/10/22 and 3/17/22 refusals to the wound clinic. The 2/2022 Documentation Survey Report indicated Resident 36 refused care from CNA staff two times out of 84 opportunities. The 3/2022 Documentation Survey Report indicated Resident 36 refused care from CNA staff 11 times out of 96 opportunities. The 3/2022 TAR indicated staff were to provide physician ordered wound care. From 3/3/22 through 3/31/22 Resident 36 refused wound care seven times out of 28 days. On 6/15/22 at 11:34 AM Staff 2 (DNS) acknowledged staff tend to get in the rut of charting and do not always complete it correctly. Staff 2 stated staff could do a lot better on their documentation. Staff 2 further stated if staff documented Resident 36 had no refusals for CNA care and wound care then there were no refusals. 6. Resident 42 admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CMS provided the following definition for pressure ulcer stages: Stage 3 Pressure Ulcer: Full-thickness skin loss: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Deep Tissue Pressure Injury (DTPI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The 11/2021 admission Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No pressure ulcers were identified on admission for Resident 42. The 11/21/21 Admission MDS Pressure Injury CAA indicated Resident 42 did not appear to have any existing pressure ulcers. The 11/21/21 admission Braden Scale for Predicting Pressure Sore Risk indicated Resident 42 was at Mild Risk for developing pressure ulcers. The 11/23/21 provider encounter note indicated Resident 42 had been seen for an initial admission visit. The resident had an infected chronic left lower extremity venous stasis ulcer and was at risk for other skin breakdown. The facility was to continue DME (durable medical equipment) including pressure redistributing mattress and wheelchair cushion to promote skin integrity. An Incident Note dated 12/9/21 at 11:06 AM indicated Resident 42 returned from Unit C (wound care clinic) and the RN at the clinic had identified and noted a new skin issue. Resident 42 had a DTI (deep tissue injury) to the left heel. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/16/21 Weekly Skin Ulcer Measurement Wound Evaluation for Resident 42's left heel SDTI included: Current length (cm): 3 Current width (cm): 3 Current depth (cm): (non-measurable = <0.25 cm) 0 Presenting stage of the wound: e) Unstageable: Obscured full-thickness skin and tissue loss The 2/11/22 Weekly Skin Ulcer Measurement Wound Evaluation for Resident 42's left heel Suspected Deep Tissue Injury included: Current length (cm): 5.1 Current width (cm): 6.5 Current depth (cm): (non-measurable = <0.25 cm) 0 Presenting stage of the wound: e) Unstageable: Obscured full-thickness skin and tissue loss The Weekly Skin Ulcer Measurement Wound Evaluations from 12/16/21 through 2/11/22 indicated the wound had increased in size. The 1/27/22 at 4:22 PM Alert Note indicated Resident 42 was placed on alert for a new pressure ulcer on the coccyx. The 2/16/22 Wound Care Order from the Wound Clinic indicated the facility was to develop a toileting schedule for Resident 42 including to check hourly during the day for incontinence and changes. The note also included treatment instructions for the sacrum wound and treatment instructions for the unstageable pressure injury to the left posterior heel. No documentation was found to indicate the facility increased the resident to hourly checks per the Wound Clinic's order. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/18/22 (Re-Entry) Medicare - 5 Day MDS revealed Resident 42 had a Stage 3 pressure ulcer/injury and an Unstageable pressure injury presenting as a deep tissue injury. Skin and Ulcer Injury Treatments included: a pressure reducing device for the wheelchair but no pressure reducing device for the bed and no turning or repositioning program. A 2/18/22 Weekly Skin Ulcer Measurement Wound Evaluation for Resident 42's coccyx wound included: Middle: 4 x 5 x 0.2 cm 100% slough Left: 3 x 4.5 x 0.2 cm 25% slough Right: 3 x 4.25 x 0.1 cm 40% slough Presenting stage of the wound: c.) Stage 3: Full thickness skin loss A 2/25/22 Weekly Skin Ulcer Measurement Wound Evaluation for Resident 42's coccyx wound indicated the wound had increased to: Current length (cm): 11 Current width (cm): 20 Current depth (cm): (non-measurable = <0.25 cm) 0.3 Presenting stage of the wound: Stage 3 Measurements were done at Unit C (hospital wound care clinic). Resident 42's care plan dated 2/23/22 included Resident 42 was to have an air mattress with bolsters related to skin integrity. The care plan did not include this preventive intervention until eight days before the resident discharged and was not put in place on 11/23/21 per the Provider's encounter note. A Wound Follow-Up note dated 2/25/22 from the Wound Care Clinic indicated in the Fall of 2021 the resident had a workup that revealed no significant vascular disease. There was concern the resident was not having her/his weight adequately redistributed to prevent pressure wound development at the facility where she/he currently resided. On 5/18/22 at 3:11 PM Witness 16 (Family member) indicated they had asked the facility to get the resident an air mattress since her/his 2/11/22 admission but they did not get one until shortly before the resident discharged on [DATE]. Witness 16 also felt staff were not getting the resident up, were not assisting the resident to reposition and were not changing her/his brief often enough. Witness 16 said the wound care at the facility was poor and they were [TRU

Based on interview and record review it was determined the facility failed to implement or mitagate appropriate fall risk interventions for 5 of 6 sampled residents (#s 7, 19, 21, 29 and 43,) reviewed for falls. This failure resulted in Residents 7, 19 and 43 having falls with fractures. Findings include: 1. Resident 7 was admitted to the facility in 5/2018 with diagnoses including [CONDITION(S)]. A 12/28/19 Hospital record revealed Resident 7 was admitted to the hospital with a right leg fracture which she/he received in the facility from a fall out of bed. Resident 7 also hit her/his head on the bedside table. On 1/7/20 Resident 7 was sent back to the hospital due to pain in her/his left leg. The left leg was found to have a fracture from the 12/28/19 fall. A comprehensive care plan initiated on 5/14/18 indicated Resident 7 had an ADL self-care deficit related to limited physical mobility and [CONDITION(S)]. Resident 7 required assistance by two staff to turn and reposition in bed as necessary. The 5/22/19 Annual MDS indicated Resident 7 required two person extensive assistance with bed mobility and toileting. The MDS further indicated Resident 7 had a BIMS of 15 which indicated Resident 7 was cognitively intact. A FRI was completed by the facility on 12/28/19 which indicated Resident 7 was provided care by Staff 23 (NA). Staff 23 turned Resident 7 on her/his side, the resident held onto the side rail and told Staff 23 to go to her/his backside. Staff 23 stated she saw the resident's legs slip off of the bed and then her/his upper body. Staff 23 indicated Resident 7 hit her/his head on the table. Staff 27 (RN) assessed the resident and called 911 for transfer to the hospital. The facility ruled out abuse and neglect. A public complaint was received on 12/29/19 which indicated an NA assisted Resident 7 with cares and was not listening to what the resident told her about her/his care which resulted in the fall from the bed. The complainant indicated the bed was waist high level, the resident was turned to her/his side and felt unstable that she/he might fall in this position. The complaint indicated the NA walked away while the resident indicated she/he may fall and Resident 7 fell from the bed. The investigation indicated Resident 7 was particular with her/his care and instructed the aides on how to provide care for every step. The NA was doing as the resident requested. The NA reported Resident 7 had a leg spasm while she/he was on her/his side and this contributed to her/him falling out of bed. Upon investigation, no abuse or neglect was found. On 5/19/22 at 2:32 PM Resident 7 stated Staff 23 came into her/his room alone to provide care. Resident 7 stated she/he told Staff 23 there needed to be two people to turn her/him and this was in her/his care plan but Staff 23 ignored her/him. Resident 7 stated she/he needed incontinence care. Resident 7 stated when Staff 23 turned her/him onto her/his side she had pushed her/him to close to the edge of the bed and the resident stated she/he told Staff 23 she/he was falling out of the bed but Staff 23 did not stop providing care and Resident 7 fell out of bed. Resident 7 stated staff were aware of her/his care needs and were supposed to have two people for bed mobility and if Staff 23 would have followed the care plan this would not have happened. Resident 7 stated Staff 27 (RN) came into the room and left to call the paramedics. Resident 7 stated she/he was in the hospital for 11 days. Resident 7 stated her/his legs were all messed up since the fall. Resident 7 stated staff tried to state she/he had a spasm but she/he did not have a spasm at the time of the fall. Resident 7 stated she/he had a roommate at the time of the fall but the facility moved her/him out of the room right away. Resident 7 stated she/he went to the hospital and was told she/he had a broken right leg. Resident 7 stated when she/he returned to the facility she/he complained of left leg pain and was sent to the hospital and was found to have a left leg fracture. On 5/27/22 at 12:22 PM Staff 23 (CNA) stated at the time of the incident she was an NA. Staff 23 stated Resident 7 had turned on her/his call light and stated she/he needed to be changed. Staff 23 stated the resident did not wear incontinent briefs but had an incontinence bed pad. Staff 23 stated she had rolled the resident onto her/his side. Staff 23 stated she then walked to the other side of the bed to provide the resident incontinence care. Staff 23 stated while she was doing cares on the resident she noticed the residents legs were falling off of the bed but it was too late to do anything and the resident fell out of the bed and fell hard. Staff 23 stated the resident yelled she/he was falling out of bed. Staff 23 stated the resident did not have a spasm at the time she/he fell from the bed. Staff 23 stated Resident 7's legs were twisted under her/his bed and the roommate's bed. Staff 23 stated Resident 7's roommate was in shock and did not say a word. Staff 23 stated when Resident 7 was on the floor she went to find a nurse and found Staff 27 (RN). Staff 23 stated she had trained with other CNAs providing care for Resident 7 so she was aware of her/his care. Staff 23 stated she had never looked at Resident 7's care plan because her training was done with Resident 7. Staff 23 stated an investigation was completed and she was not put on administrative leave. On 6/1/22 at 3:32 PM Staff 25 (CNA) stated Resident 7 had always been a two person extensive assist with bed mobility. On 6/4/22 at 12:55 PM Staff 27 stated Staff 23 told her Resident 7 was on the floor. Staff 27 stated the resident's bed was in a high position above the waist. Staff 27 stated she had told Staff 23 Resident 7 was supposed to have two people to assist with bed mobility and she/he had always been care planned for two person assist with bed mobility. Staff 27 stated Resident 7 was pale and looked horrible but did not complain of pain but Staff 27 knew she/he was in pain. Staff 27 stated Resident 7 hit her/his face on the table and there was a bruise to her/his cheek and forehead. Staff 27 stated the resident's bed used to have a quarter rail so she/he could hold on but this bed did not have the rail and that was probably why she/he fell out. Staff 27 stated Staff 23 and the resident stated she/he did not have a muscle spasm before the fall. Staff 27 stated the resident's roommate was not interviewed regarding the incident. On 6/5/22 at 12:45 PM Staff 35 (CNA) stated Resident 7 had always been a two person extensive assistance for bed mobility. On 6/8/22 at 1:36 PM Staff 24 (LPN) stated Resident 7's care plan had always indicated the resident required a two person extensive assistance with bed mobility. On 6/9/22 at 12:47 PM Staff 54 (CNA) stated as far as she knew the resident had always required a two person extensive assist with bed mobility. On 6/15/22 at 11:34 AM Staff 2 (DNS) stated Resident 7 must have required two person assistance for bed mobility at the time of the fall. 2. Resident 21 was admitted to the facility in 9/2021 with diagnoses including stroke. A comprehensive care plan dated 9/1/21 and revised on 9/16/21 revealed Resident 21 was a fall risk due to a history of frequent falls, right sided weakness, recent stroke and diabetes. Staff were directed to perform 30 minute checks, anticipate her/his needs, be sure her/his call light was in reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance, to wear non-skid socks when ambulating or mobilizing in the wheelchair, bed in low position and her/his bed up against the wall. A public complaint was received on 9/16/21 which indicated Resident 21 was made to sleep on a mattress on the floor because staff did not want her/him to fall. On 5/18/22 at 3:48 PM Witness 21 (Complainant) stated Resident 21 was distressed because she/he was sleeping on a mattress on the floor so she/he would not continue to fall. Investigations revealed the following: First Fall: -On 9/6/21 at 11:45 AM Resident 21 fell out of her/his wheelchair onto the floor. Staff 50 (CMA) entered the room because Resident 21 yelled for help. Resident 21 indicated she/he slipped out of her/his wheelchair and hit her/his head. Resident 21 was assessed for injuries by Staff 24 (LPN), and an abrasion was found to her/his forehead. Resident 21 complained of hand pain and was sent to the ER (emergency room ). Interventions for both falls included: bed against wall, bed in lowest position, fall mat at bedside, safety checks every 30 minutes and place the resident in a supervised area as she/he would allow. Resident 21 was educated regarding the use of her/his call light and ask for assistance with all ADLs. Staff 50 (CMA) indicated Resident 21 was wearing slipper socks at the time of the fall. Second Fall: -On 9/6/21 at 3:56 PM Resident 21 was found on the floor in her/his room by a therapist. Resident 21 stated she/he slid out of her/his wheelchair. Resident 21 was assessed for injuries by Staff 20 (RN). Resident 21 stated she/he hit her/his head but no redness, swelling or bruising noted. Staff 20 indicated Resident 21 was wearing improper footwear at the time of the fall. Staff 22 (CNA) indicated resident 21 was wearing socks at the time of the fall. Staff 48 (Licensed Physical Therapy Assistant) indicated Resident 21 was not wearing any footwear. Third Fall: -On 9/6/21 at 5:40 PM Resident 21 was found face down on the floor by Staff 22 (CNA). Resident 21 stated she/he did not know what happened that she/he rolled out of bed. Resident 21 was assessed for injuries by Staff 20 (RN) but none were found. Staff 20 indicated resident 21 was wearing improper footwear. Staff 22 indicated the resident was wearing socks. Fourth fall: -On 9/8/21 at 3:34 AM Resident 21 was found sitting on the floor with blankets from her/his bed around her/him. Resident 21 stated she/he was trying to get to the bathroom. Resident 21 was assessed for injuries by the nurse but none were found. The following interventions were added to the care plan: bolsters (soft foam surrounds the edge of the bed to prevent falls) to her/his mattress for safety. Staff 3 (CNA) indicated Resident 21 had socks on. Fifth Fall: -On 9/8/21 at 10:00 PM Resident 21 was found on the floor in her/his room on the floor by another Resident. Resident 21 stated she/he slid out of her/his wheelchair. Resident 21 was assessed for injuries by Staff 24 (LPN) but none were found. Staff 5 (CNA) indicated Resident 21 was wearing her/his own personal socks at the time of the fall. Sixth Fall: -On 9/10/21 at 6:02 AM Resident 21 was found on the floor in her/his room. Resident 21 stated her/his left side of her/his head hurt. Resident 21 stated she/he could not recall what had happened. Staff 49 (CNA) had entered the resident's room because she heard her/him yell for help. Resident 21 was assessed for injuries, no injuries were found. Staff 49 indicated Resident 21 did not have on non-skid footwear. Interventions added to the care plan included: -mattress next to the bed and body pillow on bed for body positioning. On 6/3/22 at 3:32 PM Staff 22 (CNA) indicated Resident 21 fell on [DATE] at 11:00 AM, 3:00 or 4:00 PM and then again in the evening around 6:00 PM. Staff 22 stated a therapist came down the hall and told staff Resident 21 was on the floor. Staff 22 stated Staff 20 (RN) assessed Resident 21 for injuries, none were found. Staff 22 stated the resident was assisted back to bed. Staff 22 indicated Resident 21 did not have on non-skid footwear. On 6/6/22 at 9:38 AM Staff 24 (LPN) stated Resident 21 was alert and able to state her/his needs but was confused and given safety guidelines. Staff 24 stated on 9/6/21 at 11:45 AM she believed Resident 21 fell out of her/his wheelchair. Staff 24 stated Resident 21 was not wearing non-skid footwear. Staff 24 stated multiple interventions were added to the care plan after the fall but should have been on the care plan before the fall. On 6/7/22 at 3:56 PM Staff 20 (RN) stated when a resident falls she made sure she looked at the footwear they had on. Staff 20 stated Resident 21 should have had non-skid footwear on at the time of the falls on 9/6/21 at 3:56 PM and on 9/6/21 at 5:40 PM. On 6/8/22 at 1:18 PM Staff 48 (LPTA/Licensed Physical Therapy Assistant) stated when she found Resident 21 on 9/6/21 at 3:56 PM the resident was on the fall mat in an incontinent brief without non-skid footwear. On 6/8/22 at 1:38 PM Staff 24 (LPN) stated Resident 21 had two falls on 9/8/21, one around 3:00 AM and the other one was at 10:00 AM. Resident 21 stated she/he was going to the bathroom and fell . Staff 24 stated staff were alerted by another resident that Resident 21 was on the floor. Staff 24 stated Resident 21 was not wearing non-skid footwear. Staff 24 stated interventions were added to the care plan which include: offer toileting every hour and resident will at times place herself/himself on the floor, if this occurs the nurse to assess for injuries. Staff 24 acknowledged the resident was last toileted at 7:15 AM and fell at 10:00 AM. On 6/15/22 at 10:47 AM Staff 2 (DNS) stated Resident 21 was not always compliant and chose not to wear the non-skid socks. Staff 2 acknowledged this was not on the care plan. 3. Resident 29 was admitted to the facility in 11/2021 with diagnoses including unsteadiness on feet and repeated falls. The 11/17/21 Admission MDS Fall CAA indicated Resident 29 was at risk for falls related to impaired balance, history of falls and impaired balance during transitions. Resident 29 had multiple falls at home but had not fallen since she/he admitted to the facility. The 11/25/21 comprehensive care plan indicated: -Resident 29 was at risk for falls related to limited mobility, weakness, multiple recent falls at home, use of narcotics and urinary incontinence. Interventions include: -Anticipate and meet the resident's needs -Be sure call light was within reach and encourage the resident to use the call light for assistance as needed. Resident 21 needed prompt response to all requests. -Bed in lowest position and against wall. -Educate family, resident and caregivers about safety measures and what to do if a fall occurs. -Ensure the resident is wearing non-skid footwear when ambulating or mobilizing in a wheelchair. -PT evaluate and treat. -Reassess resident's fall risk per facility policy. Investigations for the falls revealed the following: First Fall: On 12/12/21 at 3:00 PM Resident 29 was found on the bathroom floor. Resident 29 stated she/he bent over to put her/his pajama bottoms on and got her/his foot caught and fell . Resident 29 stated she/he hit her/his head. Staff 20 (RN) assessed Resident 29 and a bruise was found to her/his right hip. No lumps, bumps or bruise noted to Resident 29's head. Staff 20 indicated Resident 29 was not wearing non-skid footwear. The following was added to the care plan: Offer toileting every hour as the resident will allow. Second Fall: On 12/19/21 at 7:30 PM Resident 29 was found on the floor beside her/his bed. Resident 29 stated she/he was trying to transfer from the bed to the wheelchair when the wheelchair moved and she/he landed on the floor. Staff assisted resident 29 to her/his wheelchair and found no injuries. An Incident Report dated 12/19/21 indicated Resident 29 was not wearing non-skid footwear at the time of the fall and had not be toilet every hour. The following intervention were added to the care plan, 30 minute safety checks. On 6/15/22 at 11:34 AM Staff 2 (DNS) acknowledged Resident 29 was not wearing non-skid socks and toileting every hour was not done. 4. Resident 43 admitted to the facility in 4/2022 with diagnoses including atrophy of the right lower leg, [CONDITION(S)] and a history of falls. 4/16/22 Hospital records revealed Resident 43 admitted to the hospital because she/he had three ground level falls at her/his home. Resident 43 denied hitting her/his head but reported numbness below her/his right knee and no evidence of acute fracture. Upon discharge from the hospital Resident 43 admitted to the nursing facility. A comprehensive care plan dated 4/20/22 revealed Resident 43 was a fall risk due to a history of frequent falls, impaired balance, pain, intermittent confusion and weakness. Staff were directed to anticipate her/his needs, be sure her/his call light was in reach, wear non-skid socks when ambulating, bed in low position and her/his bed was up against the wall. An initiated care plan dated 4/21/21 revealed Resident 43 had an ADL self-care performance deficit due to limited physical mobility related to weakness and chronic pain. The care plan did not identify interventions for her/his ADL status including ambulation, locomotion, bed mobility, transfers or toilet use. A Fall Risk assessment dated [DATE] revealed Resident 43 had a history of three or more falls in the past three months, had balance problems while standing, walking, needed safety reminders and required use of an assistive device. A public complaint was received on 4/28/22 and indicated Resident 43 had three falls in a seven-day time period in the facility and facility staff did not have interventions in place to mitigate the risk. On 5/18/22 at 12:27 PM Witness 42 (Complainant) stated Resident 43 had a history of falls and was at the facility for roughly six or seven days and had three falls. Witness 42 stated she had a care conference with Staff 15 (RNCM) shortly after Resident 43 admitted to the facility and staff would place a fall mat down when Resident 43 was in bed because of her/his history of falls. Witness 42 stated the facility never placed a fall mat down which resulted in Resident 43 falling out of bed and breaking her/his right hip. Witness 42 further stated Resident 43's bed was to be in the lowest position but she had witnessed when visiting Resident 43's bed was not always in the lowest position when she/he was in bed. An investigation dated 4/21/22 revealed the following: -Resident 43 was found on the floor in front of the bathroom door. Resident 43 was assessed, denied pain and assisted back to her/his wheelchair. -The incident most likely occurred due to Resident 43 transferred herself/himself from her/his bed to her/his wheelchair independently. -Resident 43 had intermittent confusion and she/he was educated on the use of her/his call light for assistance when transferring. -The care plan was updated to include provide a safe environment, clutter-free, adequate lighting, bed in low position, secure handrails on walls and in bathroom, personal items in reach, PT evaluate and treat as indicated, and re-assess resident's fall per facility policy. Family brought in her/his recliner which they stated reduced her/his risk of falls at home. An investigation dated 4/26/22 revealed the following: (two falls approximately seven hours apart) First Fall: -Resident 43 was at risk for falls due to a history of frequent falls, impaired balance, pain, intermittent confusion and weakness. -On 4/26/22 at 9:10 AM Resident 43 was found on the floor next to her/his bed. Staff 43 (NA) entered the room because Resident 43 was screaming for help and Resident 43 indicated she/he was reaching for her/his phone. Resident 43 was assessed by Staff 7 (RN) for injury and none was found. Resident 43 denied pain, was educated on how to use her/his call light and was assisted back to bed. -No indication the care plan was updated or education of Resident 43 to utilize her/his call light was effective. Second Fall: -On 4/26/22 at 4:00 PM Resident 43 was found on the floor next to her/his bed, was assessed by Staff 12 (RN) for injury and she/he was complaining of severe right hip pain and she/he stated she/he slipped out of bed and landed on her/his right hip. -Staff 12 kept Resident 43 on the ground until paramedics arrived and she/he was transported to the hospital. -Staff 47 LPTA (Licensed Physical Therapy Assistant) indicated she was working across the hall and witnessed Resident 43 attempt to transfer from her/his wheelchair to her/his bed and the brakes were not engaged and she/he reported pain. -Staff 9 (NA) indicated Resident 43 fell transferring from her/his bed to wheelchair and Resident 43 stated her/his hip hurt. Staff 12 examined Resident 43 for injury and she/he was sent out to the hospital. The summary indicated the two falls on 4/26/22 likely occurred due to Resident 43 attempting to reach for items while in bed or rolling out of bed. Resident 43's family stated she/he had a history of falls at home, up to five falls daily. At 9:10 AM Resident 43 was educated and demonstrated the ability to use her/his call light by calling staff for assistance throughout the shift. At 4:00 PM Resident 43 was transported to the hospital and upon her/his return would add to her/his care place a fall mat at her/his bedside for safety and place her/him in a supervised area. Upon investigation, no abuse or neglect was found. An 4/26/22 Hospital record revealed Resident 43 presented to the emergency room with severe pain to her/his right hip after falling out of bed at the facility an X-Ray at 5:34 PM revealed a right femur fracture. On 5/19/22 at 9:38 AM Staff 7 (RN) stated Resident 43 was alert and able to state her/his needs but was confused and given safety guidelines often. Staff 7 stated she recalled the fall on 4/26/22 in the AM and the bed was in a low position but no fall mat was down. Staff 7 stated Resident 43 was reaching to grab an item and fell out of bed she/he was not injured. Staff 7 further stated if Resident 43 had a history of falls a fall mat should have been in place. On 5/25/22 at 2:15 PM Staff 43 (NA) stated she recalled Resident 43's fall on 4/26/22 in the am because she and Staff 7 assisted her/him back into bed after she/he rolled out of bed because Resident 43 was reaching for her/his phone. Staff 43 was not sure if Resident 43 was a fall risk but if she/he was a fall risk a fall mat should have been next to her/his bed. On 5/26/22 at 9:54 AM Staff 48 (LPTA) stated she recalled the fall on 4/26/22 in the late afternoon because she was working with another resident across from Resident 43. Staff 48 stated she witnessed Resident 43 on the floor next to her/his bed calling out for help and she called for Staff 9 (NA) to assist her/him. Staff 48 stated she did not recall seeing a fall mat on the floor but if a resident had more than one fall, they would implement having the bed in the lowest position and a fall mat next to the bed. Staff 48 stated she heard Resident 43 had a fall earlier on 4/26/22 but did not witness that fall. On 5/26/22 at 11:26 Staff 9 stated she worked with Resident 43 on 4/26/22 in the late afternoon and indicated Resident 43 was alert and oriented to self and was very confused. Staff 9 stated she heard the resident fall and when she entered the room the bed was not in its lowest position but maybe two feet off of the floor, no fall mat was in place and she/he was assessed by Staff 12 (RN) then sent out to the hospital. On 5/25/22 at 2:33 PM Staff 12 stated he remembered Resident 43 and she/he was a high fall risk. Staff 12 stated on 4/26/22 he entered the room and the resident was already on the floor, in pain. Staff 12 stated he could not recall if a fall mat was in place or the height of the bed at the time of the fall. Staff 12 stated she/he attempted to reach for an item from bed and landed on her/his hip. Staff 12 stated she/he was sent out to the hospital and Resident 43 broke her/his right hip as a result of the fall. On 6/2/22 at 11:01 AM Staff 15 (RNCM) stated Resident 43 was confused and had a history of falls. Staff 15 stated they had a care conference on 4/22/22 and family reported Resident 43 falling four to five times daily at home, the resident would stand up and fall forward. Staff 15 stated they implemented fall safety risk of side rails, bed in low position, have bedside table next to bed in reach and educated Resident 43 on use of her/his call light after the first fall on 4/21/22 but did not recall a discussion with the family of placing a fall mat down. Staff 15 stated Resident 43 did have three falls while at the facility but did not implement the fall mat after the second fall on 4/26/22 at 9:00 AM because felt Resident 43's falls were not from her/him transferring to or from her/his bed. Staff 15 further stated she was going to implement a fall mat after the 4/26/22 at 4:00 PM fall upon her/his return from the hospital. 5. Resident 19 was admitted to the facility in 2017 with diagnoses including chronic pain, [CONDITION(S)] and respiratory failure. The resident's care plan initiated 11/25/15 and revised on 1/21/22 indicated Resident 19 required extensive assistance by two staff to turn and reposition in bed, total assist of two staff for toileting and was a mechanical lift with two-person assist for transfers. The resident also used a trapeze (metal bar to help resident change position in bed), to aide in mobility. A review of eleven Fall Risk Evaluations completed by the facility from 4/17/20 through 1/19/22 indicated Resident 19 was at High Risk for falls. An Incident Report dated 8/6/21 at 8:35 PM indicated Staff 30 (CNA) was changing the resident's brief. Staff 30 was working alone. She rolled the resident onto her/his back and then left the room to get a bandage from the nurse. Staff 30 reported the resident's legs were off the edge of the bed before she left the room. When Staff 30 returned to the room she found the resident stuck between the bed and the wall. The resident's legs were on the floor and her/his upper body was held up by the trapeze. The resident yelled in pain when staff tried to move her/him and 911 was called. The resident was transported to the hospital where she/he was diagnosed with a closed head injury and worsening of the left tibia (bone from just under the knee to the ankle) fracture. The report identified Staff 30 as a CNA but she was an NA (not licensed). On 6/3/22 at 11:30 AM Staff 30 (NA) said she remembered the unwitnessed fall. She was changing Resident 19 in bed without assistance because she could not find anyone to help. She said she knew the resident was a two-person assist but no one was available to help her. She rolled the resident onto her/his side and remembered she needed to get a new bandage, so she rolled the resident onto her/his back and went to get a bandage from the nurse. Staff 30 said the resident's legs were sliding towards the edge of the bed when she left. Staff 30 also stated she forgot to lock the bed wheels and she did not move the Trapeze which the resident used for bed mobility. When she got back the resident had fallen between the bed and the wall and had to be taken to the hospital. Staff 30 acknowledged she did not follow the resident's care plan and learned a lesson the hard way. The Incident Report dated 8/6/21 failed to identify the staff person's position correctly. Staff 30 was an NA and not a licensed CNA. The report also failed to include that the resident's care plan was not followed related to requiring the assistance of two staff with toileting and bed mobility. Additionally, there was no mention of the bed brakes not being locked and the trapeze had been left where the resident could grab it. On 5/27/22 Staff 2 (DNS) was interviewed related to the discrepancies in the Incident Report and the unwitnessed fall with a major injury. No additional information was provided.

Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED].#s 4 and 10) reviewed for physician orders. This resulted in potentially avoidable hospitalization for Resident 4. Findings include: 1. Resident 4 was admitted to the facility 6/2019 with [DIAGNOSES REDACTED]. Resident 4 had physician orders [REDACTED]. (Sudden increase in weight for patients with [MEDICAL CONDITION] may indicate worsening heart failure and a build up of fluid in the tissues and lungs.) The facility incorrectly transcribed the order to read notify MD if weight change of 2 lbs in 1 day and/or 5 lbs change in a week. According to the 6/2019 TAR the resident's admission weight on 6/11/19 was 207.4. Five days later on 6/15/19 it was 208.9. The following day, 6/16/19, the resident's weight was 213.4. This was a 4.5 lb weight gain in one day and an 8 pound gain in seven days. There was no documented evidence the facility notified the physician on 6/16/19 or at any time in 6/2019 until 7/3/19 when the resident complained of not feeling well. Staff did not inform the physician about the weight gain. According to nursing progress notes dated 7/5/19 and 7/6/19 the resident was not complaining of feeling short of breath. However, on 7/9/19 the resident's oxygen saturation level dropped to 87% (normal pulse oximeter readings usually range from 95 - 100 %). Resident 4 was promptly sent to the hospital by the facility via ambulance. The resident returned from the hospital the same day with orders for antibiotics and a steroid medication. According to the 7/2019 TAR the resident remained in the facility without further significant weight gain until 7/16/19 when she/he was seen by Staff 21 (Medical Director) and attending physician. According to the physician's progress note dated 7/16/19 Resident 4 had significant lower extremity [MEDICAL CONDITION] up to the level of the thighs, pain in her/his legs and increased shortness of breath with a history of [MEDICAL CONDITION] and was not on any current diuretics. The physician prescribed [MEDICATION NAME] 40 mg (a diuretic) daily, to treat the [MEDICAL CONDITION] and recommended staff closely watch the resident's weight. On 7/17/19 Resident 4 visited a cardiologist and returned with orders that she/he be evaluated at a hospital or Urgent care that day for serous (clear fluid) drainage from upper and lower extremities. She/he was promptly transported to the hospital by the facility, where she/he was diagnosed with [REDACTED]. The resident was admitted for two days and treated with intravenous [MEDICATION NAME] three times a day to reverse fluid volume overload and [MEDICAL CONDITIONS]. The last recorded weight at the facility prior to hospitalization was 210.4 pounds on 7/17/19. The resident returned to the facility at a weight of 193 lbs; a 17.4 pound weight difference indicating significant fluid weight gain while at the facility. Discharge orders from the hospital dated 7/19/19 included an order to obtain daily weights for Resident 4 and to notify the physician if patient gains 2 pounds in 2 days or 5 or more pounds in a week. Review of the 7/2019 TAR for Resident 4 revealed the order was transcribed incorrectly without the parameters for physician notification. Documentation of the resident's weights for the rest of the month did not indicate significant weight gain. On 9/19/19 at 1:27 PM Staff 14 (RN) was aware Resident 4 had a [DIAGNOSES REDACTED]. She reviewed the 6/2019 TAR and confirmed the initial weight increases for Resident 4 in 6/2019. Staff 14 stated a nursing note would be linked to an entry on the TAR if the physician was notified. Staff 14 reviewed the nursing progress notes and did not find documentation of physician notification. On 9/19/19 at 2:10 PM Staff 5 (LPN/RCM) stated Resident 14 was not compliant with fluid restriction. Staff 5 agreed that was additional rationale for reviewing and reporting weight as ordered. Staff 5 confirmed the 7/19/19 order for daily weights was not transcribed correctly. In an interview on 9/20/19 at 10:43 AM Staff 21 (Medical Director) stated he would have intervened sooner with orders for [MEDICATION NAME] if the facility had notified him of Resident 14's weight gain of 8 lbs in one week or 4.5 lbs in one day. 2. Resident 10 was admitted in 11/2018 with [DIAGNOSES REDACTED]. The 12/2018 Physician order [REDACTED]. -[MEDICATION NAME] (a readily available over the counter pain reliever) 325 mg two tablets, twice daily; -Amlodopine [MEDICATION NAME]-[MEDICATION NAME] (hypertensive medication) 10-160 mg in the morning, hold if blood pressure is less than 90/50. The 12/2018 MARs revealed the following; -On 12/7/18 Amlodopine [MEDICATION NAME]-[MEDICATION NAME] had a code 9 (other/see nurse notes) noted; -On 12/21/18 [MEDICATION NAME] had a code 9 noted. The Progress Notes revealed the following: -On 12/7/18 Amlodopine [MEDICATION NAME]-[MEDICATION NAME] was not here, will call pharmacy; -On 12/21/18 [MEDICATION NAME] do not have at hand (missed one dose). In an interview on 9/20/19 at 1:02 PM Staff 2 (DNS) stated she expected staff to follow physician's orders [REDACTED].

1. Based on interview and record review it was determined the facility failed to timely administer heart and blood pressure medications for 1 of 1 sampled resident (# 167) reviewed for hospitalization . As a result, Resident 167 was re-hospitalized with a recurrence of rapid [MEDICAL CONDITION] (fast and irregular heart beat). Findings include: Resident 167 was admitted to the facility in 12/2018 with [DIAGNOSES REDACTED]. Resident 167's 12/22/18 Hospital Admitting Orders included the following heart and blood pressure medications: -[MEDICATION NAME] (blood pressure medication) 40 mg QD; -[MEDICATION NAME] (blood pressure medication) 1 mg QD; -[MEDICATION NAME] (diuretic medication) 40 mg BID; -[MEDICATION NAME] (blood pressure medication) 150 mg QD; -Potassium Chloride 20 meq five times daily; -Xarelto (an anticoagulant medication) 20 mg QD. Resident 167's 12/2018 MAR and EMAR Progress Notes documented the following medications were not administered due to unavailable awaiting pharmacy delivery: -[MEDICATION NAME] 40 mg at 8:00 AM QD - not received on 12/23/18; -[MEDICATION NAME] 1 mg at 8:00 PM QD - not received on 12/22/18; -Metorpolol [MEDICATION NAME] 150 mg at 8:00 AM - not received on 12/22/18; -Xarelto 20 mg at 10:00 AM - not received on 12/23/18; -[MEDICATION NAME] 40 mg at 8:00 AM and at 1:00 PM - not received on 12/23/18 at 8:00 AM; and -Potassium Chloride 20 meg at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM - not received on 12/22/18 at 6:00 PM and 10:00 PM and on 12/23/18 at 6:00 AM and 10:00 AM. According to the facility's Nursing Home to Hospital Transfer Form, Resident 167 was sent to the hospital on [DATE]. Resident 167's Hospital Discharge Summary records noted she/he admitted to the hospital on [DATE] with [MEDICAL CONDITION] and rapid ventricular response (rapid heart rate) .Patient was previously hospitalized and heart rate was controlled with beta-blockers and calcium channel blockers .the facility inadvertently did not give any of her/his medication .This resulted in a recurrence of rapid [MEDICAL CONDITION] and worsening failure symptoms. The patient was readmitted for a second hospitalization . In an interview on 3/27/19 at 1:00 PM, Witness 9 (Complainant) stated Resident 167 was admitted to the facility on [DATE] at around 1:15 PM, where she/he was released from the hospital after suffering a [MEDICAL CONDITION]. Witness 9 stated Resident 167 was at the facility for 22 hours and never received any of her/his medications related to her/his [MEDICAL CONDITION]. Witness 9 stated he returned to the facility on [DATE] at about 11:30 AM, where Resident 167 told Witness 9 she/he did not receive any of her/his medications, except for pain medications. Witness 9 stated he called an ambulance to have Resident 167 sent to the hospital. Witness 9 stated Resident 167 admitted to the hospital with [REDACTED]. In an interview on 3/27/19 at 3:50 PM, Staff 13 (LPN Resident Care Manager) stated she admitted Resident 167 and had processed the resident's medication orders by 2:30 PM on 12/22/18. Staff 13 confirmed Resident 167 did not receive certain medications due to the pharmacy not delivering the medications. Staff 13 stated the facility had issues with medications not being delivered timely. In an interview on 3/28/19 at 3:59 PM, Staff 2 (DNS) stated she was aware Resident 167 had not received her/his medications as ordered, which resulted in the resident being readmitted to the hospital. Staff 2 stated after the incident involving Resident 167, the facility worked hard to make changes to ensure residents received their medications upon admit. 2. Based on observation, interview and record review it was determined the facility failed to correctly transcribe an insulin order, failed to promptly initiate a new order for antibiotics and failed to properly maintain wheelchair positioning for 3 of 8 sampled residents (#'s 41, 51 and 57) reviewed for positioning and unnecessary medications. This placed residents at risk for worsening [MEDICAL CONDITION] (high blood sugar), worsening pneumonia and improper positioning. Findings include: a. Resident 41 was admitted to the facility in 9/2017 with [DIAGNOSES REDACTED]. Resident 41's Care Plan dated 5/31/18 indicated her/his diabetes was controlled with diet and insulin. Review of the resident's physician orders [REDACTED]. If capillary blood glucose (CBG) was 150 - 199 the resident was to receive 4 units of insulin; 200 - 249 = 8 units ; 250 - 299 = 6 units ; 300 - 999 = 16 units. Review of the resident's 2/2019 and 3/2019 MAR indicated the insulin was administered according to the sliding scale. The MARs indicated she/he received nine doses of 6 units for CBG between 250 and 299. The facility failed to identify the insulin dose discrepancy should have been 12 units for a CBG between 250 and 299 rather than 6 units. On 3/27/19 at 4:10 PM Staff 26 (RN) was asked to review the sliding scale as written and confirmed 6 units for 250 - 299 was irregular and the dose should have been 12 units. On 3/27/19 at 4:32 PM Staff 17 (LPN Resident Care Manager) stated the original order was a transcription error and and the facility obtained a corrected sliding scale. The 6 units should have been 12 units. b. Resident 51 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. On the morning of 3/26/19 the resident was sent to the emergency room and returned in the afternoon with a new [DIAGNOSES REDACTED]. A 3/26/19 physician order [REDACTED]. Nursing notes on 3/26/19 at 5:00 PM and 3/27/19 at 2:27 AM indicated medication was not available pending receipt from the pharmacy. The 3/2019 MAR indicated Resident 51 received two 250 mg tablets of [MEDICATION NAME] on 3/27/19, one day later than ordered. During an interview on 3/29/19 at 11:32 Staff 2 (DNS) reported [MEDICATION NAME] was stock medication available in the OmniCell (an on-site automated medication dispensing system) and had been available on 3/26/19. She stated she was unsure why the medication had not been given sooner. c. Resident 57 was admitted to the facility in 5/2017 with [DIAGNOSES REDACTED]. On 3/25/19 at 3:16 PM, 3/26/19 at 8:33 AM, 11:15 AM, 1:38 PM and on 3/28/19 at 12:15 PM, Resident 57 was observed sitting in her/his wheelchair with no footrest and her/his feet dangling and not touching the floor. Resident 57's current care plans revealed she/he required staff assistance for locomotion using a wheelchair. In an interview on 3/27/19 at 9:42 AM, Staff 28 (CNA) stated the resident's wheelchair fit her/him but because she/he was petite her/his feet dangled and didn't touch the floor. In an interview on 3/27/19 at 12:53 PM, Staff 9 (RN) stated if residents need wheelchair evaluations she would refer to therapy. Staff 9 was not aware if Resident 57 had a wheelchair evaluation. In interviews on 3/28/19 at 1:21 PM, Staff 38 (PT) and Staff 39 (OT) stated best practice for wheelchair positioning was to not have residents feet dangle and have feet supported. Staff 38 stated if a resident's feet dangled this could cause a resident to slide forward putting them at risk of a fall or could cause compression to the back of a resident's legs resulting in lack of blood flow. During the interview, Staff 38 and Staff 39 with surveyor present, observed Resident 57's wheelchair positioning. Staff 38 stated the resident's wheelchair seat was at the highest seating and could be lowered to ensure the resident's feet touched the floor. On 4/1/19 at 11:30 AM, Staff 2 (DNS) was informed of Resident 57's lack of appropriate wheelchair positioning and stated due to the resident's repositioning herself/himself caused the resident's feet to not touch the ground.

Based on interview and record review it was determined the facility failed to monitor, assess, intervene and notify the physician for a change in condition for 1 of 1 sampled resident (# 166) reviewed for hydration/nutrition. As a result, Resident 166 was hospitalized for [REDACTED]. Findings include: Resident 166 was admitted to the facility in 7/2018, with [DIAGNOSES REDACTED]. Resident 166 was hosptalized on [DATE]. Resident 166's Admission MDS completed on 7/17/18, Section C: Cognitive Patterns assessed the resident as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. Resident 166's Dehydration/Fluid Maintenance CAA dated 7/17/18, assessed the resident was at risk for dehydration due to her/his UTI, had no symptoms of dehydration and did not have any cognitive, communication or mental status issues which would interfere with her/his oral intake. The resident consumed 720 to 1140 ccs of fluid, had no change in her/his oral intake and had no fluid restrictions. Resident 166's Care Plan dated 10/6/18, identified the resident was as risk for dehydration related to a history of UTIs. Interventions included to educate the resident on the importance of fluid intake, to encourage the resident to drink fluids of her/his choice, to identify and address underlying causes of dehydration and to monitor and report any signs/symptoms of dehydration. Resident 166's RD/Nutrition Risk Assessment completed on 10/15/18, assessed the resident consumed 76-100% of her/his meals and consumed an average of 1000 cc of fluids per day. Recommendations included to provide 2300 cc of fluid per day, to consume 1500-1900 calories per day and a desirable weight loss has been achieved with current plan. Resident 166's Quarterly MDS completed on 10/18/18, Section C: Cognitive Patterns assessed the resident as moderately cognitively impaired with a BIMS score of 12. Resident 166's Bowel Movement Flowsheet from 11/27/18 to 12/10/18, documented she/he had 11 days of loose/diarrhea bowel movements, with seven of the 11 days documented as large loose/diarrhea bowel movements. Resident 166's Meal Intake Flowsheets from 11/27/18 to 12/10/18, documented 16 days where she/he had either refused a meal (6 days) or ate less than 25% and refused a nutritional supplement (10 days). Resident 166's Fluid Intake and MARs from 11/27/18 to 12/10/18, documented nine days where her/his total fluid intake was below 1000 cc: -11/27/18: 620 cc -11/28/18: 540 cc -11/29/18: 840 cc -12/2/18: 490 cc -12/3/18: 960 cc -12/4/18: 720 cc -12/7/18: 740 cc -12/8/18: 900 cc -12/10/18: 510 cc Resident 166's Vital Signs Flowsheet from 12/5/18 to 12/10/18, documented four days of low blood pressure readings: -12/5/18 at 7:06 PM: 84/47 -12/7/18 at 2:39 PM: 91/53 -12/8/18 at 12:14 AM: 97/61 and at 2:05 PM: 87/59 -12/10/18 at 2:23 PM: 80/41 Resident 166's Progress Notes from 11/30/18 to 12/10/18, contained no documentation to indicate the resident's changes in blood pressure, the duration of the resident's loose/diarrhea bowel movements and the resident's low fluid intake were monitored, assessed, interventions were implemented and/or the physician was notified. On 12/11/18, Resident 166 was sent to the ER for abdominal pain and foul smelling loose/diarrhea according to the facility's SBAR Communication Form. According to hospital ER notes dated 12/11/18, Resident 166 arrived hypotensive (low blood pressure), [MEDICAL CONDITION](fast heart rate) and unable to appropriately answer questions. Resident 166 was later transferred to another hospital and admitted in their Intensive Care Unit. According to the resident's Hospital's Admission History and Physical dated 12/11/18, Resident 166 remained hypotensive after 2 liters of fluid resuscitation and was diagnosed with [REDACTED]. In an interview on 3/26/19 at 9:09 AM, Witness 11 (Complainant) stated Resident 166 admitted in 7/2018 and received therapy, but around mid-October the resident's cognition and mood changed. Witness 11 stated when she visited, Resident 166 stated she/he was not thirsty but her/his lips were dry and gave the resident chapstick. In interviews on 3/27/19 at 9:53 AM and on 3/28/19 at 9:17 AM, Staff 9 (RN) stated Resident 166 was ok when she/he first admitted but declined and started to have skin breakdown. Staff 9 stated she recalled an aide reported the resident did not want to get up and had loose stools that smelled. Staff 9 stated she did not recall any reports of the resident not drinking or having loose stools, but she believed the resident wasn't eating much. Staff 9 stated if a resident had two days of loose stools, she would contact the physician to rule out any concern. In an interview on 3/27/19 at 10:56 AM, Staff 37 (CNA) stated she recalled the resident had a change in her/his mental status around the time the resident discharged . In interviews on 3/27/19 at 4:10 PM and on 3/28/19 at 10:59 AM, Staff 13 (LPN Resident Care Manager) stated she recalled the resident had [MEDICAL CONDITION] to both legs and chronic UTIs. Staff 13 stated the resident was sent out to the hospital due to loose stools, which tested positive for [MEDICAL CONDITION] ([MEDICAL CONDITION], a gastrointestinal infection). When asked how the facility monitors residents' bowel movements, Staff 13 stated night nurses monitor bowel records and reported on residents who have not had a bowel movement in three days. Staff 13 stated she expected staff to report on residents who had more than one day of loose/diarrhea stools. After reviewing Resident 166's bowel flowsheet from 11/27/18 to 12/10/18, Staff 13 stated dehydration would have been a concern given the number of days the resident had loose/diarrhea stools and would have put her/him on alert. In an interview on 3/28/19 at 8:40 AM, Staff 11 (CNA) stated she remembered Resident 166 had loose stools with an odor which she reported to the nurse. Staff 11 stated Resident 166 had loose stools for awhile, maybe a week. Staff 11 stated the resident would accept water but not frequently and wasn't eating well and appeared more tired. In an interview on 3/28/19 at 3:59 PM, Staff 2 (DNS) stated she expected a resident who had at least two days of consecutive loose/diarrhea stools to be reported to the nurse and for the resident to be monitored. Staff 2 stated if loose stools continued she expected the physician to be notified, and if a change of condition occurred expected a progress note and documentation as to what the change of condition was. Staff 2 was informed of the failure to monitor, assess, intervene and notify the physician for Resident 166's change in her/his bowels, hydration and blood pressures. Staff 2 provided no further information regarding the findings.

Based on interview and record review it was determined the facility failed to ensure physicians and families were notified timely of resident issues for 4 of 7 sampled residents (#s 2, 3, 4 and 11) reviewed for notifications. Resident 2's physician was unaware of a missed lab draw with abnormal results shown on the next draw completed. Resident 2 was hospitalized with acute [MEDICAL CONDITION] and an extremely high [MEDICATION NAME] trough level. Findings include: 1. Resident 2 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated 9/21/16 indicated the resident was alert, oriented and directed her/his own care. The resident was independent in multiple activities of daily living and was able to call for assistance when needed. a. The signed physician order [REDACTED]. The IV order showed a start date of 11/29/16. Additionally, the resident was to have weekly labs to monitor kidney function and [MEDICATION NAME] levels drawn every Monday while on IV [MEDICATION NAME] and reported to the physician. The lab order showed a start date of 12/5/16. A nursing progress note dated 12/27/16 at 9:31 am indicated the resident's PICC line (thin tube inserted in a vein) flushed well but the nurse was unable to obtain a blood draw. An order was sent to the lab. Additional notes from 12/27/16 through 12/28/16 contained no information regarding physician notification or another attempt to get the blood draw. A nursing progress note dated 12/29/16 at 10:25 am indicated the lab came in and they were unable to obtain the draw. The lab tech stated someone else would come back and attempt. Additional notes on 12/29/16 through 1/1/17 indicated the resident's antibiotics were infusing without issue and the resident was medicated for intermittent nausea. No information was documented regarding a redraw of the 12/26/16 lab or physician notification of the missed lab. A nursing progress note dated 1/2/17 at 9:20 am indicated the PICC line flushed well, unable to obtain blood draw, lab to draw tomorrow. Nursing progress notes from 1/3/17 contained no information regarding a lab draw. On 1/4/17 at 9:11 am it was noted lab results from yesterday's draw were received and the results were called to Witness 6's (Infectious Disease (ID) Physician) office. The physician ordered IV antibiotics to be stopped and the resident sent to the hospital for evaluation. Review of the resident's lab reports, nursing progress notes and physician communications showed no labs were drawn on 12/26/16 as ordered. The previous lab draw was due on 12/19/16; the lab was drawn on 12/20/16 and showed a slight elevation in the [MEDICATION NAME] trough of 17.3. The normal range was noted to be 10-15. The next completed lab draw was due on 1/2/17; the lab was completed on 1/3/17 with a [MEDICATION NAME] trough level of 75. The resident's physician ordered the resident to be hospitalized for [REDACTED]. physician progress notes [REDACTED]. In interview on 4/5/17 at 9:32 am Witness 7 (RN for Witness 6) indicated she tracked all the IV antibiotic labs for Witness 6 (ID Physician). The office received no results for the 12/26/16 lab and no notification of any problem with the blood draw. The office had limited hours that week due to the holiday but continued to have a physician on call 24/7. Staff 7 stated when labs for 1/3/17 were still not received on 1/4/17 the physician tracked them down and saw the resident's creatinine was elevated and the [MEDICATION NAME] trough was very high. Staff 7 further indicated their office contacted the nursing facility and advised them to stop the [MEDICATION NAME] doses and send the resident to the emergency room . In interview on 4/5/17 at 1:45 pm and 3:00 pm Staff 6 (RN) indicated the 12/26/16 lab was missed because she could not get a blood sample. She was not sure what the issue was because she was able to draw blood from the PICC line on other occasions. Staff 6 stated she did not notify Witness 6 (ID Physician) that she was unable to get a blood sample to complete the 12/26/16 labs. When they received the elevated lab results for 1/3/17 she could not remember if she contacted the physician or if the physician contacted the facility. Staff 6 stated she remembered calling the lab and they did come in to attempt the blood draw. They were unsuccessful and as they left they told Staff 6 they would contact the physician. In interview on 4/5/17 at 9:05 am Witness 5 (Lab Manager) indicated the lab staff did not contact physicians for residents in nursing facilities. A note may be entered into the residents' file if there was a problem with the blood draw. The physician could then go in and look in the residents' file if they chose. In interview on 4/5/17 at 2:10 pm Staff 1 (DNS) indicated she was not involved in the [MEDICATION NAME] trough level issue. She was told about the problem obtaining a blood draw and the missed lab after the resident was already out of the facility. Staff 1 stated the physician should have been notified. Refer to F-309 b. An event investigation dated 9/7/16 at 10:33 am indicated the resident had an open area to the left heel that appeared to be caused from the resident's shoe rubbing on the heel. The physician was notified and treatment initiated. Nursing progress notes from 9/7/16 through 9/18/16 indicated the heel wound continued with some deterioration. There was no odor or signs of infection noted with dressing changes. On 9/19/16 a green color was noted to the wound and new orders for antibiotic treatment were received. Nursing progress notes on 9/21/16 indicated the wound had an odor. Additional notes from 9/21/16 through 9/26/16 noted the wound continued to have a foul odor. The 9/26/16 nursing progress note indicated the physician was notified on 9/26/16. The physician was in the facility to see the resident on 9/27/16 and gave additional orders for antibiotic treatment. Nursing progress notes dated 9/28/16 through 10/3/16 indicated the wound continued to have some odor, a blackened wound bed and a moderate amount of dark yellowish/red drainage. The resident continued to receive oral antibiotics during this time, requested and was seen by the physician on 10/4/16. On 10/6/16 it was noted the wound continued to be black with odor; an order was received to send the resident to the wound clinic for a consultation. Nursing progress notes dated 10/7/16 through 10/9/16 indicated the wound continued with a foul odor. The resident expressed frustration on 10/9/16 that she/he had not been seen by the wound clinic yet. On 10/10/16 the heel was noted to be black and soggy. There was no indication the physician was notified of the resident's concerns or the new description of the heel as black and soggy. The resident was seen at the wound clinic on 10/12/16 and was admitted to the hospital from the appointment with a subsequent amputation performed. In interview on 4/6/17 at 7:54 am Staff 6 (RN) stated she was not sure if she contacted the physician about the resident's heel on 10/10/16. The information should be in her nursing notes if she did. Staff 6 indicated she did not remember a lot of details from so many months ago. Three attempts were made to reach Witness 11 (Agency RN) on 4/10/17 and 4/11/17 regarding her nursing progress notes, with no return call received. Refer to F-309 c. Nursing progress notes dated 10/21/16 through 11/1/16 indicated the dressing to the stump incision was clean, dry and intact with no concerns noted. Intermittent refusals by the resident to elevate the stump and allow dressing changes were documented. A nursing progress note dated 11/2/16 indicated the left outer edge of the flap incision was no longer held together with sutures (it is pulling away). There was no indication the resident's physician was notified of the incision pulling open. On 11/4/16 the physician was notified of the surgical wound opening up and the presence of green drainage. The incision continued to open up on the outer edges until 11/8/16 when the resident was admitted to the hospital for evaluation. Three attempts were made to reach Witness 11 (Agency RN) on 4/10/17 and 4/11/17 regarding her nursing progress notes, with no return call received. Two attempts were made to reach Witness 12 (Former Facility LPN) on 4/10/17 regarding her nursing progress notes, with no return call received. In an interview on 4/12/17 at 10:27 am Staff 1 (DNS) indicated the physician should have been contacted regarding the stump incision pulling away from the sutures on 11/2/16. 2. Resident 4 was admitted to the facility in January 2017. Review of nursing progress notes and facility incident reports from January 2017 through April 2017 showed the resident experienced a fall on 3/4/17 and a resident to resident incident on 3/18/17. a. The 3/4/17 fall investigation indicated a loud noise was heard and the resident was found on the floor at the foot of her/his bed. The resident was found to have a hematoma to her/his head but was otherwise within normal cognition. The resident stated she/he was trying to get to the bathroom when she/he fell . The nursing progress notes dated 3/4/17 contained no information on when the family was notified of the fall. The fall investigation indicated the family was notified but did not indicate how or when the family was notified of the fall. In an interview on 4/4/17 at 4:40 pm Witness 1 (Family) indicated the resident had a fall in her/his room. Witness 1 stated he was informed of the fall when he arrived at the facility a few hours after the fall occurred. The facility did not call prior to Witness 1's arrival at the facility. Witness 1 stated the resident told him she/he had fallen and the resident had a large bump on her/his head. Witness 1 further stated the facility was well aware to contact him right away regarding any changes and not to wait for him to be onsite. In an interview on 4/6/17 at 10:10 am Staff 12 (LPN/RCM) indicated the resident fell after a self-transfer attempt. The resident hit her/his head and was monitored for a resulting hematoma, but did not require hospitalization . Staff 12 was not the one who notified Witness 1 about the fall, she was unsure when the nurse involved contacted Witness 1. Two attempts were made to reach Witness 10 (Agency RN) on 4/5/17 and 4/7/17 regarding her nursing notes, with no return call received. b. A nursing progress note dated 3/19/17 indicated the resident was alert, oriented and able to make needs known. A different resident has been going in the resident's room and scaring the resident. The resident asked to move to a different room and was relocated. Review of the 2nd resident's, Resident 10, nursing progress notes indicated she/he wandered through the halls and entered another resident's room multiple times upsetting the resident and their family. Multiple attempts were made to redirect the resident with little results. Increased visual checks were implemented to ensure the resident was not entering others rooms. In an interview on 4/4/17 at 4:40 pm Witness 1 (Family) stated Resident 4 called one night and was screaming and extremely upset. Resident 4 stated another resident was in her/his room. Witness 1 stated it was late at night when the resident called. Witness 1 headed to the facility to talk with the resident and staff. Staff did not inform Witness 1 of the problems with Resident 10, entering Resident 4's room and that it had occurred at least three times. Resident 4's phone call was the first time Witness 1 was made aware of a problem with another resident; no facility staff had contacted him at home or when previously in the facility. Resident 4's room was moved as a result of the reoccurring issues and her/his fear. In interviews on 4/6/17 at 11:10 am and 2:48 pm Staff 4 and Staff 11 (CNAs) indicated they worked with Resident 4 after Resident 10 repeatedly entered her/his room. Resident 10 was confused and left when Staff 4 asked her/him to go. Resident 4 was visually and verbally upset and called her/his spouse. Staff 11 stated one evening he heard Resident 10 and Resident 4 yelling back and forth at each other. The interaction was becoming very heated as Resident 4 demanded that Resident 10 get out of the room immediately. Resident 4 was very upset. In interview on 4/5/17 at 9:27 pm Witness 9 (Agency LPN) confirmed the resident referred to in her nurse's notes was Resident 4. Witness 9 stated Resident 10 was removed multiple times over a couple of days from Resident 4's room. She removed the resident on a few occasions herself. Witness 9 was unable to get any information from Resident 4 about what happened. Resident 4 was very visibly upset and did not want to talk about what occurred. Resident 4 contacted her/his spouse after one of the occasions that Resident 10 was removed. Witness 9 reported to Staff 2 (DNS) and they moved Resident 4 to a different room. Witness 9 did not contact Witness 1 about the problems between Resident 4 and Resident 10. 3. Resident 11 was admitted to the facility in March 2016 with [DIAGNOSES REDACTED]. The 12/25/16 progress note and incident investigation documented the facility heard a loud crash noise from the resident's room and found her/him on the floor beside the bed. The incident investigation documented the resident fell out of the wheelchair, hit her/his head on the night stand and sustained a skin tear on her/his forehead. There was no documentation the family was notified of the incident. On 4/17/17 at 4:53 pm Staff 1 (DNS) and Staff 2 (Administrator) were asked to provide any additional information of family notification. On 4/18/17 at 11:14 am Staff 1 and 2 stated there was no additional information to be provided. 4. Resident 3 was admitted to the facility in August 2015 with [DIAGNOSES REDACTED]. a. The 10/3/16 progress notes and incident investigation documented the resident was found on the floor beside the bed and sustained a small bump to the back of her/his head. There was no documentation the family was informed. On 4/5/17 at 10:30 am Staff 5 (LPN/Care Manager) confirmed there was no family notification of the resident's fall on 10/3/16. On 4/5/17 at 11:00 am Staff 1 (DNS) confirmed there was no family notification of the resident's fall on 10/3/16. b. The 3/3/17 physician office visit notes documented there was no one with the resident during the clinic appointment. Resident 3 was assessed with [REDACTED]. The notes indicated everything is explained to the patient, though (she/he) does not appear to quite understand The resident needed to be toileted and then transferred to the local hospital emergency department. There was no documentation the resident's responsible party was informed of the clinic appointment. On 4/3/17 at 11:59 am Witness 15 (Responsible Party/Family Member) stated she was not informed of the 3/3/17 physician's office visit. Witness 15 stated on 3/3/17 she was at the facility when she was told the resident was at the clinic appointment and Resident 3 was taken to the local hospital emergency department. Witness 15 stated she immediately went to the local hospital emergency department and was asked by the local hospital staff why she wasn't there sooner. On 4/4/17 at 11:07 am Staff 5 (LPN/Care Manager) provided a typed statement, not included in the resident's computerized record, to indicate the local hospital emergency department called to state Resident 3 was at the local hospital and there was a return appointment scheduled for 3/4/17. Staff 5 documented Witness 15 was visiting the facility and Staff 5 notified her of Resident 3's transfer to the local hospital emergency department. Staff 5 documented Witness 15 knew of the clinic appointment on 3/3/17 and did not attend.

Based on interview and record review it was determined Staff 6 (RN) failed to report to the physician a blood sample was not obtained and the corresponding weekly [MEDICATION NAME] trough level and kidney monitoring lab was not completed for 1 of 7 sampled residents (# 2) reviewed for orders. Resident 2 was hospitalized with acute [MEDICAL CONDITION] and an extremely high [MEDICATION NAME] trough level. Findings include: According to the Oregon State Board of Nursing standards of practice Scope of Practice Standards for Registered Nurses [PHONE NUMBER] .(2)(a)(C) Detecting potentially inaccurate, incomplete or missing client information and reporting as needed .Conduct Derogatory to the Standards of Nursing defined 851-045-0070 (3)(h) Failing to communicate information regarding the clients status to members of the health care team (physician, nurse practitioner, nursing supervisor, nurse coworker) in an ongoing and timely manner. Resident 2 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated 9/21/16 indicated the resident was alert, oriented and directed her/his own care. The resident was independent in multiple activities of daily living and was able to call for assistance when needed. The signed physician order [REDACTED]. The IV order showed a start date of 11/29/16. Additionally, the resident was to have weekly labs to monitor kidney function and [MEDICATION NAME] levels drawn every Monday while on IV [MEDICATION NAME] and reported to the physician. The lab order showed a start date of 12/5/16. A nursing progress note dated 12/27/16 at 9:31 am indicated the resident's PICC line (thin tube inserted in a vein) flushed well but the nurse was unable to obtain a blood draw. An order was sent to the lab. Additional notes from 12/27/16 through 12/28/16 contained no information regarding physician notification or another attempt to get the blood draw. A nursing progress note dated 12/29/16 at 10:25 am indicated the lab was in and unable to obtain the draw. The lab tech stated someone else would come back and attempt. Additional notes on 12/29/16 through 1/1/17 indicated the resident's antibiotics were infusing without issue. No information was documented regarding a redraw of the 12/26/16 lab or physician notification of the missed lab. A nursing progress note dated 1/2/17 at 9:20 am indicated the PICC line flushed well, unable to obtain blood draw, lab to draw tomorrow. Nursing progress notes from 1/3/17 contained no information regarding a lab draw. On 1/4/17 at 9:11 am it was noted lab results from yesterday's draw were received and the results were called to Witness 6's (Infectious Disease (ID) Physician) office. The physician ordered IV antibiotics to be stopped and the resident sent to the hospital for evaluation. Review of the resident's lab reports, nursing progress notes and physician communications showed no labs were drawn on 12/26/16 as ordered. The previous lab draw was due on 12/19/16; the lab was drawn on 12/20/16 and showed a slight elevation in the [MEDICATION NAME] trough of 17.3 and creatinine of 1.18. The normal [MEDICATION NAME] trough range was noted to be 10-15 and creatinine .70-1.33. The next completed lab draw was due on 1/2/17; the lab was completed on 1/3/17 with a [MEDICATION NAME] trough level of 75 and a creatinine of 4.18. The resident's physician ordered the resident to be hospitalized for [REDACTED]. physician progress notes [REDACTED]. Additional physician progress notes [REDACTED]. It is likely that properly timed labs collected during the week of December 26 would have identified upward creep up of (her/his) trough levels, which would have allowed a dosing adjustment that would have prevented this complication. The [MEDICATION NAME] level was now low enough that it should not be causing further problems. The resident's Prognosis is guarded for recovery of renal function. In interview on 4/5/17 at 9:32 am Witness 7 (RN for Witness 6) indicated she tracked all the IV antibiotic labs for Witness 6 (ID Physician). The office received no results for the 12/26/16 lab and no notification of any problem with the blood draw. The office had limited hours that week due to the holiday but continued to have a physician on call 24/7. Staff 7 stated when labs for 1/3/17 were still not received on 1/4/17 the physician tracked them down and saw the resident's creatinine was elevated and the [MEDICATION NAME] trough was very high. Staff 7 further indicated their office contacted the nursing facility and advised them to stop the [MEDICATION NAME] doses and send the resident to the emergency room . In interview on 4/5/17 at 1:45 pm and 3:00 pm Staff 6 (RN) indicated the 12/26/16 lab was missed because she could not get a blood sample. She was not sure what the issue was because she was able to draw blood from the PICC line on other occasions. Staff 6 stated she did not notify Witness 6 (ID Physician) that she was unable to get a blood sample to complete the 12/26/16 labs. When they received the elevated lab results for 1/3/17 she could not remember if she contacted the physician or the physician contacted the facility. Staff 6 stated she remembered calling the lab and they did come in to attempt the blood draw. They were unsuccessful and as they left they told Staff 6 they would contact the physician. In interview on 4/5/17 at 2:10 pm Staff 1 (DNS) indicated she was not involved in the [MEDICATION NAME] trough level issue. She was told about the problem obtaining a blood draw and the missed lab after the resident was already out of the facility. Staff 1 stated the physician should have been notified. Refer to F-309

Based on observations, interview and record review it was determined the facility failed to ensure physician orders [REDACTED].#s 1, 2, 3, 7, 10 and 11). Resident 2 had a missed lab draw; the subsequent draw showed abnormal results. Resident 2 was hospitalized with acute [MEDICAL CONDITION] and an extremely high [MEDICATION NAME] trough level. Findings include: 1. Resident 2 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated [DATE] indicated the resident was alert, oriented and directed her/his own care. The resident was independent in multiple activities of daily living and was able to call for assistance when needed. a. The signed physician order [REDACTED]. Additionally, the resident was to have weekly labs to monitor kidney function and [MEDICATION NAME] trough levels drawn every Monday while on IV [MEDICATION NAME] and reported to the physician. The lab order showed a start date of [DATE]. A nursing progress note dated [DATE] at 9:31 am indicated the resident's PICC line (thin tube inserted in a vein) flushed well but the nurse was unable to obtain a blood draw. An order was sent to the lab. Additional notes from [DATE] through [DATE] contained no information regarding physician notification or another attempt to get the blood draw. A nursing progress note dated [DATE] at 10:25 am indicated the lab was in and unable to obtain the draw. The lab tech stated someone else would come back and attempt. Additional notes on [DATE] through [DATE] indicated the resident's antibiotics were infusing without issue and the resident was medicated for intermittent nausea. No information was documented regarding a redraw of the [DATE] lab or physician notification of the missed lab. A nursing progress note dated [DATE] at 9:20 am indicated the PICC line flushed well, unable to obtain blood draw, lab to draw tomorrow. Nursing progress notes from [DATE] contained no information regarding a lab draw. On [DATE] at 9:11 am it was noted lab results from yesterday's draw were received and the results were called to Witness 6's (Infectious Disease (ID) Physician) office. The physician ordered IV antibiotics to be stopped and the resident sent to the hospital for evaluation. Review of the resident's lab reports, nursing progress notes and physician communications showed no labs were drawn on [DATE] as ordered. The previous lab draw was due on [DATE]; the lab was drawn on [DATE] and showed a slight elevation in the [MEDICATION NAME] trough of 17.3. The normal range was noted to be ,[DATE]. The next completed lab draw was due on [DATE]; the lab was completed on [DATE] with a [MEDICATION NAME] trough level of 75. The resident's physician, Witness 6, ordered the resident to be hospitalized for [REDACTED]. A physician's progress note addendum for Witness 6 (ID Physician) dated [DATE] indicated the lab results for the sample collected on [DATE] were received and showed a creatinine of 4.18 and [MEDICATION NAME] trough of 75.0. The reference range for [MEDICATION NAME] trough was ,[DATE] and for creatinine was 0XXX,[DATE].33. We have contacted the patient's facility and advised them to send the patient to the emergency room for acute [MEDICAL CONDITION]. The physician's office was never notified of any difficulty obtaining lab results. Additional physician progress notes [REDACTED]. It is likely that properly timed labs collected during the week of [DATE] would have identified upward creep up of (her/his) trough levels, which would have allowed a dosing adjustment that would have prevented this complication. The [MEDICATION NAME] level was now low enough that it should not be causing further problems. The resident's Prognosis is guarded for recovery of renal function. In interview on [DATE] at 3:40 pm Resident 2 stated Staff 6 (RN) came to draw a blood sample from the resident's PICC line for labs on [DATE]. Staff 6 was unable to get a blood sample and did not attempt a second time or in a different location. The resident was confused by the situation because Staff 6 had drawn blood on previous occasions without an issue. The resident was told the PICC line was clogged so she/he contacted the wound clinic she/he was being seen at and was told they could fix the PICC line. Resident 2 told Staff 6 the information given to her/him by the wound clinic but she said that wasn't the problem and they would handle it at the facility. Resident 2 indicated the lab was never completed and by the time the next one was done she/he was sent to the hospital because the [MEDICATION NAME] level was so high. The resident stated her/his kidneys were not working properly. The resident stated she/he was very sick, spent about a week in the hospital and another few weeks to get her/his head clear and feel like herself/himself again In interview on [DATE] at 9:32 am Witness 7 (RN for Witness 6 (ID Physician)) indicated she tracked all the IV antibiotic labs for patients of Witness 6. The office received no results for the [DATE] lab and no notification of any problem with the blood draw. The office had limited hours that week due to the holiday but continued to have a physician on call ,[DATE]. Staff 7 stated when labs for [DATE] were still not received on [DATE] the physician tracked them down and saw the resident's creatinine was elevated and the [MEDICATION NAME] trough was very high. Staff 7 further indicated their office contacted the nursing facility and advised them to stop the [MEDICATION NAME] doses and send the resident to the emergency room . In interviews on [DATE] at 1:45 pm and 3:00 pm Staff 6 (RN) indicated the [DATE] lab was missed because she could not get a blood sample. She was not sure what the issue was because she was able to draw blood from the PICC line on other occasions. Staff 6 stated she did not notify Witness 6 (ID Physician) that she was unable to get a blood sample to complete the [DATE] labs. When they received the elevated lab results for [DATE] she could not remember if she contacted the physician or if the physician contacted the facility. In interview on [DATE] at 1:10 pm Staff 12 (LPN/RCM) indicated the resident was on weekly labs and one of the draws they could not complete. Staff 6 attempted to get the sample but was unable to get it. Staff 12 stated the lab came in to try and get the blood sample possibly more than once she was not sure. Staff 12 further indicated she was not involved with any communications to the physician regarding the missed lab nor did Staff 6 notify the physician of the missed lab. Staff 12 stated there was not usually any problem obtaining a blood sample from Resident 2. b. An event investigation dated [DATE] at 10:33 am indicated the resident had an open area to the left heel that appeared to be caused from the resident's shoe rubbing on the heel. The physician was notified and treatment was initiated. The resident's [DATE] TAR reflected weekly skin checks to be completed every Wednesday morning. The documentation indicated there were no new skin conditions on [DATE] and the remainder of the month of [DATE]. Nursing progress notes from [DATE] through [DATE] indicated the heel wound continued with some deterioration. There was no odor or signs of infection noted with dressing changes. On [DATE] a green color was noted to the wound and new orders for antibiotic treatment were received. Physician visit notes dated [DATE] indicated the resident was seen the previous week for prosthetic follow-up and her/his shoe was noted to be crumpled behind the resident's foot. There was a spot of blood on the resident's sock and when removed a large ulcer was noted behind the shoe. The resident refused staff assistance with shoe placement and the ulcer was likely related to the shoe not being on correctly. The resident was seen again on [DATE] at the facility, no antibiotics were deemed necessary for treatment of [REDACTED]. The heel wound was noted to be infectious and initial oral antibiotics were not showing any improvement in the wound. Antibiotic treatment was extended and at recheck the foot wound was now open with purulent discharge (containing pus). The physician noted he would set up a referral to the wound care clinic at which the resident had previously been a patient. Nursing progress notes on [DATE] indicated the wound now had an odor. Additional notes from [DATE] through [DATE] indicated the wound continued to have a foul odor. The [DATE] nursing progress note indicated the physician was notified on [DATE]. The physician was in the facility to see the resident on [DATE] and gave additional orders for antibiotic treatment. Nursing progress notes dated [DATE] through [DATE] indicated the wound continued to have some odor, a blackened wound bed and a moderate amount of dark yellowish/red drainage was also noted. The resident continued to receive oral antibiotics during this time, requested and was seen by the physician on [DATE]. On [DATE] it was noted the wound continued to be black with odor; an order was received to send the resident to the wound clinic for a consultation. A phone order dated [DATE] was received to send the resident to the wound care clinic for a wound consult on left heel wound. Nursing progress notes dated [DATE] through [DATE] indicated the wound continued with a foul odor. The resident expressed frustration on [DATE] she/he had not been seen by the wound clinic yet. On [DATE] the heel was noted to be black and soggy. There was no indication the physician was notified of the resident's concerns or the new description of the heel as black and soggy. The resident was seen at the wound clinic on [DATE] and was admitted to the hospital from the appointment with a subsequent amputation performed. Hospital wound care clinic notes dated [DATE] indicated the resident was seen for wound care and debridement of the heel. The resident's wound required deep debridement, IV antibiotics and an MRI so she/he was transferred to the emergency department for evaluation and treatment. Emergency Department notes dated [DATE] indicated the heel wound had odor coming from the center of the wound, with gangrene of the foot. The resident was admitted for evaluation and a subsequent amputation was performed. In interview on [DATE] at 3:40 pm Resident 2 stated when she/he admitted to the facility there was no breakdown on her/his heel or foot. The resident indicated the wound was caused when working in the therapy room, she/he was not sure exactly how it occurred. Resident 2 further stated she/he requested multiple times to go to the wound clinic, but was told no because it could be handled by the facility. The resident indicated she/he already had one amputation and did not want to go down the same road. The resident felt if she/he had been seen sooner, rather than waiting a month to get to the wound clinic, the outcome might have been different. In interview on [DATE] at 7:54 am Staff 6 (RN) stated she was not sure if she contacted the physician about the resident's heel on [DATE]. The information should be in her nursing notes if she did. Staff 6 indicated she did not remember a lot of details from so many months ago. Staff 6 had no additional information on the timeframes related to receipt of the wound clinic referral and the resident being seen. In interview on [DATE] at 12:30 pm Witness 13 (Wound Clinic Scheduling) indicated they usually were able to schedule appointments within a few days after receipt of the necessary orders, holidays can extend the time frame. They did not receive any orders for Resident 2 until [DATE]. The initial orders were incomplete and once they received the missing pieces the resident was scheduled for an appointment on [DATE]. In interview on [DATE] at 10:27 am Staff 1 (DNS) was unsure why there was a delay between the physician visit on [DATE] when the physician indicated the resident should be seen by the wound clinic and the receipt of the phone order on [DATE]. Staff 1 could not say why the wound clinic stated they did not receive any order information until [DATE]. The transportation for the resident's [DATE] appointment was set up on [DATE]. The resident had more than one appointment during that week. Three attempts were made to reach Witness 11 (Agency RN) on [DATE] and [DATE] regarding her nursing progress notes with no return call received. c. Review of the September, October and [DATE] and January, February and [DATE] TARs showed the following treatments and medications were not signed as completed: -[DATE] the 8:00 am Testosterone injection was not signed as given. -[DATE] and [DATE] right buttock pressure ulcer treatment and dressing changes were unsigned. -[DATE] and [DATE] the right buttock pressure ulcer treatment and dressing changes were unsigned. -[DATE] the 9:00 am [MEDICATION NAME] injection was unsigned. -[DATE] the 7:00 am and 11:00 am, [MEDICATION NAME]doses were not signed as given. -[DATE] the 8:00 pm stump incision monitoring and dressing order was unsigned. -[DATE] the PICC line dressing change was not signed as completed. -[DATE] the 11:00 am [MEDICATION NAME]dose was not signed as given. -[DATE] the left buttock abrasion and right stump pressure ulcer treatments and dressing change were not signed as completed. -[DATE] [MEDICAL CONDITION] (assistive breathing device) placement at bedtime was not signed as completed. -[DATE] and [DATE] [MEDICAL CONDITION] placement at bedtime was not signed as completed. Review of nursing progress notes for [DATE] through [DATE] showed no documentation of the unsigned items being administered and/or treatments completed. In interviews on [DATE] and [DATE] Staff 1 (DNS) indicated she had no additional documentation for the unsigned items on the TARs. Staff 1 stated she believed the issues were related to a couple agency staff. Staff 1 indicated incomplete charting was an ongoing problem with a few of the staff and the reason they no longer worked for the facility. 2. Resident 7 was readmitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The resident's care plan dated [DATE] indicated the resident was a fall risk due to a history of falls, extensive assistance with transfers and bed mobility, pain and medication use. The resident's in room Kardex (CNA care plan) dated [DATE] reflected multiple safety interventions including to keep the resident's bed in the lowest position and keep the bed remote out of reach. Multiple observations of the resident on the afternoon of [DATE] and throughout the day on [DATE] showed: -4:30 pm the top of the resident's bed frame was above the top of the surveyors thigh, approximately three feet. The bed was in the lowest position at 4:45 pm, approximately two feet. -Continuous observations were made from 8:05 am to 8:30 am which showed the resident's bed was in the high position. The resident's bed was put in the lowest position when Staff 18 (CNA) was asked about the resident's bed. -10:00 am the top of the resident's bed frame was again in the high position. A return observation at 10:11 am showed the bed height was unchanged. -Continuous observations were made from 10:11 am to 10:50 am, the resident's bed continued in the high position while the resident rolled and called out incoherently. Staff entered the room to assist the resident and lowered the bed before leaving. In an Interview on [DATE] at 8:30 am Staff 18 (CNA) indicated she was not sure about the resident's bed height. Staff 18 was directed by the surveyor to verify the intervention on the care plan and Kardex located in the resident's closet and showed Staff 18 the entry regarding bed height. Staff 18 lowered the bed as far as it would go which was to the height of the surveyors knees. The resident continued to sleep throughout the interaction. In an Interview on [DATE] at 12:30 pm Staff 5 (LPN/RCM) indicated the bed in the lowest position was a current intervention for the resident. The resident cannot get out of bed on her/his own. The resident's bed did not go all the way to the floor when lowered. Staff 5 stated the resident was able to raise the bed if the controller was in reach so staff were to insure it was not in reach as well as putting the bed in the lowest position. 3. On [DATE] at 11:07 am Staff 1 (DNS) was asked for the facility's policy and procedure regarding neurological checks. Staff 1 stated the facility did not have a specific policy regarding neurological checks. According to the HcPro website and Long Term Care Nursing Library an assessment needed to be conducted immediately after a fall with head injury. Frequent checks needed to be conducted throughout the shift and continued for a minimum of 72 hours. The neurological check needed to include as a minimum: pulse, respiration, blood pressure, assessment of pupil size and reactivity; and equality of hand grip strength. a. Resident 11 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The [DATE] progress note written at 4:01 am documented the facility heard a loud crash noise from the resident's room and she/he was found on the floor beside her/his bed. The incident investigation documented the resident fell out of the wheelchair and hit her/his head on the night stand and sustained a skin tear on her/his forehead. There was no documentation neurological checks were completed. The [DATE] progress notes written at 1:56 am revealed the staff heard a noise from the resident's room and found her/him lying on her/his left side beside the bed. The progress notes indicated neurological checks were started due to un-witnessed fall/roll out of bed. There was no documentation neurological checks were conducted after 1:56 am. On [DATE] at 4:53 pm Staff 1 (DNS) and Staff 2 (Administrator) were asked to provide any additional information about neurological checks conducted for Resident 11. On [DATE] at 11:14 am Staff 1 and 2 stated there was no additional information to be provided. b. Resident 3 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The [DATE] progress notes written at 4:07 pm revealed the resident was found on the floor with wheelchair beside her/him. The resident was assessed to have a small bump on the back of her/his head. The [DATE] Incident investigation documented the resident's neurological checks were done and were within normal limits. The [DATE] progress notes written at 12:41 pm documented the resident had a non-injury fall on the night shift. The notes indicated neuro checks were done and were within normal limits. On [DATE] at 11:00 am Staff 1 (DNS) was asked to provide any additional documentation of neurological checks conducted for Resident 3. Staff 1 confirmed there was no record of additional neurological checks. c. Resident 10 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The [DATE] progress notes written at 10:55 am documented the resident was found on the floor beside her/his bed. The resident was assessed to have an abrasion on her/his forehead. There was no documentation neuro checks were conducted. The [DATE] progress notes written at 10:56 am documented the resident was found on the floor beside her/his bed. The incident investigation documented the resident's neuro checks were found to be within normal limits. The [DATE] progress notes written at 2:51 pm revealed the resident fell in the guest bathroom and had a red mark on the back of her/his head and back. The incident investigation documented the resident fell at 2:51 pm and neuro checks were within normal limits. The [DATE] neurological checks form documented an initial assessment conducted at 11:30 am included the resident's temperature, respiration, pulse, blood pressure and oxygen levels. There was no documentation of an assessment of pupil size and reactivity; and equality of hand grip strength. The next assessments were done at 7:30 pm, 11:30 pm and on [DATE] at 3:30 am. These assessments also did not include an assessment of pupil size and reactivity; and equality of hand grip strength. On [DATE] at 3:25 pm Staff 1 (DNS) was asked to provide any additional documentation of neurological assessments conducted for Resident 10. Staff 1 confirmed there was no record of additional neurological checks. 4. Resident 11 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED].>The [DATE] physician's orders [REDACTED]. and recheck in ,[DATE] minutes. If still below 60 the staff were to notify the resident's physician. a. There was a [DATE] physician's orders [REDACTED]. There was no documentation in the [DATE] TAR or progress notes for CBG readings regarding Humalog at 7:00 am on [DATE], [DATE] and [DATE]. There was no documentation of CBG readings at 4:00 pm on [DATE] and [DATE]. There was no documentation in the February 2017 TAR or progress notes for CBG readings regarding Humalog at 7:00 am on [DATE] and [DATE] and at 11:00 am on [DATE] and [DATE]. b. There was a [DATE] physician's orders [REDACTED]. The February 2017 TAR for [MEDICATION NAME] documented On [DATE] CBG at 5:00 pm was 55. On [DATE] at 7:00 am CBG was 57. On [DATE] at 7:00 am CBG was 59. There was no documentation on the TAR or in the progress notes of what was done when the CBG reading was below 60. There was no documentation the resident's CBG was rechecked and [DIAGNOSES REDACTED] protocol followed. The [DATE] TAR for [MEDICATION NAME]/progress notes contained no documentation of a CBG reading at 5:00 pm [DATE] and at [DATE] at 12:00 pm. The TAR documented on [DATE] at 7:00 am the resident's CBG reading was 53 and [DATE] at 7:00 am CBG was 46. There was no documentation on the TAR or in the progress notes of what was done when the CBG reading was below 60. There was no documentation the resident's CBG was rechecked and [DIAGNOSES REDACTED] protocol followed. The [DATE] TAR for [MEDICATION NAME] recorded a CBG on [DATE] at 7:00 CBG as 47. There was no documentation on the TAR or in the progress notes of what was done when the CBG reading was below 60. There was no documentation the resident's CBG was rechecked and [DIAGNOSES REDACTED] protocol followed. c. There was a [DATE] physician's orders [REDACTED]. The [DATE] TAR and progress notes for [MEDICATION NAME] contained no documentation to indicate [MEDICATION NAME] was provided on [DATE], [DATE] and [DATE]. The February 2017 TAR and progress notes for [MEDICATION NAME] had no CBG recorded on [DATE] at 8:00 pm. On [DATE] at 9:00 pm there was no documentation of a CBG or [MEDICATION NAME] provided. The [DATE] TAR and progress notes for [MEDICATION NAME] had no CBG recorded or [MEDICATION NAME] provided on [DATE]. On [DATE] the resident did not receive the [MEDICATION NAME] and there was no documentation why the [MEDICATION NAME] was not provided. The [DATE] TAR documented the resident did not receive [MEDICATION NAME] for a CBG reading of 77. There was no documentation why the [MEDICATION NAME] was not provided. On [DATE] at 4:53 pm Staff 1 (DNS) and Staff 2 (Administrator) were asked to provide any additional information about the resident's CBGs and the provision of approaches for [DIAGNOSES REDACTED] events. On [DATE] at 11:14 am Staff 1 and 2 stated there was no additional information to be provided. 5. Resident 1 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The [DATE] physician's orders [REDACTED]. The [DATE] progress note documented the resident was on alert for a medication error. The [DATE] Medication Error/Adverse Drug Reaction Report documented on [DATE] Staff 7 (CMA/Medical Records) discovered the resident had two 25 mcq patches applied instead of one 25 mcq and one 12 mcq. There had been no nurses note to document the error and Staff 1 (DNS) was informed on [DATE]. The resident was assessed not to have adverse side effects from the medication error. Staff 21(LPN) was identified as the staff member who made the medication error and was provided with reeducation of proper medication administration. On [DATE] at 10:00 am Staff 21 (LPN) stated she could not remember the medication error. On [DATE] at 1:45 pm Staff 1 (DNS) stated the resident received 50 mcq of narcotic pain medication instead of 37 mcq as ordered by the physician. Staff 1 stated the resident did not have any side effects. Staff 1 stated she provided reeducation to Staff 21 after the occurrence. 6. Resident 3 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. a. The [DATE] comprehensive care plan and Kardex (in room care plan for CNAs) directed the CNAs to conduct 1 hour safety checks to anticipate the resident's needs of toileting or anything else to prevent falls. The care plans also directed the CNAs to toilet the resident every two hours routinely to encourage the resident to allow staff to assist with toileting/peri care even when the resident stated she/he was independent with toileting. The interventions of the 1 hour safety check and two hour toilet schedule was included in the ADL interventions in the computer. The form provided an area for the CNAs to document the care was provided for safety and toileting/ peri-care. The ADL intervention forms were reviewed from [DATE] through [DATE]. The documentation revealed the CNAs failed to consistently document the care was provided every one and two hours. There were 88 occasions there was no documentation the CNAs provided safety checks and toileting needs between 4 to 9 hours. On [DATE] at 6:48 pm Resident 3 fell during a self-transfer. There was no documentation on the ADL intervention form the resident had been provided with a safety check or toileting from 12:22 pm through 8:35 pm. On [DATE] at 4:53 pm Staff 1 (DNS) and Staff 2 (Administrator) were asked to provide any additional information about the safety checks and toileting needs provided for Resident 3. On [DATE] at 11:14 am Staff 1 and 2 stated there was no additional information to be provided. b. The [DATE] physician office visit notes documented the resident was at the clinic appointment unattended. Resident 3 was assessed with [REDACTED]. The notes indicated everything is explained to the patient, though (she/he) does not appear to quite understand The resident needed to be toileted and then transferred to the local hospital emergency department. On [DATE] at 11:59 am Witness 15 (Family Member/Responsible Party) stated the facility arranged transportation through the local transportation service. Witness 15 stated Resident 3 was diagnosed with [REDACTED]. Witness 15 stated the transportation service drove the resident to her/his appointments and left the resident alone in the clinic waiting area without assistance. On [DATE] at 11:07 am Staff 2 (Administrator) provided documentation to indicate when a resident needed an MD appointment outside of the facility, the transportation coordinator (Staff 22) contacted the resident's family members to inform them of the appointment and request assistance from the family members if the resident was not capable of going to the appointment alone. If the family member was not able to attend the appointment and it was necessary for someone to attend with the resident, the facility was then to provide a caregiver to go with the resident to the appointment. On [DATE] at 2:15 pm Staff 22 (Transportation Coordinator) stated once the appointments were set up she arranged transportation. Staff 22 stated she usually left a message on Witness 15's phone to inform her of the resident's appointment. Staff 22 stated she did not verify if the family members were going to attend the appointments. Staff 22 stated if a resident was confused the facility ensured the resident was assisted to the appointments and did not go to the appointments alone. Staff 22 stated she remembered the local clinic secretary was upset Resident 3 was not accompanied at a clinic appointment. Staff 22 stated the resident needed to use the toilet and the secretary assisted the resident. Staff 22 stated Resident 3 was able to self-transfer on and off the toilet to her/his wheelchair. Staff 22 was asked if Resident 3 had a [DIAGNOSES REDACTED].

A. Based on interview and record review it was determined the facility failed to provide adequate equipment and supervision to prevent injury for 2 of 3 sampled residents (#s 68 and 122) reviewed for accidents. Resident 68 sustained a fracture. Findings include: 1. Resident 68 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated [DATE] indicated the resident was alert and oriented, independent in electric wheelchair and used a hoyer lift with two staff for transfers. The resident was noted to be high risk for lower body injuries due to a lack of sensation and inability to feel pain in her/his lower extremities. The resident's [DATE] annual and [DATE] quarterly MDS indicated the resident was alert and oriented with a brief interview for mental status score of 15 out of 15. NNs dated [DATE] indicated the resident returned from an outing and stated she/he might have a broken leg. The resident stated her/his wheelchair footrest broke off after hitting a bump. The resident's right foot and left foot had been tied together by someone who came to the resident's aide. The resident then returned to the facility. The resident's foot was turned inward at a 90 degree angle. The resident was assisted to bed and the foot was examined. There was no new swelling but a small abrasion and dried blood were noted. The resident repeatedly refused to go to the emergency room . No communication with the physician was noted. An Incident Report was completed on [DATE] for an incident on [DATE] at 6:50 pm that occurred outside the facility. The resident's right wheelchair footrest was missing and the resident's right foot was turned inward at a 90 degree angle with a new abrasion. The resident stated I might have a broken leg. The resident stated she/he was almost to bingo when the resident hit a bump and the right footrest broke off. A witness statement from the incident report by Staff 7 (CNA) indicated on [DATE] the resident was going out of the facility to bingo at 5:00 pm. The resident was transferred to her/his wheelchair but the footrests would not function properly. Staff 7 stated they put another pair of footrests on the resident's chair that were obtained from the resident's closet. The right footrest would not stay locked so Staff 7 and Witness 1 (Former Facility CNA) used a velcro band around the footrests to keep them securely in place. An incident summary completed by Staff 3 (RNCM) indicated the resident was alert, oriented and able to make needs known. The resident told staff she/he hit a bump on the way to bingo and the footrest broke off. The resident was found to have an ankle fracture and a cast was placed on [DATE]. Review of the resident's record showed no additional information regarding hospital treatment, x-ray results, treatment monitoring or progress notes related to the resident's ankle fracture. A NN dated [DATE] contained the first mention of a cast to the resident's leg. Interview on [DATE] at 8:40 am and 3:20 pm Staff 3 (RNCM) stated she did not remember specifically what occurred on [DATE], but she believed the CNAs knew the resident would leave regardless of what they said so they put the strap around the rests to keep them held together. Staff 3 acknowledged letting the resident leave the facility with a faulty footrest was not the best plan. In an interview on [DATE] at 1:10 pm and 1:17 pm Staff 13 (PT) and Staff 14 (PTA) indicated they had received no requests for an evaluation of the resident's footrests or wheelchair. Staff 14 stated the resident previously had a trough to support her/his legs but she was unsure when or why it was discontinued. The staff indicated the resident moved very fast in the wheelchair and often bumped into things or caught a corner as she/he went. Staff 13 and 14 stated a strap to hold the footrests together could be used as a short term fix but only while in the facility; it would not be safe out in the community, especially for this resident. In an interview on [DATE] at 2:30 and 2:45 pm Staff 7 (CNA) indicated the resident's footrests were not working properly and a second set of foot rests were pulled out of the resident's closet. The second set had problems as well. Staff 7 stated the right footrest would not stay latched and kept opening up so they put a Velcro strap around the back to hold the two footrests together. Staff 7 told the nurse about the footrest and the resident left, she could not remember which nurse she talked to at the time. Staff 7 did not ask the resident to wait or try to find additional footrests. Staff 7 stated the resident usually would not wait when she/he wanted to leave so Staff 7 did not make additional attempts. In an interview on [DATE] at 1:50 pm Resident 68 indicated the staff pulled footrests out of her/his closet and put on the wheelchair because the first set did not work. The resident stated the staff had problems with the second set of footrests as well but did not recall anything additional about the footrests. The resident stated while she/he was out she/he hit a bump and the whole footrest broke off. When the footrest came off the resident stated her/his foot dropped down and bent back. In an interview on [DATE] at 9:25 am Staff 2 (DNS) indicated maintenance had worked on the resident's chair several times. Staff 2 was not aware of any requests to therapy for an evaluation or suggestions related to the footrests. The staff did try to get the resident to stay but she/he refused. Staff 2 acknowledged there was no documentation of the staffs' actions. 2. Resident 122 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The resident's care plan dated [DATE] noted the resident required one staff assist for locomotion, bathing and showering, mobility, dressing, personal hygiene and transfers. The resident was noted as a fall risk due to a history of falls and impaired balance. The resident's mobility was also impaired related to a left tibia fracture, as well as a left wrist fracture. The resident's admission MDS dated [DATE] indicated the resident was alert and oriented with a brief interview for mental status score of 15 out of 15. There were no behaviors or hallucinations noted. The resident required extensive assistance of ,[DATE] staff with individual activities of daily living. The resident did not walk on or off the unit during the assessment period. In an interview on [DATE] at 10:17 am Witness 3 (Ombudsman) indicated Resident 122 was left for an extended period on the facility bus after an appointment. Witness 3 stated the information was reported to her a few months back but when she approached the resident she/he did not want anything further done. In an interview on [DATE] at 10:16 am Resident 122 stated a few months ago she/he was left in the facility bus for 45 minutes while staff went to pickup another resident. Resident 122 stated the bus was running, the air conditioning was on and the doors were open. The resident stated it was very hot out and the running engine made it worse as the heat from the engine just blew back into the bus; she/he was mad, miserable and uncomfortable. The resident indicated she/he had a cell phone but it died part way through the incident so she/he could not use it. The resident further indicated a woman in the parking lot offered assistance. Review of NNs for July through [DATE] showed no information regarding the incident. The July NNs and TAR indicated the resident had a knee immobilizer/brace on the left leg and a brace to the left wrist. A witness statement from Staff 20 (CNA/Transportation) dated [DATE] indicated they arrived at the hospital at 12:50 pm to pick up the new resident. Staff 20 noted she explained to Resident 122 what she needed to do and it would not take long. Staff 20 went into the hospital, dropped off the wheelchair, obtained a snack for the resident and returned to the bus. A female was outside the vehicle and questioned how long Staff 20 had been gone as Resident 122 seemed to be in distress. Staff 20 noted the resident did not seem hot, the AC was running on high, the w/c door was open and the bus did not seem hot. The new resident was brought out at 1:03 pm and they left the hospital. In an interview on [DATE] at 2:16 at pm Staff 20 (CNA/Transportation) indicated she left the resident in the bus for about ten minutes. Staff 20 stated she left the bus parked near the emergency room and valet parking. The bus was running, the lift door was open with the wheelchair lift in a down position, the folding door was open as well and the air conditioning was running. Staff 20 further indicated the drivers door was shut. Staff 20 exited the bus, walked the wheelchair into the hospital, took the elevator to the 4th floor, spoke to the nurse, went back down stairs, purchased a snack for Resident 122 and then returned to the bus. A woman was outside the bus and questioned Staff 20 on her timeframes because the resident was distressed. Staff 20 stated she had left alert and oriented residents in the bus on many occasions while picking up someone from the hospital and would do it again. In an interview on [DATE] at 9:16 am and 12:11 pm Staff 2 (DNS) indicated their investigation determined the resident was left for a very short time with the bus running, doors open and the air conditioning going. On discussion, Staff 2 acknowledged with the bus running and the doors open anyone could have entered the bus. Staff 2 stated the best practice would be not to leave a resident unattended in a running bus. At the time of the incident on [DATE] the resident was in a leg immobilizer/brace with healing leg and wrist fractures. The resident was confined to a wheelchair and required extensive assistance from staff to move in or out of the wheelchair. The resident did not have adequate staff supervision for safety while left in the unsecured bus. B. Based on interview and record review it was determined the facility failed to provide adequate supervision or implement interventions to prevent resident to resident altercations for 1 of 3 sampled residents (#94) reviewed for behaviors. Resident 94 initiated multiple resident to resident altercations and attempted to choke another resident. Findings include: Resident 94 was admitted to the facility in [DATE] with [DIAGNOSES REDACTED]. The resident's [DATE] care plan indicated the resident was at risk for behavior symptoms r/t (related to) resistance to care, hitting/slapping others including resident's verbal outbursts (cursing and name calling). Throwing things at people, threats, grabbing others belongings and refusing to give them back, ripping (her/his) O2 tubing in half and making harmful decisions about (her/his) health. The interventions indicated administer medications as ordered. Monitor effectiveness and side effects .Allow resident to make choices about daily routine and care when possible. Anticipate and meet resident's needs. Approach resident in a calm manner; reapproach at a later time if agitated or uncooperative. If appropriate discuss the resident's behaviors and suggest alternatives. The resident's care plan was updated on [DATE] to include If resident feels up to talking when upset, allow time for (her/him) to vent to staff member who (she/he) trusts. Review of the resident's progress notes from admission until [DATE] revealed the resident had occasional verbal outbursts directed toward staff. Progress notes written on [DATE] at 3:44 pm indicated the resident was yelling, cussing, hallucinating, throwing things at people, grabbing at visitors, taking nurses chair at nurses station-refusing to give back. Grabbing nurses items on desk-refusing to give back Staff documented the resident was offered food, drinks, approached and reapproached calmly, attempted redirecting let (her/him) speak with administrator on phone. The facility called the MD and received an order for [REDACTED]. On [DATE] at 3:04 pm progress notes indicated Resident 94 had been verbally aggressive with another resident early this AM. On [DATE] at 11:19 pm NN indicated the resident was aggressive with yelling cursing, threatening, making fists and pulling back to hit another resident. The facility attempted non-pharmacological interventions of: Removed other resident from danger. Kept both separated. Attempted redirection with no success .Resident continued with these behaviors along with extreme confusion A [DATE] CAA summary indicated the resident's behavioral symptoms will be addressed in the care plan in order to avoid complications and minimize risks. Resident has behavioral issues throws things at staff .throws things across the hall .attempts to hit staff .refused care. The resident's care plan was updated on [DATE] to include 15 minute safety checks and the resident was to be in a supervised area when out of bed as she/he would allow. Progress notes written on [DATE] at 11:16 am indicated the resident was yelling down the hall .Called administrator to come and talk to (her/him) .Resident allowed administrator to place tubing. Behaviors immediately stopped Progress notes written on [DATE] at 7:35 pm indicated the resident was in a wheelchair in hallway. When the nurse asked what she/he needed the resident became verbally abusive to staff and started grabbing things off the counter at the nurses desk, throwing papers down on floor, throwing TV remote The resident threw a filled water cup/pitcher at another resident's back. Staff documented other residents were removed from the area and the resident demanded to be taken to (her/his) room so (she/he) could lay down The investigation for the [DATE] incident indicated Resident 94 was often confused, combative, and non-redirectable at times. The investigation repeated the events from the progress notes but did not identify if new interventions were implemented. Progress notes written on [DATE] at 6:59 pm indicated Calling another resident an (foul name) and other names. Arguing with multiple staff On [DATE] at 11:16 pm progress notes indicated the resident had an altercation with another resident. The incident investigation for [DATE] indicated both residents were at the nurses' station and the residents began arguing and wheeling toward each other and then slapping at each other. The investigation indicated that Staff 1 (Administrator) was called and Resident 94 was given the phone to talk to him. (Resident 94) is often only able to be redirected if she/he speaks to the administrator. On [DATE] the resident's care plan for behavior symptoms included approaches which included ensure resident is supervised when in a group setting, explain all procedures to resident before starting and allow resident time to adjust, identify and treat underlying cause(s) of behaviors as appropriate and if resident becomes agitated or upset call the administrator or her/his friend to calm (her/him) down. Progress notes written on [DATE] at 11:34 pm indicated Resident had multiple verbal altercations with other residents and staff this evening. Resident called staff and other resident names and cursed at them. Resident 94 had a physical altercation with another resident, when Resident 94 came up behind the other resident and wrapped (her/his) oxygen tubing around (Resident 39's) neck and proceeded to choke (her/him) and stated I want to kill (her/him). The med aide and this LN got the tubing off of (Resident 39's) neck and made sure (she/he) was ok. Staff 1 and the MD was called and the MD ordered Resident 94 to go to the emergency room for a psychiatric evaluation. On [DATE] at 3:22:25 PM Staff 2 (DNS) stated the facility sent Resident 94 out to the local hospital after she/he tried to strangle another resident. Staff 2 stated the facility was unable to provide one on one supervision for Resident 94. Staff 2 stated she was aware of three physical altercations Resident 94 had with other residents. The first incident involved Resident 45, Second altercation happened on [DATE] and it appeared as though both of the residents slapped one another. Staff 2 stated the incident on [DATE] occurred at the nurses station with two staff members present. Staff 2 was asked if the facility had the resident assessed by a mental health professional. Staff 2 stated there were limited resources available in the area though acknowledged there were mental health professionals in the area who were involved with other residents in the facility. On [DATE] at 3:35:00 PM Staff 1 (Administrator) stated he was called when the resident was upset and he attempted to calm the resident. Staff 1 stated on [DATE] Resident 94 was under direct supervision of the staff at the nurses station. Staff 1 and Staff 2 (DNS) stated the resident's physician was contacted regarding the resident's behaviors and started the resident Seroquel. Staff 1 stated he thought the facility had made a referral for mental health services for (Resident 94). Staff 1 stated Staff 23 (Social Services) would know if a mental health referral was made. On [DATE] at 3:50:40 PM Staff 23 (Social Services) stated there was no documentation of a referral made to the local mental health specialist. No additional information was provided. On [DATE] at 10:45:50 AM Staff 3 (RNCM) stated Resident 94's outbursts gradually became worse and more frequent. Staff 3 stated the resident's behaviors were normally directed toward staff. Staff 3 stated she was aware Resident 94 had three altercations with other residents. The first altercation was when Resident 94 threw a picture of water at another resident. Resident 94 had a tendency to throw things when she/he didn't like it. The second altercation was when Resident 94 and another resident were fighting with one another. As for the third altercation, Staff 3 stated she didn't know why the resident tried to strangle Resident 39 as they were not arguing. The behavior just came out of nowhere.

Based on observation, interview and record review it was determined the facility failed to prevent a severe weight loss and implement new interventions for 1 of 4 sampled residents (# 18) reviewed for nutritional status. As a result the resident had a severe weight loss of 10 lbs (6.5%) in a 30 day period. Findings include: Resident 18 was admitted to the facility in 7/2015 with [DIAGNOSES REDACTED]. The resident's 7/11/15 Admission profile identified the resident weighed 154 lbs and had no [MEDICAL CONDITION]. On 7/12/15 a physician order [REDACTED]. On 7/14/15 a Nutritional Risk Assessment was completed by a Registered Dietician (RD). The resident weighed 158.2 lbs and meal intakes were 51-75%. The RD's summary included the resident's heart healthy diet was not meeting the resident's protein need to support repletion and healing. The RD suspected wt gain since admit was related to lower extremity [MEDICAL CONDITION] as oral intake had been fair. The RD recommended to change the diet to No Added Salt regular and to implement Nutritionally Enhanced Meals (NEM) to maximize calories at meal time, add 90mls of 2.0 cal three times daily for extra an 540 calories and 22 grams of protein. On 7/15/15 a physician order [REDACTED]. The resident's 7/18/15 Admission RAI/MDS indicated the resident required supervision of eating and set up of meals, weighed 158, had no swallowing problems. The Dental CAA indicated the resident had full upper and partial bottom dentures and her/his remaining teeth were in poor condition. The Nutritional CAA revealed the resident was still on a heart healthy diet and ate between 75-100% of most meals at that time. The resident's care plan, dated 7/23/15, identified the resident was at a risk for nutritional problems with a high BMI (body mass Index) and being on a therapeutic diet. The interventions included to monitor weights, provide and serve diet as ordered, and RD (Registered Dietician) to evaluate and make recommendations. The care plan did not identify the resident's supplements, or specific diet order. On 7/31/15 a physician order [REDACTED]. On 8/5/15 the resident was reviewed by a different RD for Nutrition at Risk Review of a new admission. The resident was noted to weigh 154.6 lbs on 7/29/15, to have excellent meal intakes and stable weight. The RD recommended to discontinue the NEM and 2.0 calorie drinks three times daily. A Nutrition at Risk Review (NAR) on 8/21/15 indicated the resident's weight was the same as 30 days ago. Wt stable. The resident weighed 159.2 lbs A NAR note signed by the Staff 3 (RNCM), Staff 4 (RCM), Staff 6 (Dietary Service Manager) and Staff 2 (DNS) on 8/27/15 indicated the resident's weight was the same as 30 days ago without change. The resident weighed 154.6 lbs which reflected a greater than 4 pound weight loss in 6 days. A NAR note on 9/4/15 indicated the resident weighed 156.4 pounds, had no [MEDICAL CONDITION], and no interventions were recommended. A NAR review on 9/18/15 indicated the resident weighed 146.8 lbs and had a 7.8% weight loss. There was no assessment of the weight loss or potential factors affecting the resident's nutritional status. No new interventions were implemented or referral to the RD suggested. A greater than 5% unplanned & undesired weight loss in less than one month indicated a severe weight loss. A NAR Review note dated 9/24/15 indicated the resident had weight loss and reflected the resident's 9/28/15 weight of 144.6 lbs. The weight was noted to be a 10 lbs (6.5%) weight loss in the last 30 days. [MEDICAL CONDITION] was not noted as a potential factor affecting the resident's nutritional status. There were no new goals, interventions, or plans recommended and the RD was not notified of the resident's severe weight loss. Review of the resident's weight record indicated a gradual decline in weight since 8/21/15 from 159.2 lbs to 144.6 lbs on 9/28/15 for a 14.5 lbs weight loss in less than 60 days. The weight record revealed four different methods to weigh the resident were used: standing scale, wheelchair scale, mechanical lift scale, and other. The weight record also showed weights were done at different times of the day ranging from 5:50 am to 3:53 pm. On 9/28/15 at 11:02 am Resident 18 stated the food did not taste good and was always cold. The resident stated she/he ate because she/he was hungry but did not like the food. On 9/29/15 the resident's care plan had not been updated to include the severe weight loss or the resident's diet order. There was no evidence in the medical record a referral was made to a RD. On 9/30/15 at 3:33 pm Staff 25 (RD) verified the resident's severe weight loss in one month based on NAR notes and the resident's weight record. Staff 25 verified there were no interventions recommended or implemented by the NAR committee to prevent Resident 18's further unplanned weight loss, the use of inconsistent weight methods and the weights obtained were at various times of the day. She stated the resident was not referred to her for evaluation until she saw the resident's medical record on 9/30/15.

1. Based on observation, interview and record review it was determined the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 3 sampled residents (# 2) who wandered. Resident 2 was diagnosed with [REDACTED]. The facility staff stated Resident 2 eloped out of the building, without staff knowledge, into the parking lot during the night shift. The local municipal airport historical weather website indicated the outside low air temperature for November 2013 ranged from 25 to 32 degrees. Not all of the facility's exit doors were alarmed or secure to prevent elopement. This placed the resident in immediate jeopardy and constituted substandard quality of care. Findings include: Observation on 12/31/13 at 7:30 am of the east entrance doors (long term care section) revealed there was an apparatus near the doorway to identify a wander guard system was available. On 12/31/13 at 10:30 am and 1:30 pm Staff 7 (Maintenance Director) stated the wander guard system was not functional. Staff 7 stated there was an alarm on the east entrance doors (long term care section) which would sound if the doors were held open. Staff 7 stated the alarm would not sound if a resident went through the doors without the door being held open. Staff 7 stated at night the door was locked to prevent entry from the outside though a resident was able to open the exit door from the inside to leave the facility into the parking lot. Resident 2 was admitted to the facility in September 2009 with vascular dementia with behavioral disturbances/delusions. On 12/30/13 at 3:00 pm Staff 1 (DNS) identified Resident 2 as a wanderer at risk for elopement. There was no documentation in the resident's record of an assessment and care plan regarding the resident's wandering and elopement risk. The 11/14/13 and 11/19/13 Multi-Disciplinary Progress Notes indicated the resident wandered the halls frequently during the night and the resident tried to go into other resident rooms. The 12/8/13 Multi-Disciplinary Progress Notes written during the night shift indicated the resident was "very manic acting, up in w/c (wheelchair) wandering and trying to go out doors and into others' rooms ...." On 12/31/13 at 5:10 am and 1/6/14 at 7:34 am Staff 3 (CNA) was asked if she was aware of a resident who eloped from the facility. Staff 3 stated she was not sure when the incident occurred though she knew it happened on a Monday night during the first two weeks of November 2013. Staff 3 stated when she was finished providing care for another resident she was not able to locate Resident 2. Staff 3 stated she looked for the resident and found her/him in the parking lot on the west side/skilled section of the building. Staff 3 stated she informed Staff 4 (LPN). Staff 3 believed there was no documentation of the incident. Staff 3 stated Staff 5 (CNA) and Staff 8 (CNA) were working in the facility at the time of incident. Staff 3 stated she estimated the resident was out of the facility for a period of ten minutes. Staff 3 stated the air temperature was very cold and the resident complained of being cold. Staff 3 stated this was the only occasion Resident 2 eloped from the facility when she provided care for the resident. Staff 3 stated many residents required the assistance of two CNAs and it was difficult to monitor Resident 2 and care for the other residents. Attempts to interview Staff 3 on 2/18/14, 2/19/14 and 2/20/14 were unsuccessful. On 12/31/13 at 5:20 am Staff 5 (CNA) stated she was aware Resident 2 wandered throughout the facility and was an exit seeker. Staff 5 stated she was not aware Resident 2 eloped out of the building. On 1/7/14 at 2:30 pm Staff 8 (CNA) revealed during the night shift in the middle of November 2013 she observed Staff 3 (CNA) "desperately" searching for Resident 2. Staff 8 stated Staff 3 found the resident outside in the parking lot on the west side of the building. Staff 8 stated the resident was usually seeking the exits and the resident stated she/he was looking for her/his spouse. On 12/31/13 at 8:00 am and 1/3/14 at 9:00 am Staff 4 (LPN) stated she was aware Resident 2 was an elopement risk and was not able to remember being told the resident was found in the parking lot by Staff 3 (CNA). Staff 4 stated the facility was very spread out and consisted of a long term care section (east) and skilled care section (west). Staff 4 stated there were occasions when there were two CNAs in the facility on the night shift and it was difficult to monitor Resident 2 and care for the other residents. Staff 4 stated she was the only charge nurse for the entire building during the night shift. Staff 4 stated Resident 2's room was near the long term care nurse's station (east side of the building) though Staff 4 spent the majority of the night at the skilled care nurse's station (west side of the building). Staff 4 stated she cared for up to 50 residents during the night shift. Staff 4 stated there was so much for her to accomplish during the night shift it was difficult to complete all of the tasks. Periodic observations on 12/31/13 from 7:30 am through 4:00 pm revealed Resident 2 was able to mobilize her/his wheelchair throughout the facility. The resident was observed to be agitated with the facility staff and stated she/he wanted to "go home." The resident was observed to mobilize her/his wheelchair independently from her/his room on the long term care section (east side) of the facility to the skilled section (west side) of the facility without staff observation. The staff on the skilled (west) section escorted the resident to her/his room in the long term care (east) section of the facility. On 12/31/13 at 10:00 am Staff 6 (CNA) revealed the resident had attempted to open the sliding door to the courtyard unescorted. The resident was in the process of exiting the door when the staff assisted the resident away from the door. The bar to prevent the sliding door from opening was not in place. On 12/31/13 at 10:30 am Staff 7 (Maintenance Director) revealed the bar to prevent the sliding door from opening was not in place after the window maintenance workers were in the building on 12/30/13. Staff 7 confirmed there was no alarm on the sliding door to the courtyard. On 12/31/13 at 10:45 am and 1:00 pm Staff 1 (DNS) confirmed the bar to restrict the resident from exiting into the courtyard was not in place and there was no alarm on the patio door. Staff 1 confirmed there was no assessment and care plan regarding the resident's wandering and elopement risk. Staff 1 stated the facility staff were aware of the resident's wandering behaviors and the resident was to be visually monitored. Staff 1 stated the resident's room was near the nurse's station to be within line of sight and located on a "highly traveled hallway." Staff 1 confirmed the facility had CNAs from an agency who worked at the facility and the care plan was needed for the agency staff to provide care for the residents; and also confirmed the resident was able to mobilize her/his wheelchair independently throughout the building. On 12/31/13 at 1:00 pm, following consultation with a Nursing Facility Survey Unit supervisor, surveyor informed Staff 2 (DNS), the facility staff reported Resident 2 eloped out of the building, without staff knowledge, into the parking lot during the night shift in November 2013. Observations revealed not all of the facility's exit doors were alarmed or secure to prevent elopement. Staff 2 was informed of a situation of immediate jeopardy to residents. On 12/31/13 by 2:30 pm the facility's plan of correction was accepted and the immediate jeopardy was abated. Staff 1 (DNS) was asked to provide an investigation regarding the resident's behavior on 12/31/13. The investigation revealed Staff 14 (LPN) stated Resident 2 had been restless all day and trying the exit doors. Staff 14 stated she had been told by someone on the staff Resident 2 was trying to leave the facility. Staff 14 did not chart the behavior, notify Staff 1 (DNS) or place the resident on alert charting. Staff 13 (CNA) stated Resident 2 was pushing at an exit door on the long term section of the building. The resident did not get the door open or go out of the building. Staff 13 did not inform the charge nurse or chart the behavior. On 1/6/14 at 1:43 pm and 2/19/14 at 1:00 pm Staff 11 (RN) stated she did not have first hand knowledge Resident 2 eloped from the building. Staff 11 stated multiple staff (CNAs, CMAs and other nurses) stated the resident eloped from the building. Staff 11 was not aware of who completed an incident report for the event. Staff 11 stated it was a well known fact the resident was an exit seeker. Staff 11 stated the resident would attempt to open the exit doors and the staff had to always be on the look out as to where the resident was. Staff 11 stated the resident would most likely attempt to exit the building unaccompanied when the resident was in a manic state. Staff 11 stated when the resident stated she/he wanted to buy flowers to take to her/his spouse the staff needed to be on " extra alert " for exit seeking. Staff 11 stated the resident was able to mobilize her/his wheelchair throughout the building. Staff 11 stated the resident needed to be closely supervised though this was difficult when she/he moved throughout the building independently. On 2/19/14 at 9:11 am Staff 17 (CNA) stated she was aware Resident 2 attempted to exit seek from the facility. Staff 17 stated she heard Resident 2 went through the exit doors and was five feet away from the building before being brought back into the facility. Staff 17 was unable to remember the date and time of the incident. On 2/19/14 at 9:52 am Staff 18 (CNA) stated she was assigned to west side/skilled section of the building. Staff 18 stated she observed Resident 2 moving her/his wheelchair independently throughout the building and went into other resident rooms uninvited. Staff 18 stated she did not observe Resident 2 leaving the building unaccompanied. 2. Based on observation, interview and record review it was determined the facility failed to provide adequate supervision to prevent accidents for 2 of 3 sampled residents (#s 3 and 4) who wandered. This placed the residents at risk for injury. Findings include: a. Resident 3 was admitted to the facility in November 2013 with [DIAGNOSES REDACTED]. The resident's chart contained no documented assessment of the resident's elopement risk and there was no documentation of interventions on the care plan to address the resident's wandering behavior. The 11/21/13 Multi-Disciplinary Progress Notes written at 3:10 am documented the resident was verbally aggressive and wanted to leave the facility. At 10:45 am the Progress Notes indicated the resident continued to "try to find the exit-redirected several times, resident appeared to get more agitated each time...." The 11/27/13 Social Services Note documented the resident had exhibited physical and verbal behaviors and needed constant supervision. The Multi-Disciplinary Progress Notes written on 11/29/13 and 1/30/13 indicated the resident was restless and wandering throughout the facility. The 12/5/13 Social Services Note documented the resident was in need of a different level of care for her/his severe dementia and behavioral issues. On 12/30/13 at 3:00 pm Staff 1(DNS) identified Resident 3 as wanderer at risk for elopement. Periodic observations of Resident 3 on 12/31/13 from 7:30 am through 4:00 pm revealed the resident was able to mobilize her/his wheelchair throughout the building. On 12/31/13 at 10:45 am and 1:00 pm Staff 1 (DNS) confirmed there was no assessment and care plan regarding the resident's wandering and elopement risk. Staff 1 stated the facility staff were aware of the resident's wandering behaviors and Resident 3 was to be visually monitored. Staff 1 stated the resident's room was located near the nurse's station to be in line of sight and was on a "highly traveled hallway." Staff 1 confirmed the facility had CNAs from an agency who worked at the facility and the care plan was needed for the agency staff to provide care for the residents. Staff 1 confirmed the resident was able to mobilize her/his wheelchair throughout the building. On 12/31/13 at 8:00 am and 1/3/14 at 9:00 am Staff 4 (LPN) stated the facility was very spread out and consisted of a long term care section (east) and skilled care section (west). Staff 4 stated there were occasions when there were two CNAs in the facility on the night shift and it was difficult to monitor Resident 3 and care for the other residents. Staff 4 stated she was the only charge nurse for the entire building during the night shift. Staff 4 stated Resident 3's room was near the long term care nurse's station (east) though Staff 4 spent the majority of the night at the skilled care nurse's station (west). Staff 4 stated she cared for up to 50 residents during the night shift. Staff 4 stated there was so much for her to accomplish during the night shift it was difficult to complete all of the tasks. On 2/19/14 at 9:11 am Staff 17 (CNA) and at 9:52 am Staff 18 (CNA) stated they observed Resident 3 mobilize her/his wheelchair throughout the building. There were no observations of Resident 3 attempting to exit the facility. On 2/19/14 at 1:00 pm Staff 11 (RN) stated Resident 3 was able to mobilize her/his wheelchair throughout the facility. Staff 11 stated the resident had dementia and was very hard of hearing. Staff 11 stated the resident usually wandered into other resident rooms and was not aware of the resident attempting to leave the building unaccompanied. b. Resident 4 was admitted to the facility in December 2013 with [DIAGNOSES REDACTED]. The facility's Elopement/Missing Residents Procedure indicated "Should an employee observe a resident leaving the premises, he/she should ...Complete an Incident/Accident Investigation Report ...." The facility's Investigation Process involved "collecting, reviewing and analyzing data/information in order to determine the root cause of the event ...Phase one: Initial Investigation ...evidence is collected and analyzed within 24 hours of the event or occurrence ...Once evidence has been collected, it must be analyzed to establish the "root cause" or " reasonable cause " of the event or occurrence, and to determine if abuse and/or neglect can be ruled out ...." The 12/25/13 Multi-Disciplinary Progress Notes written at 9:30 am by Staff 15 (LPN) indicated the resident had gone out the fire doors into the parking lot. Staff 15 approached the resident to keep her/him stable as she/he was walking with a very unsteady gait. The resident was attempting to punch the nurse in the face. The facility staff were able to assist the resident back into the building and into her/his room. The 12/26/13 Multi-Disciplinary Progress Notes written at 8:15 am indicated the resident stated there was a fire in her/his room and the resident was wandering in other residents' rooms. Resident 4 was demonstrating "unpredictable behaviors...." The 12/28/13 Social Services Note indicated prior to the resident's admission to the facility the resident fell at home and had changes in her/his mental status. The resident was described as combative with her/his spouse and had long periods of sleeping with nightmare type episodes. The initial discharge plan from the local hospital was for the resident to be "transferred to a local facility, a secured facility if she/he wasn't accepted for admission to this facility ...On the morning of 12/25/13 resident exited the building through emergency fire door and was able to get out to the parking lot ...." On 12/26/13 the resident had another episode of unusual behaviors of ambulating into other resident rooms and talked about a fire in her/his room. The resident's behaviors were assessed to place the resident at significant risk for physical illness or injury. There was no documentation of a written investigation of the resident's elopement into the parking lot. The resident's care plan was not updated regarding the resident's elopement out of the building. On 12/30/13 the resident fell at the facility and was treated at the local hospital. On 12/31/13 at 10:30 am and 1:30 pm Staff 7 (Maintenance Director) stated there was no alarm on the west/skilled entrance doors. Staff 7 stated the entrance doors were locked from the outside at 4:00 pm after the office staff left for the day. Staff 7 stated a resident was able to push the door open to exit from the inside of the facility and to the parking lot. Staff 7 stated once the resident closed the door behind them the resident would not be able to re-enter the door because it would lock. Staff 7 stated the facility staff closed the fire doors in the hallway leading to the west parking lot at night. Staff 7 stated the fire door did not have an alarm in place to alert the facility staff a resident went through the fire doors. On 12/31/13 at 10:45 am and 1:00 pm Staff 1 (DNS) confirmed there was no assessment and care plan regarding the resident's wandering and elopement risk and no written investigation of the resident's elopement into the parking lot. On 12/31/13 an investigation was conducted by Staff 1 (DNS) for the 12/25/13 incident. The documentation indicated an alert and oriented resident saw Resident 4 wheeling herself/himself down the 300 hallway toward the exit door. Resident 4 found the door opened without resistance and the resident was observed to stand up out of her/his wheelchair and went out the door. Staff 15 (LPN) was alerted Resident 4 went out the door. Staff 15, Staff 16 (CMA) and Staff 17 (CNA) went outside to redirect Resident 4 into the building. Staff 15 reported Resident 4 had gone out the courtyard and into the parking lot, a distance of 50 feet from the building. Staff 1 documented "this event occurred but was not considered an elopement. The resident was witnessed leaving the building, physician was notified, medication administered and Resident 4's family member was notified to provide support. Social Services was notified and instructed to arrange for transfer to a more appropriate facility for psychiatric evaluation and/or treatment. There were no further exit seeking attempts and the resident was discharged to another facility on 12/30/13 ...." On 1/27/14 at 3:04 pm Staff 15 (LPN) stated she was alerted Resident 4 left the building through the 300 hallway exit door and wandered into the parking lot. Staff 15 stated she informed Staff 1 (DNS) of the incident. Staff 15 stated there was no security device or alarm on the door at the time of the incident. On 1/28/14 at 8:02 am Staff 16 (CMA) revealed Resident 4 went through the exit door un-escorted and there was no alarm or security device on the exit door at the time of the incident. On 2/19/14 at 9:11 am Staff 17 (CNA) revealed Staff 18 (CNA) reported on 12/25/13 Resident 4 went out into the courtyard unaccompanied five to ten minutes prior to when the resident eloped into the parking lot. Staff 17 stated she reported the incident to Staff 1 (DNS). Staff 17 stated she did not believe the incident was documented. Staff 17 stated when the resident ambulated out into the parking lot she followed Staff 15 (LPN) and Staff 16 (CMA) and brought a wheelchair for the resident. Staff 17 stated she was surprised the resident was able to ambulate without assistance. Staff 17 stated the resident was very agitated when she/he was assisted back into the facility. Staff 17 stated she was not aware of another incident when the resident tried to elope from the building. On 2/19/14 at 9:52 am Staff 18 (CNA) revealed she was not assigned to care for Resident 4 on 12/25/13. Staff 18 stated she was assigned to the 300 hallway and a resident reported Resident 4 was outside. Staff 18 stated she looked outside in the courtyard and found Resident 4. Staff 18 stated she went outside to talk with the resident and discovered she/he needed a toilet. Staff 18 stated she told the resident the nearest toilet was inside the building. Staff 18 stated she assisted the resident into the building with her/his wheelchair. Staff 18 stated as soon as Resident 4 was back in the building the resident became agitated, put her/his feet down and tried to strike Staff 18. Staff 18 stated she tried to calm the resident though she/he was very agitated. Staff 18 stated the resident proceeded to get up from her/his wheelchair and ran down the hallway. Staff 18 stated Staff 15 (LPN), Staff 16 (CMA) and Staff 17 (CNA) went outside and assisted the resident back into the facility. Staff 18 stated she was surprised the resident was able to ambulate independently. Staff 18 stated the CNAs were instructed to inform the charge nurse when an incident occurred at the facility. Staff 18 stated she reported the incident to Staff 15 (LPN). Staff 18 stated she was not aware of any other incident when the resident left the building unaccompanied. There was no documentation of an investigation regarding Resident 4's elopement into the courtyard observed by Staff 18 (CNA). The documentation revealed the facility was aware Resident 4 exited the building unescorted on 12/25/13. There was no documentation the facility assessed the security of all of the exit doors when the facility identified there were residents who wandered and were actively seeking the exits.

Based on interview and record review it was determined that the facility failed to thoroughly investigate a fall for 1 of 3 sampled residents (#1) who had falls. Resident 1 sustained a fracture. Findings include: Resident 1 was admitted to the facility on [DATE] for therapy which [DIAGNOSES REDACTED]. On 8/10/11 the resident's Plan of Care was updated and indicated the resident was at "extreme risk" for falls and facility interventions included a fall mat, the call light within reach and a "tab alarm at all times." On 8/13/11 at 11:30 pm a nursing note identified the resident was found on the floor in front of the bed. The 8/13/11 witness statement completed by Staff 6, CNA, identified she found the resident and was alerted to the resident's fall when she "heard a loud noise." The Resident Incident Investigation Report completed by Staff 3, RN, on 8/14/11, identified the resident was found on the floor in front of the bed with the fall mat beside her/him. The report indicated the "alarm did not sound." The portion of the report completed on 8/15/11 by Staff 1, DNS, indicated the resident got out of bed to retrieve a coat, fell , and fractured a hip. On 9/1/11 at 12:10 pm Staff 1, DNS, was unable to provide further information as to why the "alarm did not sound." On 9/2/11 at 5:40 pm Staff 6, CNA, reported she had not observed the resident prior to the incident since it was the beginning of her shift. Staff 6 reported the resident used a tab alarm which was "not there" when she found the resident on the floor. On 9/4/11 at 5:45 am, Staff 3, RN, reported the resident had a tab alarm which was not attached to the resident or sounding when she entered the room and found the resident on the floor. Staff 1 stated the CNAs assigned to the resident on the previous shift had not been interviewed regarding the incident. On 9/6/11 at 10:10 am Witness 1, Family, reported visiting Resident 1 daily and observing the resident in the wheel chair and in the bed. Witness 1 stated the resident had a tab alarm that was attached to her/him when in the wheel chair but stated she had never seen it attached to her/him while in bed. Witness 1 reported the resident reported to her that she/he was in bed (on 8/13/11) and was cold. The resident reported the call light was not in reach so she/he attempted to get a coat out of the closet without assistance and fell . The facility investigation did not address the resident's call light not being within reach. Refer to F323

Based on interview and record review it was determined the facility failed to implement care planned interventions which resulted in a fall for 1 of 3 sampled residents (#1) who had falls. Resident 1 sustained a fractured hip. Findings include: Resident 1 was admitted to the facility on [DATE] for therapy with [DIAGNOSES REDACTED]. On 6/18/11 A Fall Assessment identified the resident had high potential for falls and "prevention protocol should be initiated and documented on the care plan." On 6/23/11 a facility fax to the resident's physician indicated the resident had a non-injury fall. The fax identified the physician responded with, "will need fall precautions ...." On 6/28/11 the resident's Plan of Care (comprehensive care plan) indicated the resident was at "extreme risk" for falls due to a history of falls, impaired cognition, poor safety awareness, imbalance due to [DIAGNOSES REDACTED] status [REDACTED]. There were no alarms listed on the plan at that time. On 7/27/11 the resident's Bedside Care Plan (in-room care plan) identified, under Safety Warning Devices, she/he needed a pressure alarm (an alarm pad that can be placed on a bed or a chair and sounds with movement). The plan did not indicate if the alarm was to be placed on the bed and/or chair. On 8/10/11 the resident's Plan of Care was updated and included additional interventions of a "tab alarm at all times" (an alarm box that can be attached to a bed or chair and connected to a resident by a string which sounds when the string is pulled taunt) and a fall mat when in bed. As of 9/1/11 the Bedside Care Plan had not been updated to reflect the change to a tab alarm at all times. The August 2011 CNA Flow Sheet (ADL care plan) did not identify specific safety interventions but indicated the CNAs gave "care according to the individual care plan." The flow sheet contained CNA signatures for all three shifts; days, evenings, and nights from 8/1/11 through 8/13/11. On 8/13/11 at 11:30 pm a nursing note identified the resident was found on the floor in front of the bed. The 8/13/11 witness statement completed by Staff 6, CNA, found the resident and identified she was alerted to the resident's fall when she "heard a loud noise." The Resident Incident Investigation Report completed by Staff 3, RN, on 8/14/11, identified the resident was found on the floor in front of the bed with the fall mat beside her/him. The report indicated the "alarm did not sound." The report did not include a resident interview, previous shift staff interviews, or if the call light had been in reach at the time of the fall. On 8/14/11 at 2:30 am a nursing note identified the resident "continued to have severe pain" in the right groin. At 5:25 am a nursing note indicated the resident left by ambulance to be evaluated at the hospital. On 8/15/11 the Resident Incident Investigation Report identified the resident fractured a hip. On 9/1/11 at 12:40 pm Staff 4, RN, reported she initiated Resident 1's safety interventions and completed the initial care plan. Staff 4 stated she had originally assessed Resident 1 to need a pressure alarm but one was not available so a tab alarm was used instead. On 9/1/11 at 1:55 pm Staff 2, RNCM, identified that she was responsible for updating Resident 1's bedside and comprehensive care plans. She acknowledged that she updated the comprehensive plan to include the tab alarm intervention but forgot to update the information on the Bedside Care Plan. Staff 2 stated that CNAs knew what care plan interventions to use by observing what was in place at the time. On 9/1/11 at 2:10 pm Staff 5, CNA, confirmed she had been assigned to Resident 1 on the evening shift prior to the fall (on 8/13/11). Staff 5 reported the resident had a pressure alarm on the bed at the time she assisted the resident to bed. Staff 5 stated she knew which safety interventions residents' had by asking the RNCM or observing what the resident had on at the time of her shift. She reported she read the Bedside Care Plan when residents were first admitted . On 9/2/11 at 5:40 pm Staff 6, CNA, reported she had not observed the resident prior to the incident since it was the beginning of her shift. Staff 6 reported the resident used a tab alarm which was "not there" when she found the resident on the floor in her/his room. On 9/4/11 at 5:45 am, Staff 3, RN, reported the resident's tab alarm was not attached to the resident or sounding at the time of the fall (on 8/13/11). Staff 3 stated the resident complained of right groin pain, was given pain medications, and then sent out for evaluation at the hospital. Staff 3 reported that CNAs use to find resident care plan instructions on the CNA Flow Sheet, however, the sheet no longer had interventions listed. On 9/6/11 at 10:10 am Witness 1, Family, reported visiting Resident 1 daily. Witness 1 stated she had observed the resident in bed on many occasions and had never seen an alarm on her/him when in bed. Witness 1 reported that an alarm would have been effective in stopping the resident from self transferring. Witness 1 stated the resident reported to her that she/he couldn't reach the call light to ask for assistance on 8/13/11 and attempted to get a coat out of the closet when she/he fell . Witness 1 stated Resident 1 broke a hip as a result of the fall.