Every finding on record at Regency House Nursing and Rehabilitation Center

Based on review of facility documents and staff interviews, the facility failed to ensure weekend staffing was reported correctly to the Payroll Based Journal (PBJ) for quarters 3 and 4 in 2024. The findings include:The PBJ Staffing Data Report labeled Fiscal Year (FY)Quarter 3, 2024 (4/1/2024-6/30/2024) and FY Quarter 4 (7/1/2024 -9/30/2024) indicated the staffing reported by the facility for quarter 3 and 4 in the year of 2024 was considered Excessively Low Weekend Staffing.An interview with the Administrator on 7/28/2025 at 10:20 AM indicated corporate managers submit the facility's PBJ staffing and had been focused on finding the reason(s) why weekend staffing as reported for quarter 3 and 4 were considered by the PBJ system as Excessively Low Weekend Staffing. The Administrator further indicated that when there is a staffing need the facility offers a bonus to cover call outs and meet the staffing levels.An interview on 7/31/2025 at with the Corporate Director #1 indicated Quarters 3 and 4 of 2024 were found to have correct staffing but the staff who worked were not placed in the appropriate classification when reported, causing the PBJ to not accurately reflect weekend staffing for Quarters 3 and 4 in 2024.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents reviewed for abuse (Resident # 92), the facility failed to ensure the resident was free from physical abuse. The findings include:Resident #92's diagnoses included vascular dementia, anxiety, cognitive impairment and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #92 was cognitively impaired, requires maximal assistance with sit-to-stand transfers and personal hygiene and noted dependent on staff for lower body dressing. The care plan dated 4/22/24 identified Need for Continued Safety and Appropriate for Skilled Nursing Facility (SNF) level of care in the facility. Interventions included providing information to family at meetings as needed.A nurse's note dated 6/29/24 at 2:58 PM identified an incident was witnessed by charge nurse- sitting in hallway. Resident #92 was arm's length away from Resident #134 who turned to Resident #92 and punched him/her in the face. The residents were immediately separated to another area of the hallway and assessed for injury. No injury was observed and Resident #92 denied any pain and stated that man hit me but within a short period of time had no recollection of the incident. All parties were notified by the Director of Nursing Services (DNS), third eye provider, family and the local police. A nurse's note dated 6/30/24 at 1:16 PM indicated no adverse signs or symptoms post- incident. Resident #134 stated Resident #92 kicked his/her chair and that is why he/she punched him/her. The physical altercation was witnessed by a charge nurse whose statement identified Resident #92 never kicked Residents #134's chair. Attempts were made to interview the Licensed Practical Nurse (LPN) charge nurse who witnessed the incident but were unsuccessful An interview with DNS on 7/31/25 at 10:27 AM indicated that once an allegation of abuse occurs, residents are removed from any danger, investigation is initiated, affected residents are seen by psychological services and social workers and all key personnel are informed. Interview with the Social Worker (SW #2) on 7/31/2025 at 10:50 AM identified once there are any altercations involving residents, the social worker would follow up as soon as informed and for 3 days after the incident. SW #2 was unable to recall details of the incident, however, reported Resident #92 is not usually aggressive towards other residents. SW#2 documentation indicated SW#2 was informed on 7/8/25 about the incident. Facility Abuse Policy and procedure (revised 1/2023) indicated in part Residents have the rights to be free from abuse.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents reviewed for abuse (Resident # 92), the facility failed to notify the social work department of a resident-to-resident altercation to ensure timely follow up per facility practice. The findings include:Resident #92's diagnoses included vascular dementia, anxiety, cognitive impairment and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #92 was cognitively impaired, requires maximal assistance with sit-to-stand transfers and personal hygiene and noted dependent on staff for lower body dressing. The care plan dated 4/22/24 identified Need for Continued Safety and Appropriate for Skilled Nursing Facility (SNF) level of care in the facility. Interventions included providing information to family at meetings as needed.A nurse's note dated 6/29/24 at 2:58 PM identified an incident was witnessed by charge nurse- sitting in hallway. Resident #92 was arm's length away from Resident #134 who turned to Resident #92 and punched him/her in the face. The residents were immediately separated to another area of the hallway and assessed for injury. No injury was observed and Resident #92 denied any pain and stated that man hit me but within a short period of time had no recollection of the incident. All parties were notified by the Director of Nursing Services (DNS), third eye provider, family and the local police. Interview with the Social Worker (SW #2) on 7/31/2025 at 10:50 AM indicated once there are any altercations involving residents, social workers would follow up as soon as informed and for 3 days prior after incident. SW #2 was unable to recall details of the incident. However, SW # 2 reported Resident #92 is usually not aggressive towards other residents and denied any other altercations. SW#2 documentation indicated SW#2 was informed of the altercation on 7/8/24 (7 days later). Interview with Social Worker (SW #1) on 7/31/2025 at 11:09 AM identified secondary to the late notification of the resident-to-resident altercation with Resident # 92 and Resident # 134 on 6/29/24. SW #1 further indicated the social services department oversees timely reporting incidents. Interview with DNS and RN #1 on 8/1/2025 at 11:43 AM indicated the resident to resident between Resident # 92 and Resident # 134 was discussed at the Monday morning report (7/1/24). However, at that time she/he did not notice there was no social work representative present. The DNS further indicated she/he was unsure when the social work department was notified of the resident-to-resident altercation.Interview with and Registered Nurse (RN #1) on 8/01/2025 at 11:43 AM identified as a result of miscommunication, the facility has re-educated staff, conducted audits and reported the facility was back into compliance as of 12/31/24. Plan of Correction1.Social Service immediately notified to complete psychosocial assessment follow up; investigation completed and documented per policy.2. All managers re-educated on abuse investigation protocols to include immediate notification to social worker.3. Social Worker to maintain daily communication with nursing supervisor4. Social Worker to complete any audits on any resident-to-resident altercations beginning July 2024 to December 2024 to ensure that the social service department was notified timely.5. All resident to resident to altercation in AM report and Quality Assurance and Performance Improvement (QAPI).6. Social Worker has access to Facility Licensing and Investigations Section Reporting line7 Email notification to administrator / Social Worker and Director of Nursing Services Resident to Resident altercations.8. Review results monthly in QAPI. Date of Completion 12-31-24

Based on clinical record review, review of facility policy and staff interviews for 1 of 3 residents (Resident # 85) reviewed for pain management, the facility failed to ensure that licensed staff used the correct formation of a medication as per physician orders to meet professional standards. The findings include: Resident #85's diagnoses included Alzheimer's disease, dementia, and anxiety. A quarterly MDS assessment dated [DATE] identified Resident #85 had severe cognitive impairment. A physician's order dated 7/1/2025 directed to admit Resident #85 to hospice care. A physician's order dated 7/2/2025 directed to administer a 0.5 milligram (mg) tablet of lorazepam (a medication for anxiety) every one hour by mouth as needed for 14 days. The significant change MDS assessment dated [DATE] identified Resident #85 had severe short-term and long-term memory problems and noted severely impaired cognitive skills for daily decision making. The significant change MDS assessment also identified that Resident #85 was receiving hospice services. On 7/15/2025, the physician's order for lorazepam (anti-anxiety) tablets was discontinued. A physician's order dated 7/15/2025 directed to administer 0.5mg of lorazepam 2 mg/1 ml concentrate (a liquid form) every one hour by mouth as needed for 14 days. A care plan, last reviewed 7/28/2025, identified Resident #85 had a behavior problem of agitation. Interventions included administering medications as ordered. On 7/31/2025, a review of the controlled substance disposition record for lorazepam 0.5 mg tablets identified tablets were removed for administration after the discontinued date. One tablet was removed on 7/16/2025, 7/18/2025, and 7/21/2025, and the disposition record was signed by Licensed Practical Nurse (LPN#7). A review of nursing notes and the Medication Administration Record (MAR) from 7/1/2025 through 7/31/2025 failed to indicate Resident #85 received lorazepam 0.5 mg tablets on 7/16/2025, 7/18/2025, and 7/21/2025. The MAR indicated that Resident #85 received lorazepam 0.5 mg concentrate on 7/22/2025, 7/23/2025, and 7/24/2025. A review of the controlled substance disposition record for lorazepam 2 mg/1 ml concentrate was received by the facility on 7/4/2025. On 7/31/2025 at 1:14 PM, an interview with Advanced Practiced Registered Nurse (APRN #1) indicated that she was asked to evaluate Resident #85 for renewal of as-needed medications. APRN #1 indicated she ordered the as-needed administration of 0.5mg of lorazepam 2mg/1ml concentrate because the resident was receiving hospice care and hospice had recommended liquid medications. APRN#1 indicated there would be no adverse effects from receiving 0.5 mg of liquid lorazepam versus 0.5 mg in tablet form as long as a resident is able to swallow. On 7/31/2025 at 2:56 PM, an interview with LPN#7 identified she administered lorazepam 0.5 tablets to Resident #85 on 7/16/2025, 7/18/2025, and 7/21/2025. LPN#7 indicated that at that time she was not aware the order for lorazepam had been changed from tablet to liquid formulary. LPN#7 indicated she had not checked the MAR prior to administration of the lorazepam tablets and indicated she could not recall if she had attempted to document the administration in the MAR after administering. LPN#7 further indicated she had been made aware after 7/21/2025 by a day shift nurse the formulary for lorazepam had been changed. On 7/31/2025 at 3:30 PM, an interview with the Regional Nurse (RN #1) indicated LPN#7 should have notified the DNS when LPN#7 found out that she had administered tablets of lorazepam instead of the ordered concentrate. A review of the facility policy for Medication Pass identified that when as-needed medications are administered, documentation should include date and time of administration, medication, dose, and route. Additionally, the policy indicated that staff were to remember the six rights of medication pass, which included administering the right dosage form of a medication.

Based on clinical record review, review of facility documentation, review of facility policy and staff interviews for 2 of 3 residents (Residents # 7 and Resident # 85) reviewed for pain management and medication documentation, the facility failed to ensure that administration of as-needed medications was documented in the medical record. The findings included: 1.Resident #7 was admitted on [DATE] to the facility, The resident's diagnoses included gangrene (death of body tissue due to a lack of blood supply) and amputation of left and right toes. A physician's order dated 7/5/2025 directed to administer 2 milligrams (mg) of hydromorphone (an opioid pain medication) every four hours as needed for severe or moderate pain. A care plan dated 7/6/2025 identified Resident #7 had a potential for pain related to peripheral vascular disease, wounds, and neuropathy. Interventions included administering medications per physician's orders. The admission MDS assessment dated [DATE] identified that Resident #7 was cognitively intact, had a recent surgery requiring a stay in a skilled nursing facility, and had experienced occasional pain. On 7/29/2025 at 11:21 AM, during resident screening, Resident #7 indicated although she/he had no issues receiving her/his pain medications, there was one night where she/he had to wait a long time. Resident #7 indicated this occurred three to four weeks ago but was unable to recall the length of time she/he had to wait. Resident #7 indicated she/he told the day nurse but did not recall the name of the staff member. On 7/30/2025, an interview with LPN#3 indicated she had not received any complaints from Resident #7 regarding getting her/his pain medications timely. LPN #3 indicated the resident was able to get hydromorphone every four hours as needed and the resident would call when she/he need the medication. A review of the hydromorphone blister pack (where the medication is package) identified the correct number of tablets compared to the controlled substance disposition record. LPN#3 indicated older disposition records would be located with the DNS. A review of facility-controlled substance disposition records and the MAR from 7/5/2025 through 7/28/2025 identified hydromorphone 2mg tablets were removed on 7/13/2025 at 8:00 AM, 1:00 PM, and 8:00 PM and the disposition record was signed by LPN#4; however, the MAR failed to identify corresponding administration for the tablets removed. On 7/14/2025, the controlled substance disposition record identified that hydromorphone 2mg tablets were removed at 7:15 AM and signed with an illegible signature. Tablets were also removed at 4:00 PM and 8:00 PM by LPN#4. The MAR failed to identify a corresponding administration for the tablets removed. On 7/24/2025, the controlled substance disposition record indicated hydromorphone 2mg tablets were removed at 1:00 PM and signed with an illegible signature. Tablets were also removed at 4:45 PM and 8:40 PM by LPN#4. The MAR failed to identify a corresponding administration for the tablets removed. On 7/26/2025, the controlled substance disposition record indicated hydromorphone 2mg tablets were removed at 10:00 AM and 2:00 PM by LPN#4 and at 8:00 PM by LPN#8. The MAR failed to identify a corresponding administration for the tablets removed. On 7/30/2025 at 3:25 PM, an interview with the DNS identified controlled substance disposition records are reconciled every two weeks. The DNS indicated there was no formal process for reconciling the controlled substance disposition record with the documentation in the MAR. On 7/30/2025 at 3:30 PM, an interview and record review with the Regional Nurse (RN#1) identified there were additional scattered days where hydromorphone 2mg tablets were removed but did not have corresponding documentation in the MAR. Additionally, RN #1 indicated the MAR would be audited only if irregularities were noted. RN#1 indicated that the facility would conduct an audit of the administration of hydromorphone 2mg tablets for Resident #7, including an interview with the resident. On 7/31/2025 at 10:00 AM an interview with RN #1 identified the facility had reviewed Resident #7 and other residents on the same unit and residents taken care of by LPN#4. The DNS indicated that although they had not identified irregularities in the management of controlled substances the facility determined that staff had not been consistently documenting as needed medications in the MAR and she/he would start education of all licensed staff. On 7/31/2025 at 10:52 AM, an interview with LPN#4 indicated she had administered hydromorphone 2mg tablets to Resident #7, but indicated that she does not always documented the administrations in the MAR. LPN#4 indicated she sometimes gets focused on providing care and forgets to document as-needed medications in the MAR. LPN#4 further indicated that for determining when a resident is due for as-needed medications, she would not always look in the MAR but would look at the controlled substance disposition record instead. LPN#4 further indicated she knew that as-needed medications should have been documented in the MAR. 2. Resident #85's diagnoses included Alzheimer's disease, dementia, and anxiety. A quarterly MDS assessment dated [DATE] identified Resident #85 had severe cognitive impairment. A physician's order dated 7/2/2025 directed to administer a 0.5 milligram (mg) tablet of lorazepam (a medication for anxiety) every one hour by mouth as needed for 14 days. On 7/15/2025, the order for lorazepam tablets was discontinued. A care plan, last reviewed 7/28/2025, identified Resident #85 had a behavior problem of agitation. Interventions included administering medications as ordered. On 7/31/2025, a review of the controlled substance disposition record identified that on 7/6/2025 at 3:00 AM and on 7/13/2025 (at an illegible time), one tablet of lorazepam 0.5mg was removed and signed with an illegible signature. The MAR failed to identify a corresponding administration for the tablets removed. The controlled substance disposition record for lorazepam 0.5 mg tablets also identified that tablets were removed for administration after the discontinued date. One tablet was removed on 7/16/2025, 7/18/2025, and 7/21/2025, and the disposition record was signed by LPN#7. A review of nursing notes and the MAR from 7/1/2025 through 7/31/2025 failed to indicate Resident #85 received lorazepam 0.5 mg tablets on 7/16/2025, 7/18/2025, and 7/21/2025. On 7/31/2025 at 2:56 PM, an interview with LPN#7 identified she administered lorazepam 0.5 tablets to Resident #85 on 7/16/2025, 7/18/2025, and 7/21/2025. LPN#7 indicated that at that time of the administration she was not aware the order for lorazepam tablets had been discontinued and replaced with a different formulary. LPN#7 indicated she had not checked the MAR prior to administration of the lorazepam tablets and indicated she could not recall if she had attempted to document the administration in the MAR after administering. LPN#7 indicated she had been made aware after 7/21/2025 by a day shift nurse that the formulary for lorazepam had been changed. On 7/31/2025 at 3:30 PM, an interview with the Regional Nurse (RN #1) indicated LPN#7 should have notified the DNS when LPN#7 found out she had administered tablets of lorazepam instead of the ordered concentrate. A review of the facility policy for Medication Pass notes when as-needed medications are administered, documentation should include date and time of administration, medication, dose, and route. A review of the Opioid medication policy identified that for as-needed orders, the nurse should document in the resident's medical record. The Policy for Bi-monthly narcotic drug audit identified the DNS would conduct an audit of the controlled substance disposition record every two weeks. The policy did not indicate if the MAR should have been part of the narcotic drug audit.

Based on review of the clinical record, facility documentation, facility policy and interviews for the one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to ensure that a full investigation was conducted related to an injury of unknown origin. The findings include: Resident #1's diagnoses included left tibial fracture (shin bone), age-related osteoporosis without current pathological fracture (loss of bone), unequal limb length, muscle weakness, and vascular dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required moderate assistance with bed mobility, extensive assistance with transfers and toileting, and required setup assistance with eating. A nurse's change in condition note dated 7/1/24 at 10:49 PM identified that Resident #1's left lower extremity was warm to touch with noted redness and pitting edema, but had normal range of motion, staff was able to bend left lower extremity without difficulties, and no pain was noted. APRN #1 was notified, and a new order was obtained for a STAT (immediate) venous doppler ultrasound to the left lower extremity. A medical progress note dated 7/2/24 at 3:41 PM identified that APRN #1 had assessed Resident #1 due to nursing reports that the left lower extremity was red, warm, edematous, and the resident was calling out in pain with palpation. It indicated that the resident was also noted with an episode of hypertension the previous evening. The resident was alert and responsive earlier in the morning, but nursing reported altered mental status, and staff having to assist with breakfast. She indicated she was called urgently to the resident's room later in the day per request of a family member, as the resident was lethargic, would not open his/her eyes, and was unable to follow directions. The resident's family member requested that they were sent to the ED. A physician's order dated 7/2/24 directed that Resident #1 was sent to the ED for further evaluation. A nurse's note dated 7/3/24 at 5:20 PM identified that the facility received a call from Resident #1's family reporting hospital findings of a left tibial fracture. Review of the facility Accident and Investigation (A & I) documentation dated 7/3/24 identified that the facility sent Resident #1 to the Emergency Department (ED) on 7/2/24 to be evaluated for stroke-like symptoms and the facility received a phone call on 7/3/24 at 3:19 PM from Resident #1's family member reporting that the resident had a left tibial fracture. It reported the facility was not aware of a recent fall. Review of the facility schedules from the 3:00 PM to 11:00 PM shift on 6/28/24 (72 hours prior to the discovered change in condition) through the 3:00 PM to 11:00 PM shift on 7/1/24 (the initial change in condition) identified 12 staff members with direct contact with Resident #1 (RN#1, RN #2, RN #3, RN #8, LPN #2, LPN #3, LPN #4, LPN #5, NA #1, NA #2, NA #3, NA#8). For that time period, only 5 out of 12 statements were obtained (42%). Interview with the DNS on 7/23/24 at 11:30 AM identified she wasn't notified that Resident #1 had a fracture until 7/3/24. She indicated she reported the incident to the state agency immediately and then started her investigation, identifying she interviewed and obtained statements from the staff going back 72 hours from the date the fracture was reported (7/3/24), not 72 hours from when the resident was first noted to have redness and swelling to the left lower extremity (7/1/24), which she indicated she should have done. She reported that the resident had not left the facility, and after investigation the facility could not determine how the fracture had occurred, identifying that there were no reports of falls or injuries. Review of the Accident/Incident policy dated 6/2024 directed, in part, that the licensed nurse will complete an investigation for accidents/incidents. The investigation will include written statements from staff members caring for the resident and from people having knowledge of the event. If the occurrence is an injury of unknown origin, statements from staff members on the unit will be taken to try and determine the cause of the injury. Statements may need to continue for the previous 24-72 hours or more if needed and cease once the cause is identified. The Director of Nursing reviews the events to ensure accurate and complete documentation of the incident, and to determine if there is credible evidence to substantiate the allegations of abuse, neglect, or mistreatment.

Based on review of the clinical record, facility documentation, facility policy and interviews for the one (1) of three (3) residents, (Resident #1), reviewed for accidents, the facility failed to notify a provider timely of a change in condition. The findings include: Resident #1's diagnoses included vascular dementia with behavioral disturbances, anxiety disorder, age-related osteoporosis without current pathological fracture (loss of bone), unequal limb length, and muscle weakness. The Resident Care Plan (RCP) dated 4/2/24 identified that Resident #1 had a self-care performance deficit due to dementia with interventions that included a low bed, extensive assistance of one (1) staff for personal hygiene, toileting, and dressing. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired, required moderate assistance with bed mobility, extensive assistance with transfers and toileting, and required setup assistance with eating. A change in condition progress note dated 7/1/24 at 10:49 PM identified that Resident #1's left lower extremity was warm to touch with noted redness and edema, however with normal range of motion, staff was able to bend left lower extremity without difficulties, and no pain was noted. APRN #1 was notified, and a new order was obtained for a STAT (immediate) venous doppler ultrasound to the left lower extremity. Review of the clinical record failed to identify that the STAT doppler was completed (please refer to F 684). A medical progress note dated 7/2/24 at 3:41 PM identified that APRN #1 had assessed Resident #1 due to nursing reports that the left lower extremity was red, warm, edematous, and the resident was calling out in pain with palpation. It indicated that the resident was alert and responsive earlier in the morning, but nursing reported altered mental status, and staff having to assist with breakfast. She indicated she was called urgently to the resident's room later in the day per request of a family member, as the resident was lethargic, would not open his/her eyes, and was unable to follow directions. The resident's family member requested that they were sent to the ED. Review of the facility Accident and Investigation (A & I) documentation dated 7/3/24 identified that the facility sent Resident #1 to the Emergency Department (ED) on 7/2/24 to be evaluated for stroke-like symptoms and received a phone call on 7/3/24 at 3:19 PM from Resident #1's family member reporting that the resident had a left tibial fracture. It reported the facility was not aware of a recent fall. Interview with NA #1 on 7/24/24 at 12:10 PM identified that she worked the 7:00 AM to 3:00 PM shift on 7/1/24. She indentified that she received in report from NA #8 that Resident #1 was restless and awake all night. She reported she went to go see the resident who wasn't eating breakfast so NA#1 had to feed the resident, (the resident usually feeds h/herself after set-up). When NA#1 attempted to bring the resident to the dining room for lunch in the wheelchair, he/she wouldn't lift h/her feet to be pushed in the wheelchair. At that point, she notified LPN #2 about the residents unusual behavior, who stated, he/she probably has a Urinary Tract Infection (UTI) and then LPN #2 proceeded to feed the resident lunch. NA #1 identified that after lunch she brought Resident #1 into the bathroom as she always does and cued him/her to grab the bar and stand so she could change him/her, the resident could not stand so she put him/her back in the wheelchair, transferred him/her into bed and changed h/[NAME] the bed. She indicated she did not notice any signs and symptoms of pain and did not notice any redness or swelling to his/her left extremity. She could not recall if LPN #2 went in to see the resident after she put him/her back to bed. Interview with LPN #2 on 7/24/24 at 12:25 PM identified that she worked the 7:00 AM to 3:00 PM shift on 7/1/24. She indicated that she received in report from LPN #3 that Resident #1 was awake all night, which was out of the ordinary for him/her. She indicated that NA #1 reported that the resident was having difficulty eating and she had to assist him/her with breakfast, but she attributed it to the resident being tired from being up all night. She reported that Resident #1 also required assistance with lunch, and she fed him/her, but the resident did not appear to be in pain and she didn't notice any other changes so did not feel that it needed to be reported. Review of the clinical record on Resident #1 from 6/30/24 to 7/1/24 failed to show documentation from LPN #3 or LPN #2 regarding a change in condition or communication with NA #1. Interview with LPN #3 on 7/24/24 at 9:04 AM identified that she worked the 11:00 PM to 7:00 AM shift on 6/30/24 and the resident didn't sleep well and was awake a majority of the night but she appeared comfortable and the NA didn't report anything out of the ordinary. She indicated she also worked the 3:00 PM to 11:00 PM shift on 7/1/24 and prior to dinner, NA #4 came to her and requested she come take a look at Resident #1. She stated that she was in bed and appeared comfortable but below her left knee to her ankle was red and swollen, and she couldn't find his/her pedal (foot) pulse so she notified RN #8 right away, identifying RN #8 assessed her and got an order for a doppler ultrasound to the left leg to rule out a blood clot. She reported they kept him in bed that night and did not transfer her to the wheelchair. Interview with the DNS and RN #1 (Unit Manager) on 7/24/24 at 12:46 PM identified that they were not made aware or notified of a change in condition on Resident #1 prior to the change in condition regarding the redness and swelling to the left lower extremity that was documented on 7/1/24 at 10:49 PM by RN #8. The DNS indicated that she had interviewed LPN #2 and NA #1 as part of the investigation for Resident #1, but that they had not reported any change in condition in their statements at that time. They identified that they have a whole protocol for a resident change in condition, and if a RN had been notified of the change, they would have assessed the resident immediately, reported their findings to the provider, obtained orders if indicated, notified the responsible party, documented in the change in condition communication form, and could have put in a therapy screen if it was warranted. Review of the Change of Condition Notification policy dated 4/2023 directed, in part, that staff will identify a change of condition and notify the licensed nurse, who will per state regulations conduct a complete physical/mental evaluation and document the findings in the medical record. The licensed nurse will notify the resident, the attending physician, and the family/responsible party of the change in condition

Based on review of the clinical record, facility documentation, facility policy and interviews for the one (1) of three (3) residents, (Resident #1), reviewed for abuse, the facility failed to follow a physician's order related to a STAT (to be done immediately) doppler ultrasound and failed to supervise a resident while on the toilet. The findings include: 1) Resident #1's diagnoses included vascular dementia with behavioral disturbances, anxiety disorder, age-related osteoporosis without current pathological fracture (loss of bone), unequal limb length, and muscle weakness. The Resident Care Plan (RCP) dated 4/2/24 identified that Resident #1 had a self-care performance deficit due to dementia. Interventions included a low bed, extensive assistance of 1 staff for personal hygiene, toileting, and dressing. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was severely cognitively impaired and required moderate assistance with bed mobility, extensive assistance with transfers and toileting, and required setup assistance with eating. a. A nurse's change in condition note dated 7/1/24 at 10:49 PM identified that Resident #1's left lower extremity was warm to touch with noted redness and pitting edema, but had normal range of motion, staff was able to bend the left lower extremity without difficulties, and no pain was noted. APRN #1 was notified, and a new order was obtained for a STAT (immediate) venous doppler ultrasound to the left lower extremity. A physician's order dated 7/1/24 directed to obtain a STAT Venous Doppler to the left lower extremity due to redness and warmth to rule out a deep vein thrombosis (blood clot). Review of the clinical record from 7/1-7/3/24 failed to identify that the venous doppler had been obtained STAT on Resident #1. Interview with the contracted X-ray company #2 on 7/23/24 at 3:20 PM identified that the facility called in the order for the venous doppler to the left lower extremity for Resident #1 on 7/1/24 at 5:45 PM but indicated that they had not been ordered to be a STAT exam and that the notes in their system did not communicate that. She stated that they do complete STAT venous dopplers, and that they try to come out within 3 hours. She reported that the facility was alerted that the doppler would not be done until the next day when they first called in the order, as they don't offer 24-hour services and the technician was already booked until his 8:00 PM end of shift that day, 7/1/24. She identified that if an exam is not booked STAT, the ultrasound technician completes all of the abdominal ultrasounds that are ordered first, as residents are to be nothing by mouth, and when those are completed, they will then prioritize and complete the remaining orders, usually in the afternoon. She indicated if they had been aware that the order was STAT, they would have moved their schedule around sent the technician in the early morning. Further, she reported that the technician called the facility at around 2:00 PM on 7/2/24 to request that they had the resident ready in bed and that they were on their way, but the technician was told that they wanted to cancel the exam, so the technician never arrived at the facility. A nurse's note dated 7/2/24 at 3:07 PM identified that Resident #1 was transferred to the hospital emergency department for evaluation after new noted lethargy. It noted the family accompanied the resident. Interview with RN #1 (Unit Manager) on 7/24/24 at 10:40 AM identified that she called the diagnostic company on 7/2/24 inquiring when they would arrive to complete the venous doppler on Resident #1 after she was notified of the order in morning report. She indicated that they reported the order had been called in, but that they were still waiting for a technician to be assigned and gave no timeframe as to when someone would be out to complete it. Further, she identified that she did not inquire about the order being STAT, as she was not aware at that time that it was ordered STAT. Interview with RN #8 on 7/24/24 at 11:53 AM identified that she was aware that the order for the venous doppler was STAT, as she obtained the order from APRN #1 on 7/1/24. She reported that she was almost certain she called it in STAT and stated she could not recall them indicating that they would not be out until the next day. She identified they had not arrived by the end of her 3:00 PM to 11:00 AM shift, so she passed it on in report, but did not call to follow up with the diagnostic company. Although requested, policies on following physician's orders and outside vendors were not obtained. b. Review of facility statements from the 7/3/24 Accident and Investigation on Resident #1 identified that on 7/2/24, the 7:00 to 3:00 PM nurse, LPN #1, indicated that it was communicated on report from the 11:00 PM to 7:00 AM shift that the resident was tired, had bruising and warmth noted to the left lower extremity, and they were waiting for a doppler to be completed. She reported that later in the morning, there was a new order to obtain a urine from the resident, so she had put him/her on the toilet to obtain the urine but the resident had a bowel movement in the collection hat so she stepped out to get help from NA #5. NA #5 helped LPN #1 stand the resident and they replaced the soiled collection hat with a new one. LPN31 stepped out of the bathroom again, and waited a few minutes and was listening to hear if the resident urinated. She indicated that there was nothing in the orders stating that Resident #1 could not be left alone in the bathroom and that the resident was safe. Review of the July 2024 monthly orders identified a physician's order dated 12/19/22 directing that Resident #1 was a staff assist of 1 for all activities of daily living. A medical progress note dated 7/2/24 at 3:41 PM identified that APRN #1 had assessed Resident #1 due to nursing reports that the left lower extremity was red, warm, edematous, and the resident was calling out in pain with palpation. It indicated that the resident was alert and responsive earlier in the morning, but nursing reported altered mental status, and staff having to assist with breakfast. She indicated she was called urgently to the resident's room later in the day per request of a family member, as the resident was lethargic, would not open his/her eyes, and was unable to follow directions. The resident's family member requested that they were sent to the ED. Interview with PTA #1 (Rehab Director) on 7/23/24 at 12:24 PM identified that Resident #1 had last been on therapy services from 3/6/24 to 3/26/24. She indicated that prior to the resident being transferred to the hospital on 7/2/24, he/she was a 1 person assist for bed mobility, transfers and toileting and should not have been left unattended on the toilet for safety concerns. Interview with LPN #1 on 7/23/24 at 12:35 PM identified that Resident #1's left lower extremity had been bruised and was warm to touch when she first saw her the morning of 7/2/24, indicating she was waiting for the technician to show up to perform the doppler ultrasound. She also reported that the resident was alert, but sleepy. She identified that after lunch, she put the resident on the toilet to obtain a urine that had been ordered, but that he/she had a bowel movement in the collection hat, so she ran across the hall to get a clean collection hat and notify the NA that she required assistance. She reported that she thought it was okay to leave him/her on the toilet because he/she couldn't physically get up on their own and she only left the resident briefly, but identified that the resident had cognitive deficits and could have fallen off the toilet. Interview with Person #1 on 7/23/24 at 12:57 PM identified that when she arrived on the unit to visit Resident #1 on 7/2/24, Person #1 walked into the room with NA #7 who had just come back from break, and they found Resident #1 on the toilet, slumped back with her eyes closed, unattended. She reported that the resident called her the wrong name, and that NA #7 was not able to get him/her off the toilet, because h/she was so weak. She identified that this incident was not the first time that she has found the resident in the bathroom unattended. Interview with NA #5 on 7/23/24 at 1:38 PM identified that she assisted LPN #1 on 7/2/24 in getting Resident #1 off the toilet. She indicated that LPN #1 had asked her to switch out a collection hat with a clean one while she stood the resident, so that she could obtain a urine. She reported after she switched the hat, she left the bathroom and then later, she heard NA #7 calling her name, requesting her assistance in getting him/her off the toilet, as he/she was weak and confused. She identified that they both stood her up, got her in the wheelchair and then transferred her back to bed. Interview with NA #7 on 7/23/24 at 1:51 PM identified that on 7/2/24, she came back from her lunch break after 1:00 PM and she walked into the resident's bathroom with Person #1 and Resident #1 was slumped over on the toilet unattended. She indicated the resident was so weak, she couldn't get her off the toilet, so she yelled to NA #5 to come help her. She reported that with NA #5's assistance, they were able to get him/her into a wheelchair and then from the wheelchair into bed. She identified that Resident #1 was an assist of 1 and was not safe to be left unattended in the bathroom. Interview with the DNS on 7/24/24 at 12:40 PM identified that LPN #1 should not have left Resident #1 on the toilet unattended, especially when he/she was experiencing a change in condition. She indicated she spoke with LPN #1 regarding not leaving a resident who requires assistance and has a change in condition on the toilet unattended.

Based on observations, review of facility policy, and interviews, the facility failed to ensure food items were appropriately dated to reflect the opening date and/or the used-by date. The findings include: A tour of the Dietary Department on 10/2/23 at 9:55 AM with the Food Service Director identified food items that were opened and undated without the benefit of a use by and/or discard date. The walk-in refrigerator contained open containers/bottles of barbeque sauce, coleslaw salad dressing, balsamic salad dressing, sweet relish, mayonnaise and maraschino cherries. The Ice-cream freezer identified a clear plastic bag containing cookie dough that had been opened and was not in the original packaging as well as a clear plastic bag that contained frozen ready-made pancakes that was also not in its original packaging. Interview with the Food Service Director on 10/2/23 at 10:10 AM identified that items should be dated once opened and that the facility had a separate list which contained food storage guidelines that included when to discard food items. The Food Service Director indicated that she had new staff that contributed to the reason why the items were not dated per their policy and will in-service staff, label items and discard items as needed. After surveyor's inquiry, the Food Service Director provided an in-service document identifying that staff were in-serviced on dating items when opened even food with expiration dates. Review of the facility's food storage reference guide identified the stored by dates for the following items: salad dressings for 3 months when opened in refrigerator, mayonnaise for 2 to 3 months, pancakes commercially frozen for 2 months in freezer, and cookie dough unbaked for 6 months in the freezer. Review of the Storage of Food and Supplies policy identified that refrigerated time/temperature control for safety food, ready to eat food that are opened but not completely used and is held longer than 24 hours should be labeled with the common name and a use-by date with day 1 counted as the opened date.

Based on clinical record review and interviews for two sampled residents (Resident #45 and Resident #100) reviewed for privacy, the facility failed to develop and implemented a comprehensive care plan to ensure nursing staff were aware of boundary restrictions between the residents. The findings include: 1. Resident # 45 's diagnoses included mild intellectual disabilities, post-traumatic stress disorder, depression, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #45 had intact cognition, required moderate assistance with toileting, dressing, and transfers, was ambulatory with the use of a rolling walker and was independent with wheelchair mobility. A Social Worker (SW #1) progress note dated 8/16/23 identified that SW #1 spoke with Resident #45 and requested that he/she give Resident #100 some space when he/she was in his/her room. Resident #45 verbalized that he/she understood and would respect the wishes of Resident #100. The note further identified SW #1 would continue to provide education and guidance to Resident #45 related to his/her mild intellectual disabilities. The Resident Care Plan (RCP) dated 8/22/23 identified Resident #45 could have a private intimate relationship with a consensual partner of his/her choice with an intervention for staff to speak with the resident about relationship boundaries. SW #1's progress noted dated 8/25/23 identified Resident #45 was spoken to regarding an observation of the resident seated in the hallway with inappropriate clothing on like the wearing of short pajama bottoms or no pajama bottoms around peers. The note further identified that SW #1 spoke to the resident about maintaining his/her dignity and dressing appropriately. In addition, the note identified that Resident #45 verbalized that the peers were his/her friends, so he/she thought it was alright. SW #1's progress note dated 9/7/23 identified Resident #45 was seen boundaries were put in place regarding Resident #100, due to a request by Resident #100's representative. The resident's representative made a request that Resident #45 and Resident #100 refrain from having physical contact. The note further identified Resident #45 had developed a relationship with Resident #100. Resident #45 and Resident #100 had spent time together and were observed holding hands and exchanging kisses. Resident #45 verbalized understanding of the boundaries but expressed sadness because he/she felt that they were in love with each other. The APRN (psychiatric) progress note dated 9/15/23 identified Resident #45 was referred for psychiatric evaluation due to depressed mood because he/she cannot have physical contact with Resident #100. Interview with NA #3 on 10/4/23 at 1:45 PM identified Resident #45 needed assistance with clothing and toileting, was independent using the wheelchair in the hallway, and was aware Resident #45 had a close male friend in the facility and noted she observed them sitting together and talking in the hallway. NA #3 further identified that she was not aware that Resident #45 and Resident #100 had restrictions. She further identified that she was not aware of the kissing incident in Resident #100 room with Resident #45. Interview with LPN #3 on 10/5/23 at 11:20 AM identified Resident #45 was independent using the wheelchair in the hallway and was freely allowed to roam independently on the unit. She also identified that Resident #45 had an affection for Resident #100. LPN #3 identified that she was unaware of the kissing incident that occurred between the two residents and further identified she was unaware of restrictions between Resident #45 and Resident #100 but knew that the residents could not be alone together inside their individual rooms. Interview with NA #2 on 10/5/23 at 11:30AM identified he knew Resident #45 had a close male friend (Resident #100) in the facility because other staff were talking about them. He was not aware of a kissing incident between the two residents and was also unaware that Resident #45 and Resident #100 had boundary restrictions regarding their relationship. Interview with SW #1 on 10/5/23 at 11:20 AM identified that once Resident #100's representative expressed concerns about the physical relationship between Resident #45 and Resident #100, boundary restrictions were developed that identified the residents could not be alone in either of the resident's rooms, could not have a physical relationship, but could be together in the hallway or common areas. SW #1 further identified that the boundary restrictions should have been added to the residents' plan of care to make the nursing staff aware of the boundary restrictions set between the residents. SW #1 did not provide a reason why the care plan was not updated to reflect the residents' status. Interview with the DNS on 10/5/23 at 1:45 PM identified that she was aware Resident #45 wanted to have a relationship with Resident #100, but she was not aware that Resident #100's representative had witnessed the two residents kissing in Resident #100's room. She further identified that when the Resident's Representative identified that he/she did not agree to the residents having a relationship, Resident #100's care plan should had been develop and implemented so the nursing staff were aware of the set boundary restrictions between the residents and the NA care card updated to reflect the restrictions between the residents. The facility failed to ensure the care plan reflected measures to address restrictions between Resident #45 and Resident #100 and failed to identify interventions to address identified concerns related to the residents' behaviors. 2. Resident #100's diagnoses included dementia, persistent mood disorder, atrial fibrillation, and cognitive communication deficit. The quarterly MDS assessment dated [DATE] identified Resident #100 had moderately impaired cognition and was independent with ambulation up to 50 feet with the use of a rolling walker. The Resident Care Plan (RCP) dated 7/18/23 identified Resident #100 had impaired cognitive function/dementia or impaired thought process with interventions that included: communicate with resident/family/caregiver regarding resident capabilities and needs, offer cues, re-orient and supervise as needed, encourage resident in simple structure activity and discuss concerns about confusion and disease process. SW #1's progress note dated 9/7/23 identified a call was received from Resident #100's representative who was concerned about Resident #100's relationship with Resident #45. The note identified Resident #100's representative was visiting with the resident when he/she witnessed Resident #100 kissing Resident #45. Resident #100's representative noted Resident #45 was younger and felt Resident #100 did not truly understand what was going on. In addition, Resident #100's representative identified that he/she was okay with both residents being friends, but not having a relationship. The APRN (psychiatric) progress note dated 9/15/23 identified Resident #100 was referred for psychiatric evaluation of mood because the nursing staff reported that Resident #100 had an altercation with another resident because he/she was angry because he/she could not have physical contact with Resident #45. Interview with NA #3 on 10/4/23 at 1:45 PM identified she was aware Resident #45 had a close male friend in the facility and noted she observed them sitting together and talking in the hallway. NA #3 further identified that she was unaware that Resident #45 and Resident #100 had boundary restrictions. She further identified that she was also unaware of the kissing incident in Resident #100 room with Resident #45. Interview with LPN #3 on 10/5/23 at 11:20 AM identified Resident #45 had an affection for Resident #100. LPN #3 identified that she was unaware of the kissing incident that occurred between the two residents and further identified she was unaware of boundary restrictions between Resident #45 and Resident #100 but knew that the residents could not be alone together inside their individual rooms. Interview with NA #2 on 10/5/23 at 11:30AM identified he knew Resident #45 had a close male friend (Resident #100) in the facility because other staff were talking about them. He was not aware of a kissing incident between the two residents and was also unaware that Resident #45 and Resident #100 had boundary restrictions regarding their relationship. Interview with SW #1 on 10/5/23 at 11:20 AM identified that she was aware of Resident #45 wanting to have a romantic relationship with Resident #100 and developed a care plan to allow Resident #45 to have a relationship of his/ choice. She also identified that she did receive a call from Resident #100's Representative who requested that the two residents not have a romantic/physical relationship other than friendship. She further identified that both residents were evaluated by APRN #1 and Resident #45 was able to consent a having a relationship of his/her choice, but Resident #100 cannot consent to a relationship due to his/her inability to give consent because of his/her dementia diagnosis. Additionally, she identified that boundary restrictions were developed that both residents cannot be together inside each other's rooms, but both residents can be together in the hallway or common areas. She further identified that the boundary restrictions should have been added to the residents' plan of care to make the nursing staff aware. SW #1 did not provide a reason why the care plan was not updated to reflect the residents' status. Interview with the DNS on 10/5/23 at 1:45 PM identified that she was aware Resident #45 wanted to have a relationship with Resident #100, but she was not aware that Resident #100's representative had witnessed the two residents kissing in Resident #100's room. She further identified that when the Resident's Representative identified that he/she did not agree to the residents having a relationship, Resident #100's care plan should had been develop and implemented so the nursing staff were aware of the set boundary restrictions between the residents and the NA care card updated to reflect the restrictions between the residents. The facility failed to ensure the care plan reflected measures to address restrictions between Resident #45 and Resident #100 and failed to identify interventions to address identified concerns related to the residents' behaviors.

Based on review of the clinical record, review of facility policy, and interviews for one of two sampled residents (Resident #50) reviewed for advance directives, the facility failed to ensure there was a physician's order directing cardiopulmonary code status elected by the resident. The findings include: Resident #50's was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, atrial fibrillation, and abnormal posture. The Advanced Directive Consent Form dated [DATE] identified Resident #50 elected to not have cardiopulmonary resuscitation (CPR) administered, and no artificial nutrition and hydration. The quarterly MDS assessment dated [DATE] identified Resident #50 had intact cognition, was independent with bed mobility, and required supervision with transfers, dressing, toileting, and personal hygiene. The care plan dated [DATE] identified Resident #50's code status was do not resuscitate and/or do not intubate (DNR/DNI) with interventions that included, honor advance directives as directed by resident and review advanced directives with resident and/or power of Attorney (POA) on admission and at least quarterly. A code state of DNR means the resident has chosen to not have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops. The monthly physician's orders for September/2023 (most current orders) directed Resident #48 had a code status of full code. A full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR. Interview with LPN #4 on [DATE] at 11:50 AM identified that if Resident #50 had a life-threatening emergency, she would look in the physical clinical record under the advance directive tab and review the Advanced Directive Consent Form and review the physician's orders in the electronic medical record to identify the resident's code status. After reviewing the physician's orders, LPN #4 noted that there was a physician's order addressing the resident's code status dated [DATE] that was written by APRN #1. Interview with APRN #1 on [DATE] at 12:15 PM identified that the process in place once the advanced directives are signed by the resident or the resident's representative is that a physician's order directing DNR or Full Code is entered into the electronic medical record by a nurse. A message indicating the order is sent and then she reviews and signs the order. APRN #1 further identified that the expectation is when a resident or POA signs the Advance Directive Consent Form, a physician's order be placed in the electronic record at least within 24 hours of obtaining the consent. Interview with the DNS on [DATE] at 12:23 PM identified that the order for DNR was inputted by her on [DATE] after reviewing Resident #50's record. The DNS indicated that the reason why the DNR order was missed was because the batch orders were not entered into the electronic medical record correctly. In addition, the DNS indicated that the facility identified an issue with Advance Directives and initiated a Quality Improvement Plan (QIP) on [DATE]. Review of the electronic physician's orders for the month of [DATE] identified that a physician's order directing DNR was ordered on [DATE] at 11:46 AM. Review of the facility's policy on Advanced Care Planning Code Status identified that on admission the option of choosing to resuscitate or not to resuscitate will be offered and reviewed with the resident/family/surrogate/designated representative, the consent signed and witnessed, and a physician order must be written accordingly.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse and dignity, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident # 1's diagnoses included type 2 diabetes, hepatic failure, dementia, heart failure and hypertension. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented with no cognitive impairment and required supervision or was independent with activities of daily life. The facility incident report dated 12/15/2022 at 5:30 PM identified Resident #1 had a verbal altercation with NA #2 and felt threatened by that NA #2. Review of the facility investigation identified a statement by Resident #1 that indicated NA #2 was yelling at the nurse and Resident #1 intervened and told NA #2 to be nice. Resident #1 further identified that NA #2 put her hand in his/her face and threatened him/her. Facility investigation included a written statement by NA #2 that alleged Resident #1 did not like her. The nurse's note dated 12/15/2022 at 7:46 PM identified Resident #1 had a verbal altercation with a NA #2 and felt threatened by the NA #2. Resident #1 stated that NA #2 was yelling at the charge nurse, and he/ she intervened and told NA #2 to be nice. The note further identified that NA #2 jumped at Resident #1 and put her hand in Resident #1's face and threatened him/her. Resident #1 was given emotional support and calmed. NA #2 was sent home, police, DNS, power of attorney (POA), and APRN were notified. Resident #1 was referred for psych evaluation. An interview with NA #1 on 1/3/2023 at 12:40 PM identified on 12/15/2022 she was picking up dinner trays from the resident rooms when she heard yelling. NA #1 indicated she looked down the hallway and saw Resident #1 standing at the nurse's station and NA #2 was yelling and pointing in Resident #1's face. NA #1 further indicated she was unable to hear distinctively what each party was saying at the time. Interview with LPN #1 on 1/3/2023 at 12:52 PM identified on 12/15/2022 she directed NA #2 to help putting away the dinner trays. NA #2 got upset and wanted to know who was talking about her behind her back, Resident #1 intervened and told NA #2 to be nice. LPN #1 further identified that NA #2 then turned to Resident #1. While NA #2 was standing in front of Resident #1 and pointing in his/her face, NA #2 told Resident #1 to be quiet and mind his/her own business because she was not talking to him/her. LPN #1 further indicated that NA #2 accused Resident #1 of being racist. LPN #1 identified both NA #2 and Resident #1 were yelling, and to attempt to de-escalate the situation she stood between them to separate them, and notified the supervisor. LPN #1 indicated NA #2 should not have behaved in that manner toward Resident #1. Interview with the DNS on 1/3/2023 at 1:30 PM identified that NA failed to act in accordance with the policy and expectations of the facility when she was involved in confrontation with Resident #1. She further identified following the completion of the investigation of the alleged incident with Resident #1, the facility terminated NA #2 from employment because of this incident. Although attempted, an interview with NA #2 and LPN #2 was not obtained (NA #2 was not available for interview). Review of facility's Abuse Policy dated 11/2019 directed in part, each resident had the right to be free from abuse. The Policy defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy defined verbal abuse as the use of oral written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. The Policy further directed the facility's philosophy was to encourage an environment that recognizes the qualities of residents and to provide them with a safe environment. The facility failed to protect Resident #1 from verbal abuse and disrespect by NA #2, when a confrontation with NA #2 resulted in Resident #1 feeling threatened/ intimidated related to NA #2's behavior toward LPN #1 within view and hearing of Resident #1, and NA #2's behavior directed toward Resident #1. A review of facility's Residents Rights Policy dated 10/2022 identified that the Residents had the right to be treated with consideration, respect and full recognition of their dignity and individuality. The facility failed to uphold the Resident's right to dignity and respect when NA #2's actions and responses during an incident did not display any consideration for Resident #1's (or the other residents and family members that overheard the incident) dignity and individuality.

Based on observations, facility policy review, and interviews, for facility infection control review, the facility failed to disinfect the facility glucometer after resident use in accordance with facility policy. The findings include: Observation and interview with LPN #1 on 7/26/21 at 11:20 AM identified LPN #1 took the Assure Prism Multi Blood Glucose Monitoring System (glucometer machine that tests blood sugar levels) from her medication cart and proceeded perform a blood glucose test for Resident #27. Upon completion of the blood glucose test, LPN #1 returned to her medication cart and utilized a Super Sani Cloth wipe (purple top) to wipe down the glucometer. She wiped the entire surface of the glucometer horizontally three (3) times and vertically three (3) times and then placed the glucometer on the top of her medication cart. LPN #1 then took another a Super Sani Cloth (purple top) sanitizing wipe and wiped the top of her medication cart. LPN #1 indicated that she wipes down the glucometer and allows it to air dry stating that the glucometer should remain wet for 2 minutes after her cleaning as it would take that long for the glucometer to air dry. Interview with RN #2 on 7/26/21 at 12:00 PM identified that the glucometer should be cleaned after use by using a disinfectant wipe cleaning the entire surface of the glucometer three (3) times horizontally and three (3) times vertically. The nurse would dispose of that wipe and then use a new disinfectant wipe to disinfect the glucometer surface horizontally three (3) times and three (3) times vertically. Additionally, RN #2 stated that utilizing two (2) wipes was requrired; the use of one disposable wipe to clean and one disposable wipe to disinfect, would wet the glucometer sufficiently to maintain the required 2-minute contact time for disinfection. Review of the facility Glucometer Cleaning Policy and Procedure, Subject: Assure Prism - Glucometer Cleaning, dated 3/2020, directed in part, that the glucometer should be cleaned and disinfected after use on each patient. Two disposable wipes will be needed for the cleaning and disinfecting procedure: one wipe for cleaning and a second wipe for disinfecting. The Policy further directed to use PDI Super Sani-Cloth Germicidal Disposable Wipe (Purple Top). The procedure directed to clean the glucometer, wipe the surface of the meter three times horizontally and three times vertically using one approved disinfectant towelette. Dispose of the used towelette. No drying of the meter is necessary before starting the disinfecting procedure. The Policy then directed to disinfect the glucometer to use a new towelette, wipe the entire surface of the meter three times horizontally and three times vertically to remove blood-borne pathogens. Dispose of the used towelette in a trash bin. Allow the exterior to remain wet for two minutes. LPN #1 failed to utilize a second wipe as per facility policy to properly disinfect the glucometer.

Based on observations, and interviews for medication storage review, the facility failed to ensure cleaning supplies and personal supplies were stored appropriately, and the facility failed to ensure multidose medications were dated when opened, and the facility failed to ensure expired medications were removed from the medication cart. The findings include: a. Observation and interview with the ADNS on 7/26/2021 at 11:30 AM identified that the first floor Medication Room bottom cabinet contained a half-full gallon size jug of white distilled vinegar with the expiration date of 2/2021 (5 months prior to the observation), a bottle of crystal odor, a bottle of protein stain and an odor, and a bottle of soft scrub, ten (10) ounces with no expiration dates. The ADNS indicated that the items should not be stored in the medication room. Subsequent to surveyor inquiry, the ADNS discarded the items. b. Observation and interview with LPN #3 on 7/26/2021 at 12:00 PM of the second floor Medication Room identified two personal cups on the counter, and a plastic bag that contained a purse with food, an unopened can of soda, a three-ring binder, post-its, lotion, papers, throat [MEDICATION(S)], and [MEDICATION(S)] patches. LPN #3 identified that all the items observed belonged to her. She indicated that she did not have anywhere to put her items and she did not put them in the staff locker room. Subsequent to surveyor inquiry, LPN #3 removed the items from the medication room. c. Observations and interview with LPN #2 on 7/26/ at 12:00 PM identified the Westview Unit, side A medication cart contained the following items: two (2) open containers of artificial tears with no date to identify when they were opened (pharmacy label identified they were dispensed on 10/22/2020 and 11/22/2020). Additional observation identified the medication cart also contained the following treatment items: three (3) individual-use size packets of [MEDICATION(S)] ointment, a bottle of hemocult solution, a tube of santyl ointment, two (2) tubes labeled muscle rub and a tube of [MEDICATION(S)]. Interview with LPN #2 at the time of the observation identified the artificial tears should be dated when opened and the treatment supplies should not be located in the medication cart. Subsequent to surveyor inquiry, LPN #2 removed the items from the medication cart. d. Observation and interview with LPN #2 on 7/27/21 at 10:29 AM on the Passport Unit, short side, identified the medication cart contained an open, undated bottle of [MEDICATION(S)] solution 0.5% eye drop solution (dispensed 7/14/2021), an open, undated bottle of [MEDICATION(S)] drop 0.004% eye drop solution, and an open, undated bottle of [MEDICATION(S)] spray 50mcg (dispensed 7/12/2021). Interview with LPN #2 at the time of the observation identified the items should all be dated when opened. Subsequent to surveyor inquiry, LPN #2 removed the items from the medication cart. e. Observation and interview with LPN #3 on 7/27/2021 at 10:56 AM of the Westview Unit, side B identified a bottle of [MEDICATION(S)] ear drops with an expiration date 3/2021. Further observations identified the following treatment supplies were located in the bottom drawer: a bottle of saline wound cleanser, gauze, skin prep pads, kerlix wrap, [MEDICATION(S)] cream, and [MEDICATION(S)] ointment. Interview with LPN #3 at the time of the observation identified that the expired [MEDICATION(S)] ear drops should have been removed from the medication cart, and the treatment supplies should not be stored in the medication cart. Subsequent to surveyor inquiry, LPN #3 removed the items from the medication cart. Although requested, a facility policy for medication room storage was not provided.

Based on observations, clinical record review, and interviews for two of six residents (Resident #43, Resident #78) reviewed for respiratory care, the facility failed to ensure the oxygen tubing was dated to identify the date it was last changed. The findings include: A) Resident #43's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #43 had severe cognitive impairment and received oxygen therapy. The Resident Care Plan (RCP) dated 11/9/2020 identified Resident #43 had [CONDITION(S)] and shortness of breath. Interventions directed oxygen at two (2) liters (L) via nasal cannula/facemask. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 7/20/21 at 9:30 AM identified that Resident #43's oxygen tubing lacked a date to identify when the tubing was last changed. B) Resident #78's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP dated 3/1/2021 identified Resident #78 had difficulty breathing related to respiratory failure and was short of breath when lying flat. Interventions directed oxygen at two (2) L via nasal canula. The admission MDS dated [DATE] identified Resident #78 was alert and oriented and received oxygen therapy. Observation on 7/20/21 at 10:30 AM identified Resident #78's oxygen tubing was dated 7/5/21 (16 days prior to the observation). Interview and clinical record review with RN #3 on 7/21/2021 at 11:30 AM identified she could not remember when the oxygen tubing was scheduled to be changed (Saturdays or Sundays). Review of clinical records identified that the tubing was due to be changed on 7/18/21. Subsequent to surveyor inquiry, RN #3 removed and replaced the undated oxygen tubing for Resident #43 and Resident #78.

Based on clinical record review, facility documentation review, facility policy review, observation and interviews for one of five residents (Resident #13) reviewed for accidents, the facility failed to ensure an RN assessment was completed timely after a resident fall before the resident was moved. The findings include: Resident #13's diagnoses included [CONDITION(S)], dementia with behavioral disturbance and anxiety. The admission Minimum Data Set assessment (MDS) dated [DATE] identified Resident #13 had severe cognitive impairment, required extensive assist of two (2) staff for transfers, and extensive assist of one (1) staff for locomotion on and off unit. The MDS further identified that Resident #13 had a fall in the month prior to admission and no falls since admission. The Resident Care Plan (RCP) dated 5/5/2021 identified Resident #13 was at risk for falls related to confusion, deconditioning, psychoactive drug use and was unaware of safety needs. Interventions directed to wear appropriate footwear (nonskid socks, use shoes with non-slip soles) when ambulating or mobilizing in wheelchair, note any changes in gait and report, and to use Dycem in the wheelchair. The physician's order dated 5/10/2021 directed to ambulate with a rolling walker and one (1) assist to/from the bathroom and up to 250 feet as tolerated. Review of facility incident report dated 7/7/2021 identified that at 9:00 PM, NA #5 witnessed Resident #13 slide from his/her wheelchair to the floor, lying on the left side of the wheelchair, and complained of left hip pain. APRN #1 was notified, and a new order for left hip and lumbar sacrum x-rays were obtained. Review of the facility investigation statement written by NA #5, dated 7/7/2021, identified she had attempted to redirect Resident #13 to sit back in the chair and then witnessed Resident #13 slide to the floor, lying on left side of the wheelchair. NA #5 identified a co-worker assisted her to pick Resident #13 up off the floor. Review of the facility Summary of Investigation Report dated 7/7/2021 identified after NA #5 witnessed Resident #13 slide from his/her wheelchair onto the floor, Resident #13 was transferred off the floor back into the wheelchair and then transferred into bed. Nurse's note dated 7/8/2021 at 1:15 AM written by RN #6 identified NA #5 witnessed resident slide from wheelchair to the floor and staff transferred Resident #13 back to the wheelchair. Resident #13 was assessed and grimaced when his/her left leg and hip were touched. APRN #1 was notified of the fall and Resident #13's leg pain, and ordered x-rays of the left hip and lumbar sacrum. Further review of the nurse's notes identified x-ray results status post fall identified an acute left intertrochanteric femoral fracture with moderate displacement with varus angulation; left lesser trochanter is mildly medially displaced. APRN #1 was updated and recommended to send Resident #13 to the emergency department. Additional clinical record review identified Resident #13 was readmitted to the facility on [DATE]. Review of facility documentation, In-service Training Attendance dated 7/8/2021 for NA #5, identified NA #5 received education that if a resident falls, not to transfer the resident off the floor. The RN supervisor must assess the resident and give the approval for any transfer. A facility Reenactment Form completed by the ADNS on 7/12/2021 identified an interview with NA #5 indicated Resident #13 had been attempting to stand independently from after dinner. Staff positioned Resident #13's wheelchair by the nurse's station for observation and gave frequent reminders to Resident #13, and Dycem was in place in the wheelchair in accordance with the plan of care. NA #5 observed Resident #13 stand up from wheelchair and asked him/her to sit down. Although Resident #13 sat back down into wheelchair, he/she did not sit back completely, and Resident #13 was observed to slide onto the floor. Interview and review of statement with NA #5 on 7/26/2021 at 3:05 PM identified she witnessed the Resident #13 stand and then slide from the wheelchair on 7/7/2021. She notified the charge nurse, LPN #5, who was off the unit at the time. NA #5 identified LPN #5 came immediately and RN #6 (supervisor) also arrived on the floor after being summoned by LPN #5. NA #5 indicated that she could not remember when she and her coworker transferred Resident #13 off the floor and back into the wheelchair, but she thought both LPN #5 and RN #6 were present when they transferred Resident #13 off the floor. Interview with RN #6 on 7/26/2021 at 3:15 PM identified that she was notified by LPN #5 that the resident had a fall which was witnessed by NA #5. RN #6 identified that when she arrived on the unit to assess Resident #13, he/she was already sitting up in the wheelchair. RN #6 identified that NA #5 and an agency NA had assisted Resident #13 back into the wheelchair prior to LPN #5's arrival to the unit. RN #6 indicated she was upset because the NA's know they should not move a resident after a fall before the RN assesses the resident. RN #6 indicated she did not know why NA #5 and the other NA transferred Resident #13 prior to her arrival, and they should not have moved Resident #13 prior to her assessing the resident. RN #6 identified she assessed Resident #13 and she identified Resident #13 had no complaints of pain, no bruising or other indication of injury at that time. When Resident #13 was assisted back to bed less than 30 minutes later, RN #6 identified Resident #13 complained of hip pain. She performed an additional assessment once resident was in bed and although Resident #13 complained of pain, she did not observe any shortening or rotation of the legs. APRN #1 was contacted an ordered an x-ray. Interview with LPN #5 on 7/26/2021 at 7:20 PM identified that while she was off the unit she was notified that Resident #13 had a fall. LPN #5 identified she immediately went back to the unit and upon arrival she observed Resident #13 was sitting in his/her wheelchair and she called RN #6 (RN supervisor). LPN #5 identified NA #5 and another NA assisted Resident #13 back to the wheelchair prior to her arrival on the unit (prior to her observing Resident #13 on the floor). She indicated she did not know why the NAs moved Resident #13 prior to her and RN #6's arrival, as staff are aware they can't move a resident after a fall until they are assessed by the RN. She indicated that Resident #13 should have remained on the floor until the RN assessed Resident #13. Interview and facility documentation review with the ADNS on 7/27/2021 at 8:45 AM identified that NA #5 and the agency NA should not have transferred Resident #13 back into the wheelchair before the RN supervisor assessed the resident. Interview and clinical record review with APRN #1 on 7/27/2021 at 11:00 AM identified the transfers back into the wheelchair and into bed after the fall would not have contributed to, or worsened the hip fracture. Review of the facility's Fall Prevention Policy directed in part, that if a fall occurs, keep the resident immobile until the resident is examined and determined to be free from fractures.

Based on observations, clinical record review, facility policy review, and staff interviews for one of five residents (Resident #89) reviewed for accidents, the facility failed to ensure staff addressed a physician recommendation timely for a resident with exit seeking behavior. The findings included: Resident #89 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set assessment (MDS) dated [DATE] identified Resident #89 had severe cognitive impairment, required limited assistance of one person for ambulation and limited assistance of two staff for transfers, used a walker to ambulate, and did not wander. The Resident Care Plan (RCP) dated 6/22/2021 identified Resident #89 had a high risk for elopement. Interventions directed to place a wandering alert device and to move Resident #89 to a safe designated unit. The nursing progress note dated 6/22/2021 identified Resident #89 stated he/she was going to walk out the door. An elopement risk assessment dated [DATE] identified Resident #89 was at risk for elopement and a wandering alert device was placed on his/her left wrist. Physicians order dated 6/22/2021 directed a Wander Guard (wander alert device), check the location every shift and check the function every night. Nurse's note dated 6/23/2021 at 11:42 AM identified that Resident #89 was transferred to a secured dementia unit. The elopement risk assessment dated [DATE] identified Resident #89 was at low risk for elopement. The nursing progress noted dated 7/6/2021 identified the wander alert device was discontinued due to Resident #89 removing the device. Additionally, the note indicated Resident #89 was safe, made no attempts to elope, had no wandering behaviors, and had not verbalized a desire to go home; Resident #89 appeared to have adjusted well and the wander alert was no longer required. Physicians order dated 7/6/2021 directed to discontinue the Wander Guard. The psychiatric APRN #1 progress note dated 7/19/2021 identified Resident #89 was pacing, exit seeking, wandering in and out of other residents' rooms and attempted to get out the front door of the dementia unit. The note further identified APRN #1 recommended a Wander Guard device. Observation on 7/20/2021 at 12:13 PM identified Resident #89 was ambulating independently in the hallway of the secured Dementia Unit looking for an exit and asking staff how he/she could leave the unit. Additionally, Resident #89 verbalized he/she wanted to go outside and go for a walk. Review of the clinical record failed to identify that APRN #1's recommendation on 7/19/2021 for a Wander Guard device was addressed. Interview with RN #1 on 7/21/2021 at 2:47 PM identified Resident #89 no longer required a wander alert device because he/she was moved to the secured dementia unit, had no exit seeking behaviors and the device was discontinued on 7/6/2021. Additionally, RN #1 identified she was not aware Resident #89 had exhibited exit seeking behavior, was not aware that APRN #1 recommended use of a Wander Guard device, and indicated she would complete an elopement risk assessment. Interview with APRN #1 on 7/22/2021 at 10:14 AM identified she notified the Nursing Supervisor (RN #1) on 7/19/2021 that she was concerned with Resident #89's exit seeking behavior and attempts to get out the Dementia Unit doors. She was concerned Resident #89 may get off the unit and she requested a Wander Guard monitoring bracelet be applied to Resident #89's ankle. Interview and clinical record review with RN #1 on 7/22/2021 at 10:20 AM identified she could not remember if APRN #1 recommended a Wander Guard device. RN #1 further indicated that if she had been informed, she would have completed an assessment and implemented the recommendations. She further indicated that she had not completed an assessment or followed APRN #1's recommendations for a Wander Guard device. She identified that she did not complete the elopement risk assessment on 7/21/2021 because it slipped her mind. Interview with The Corporate Nurse RN #2 on 7/22/2021 at 10:30 AM identified RN #1 should have followed through with APRN #1's recommendations and completed the elopement risk assessment when she was notified that Resident #89 had exit seeking behaviors. Subsequent to surveyor inquiry, an elopement risk assessment was completed on 7/22/2021. The assessment identified Resident #89 was at risk for elopement and a wander alert bracelet was applied to his/her left ankle. The facility Elopement Policy dated 3/2013, directed in part, that the facility would assess and identify all residents who are at risk for elopement and a risk evaluation would be completed upon admission, and with a change on condition. Although requested, a facility policy regarding physician recommendations was not provided.

Based on observation, facility policy, and interviews for Dietary reviewed for infection Control, the facility failed to have dietary staff wear hair restraints (e.g., hairnet, hat, and beard restraint) while in the kitchen to prevent hair from contaminating food and personal food items in resident refrigerators. The findings include: Observations on 12/1/20 at 9:50 AM with the Director of Dietary Services identified there are 2 males and 3 females working in the dietary kitchen one male transporting pans to the dish room wearing a surgical mask which did not cover the beard over 3 inches long on the sides of his face, chin, and neck area. DA #1 did not benefit from wearing a beard guard. DA #2 was standing in front of the stove stirring a liquid in a large pot with a surgical mask on but it did not cover the over 3 inch long beard on the sides of his face, chin and neck area and he had on a baseball cap sitting on the top of his head with a large ball of hair covering his lower neck and large amount of hair hanging down past shoulder length and did not benefit from a hair net. DA #2 did not benefit from a beard guard or a hair-net to cover all of his hair. An interview with DA #1 on12/1/20 at 9:51 AM noted he usually wears a beard guard but unable to explain why he did not have a beard guard on today. DA #1 indicated he was aware he should always wear a beard guard in the kitchen. After surveyor inquiry DA #1 put on a beard guard. An interview with Cook #1 on 12/1/20 at 9:55 AM noted he was making macaroni and cheese and he was stirring the cheese sauce in the large metal pan on the stove. Cook #1 indicated he now had a beard guard on after surveyor was questioning DA #1 and Cook #1 was witnessing conversation. Cook #2 indicated he should wear a beard guard and a hair net with the baseball cap in the kitchen because if your hair sticks out from the hat you need a hair net, but was no able to explain why he did not put a beard guard or a hair net on when he came into the kitchen. Observations on 12/1/20 at 9:57 AM identified in the resident refrigerator there was a used Shop Rite re-useable shopping bag with items inside and a tray with 2 dozen hard boiled eggs, milk cartoons, yogurts, 22 Styrofoam bowls with applesauce in them, small plastic cups of ketchup, small plastic cups of sour cream individual servings, 2 pitchers of juice. An interview with Director of Dietary on 12/1/20 at 10:00 AM indicated the used Shop Rite bag with food items inside the resident refrigerator was her personal shopping bag with her personal lunch items and the tray of hard-boiled eggs were hers also. The Director of Dietary indicated there was a staff refrigerator to put her personal items in but chose to use the refrigerator in the kitchen that was the resident refrigerator due to COVID 19. The Director of Dietary did not want to put her food items with the rest of the staff. Additionally, the Director of Dietary indicated that the 2 male staff in the kitchen should have had on a beard guard when they are working in the kitchen because of the length of the facial hair and all hair must be covered with a hair net and that Cook #1 had a lot of hair sticking out of his baseball cap he should have had a hair net on with the baseball cap. An interview with the Administrator on 12/1/20 at 10:30 AM noted that dietary staff need to wear a hair net or a baseball cap and the males with facial hair need to wear a beard guard. The Administrator was not sure if someone had on a baseball cap and hair hung down there back shoulder length if they would have to wear a hair net with the baseball cap. Additionally, staff should not put personal food in the refrigerators for residents but if they do the staff know not to give the staff personal items to the residents, so the residents wouldn't get the staffs food. An interview with Infection Control Nurse RN #1 on 12/1/20 at 12:55 PM noted that all dietary staff must always have all hair covered while in the dietary kitchen. Additionally, RN #1 indicated that the male staff in dietary should absolutely wear a beard guard if they have facial hair. Furthermore RN #1 indicated that the staff are not to place personal items in the refrigerators in the kitchen those refrigerators are allocated only for the residents items not staff because it has resident food items and the staff have a refrigerator designated for staff to use. Review of facility policy on Uniform Dress code for the Foodservice Department employees in the dietary department must wear a hat, hair-net, beard restraint (used as a barrier for any length of hair) when in the kitchen. Although requested, a facility policy for personal food items in the resident refrigerators for infection control was not provided.

Based on clinical record review, facility documentation, interviews, and policy review, for one of three residents reviewed for falls, (Resident #1) the facility failed to ensure that appropriate care and treatment was provided to a resident who was non-ambulatory and dependent on a mechanical lift for transfers and had a known behavior of raising the height of the bed to high levels, failed to addressed an abnormal diagnostic X-ray finding in a timely manner and failed to ensure that post fall resident monitoring was completed in accordance with facility policy, The findings include: The findings include: Resident #1 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] identified that the resident had intact cognition, was non-ambulatory, required extensive assistance with toileting and bed mobility, and required total assist with ADL's. a. Review of a fall care plan dated 3/7/20 identified that the resident was at risk for falls related to gait and balance problems and [MEDICAL CONDITION] medications with interventions to anticipate the resident's needs, to ensure the call bell was in reach, encourage the resident to call for assistance as needed, and to use 2 1/2 side rails to assist with bed mobility. Review of a Nurse Aide (NA) care card (directs care in accordance with the care plan) identified that the resident should have 2 1/2 siderails and required a Hoyer lift for transfers with assistance of 2 staff. Review of a facility incident report and investigation dated 4/26/20 at 2:50 PM identified that Resident #1 was found on the floor next to the bed sitting up with legs bent beneath him/her yelling for help, the resident then fell forward onto the floor. Review of a statement from Licensed Practical Nurse (LPN) #1 dated 4/26/20 identified that when she entered the room (at the time of the fall) Resident #1's bed was elevated off of the floor in a high position with the head of the bed elevated. An undated statement from NA #1 identified that when she entered the resident's room on 4/26/20 after the resident's fall, the resident's bed was up in the air, and that the resident was known to take the bed controller and use it by him/herself. Review of an X-ray report dated 4/27/20 identified that Resident #1 had acute right and left femur fractures. Interview with the facility contracted X-ray Company staff on 5/6/20 at 12:05 PM identified that the order for the X-ray was called in by the facility at 11:00 AM and the X-ray was taken at 10:10 PM and the X-ray results were faxed to the facility on [DATE] at 10:39 PM. Review of a nurse's note dated 4/28/20 at 8:41 AM identified that the resident was in bed with severe pain with movement, the X-rays showed femur fractures, the resident was medicated with the as needed [MEDICATION NAME] and was transferred to the emergency department. Review of hospital paperwork dated 4/28/20 identified that the resident was admitted to the hospital with [REDACTED]. The resident was also identified with closed fractures of the distal end of the left fibula and tibia. Interview with NA #5 on 5/5/20 at 2:03 PM identified that the resident was non-ambulatory, a Hoyer lift for transfers, and needed assistance with bed mobility. NA #5 stated that on 4/26/20 she provided incontinent care to the resident prior to and after breakfast. NA#5 stated that she checked the resident for incontinence just after lunch, the resident was dry, and the bed was in the low position when she left the room. NA#5 identified that she left the facility around 1:00 PM that day, and had reported off to NA#1 and NA #2 prior to leaving. NA #5 stated that although she was unsure of how the resident could have fallen out of bed, the resident often played with the bed controls and would elevate the height of the bed to a high level. Interview with NA#2 on 5/6/20 at 2:00 PM identified that she had gone into Resident #1's room because the roommate was ringing the call bell. When NA#2 entered the room she noted that Resident #1 required incontinent care, and told the resident she would be back with another NA to assist with the incontinent care. NA #2 identified that the 1/2 side rails were up in the bed and the resident was not aware that he/she required incontinent care. The resident was not anxious, restless, or agitated at the time and she left to get another NA and to get supplies. She stated that as soon as she left the room she told another NA that Resident #1 needed assistance. When they went to gather supplies, they heard a noise, and the resident was found on the floor. NA #2 could not identify how the resident could have fallen out of bed, as he/she was non ambulatory and required a Hoyer lift for transfers. NA #2 could not recall the height of the bed prior to leaving the room but identified that Resident #1 tends to play with the bed controls and has a habit of putting the height of the bed in a high position. Interview with Licensed Practical Nurse (LPN) #1 on 5/6/20 at 4:30 PM identified that on 4/26/20 she heard screaming for help, and as she entered Resident #1's room she saw the resident on the floor in a kneeling position. Then the resident fell forward onto the floor with his/her face hitting the floor. LPN #1 identified that the supervisor was called, the resident was assessed and then placed back to bed with a Hoyer. LPN #1 stated that when she entered the room the 1/2 side rails were in place, and she was unsure how the resident had fallen out of bed, but the bed was high, and not at a safe level. LPN #1 identified that the resident had a known behavior of elevating the height of the bed with the bed controller. Interview with NA #1 on 5/5/20 at 2:03 PM identified that she was approached by NA #2 and told that Resident #1 required incontinent care. NA #1 went to gather supplies and before they could get to the room, they heard a noise. Staff went running to the room and she saw the resident on the floor. When NA #1 entered the room she noted that the bed was in a high position. NA #1 identified that the resident had a habit of leaving the bed in a high position because he/she had a habit of playing with the bed controls. NA#1 further stated that the resident was totally dependent for bed mobility, was non ambulatory required a Hoyer lift for transfers and she was unsure of how the resident had fallen out of bed. Interview with LPN #5 on 5/7/20 at 12:00 PM identified that she was Resident #1's primary nurse and the resident had a long history of elevating the bed to a high level with the controllers, usually higher than it should be. Review of the NA care card and plan of care failed to identify that Resident #1 had the behavior of elevating the height of the bed and did not identify interventions to address the behavior. Interview with the regional nurse on 5/8/20 at 12:48 PM identified that she reviewed the plan of care and noted that the resident's behavior of using the bed controls to elevate the height of the bed to a high position was not addressed in the care plan and it should have been. Review of the comprehensive care plan policy identified that the care plans should address resident problems in order to properly care for the residents. b. Review of a reportable event dated 4/26/20 at 2:45 PM identified that the resident was observed on the floor next to the bed sitting up with legs and knees beneath him/her yelling for help, then the resident fell forward onto his/her face. Review of nurse's notes on 4/27/20 from 11:08 AM through 12:23 PM identified that the resident complained of extreme pain in the bilateral lower extremities and back. The Advanced Practice Registered Nurse (APRN) was notified and ordered X-rays for the bilateral knees and the lumbosacral area and the orders were called to the X-ray company at 11:08 AM. The resident was also examined by APRN #1 on 4/27/20. An APRN note dated 4/27/20 (untimed) identified that the resident had a fall onto his/her knees, went forward and hit his/her face on the floor, the left upper lip was swollen and had one tooth missing. The resident complained of knee and ankle pain, but denied facial pain. The resident's pain level was a 7 (out of 10) in the knees and back, and rest had eased the pain. An X-ray of the lumbar spine and bilateral knees was ordered, and a dental consult when possible due to a loose and missing tooth. Review of radiology results report dated 4/27/20 at 10:28 PM identified that the X-ray was taken at 10:10 PM and the results were reported at 10:28 PM. Results identified an acute right femur fracture and an acute left femur fracture. A nurse's note dated 4/28/20 at 06:51 AM (for the 11:00 PM to 7:00 AM shift on 4/27-4/28/20) identified that the resident was alert and verbal and was status [REDACTED]. Neurological checks were within normal limits, there was positive Range of Motion (ROM) and Color Motion and Sensitivty (CMS). The upper lip remained bruised and swollen and a treatment was in place. The resident did not complain of any pain or discomfort and slept without incident. The documentation failed to include the X-ray results reported on 4/27/20 at 10:28 PM. Review of a nurse's note dated 4/28/20 at 8:41 AM identified that the resident was in bed with severe pain with movement, the X-rays showed femur fractures, the resident was medicated with the as needed [MEDICATION NAME] and was transferred to the emergency department. Interview with the facility contracted X-ray Company staff on 5/6/20 at 12:05 PM identified that the order for the X-ray was called in by the facility at 11:00 AM and the X-ray was taken at 10:10 PM. The X-ray Company staff further identified that the expectation is that the X-ray will be taken the same day, unless it is ordered STAT and then priority would be given to get the X-ray as soon as possible. This X-ray was not ordered stat. The X-ray Company staff stated that the X-ray results were faxed to the facility on [DATE] at 10:39 PM, and the X-ray Company staff attempted to call the facility several times throughout the night, but the phone rang over and over, and was never answered by staff. Interview with RN #3 on 5/6/20 at 4:46 PM identified that she was the nursing supervisor on 4/27/20 on the 3:00 PM to 11:00 PM shift and she had helped the X-ray technician take the X-rays on Resident #1. RN #3 identified that she reported to RN #1 during nursing shift report that the X-rays had been taken on the 3:00 PM to 11:00 PM and told RN #1 to look out for the X-ray results. Interview with LPN #2 on 5/8/20 at 10:44 AM identified that he worked the 3:00 PM to 11:00 PM shift on 4/27/20 and reported in nursing report to LPN #4 that Resident #1 had a pending X-ray. Interview with Nurse Aide (NA) # 3 on 5/6/20 at 5:00 PM identified that she had cared of Resident #1 on 4/27-4/28/20 on the 11:00 PM to 7:00 AM shift. NA #3 stated that the resident had pain with positioning throughout the shift. She stated that on second rounds she had NA #4 help her when Resident #1 needed incontinent care, and when turning the resident she was screaming my legs, my legs. NA#3 asked her what was wrong and the resident stated that he/she had pain in his/her legs. NA#3 stated that she reported this pain to LPN #4. Interview with NA #4 on 5/7/20 at 6:45 AM identified that she assisted NA#3 with Resident #1's incontinent care and repositioning on 4/27-4/28/20 and that the resident was complaining of pain when moved. NA #4 stated that she and NA #3 reported the resident's complaints of pain to LPN #4. Interview with LPN #4 on 5/6/20 at 5:00 PM identified that she was the charge nurse for Resident #1 on 4/27 into 4/28/20 on the 11:00 PM to 7:00 AM shift. She identified that she was aware that the resident had fallen the day before, but was not aware that an X-ray had been taken the shift before. LPN #4 identified that she assessed Resident #1 for Color Motion and Sensitivity (CMS) and Range Of Motion (ROM) and asked the resident to push her hands with his/her feet and the resident did so without any complaints of pain and ROM and CMS were within normal limits. She further identified that NA #3 and NA #4 never informed her that the resident complained of pain during repositioning and if she had been informed she would have called the supervisor for an assessment and medicated the resident for pain. Additionally, LPN #4 identified that if she had been aware that the resident's X-ray was taken, she would have checked the fax machine and called the X-ray Company to check for results. Interview with Registered Nurse (RN) #1 on 5/7/20 at 11:47 AM who was the nursing supervisor on 4/27-4/28/20 on the 11:00 PM to 7:00 AM shift identified that she received in nursing report that Resident #1 had fallen the day before, but was not informed that X-rays were taken on the previous shift (3:00 PM to 11:00 PM on 4/27/20). She further identified that she checks all fax machines once a shift at the beginning of her shift, and she had not seen any faxes at that time. She stated that if she had been informed that the resident had a pending X-ray she would have been checking the fax machines, and if nothing had come through, she would have called the X-ray Company for results. RN #1 further stated that during the 11:00 PM to 7:00 AM shift the phones ring on the units and available staff will answer the phone. Interview with RN #2 (unit manager) on 5/7/20 at 10:45 AM identified that on 4/28/20 in the morning time she was walking down the hallway and heard Resident #1 yelling and asked the resident what was wrong and was told that her legs were hurting. RN #2 examined the resident's legs which were free from [MEDICAL CONDITION], bruising or any visible deformities. At that time she went to the computer and looked up the resident's X-ray results which identified that the resident had bilateral femur fractures. RN #2 called the APRN and the resident was sent to the emergency department (approximately 12 hours after the results of the X-ray identified bilateral femur fractures). RN #2 identified she was not aware of any X-ray results that may have been faxed to the facility. Interview with APRN #1 on 5/6/20 at 4:15 PM identified that she did not order a STAT X-ray on 4/27/20 because the resident was not in any distress at the time of the exam, only complained of pain when his/her legs were moved, and at the time of the exam the resident was stable. She further identified that she would expect that nursing staff follow up as soon as possible to obtain the X-ray results, and if no results were faxed that the facility staff should call the X-ray company and inquire about the results. APRN #1 identified she would expect to be notified at any time of the night due to the seriousness of the injury. Interview with the regional director of clinical operations on 5/8/30 at 12:48 PM identified that it would be the expectation that the nurse's communicate in report that an X-ray is pending and for the nurses to follow through on pending results. She further identified that she was unsure why the results were not identified until the morning of 4/28/20. Additionally, the facility deterimed the fall on 4/26/20 had caused Resident #1's fractures. Review of hospital paperwork dated 4/28/20 identfied that the resident was admitted to the hospital with [REDACTED]. c. Review of a post-accident monitoring sheet identified that documentation was initiated on 4/26/20 at 3:00 PM and continued every shift and included vital signs, skin integrity, range of motion, level of consciousness and pain for 72 hours. Review of monitoring documentation for 4/27/20 on the 3:00 PM to 11:00 PM shift identified that the resident had a bruise, but failed to include vital signs, skin integrity, range of motion, level of consciousness and pain. The clinical record also failed to identify a nurse's note for 4/27/20 on the 3:00 PM to 11:00 PM. Interview with Licensed Practical Nurse (LPN) #2 on 5/8/20 at 10:44 AM identified that he worked on 4/27/20 on the 3:00 PM to 11:00 PM shift and was informed that Resident #1 had fallen the day before and that an X-ray was ordered for the bilateral legs and back. LPN #2 did not recall that the resident had any pain, and identified that he medicated the resident with his/her scheduled [MEDICATION NAME]. LPN #2 stated that after a fall there should be post fall resident monitoring documented each shift for 72 hours and if there was no nurse's note, he probably entered the information on the post fall monitoring sheet, however the only entry on the monitoring sheet for 4/27/20 on the 3:00 PM to 11:00PM shift was facial bruising. Interview with the regional director of clinical operations on 5/8/20 at 12:48 PM identified that after a fall the resident is monitored every shift for 72 hours, and that information should be documented in the clinical record. Review of the fall policy identified that the resident will be monitored for 72 hours after the fall as some injuries may not be apparent immediately after a fall.

Review of facility documentation, clinical record review, and interviews for one of three residents reviewed for falls (Resident #1), the facility failed to contact the physician as directed when pain continued after a fall. The findings include: Resident #1 had [DIAGNOSES REDACTED]. A quarterly Minimum (MDS) data set [DATE] identified that the resident had intact cognition, and required total care with activities of daily living. A fall care plan dated 3/7/20 identified that the resident was at risk for falls related to gait/balance problems, incontinence, and [MEDICAL CONDITION] medication with interventions that included to anticipate the resident's needs, ensure call light is within reach and encourage the resident to call for assistance as needed. Review of a reportable event dated 4/26/20 at 2:45 PM identified that the resident was observed on the floor next to the bed sitting up with legs and knees beneath him/her yelling for help, then fell forward onto his/her face. Review of a nurse's note dated 4/26/20 at 3:12 PM identified that the resident had a fall and was found sitting on his/her knees, and then fell forward hitting his/her face on the floor. The resident was assessed and the upper body range of motion was within normal limits and the lower extremity range of motion was at the patient's baseline. There was no internal or external rotation of the lower extremities, however the resident did complain of bilateral knee and ankle pain. The Advanced Practice Registered Nurse (APRN) was notified and based on the position the resident was found in, felt X-rays were not necessary at that time, and to call back if the resident continued to complain of pain. Review of a nurse's note dated 4/26/20 at 6:34 PM (3 hours after the fall) written by Licensed Practical Nurse (LPN) #7 identified that the resident was status [REDACTED]. Interview with LPN #7 on 5/6/20 at 2:00 PM identified that she had worked 3:00 PM to 8:00 PM on 4/26/20 and when she was doing her medication pass, the resident complained of pain in his/her lower extremities. She medicated the resident with the Tylenol and scheduled [MEDICATION NAME]. She did not inform the supervisor that the resident complained of pain because she was not aware that the APRN wanted to be notified if there were any further complaints of pain. Interview with Registered Nurse #4 on 5/6/20 who supervised on 4/26/20 from 7:00 AM to 7:00 PM identified that according to her conversation with APRN #2 after the resident's fall, the APRN wanted to be notified if the resident complained of pain after the initial complaints of pain at the time of the fall. RN #4 stated that LPN #7 did not inform her that the resident complained of pain in the lower extremities if she had been informed she would have called the APRN back for further instruction. RN #4 stated that she had informed LPN #7 about reporting the pain. Interview with APRN #2 on 5/6/20 at 2:30 PM identified that she was informed of the resident's pain in the bilateral lower extremities at the time of the fall, however she thought the pain could have been due the resident sitting on her knees at the time of the fall. APRN #2 identified that the reason she did not initially order the X-rays was because there was no deformity. APRN#2 further identified that she had directed RN #4 to inform her if the resident continued to complain of pain, she would expect to be notified of continued pain and would have ordered X-rays at that time. The physician notification policy identified that the physician should be notified when there is a need to alter treatment significantly.

Based on a review of clinical records, facility documentation, interviews, and policies, for one six residents reviewed for medication administration ( Resident #19), the facility failed to ensure the that resident received a medication in accordance with a physician's orders [REDACTED]. The significance of the error resulted in Immediate Jeopardy (IJ). On 8/8/18 the facility immediately did education on the medication and/or the five rights of medication administration, conducted audits of physician orders, and audits to ensure medications were administered in accordance with the orders. On 4/11/19, compliance with the action plan was verified resulting in Immediate Jeopardy past non-compliance. The finding includes: Resident #19 had [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of bloodwork dated 7/9/18 identified a platelet level of 314 (normal level is 150-450), and a Hemoglobin (Hgb) level of 7.9 (normal level is 12.5 to 16), and a White Blood Cell (WBC) count of 9.3 (normal level is 5 to 10). A quarterly minimum data set assessment dated [DATE] identified that the resident was cognitively intact and required extensive assistance with activities of daily living. A care plan dated 7/25/18 identified that the resident had a history of [REDACTED]. Review of a report of consultation dated 7/25/18 identified that the resident had been seen by his/her rheumatologist, the exam was negative for tenderness and/or swollen joints, with recommendations to reduce [MEDICATION NAME] to 10 milligrams (mg) every week. Review of a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of a nurse's note dated 8/7/18 identified that the resident was noted with swollen cheeks, and a moderate sized bump on the left outer cheek with increased complaints of pain noted. Upon assessment the resident was unable to open his/her mouth wide enough to thoroughly inspect the oral cavity, but white patches were noted on the left cheek and gum line also with increased pain. The Advanced Practice Registered Nurse (APRN) was called and ordered a dental consult, a clear liquid diet, warm water rinses, [MEDICATION NAME] 875 mg for 10 days, a Complete Blood Count (CBC) and a Complete Metabolic Panel (CMP) were ordered for a dental infection. Review of a medication incident report and investigation dated 8/8/18 identified that the resident had been seen by his/her rheumatologist on 7/25/18 with recommendations for the [MEDICATION NAME] to be reduced to 10 mg weekly. The order was transcribed into the electronic medical record on 7/27/18 to be administered daily, the resident received a total of 13 doses, 11 doses in error. The APRN was notified and consulted with the physician with new orders to start intravenous fluids for a total of 5 liters, complete blood counts daily, and the [MEDICATION NAME] was discontinued. Review of the APRN progress notes dated 8/9/18 identified that the resident had acute mucositis with ulcerative areas in the bilateral mucosa possibly due to the increased dosing of the [MEDICATION NAME]. Antibiotics will continue to minimize risk of a bacterial infection, the folic acid will be increased, and IV fluids will continue at 75 milliliters (ml) an hour, the diet will be changed to puree foods and will be upgraded as possible with ensure nutritional supplement to help with nutritional needs. Review of an APRN progress note dated 8/10/18 identified that the resident was being treated for [REDACTED]. The blood work was reviewed and WBC count was 2.4 (normal level is 5 to 10), Hgb was 7.3 (normal level is 12.5 to 16) and platelets were 89 (normal level is 150-450), with a [MEDICATION NAME] level of 0.5 (normal is less than 0.01). Luecovorin (a medication that is used for an antidote for [MEDICATION NAME] toxic) 15 mg every 6 hours has been started and will continue until [MEDICATION NAME] level decreases to less than 0.1. The patient received 4 liters of IV fluids and when the IV site infiltrated and resident refused to have another IV site inserted. Review of an APRN progress note dated 8/13/18 identified that the WBC was 3.2, Hgb was 7.4, and the platelet count was 31. The family member was called and informed of bloodwork, and although the resident had previously stated that s/he did not want a transfusion, The APRN informed the family that if platelet count dropped below 20 the resident would need to have a platelet transfusion. Review of an APRN progress note dated 8/14/18 identified that the WBC had dropped to 2.6, the Hgb had dropped to 7.1 and the platelet level was 20, the resident agreed to a transfer to the emergency department for a platelet transfusion. Review of the nurse's notes from 8/9/18 through 8/14/18 identified that the resident continued to complain of oral pain that was treated with [MEDICATION NAME] and topical [MEDICATION NAME]. Review of the hospital record dated 8/17/18 identified that the resident was admitted on [DATE] with [MEDICATION NAME] toxicity from erroneous ingestion of [MEDICATION NAME]. The patient had mucositis, leukopenia, a drop in platelets, and increased bleeding form oral sores. The patient had worsening [MEDICAL CONDITION] and remained at high risk for increased bleeding and an intracranial bleed, and required an inpatient stay for a blood and platelet transfusion. Interview with Registered Nurse (RN) #1 on 4/9/19 at 2:00 PM identified that when Resident #19 returned from the rheumatologist on 7/25/18 she reviewed the consult and identified that the resident's [MEDICATION NAME] order had recommendations to be decreased to 10 mg weekly. RN #1 called the APRN to verify the weekly dosing of the [MEDICATION NAME] 10 mg, and when placing the order in the Electronic Medical Record (EMR) entered the [MEDICATION NAME] 10 mg to be administered daily instead of weekly, she further identified that when entering the order into the EMR, there is a drop down box to enter dosage times, and she accidentally entered daily instead of weekly. RN#1 further identified that she did not enter the [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse (LPN) #4 on 4/11/19 at 6:30 AM identified that on the 11:00 PM to 7:00 AM shift the nurses are responsible for verifying that orders are entered correctly. She further stated that she will take the physicians order and ensure that it is entered correctly into the EMR, and since she was unaware that the medication order came from a consult, she did not check the consult for verification, and furthermore was not aware that [MEDICATION NAME] should only be given weekly for a resident with RA. Interview with LPN #5 on 4/9/19 at 11:30 AM identified that she was doing the medication pass upon return from her vacation on 8/8/18 and noted that the [MEDICATION NAME] order was daily, when she was aware that the resident normally received it weekly, she then notified her supervisor of the error. Interview with the Director of Nurses on 4/9/18 identified that RN#1 entered the [MEDICATION NAME] 10 mg order daily into the EMR, instead of weekly. The error was found upon the charge nurse's return from vacation on 8/8/18. The DON further identified that 8 different nurses worked on the unit while the charge nurse was on vacation between 7/26/18 and 8/8/18, all were unaware that [MEDICATION NAME] should not be given daily for residents with RA. The DON further identified that if a nurse is uncertain of a drug he/she is administering and/or dosing of a medication she should either look up information on the medication and/or call the physician for clarification. Interview with APRN #2 on 4/9/18 identified that when she was notified of the medication error on 8/8/18 she consulted with the medical director on the course of treatment for [REDACTED]. The Leucovorin was ordered because the [MEDICATION NAME] level was elevated at 0.5, and blood work was monitored daily, until 8/14/18 when the platelet level dropped to 20 and a transfer to the hospital was necessary. Interview with Physician (MD) #1 on 4/10/18 at 12:10 PM identified that [MEDICATION NAME] is not given daily for a resident with RA, but weekly. [MEDICATION NAME] is mostly given daily [MEDICAL CONDITION] patients receiving [MEDICAL CONDITION], and can be a very toxic medication. The resident experienced [MEDICATION NAME] toxicity with corresponding mouth ulcerations and decreased blood counts which required hospitalization . The resident and family refused transport to the hospital for a transfusion, up until 8/14/18 when the platelet level dropped to 20, a discussion with the resident and family was held about the urgency to be transferred to the hospital to decrease the risk of bleeding, and the resident and family agreed to the transport. Interview with Pharmacist Supervisor #1 from the facility's contracted pharmacy on 4/8 /19 at 1:30 PM identified that pharmacist #1 had reviewed the [MEDICATION NAME] order sent by the EMR on 7/26/18, she further identified that the pharmacist should always check the medication dosing with the [DIAGNOSES REDACTED]. The Pharmacy supervisor stated that the guidelines for [MEDICATION NAME] dosing for a patient with [MEDICAL CONDITION] arthritis should be weekly. The supervisor further identified that if the [DIAGNOSES REDACTED].#1 would have called the facility to question the daily order. She further identified that the [DIAGNOSES REDACTED]. Attempts to reach pharmacist #1 were unsuccessful. Review of a memorandum from the facility's pharmacy dated 8/10/19 identified that effective immediately, all [MEDICATION NAME] orders would be flagged with an alert. This alert will appear during order entry, initial review, and the final review screen. All pharmacists will be required to initial that the [MEDICATION NAME] order was evaluated for clinical appropriateness. Review of the medication administration policy identified that medication orders will be accurately transcribed and executed to ensure accurate administration of all physician's orders [REDACTED]. The facility immediately implemented corrective measures on 8/8/18 that included RN#1 receiving disciplinary action for the error in transcription. The facility provided staff education regarding dosing and frequency of residents receiving [MEDICATION NAME] for [MEDICAL CONDITION] arthritis, the five rights of medication administration, and second nurse verification once an order is noted, as well as a verification of the order on the 11:00 PM to 7:00 AM shift, all education began on 8/8/18 when the error was identified, and staff were educated before the start of subsequent shifts. The DON immediately audited Resident #19's medications for accuracy and any resident who had received new orders on consults, these audits continued weekly for 4 weeks and then randomly monthly and continue to be conducted with no further medication errors noted.

Based on review of the clinical record, facility documentation and interviews for one of three residents (Resident #213) reviewed for accidents, the facility failed to provide adequate supervision and/or follow the plan of care to prevent an accident with injury. The findings include: Resident #213's [DIAGNOSES REDACTED]. A physical therapy screen dated 3/22/10 identified to transfer the resident with assistance of two for safety. The annual Minimum Data Set ((MDS) dated [DATE] identified short and long term memory problems, severely impaired cognitive skills and extensive assistance of two staff for transfers. The care plan dated 5/11/10 identified the resident was non-ambulatory with interventions that included to transfer out of bed to a customized wheelchair with the assistance of two staff with the use of a gait belt. The nurse aide assignment dated 7/7/10 identified to transfer the resident with assistance of two with a gait belt. The nurse's note dated 7/13/10 indicated Nurse Aide (NA) #1 reported the resident's right hip looked protrusive and was not the resident's baseline. The physician was notified and an x-ray was ordered. An x-ray report dated 7/13/10 identified an oblique fracture through the proximal femoral diaphysis and the resident was sent to the Emergency Department for treatment. Interview with NA #1 and NA #2 on 4/27/11 at 3:00 PM indicated the resident was lifted out of bed by grasping the resident under the arms and behind the knees. NA #1 further indicated she sought the assistance of NA #2 to lift the resident back to bed because she thought it would be easier to lift the resident instead of doing a stand-pivot transfer. After the resident was in bed and during the process of care, NA #1 stated she noted the resident's hip to be protruding and reported it immediately to the charge nurse. Interview with physician (MD) #1 on 4/28/11 at 10:20 AM indicated that although the resident was frail and probably had osteoporosis, the fracture was most likely caused by the nurse aides lifting the resident back to bed.