Every finding on record at Regency Park Nursing & Rehab Center of Jefferson

Based on clinical record reviews, facility investigation review, staff interviews, and policy review, the facility failed to provide adequate nursing supervision to prevent a resident to resident altercation for 2 of 4 residents reviewed (Resident #1 and Resident #2). The facility reported a census of 43 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS identified Resident #1 was independent with bed mobility and all transfers. The MDS included diagnoses of non-alzheimer's disease, bipolar disorder and schizophrenia. The Care Plan with a target date of 5/27/26 documented Resident #1 may have episodes of behaviors and potential for behaviors as evidenced by being combative, negative verbalizations, name calling, refusal of medications/care, resistance to care, attempts to leave building, crying episodes, screaming out, attention seeking behaviors, hallucination and delusions. The care plan directed staff to intervene as necessary to protect the rights and safety of the other residents. 2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 01, indicating severely impaired cognition. The MDS identified Resident #2 was independent with bed mobility and all transfers. The MDS included diagnoses of non-Alzheimer's disease and unspecified dementia with agitation.The Care Plan with a target date of 8/4/26 documented Resident #2 has the potential to be physically/verbally aggressive as evidenced by hitting, kicking, biting, spitting on staff/other residents, screaming out, and using profanity. The care plan identified Resident #2 was involved in two resident to resident altercations in April 2026. The care plan directed staff to provide one on one supervision as needed at times of agitation. The Progress Note dated 4/26/26 at 1:20 PM revealed Resident #2 entered Resident #7's room and was yelling to get out of her house. Staff A, Licensed Practical Nurse (LPN) stepped between the resident and attempted to verbally redirect Resident #2 out of Resident #7's room when Resident #2 slapped Staff A on the arm with an open hand. Staff B, certified nursing assistant (CNA) directed Resident #2 out of the room to calm down and take her afternoon medications. The Incident Report (IR) titled Resident to Resident dated 4/26/26 at 1:30 PM documented Staff C, CNA was coming on shift, walked into the unit dining room and saw Resident #2 hit Resident #1 one time on the top of the head with an open hand. Staff C reported Resident #2 was telling Resident #1 to get out of her house. Staff A, LPN documented she witnessed Resident #2 yelling at another CNA saying he doesn't pay to be here. The IR documented the immediate action was for one on one supervision with Resident #2 until further notice. The undated facility investigation titled DIAL Summary Report documented prior to the incident, Resident #2 was sitting in the recliner and Resident #1 was sitting at the table in an open room which included both the common area and dining room. Staff B, CNA had stepped out of the dining room to go to the bathroom. When Staff C, CNA arrived for her shift in the memory care unit, Staff C witnessed Resident #2 hit Resident #1 on the top of the head one time. The conclusion/root cause analysis documented a brief lapse in supervision during shift change, combined with the open layout of the unit, allowed interaction to occur before staff could intervene. The hand written statement dated 4/28/26 by Staff B, CNA documented at the time of the incident she was using the bathroom. Before Staff B left to use the bathroom, Resident #1 was sitting at the table and Resident #2 was sitting in her recliner. On 6/1/26 at 12:49 PM, Staff C, CNA reported she walked into the unit to report for work and saw Resident #2 standing by Resident #1 in the dining room. She said Resident #2 took her open hand and popped Resident #1 in the forehead area. Staff C reported Resident #2 was agitated and made comments that it was her home. She said Resident #1 made the comment that Resident #2 had hit him. Staff C reported if she needed help she would push the button for help. She said the button was on the keys that she carried in her pocket. When asked what she does when she needs to go to the bathroom, she said she would push the button and another staff member would come back to the unit to replace her. She said the employee bathrooms are located outside the unit.On 6/1/26 at 12:55 PM, Staff B, CNA reported Resident #2 was in the recliner watching TV and Resident #1 was sitting at the table in the dining room when she went to the bathroom. She said the staff outside the unit are not always able to relieve you when you need to go to the bathroom so she would use the resident's bathrooms in the unit. She said she used the bathroom in room [ROOM NUMBER]. She said she was only gone a couple of minutes, long enough to go to the bathroom. She said Staff C, CNA told her that Resident #2 was over by Resident #1 and Resident #2 had hit Resident #1 on the head. Staff B reported prior to the incident, Resident #2 tried to enter Resident #7's room and Staff A, LPN and herself had tried to redirect her out of the room. She said Resident #2 thought Resident #7 had not paid rent. She said she took Resident #2 back to her room and she laid down for a little bit. She said Resident #2 came back up the hallway and ended up in the living room in the recliner.On 6/1/26 at 1:50 PM, Staff A, LPN reported 20-30 minutes prior to the incident on 4/26/26, Resident #2 was in Resident #7's room. She said Resident #2 was upset that Resident #7 was in her house and not paying to be there. She said Resident #2 was redirected out of the room and immediately calmed down when Resident #7 was not in her vision. She said she instructed Staff B, CNA to stay with Resident #2 and to call her if she needed any help. She said about 15-20 minutes later, Staff C, CNA who was reporting to work walked into the dining room and saw Resident #2 yelling at Resident #1 and Resident #2 hit Resident #1 on the head. She said Staff B, CNA was not in the dining room during the incident. Staff A said she thought it was the same type issue as Resident #2 thought Resident #1 was in her house. On 6/2/26 at 12:01 PM, Staff D, CNA reported working in the memory care unit was not an easy task. She said it was very difficult due to Resident #2's agitation and Resident #8 trying to escape constantly. She said Resident #9 wants constant attention and yells out. When asked if she felt she was able to provide adequate supervision, she said not really. She said breaks are hit and miss. She said she would call for staff to relieve her but half of the time you don't get a response. She said in the unit you feel locked in and nobody cares about you. On 6/2/26 at 3:00 PM, the Director of Nursing (DON) stated it was an expectation when the staff member in the memory care unit needed to use the bathroom to call for assistance so a staff member could relieve them. She verified the employee bathrooms are outside the unit. The facility policy titled Accidents and Supervision dated 2025 documented the resident environment to remain as free of accident hazards as possible. Each resident to receive adequate supervision and assistive devices to prevent accidents. The policy documented supervision was an intervention, a means of mitigating accident risk and the facility would provide adequate supervision to prevent accidents. Adequacy of supervision was defined by type and frequency and based on the individual residents' assessed needs and identified hazards in the resident environment.

Based on observations, staff interviews and policy review, the facility failed to prepare and serve food under sanitary conditions to reduce the risk of contamination and food borne illness. The facility identified a census of 43 residents. Findings include: On 12/30/25 at 10:52 AM, observed the Dietary Manager puree a grilled turkey [NAME] sandwich while wearing gloves. When finished with pureeing the sandwich, the Dietary Manager removed her gloves and then proceeded to wash out the dishes used to puree the sandwich in the sink, put the dirty dishes in the dishwasher and then continued to puree the next food items without washing her hands. On 12/30/25 at 11:30 AM, observation revealed the Dietary Manager wore gloves to get the room trays ready to be delivered to the unit. During the process, the Dietary Manager touched each grilled turkey [NAME] sandwich with her gloved hands, then served the potatoes and peas with a utensil, then with her gloved hands took a cookie out of the plastic container and put the cookie on the tray. The Dietary Manager touched multiple items on the steam table and opened the refrigerator door and removed items from the refrigerator wearing the same pair of gloves. After room trays were assembled, she proceeded to wear the same pair of gloves and finished cooking a grilled cheese sandwich on the stove. The Dietary Manager obtained a spatula from a drawer wearing the same gloves and then returned to the stove. She removed her gloves and did not wash her hands. She then dated and labeled a condiment container that was sitting on the counter and put the container in the refrigerator. She returned to the stove, removed the grilled cheese using the spatula, wrapped the grilled cheese in a piece of aluminum foil and placed it on the hot cart. She then pushed the hot cart down the hallway to the North end of the building to continue meal service. The Dietary Manager used hand sanitizer and applied gloves. The Dietary Manager picked up the sandwiches with her gloved hands from the steam table without using a utensil and put the sandwich on a plate to cut it with a knife. She then with her gloves hands served the potatoes and peas with a utensil and then took a cookie from the plastic container wearing the same gloves. The Dietary Manager wore the same pair of gloves throughout the meal service in the north dining room touching multiple items including food items and nonfood items. When finished serving in the North dining room, the Dietary Manager removed the gloves and proceeded to move the hot cart to the South dining room. The Dietary Manager washed her hands in the kitchen and applied gloves. The Dietary Manager continued to serve the sandwiches and cookies with gloved hands and not utensils. On 12/30/25 at 12:00 PM, the Dietician reported it was an expectation for the dietary staff to use utensils when serving food items such as sandwiches and cookies. The Dietician reported she would expect the staff to wash their hands before and after gloving. The facility policy titled Food Preparation and Service revised October 2017 documented gloves must be worn when handling food directly, however, gloves can become contaminated and/or soiled and must be changed between tasks. The policy documented gloves are single-use items and shall be discarded after each use.

Based on observation and staff interview, the facility failed to ensure resident's had a safe, clean, comfortable and homelike environment, with 2 recliners showing extensive wear. The facility reported a census of 43 residents. Findings include:On 12/29/25 at 12:40 p.m. observed Resident #50 in her room sitting in a recliner. The arms of the recliner had large areas of the top covering warn off. The area behind the head also warn off. On 12/29/25 at 1:30 p.m. the burgundy recliner in the common area (of the 300, 400 and 500 halls) showed the burgundy covering worn off at the the back of the head area. On 12/31/25 at 7:45 a.m. the Maintenance Staff (MS) brought another chair into Resident #50's room, and said another resident may be moving in. He stated the recliner already in the room would be a facility chair, and said it looked bad, and should be replaced. On 12/31/2025 at 9:16 AM the MS verified the burgundy chair in the common area belonged to the facility. The undated facility policy, Resident Environmental Quality, documented it was the policy of the facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. The facility must provide each resident with functional furniture appropriate to the resident's needs.

Based on observations, clinical record review, staff interviews, resident interviews and policy review, the facility failed to complete and document appropriate assessments and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being for 2 of 13 residents reviewed (Resident #12 and #4). The facility failed to document a gastrointestinal assessment and notify the physician when indicated for Resident #12. The facility also failed to implement interventions for Resident #4 with new skin issues. The facility reported a census of 43 residents.Findings include: 1. Resident #12's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #12 was dependent on staff for toileting hygiene and transfers to the toilet. The MDS documented Resident #12 was frequently incontinent of bowel and constipation was present. The MDS included diagnoses of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD)(progressive lung condition) and congestive heart failure (heart inability to pump blood causing fluid build up). The Care Plan with a target date of 2/25/26 documented Resident #12 had the potential for alterations in bowel patterns due to diagnosis of constipation and risk for bowel incontinence. The care plan directed staff to follow facility protocol for administration of stool softeners/laxatives/enemas and to observe for signs and symptoms of constipation and report to the Physician as indicated.The Orders- Administration Note dated 12/27/25 documented Miralax powder (laxative) 17 grams was given for constipation for day 5 with no bowel movement (BM). The note documented the medication was ineffective. The clinical record lacked documentation of a GI/bowel assessment. The Orders- Administration note dated 12/29/25 at 6:03 AM documented a bisacodyl suppository (stimulant laxative) was given for constipation. The clinical record lacked documentation of a GI/bowel assessment.Review of Task Form titled Bowel Elimination documented Resident #12 did not have a BM from 12/22/25 to 12/29/25 (7 days). On 12/29/25 at 1:32 PM, Resident #12 reported he strained for an hour and half that morning trying to have a bowel movement. He said his stool was hard. He reported the staff gave him some medication to help him go to the bathroom. Observed emesis basin with yellow vomit in the bed. Resident #12 reported he had gotten sick but did not know why. He said he had not eaten breakfast or lunch. On 12/30/25 at 8:30 AM, Resident #12 reported he was a little uncomfortable and continued to have a hard time passing stool. He reported there was half of the stool hanging out of his rectum and he needed some assistance removing the stool. On 12/30/25 at 8:45 AM, Staff C, Licensed Practical Nurse (LPN) reported the Director of Nursing (DON) elevated Resident #12's head of the bed to promote elimination. Staff C reported it was passed on in report that Resident #12 had a suppository yesterday and was effective. She said Resident #12 required a complete bed change due to the amount of BM.On 12/30/25 at 9:05 AM, observed Staff C, LPN assess Resident #12. Resident #12 reported that he was not feeling well and that he needed someone to help him with the stool that was coming out. Staff C listened to Resident #12 bowel sounds and reported his bowel sounds were hyperactive. She asked Resident #12 how his appetite was and he said terrible. He reported he did not eat anything yesterday. Resident #12 reported to Staff C that his stool was half way out, that he couldn't get it out and needed help. On 12/30/25 at 9:10 AM, Staff D, Certified Nursing Assistant (CNA) and Staff E, CNA entered the room to assist Staff C. The CNAs assisted with changing Resident #12's brief and completing incontinent cares. Resident #12 was incontinent dark BM in the incontinent brief. Observation revealed a piece of formed stool protruding from the rectal area. The CNA removed the stool with an incontinent wipe. After the stool was removed a small amount of brown liquid bm came out of the rectum. On 12/30/25 at 9:30 AM, Staff C, LPN revealed the facility had a bowel protocol that was kept in a binder at the nurses desk.The facility form titled BM Protocol revised 6/30/21 documented it was very important to strive for the best possible health for the resident. The protocol documented bowel movements must be monitored and intervention put in place as needed. The facility protocol documented the following:1. Milk of Magnesia (MOM) to be given on day 2 without a BM.2. Overnight nurse to give a suppository on day 3 if milk of magnesia was not effective. 3. Day shift nurse to complete a bowel assessment and contact the Physician if cathartics are not effective on day 4. On 12/30/25 at 9:50 AM, the DON reported she expected the staff to follow the facility BM protocol for Resident #12. The DON said she expected on day 2 with no BM for the staff to give MOM, on day 3 with no BM to give a suppository and on day 4 with no BM to give an enema. She said If there were no results after the enema she expected the staff to contact the Physician. She verified and acknowledged the staff was late on providing bowel interventions and did not follow the BM protocol. The DON reported she expected bowel assessments to be completed and documented when bowel interventions were completed. 2. Resident #4's MDS dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS identified Resident #4 required partial/moderate assistance with bed mobility and chair/bed to chair transfers. Resident #4's MDS included diagnoses of peripheral vascular disease (circulation problem in the legs), diabetes mellitus, chronic obstructive pulmonary disease (COPD)(progressive lung condition) and Parkinson's. The MDS documented Resident #12 was at risk for developing pressure ulcers/injuries and had moisture associated skin damage. The Wound Treatment Plan dated 10/9/25 documented a new skin area to Resident #4's left heel. The note documented the etiology of the left heel wound was friction/shearing. The area measured 2.1 centimeters (cm) x 1.8 cm x 0.1 cm with the following tissues identified: 30% pink epithelial, 70% clear fluid filled blister. The wound treatment plan directed to cleanse the left heel wound with cleanser of choice, apply skin prep topically every shift and as needed (PRN). The Wound Treatment Plan dated 10/16/25 documented a new area to Resident #4's right heel. The note documented the etiology of the right heel wound was friction/shearing. The area measured 1.0 cm x 0.5 cm x 0.1 cm with the following tissue identified: 30% pink epithelial, 20% red epithelial, 50% clear fluid filled blister. The wound treatment plan directed to cleanse the right and left heel wounds with cleanser of choice, apply skin prep and allow it to dry, then cover with a foam border. Change three times per week and PRN.The Care Plan dated 10/27/25 revealed Resident #4 was at risk for impaired skin integrity related to diabetes mellitus, Parkinson's and COPD. The care plan documented Resident #12 had discoloration to his left heel. The care plan lacked documentation regarding skin impairment to the right heel. Review of the Clinical Record lacked documentation a skin intervention was implemented to prevent friction/shearing on 10/9/25 when the left heel wound was identified. The clinical record revealed 7 days later on 10/16/25 an additional wound developed on the right heel related to friction and shearing. On 12/30/25 at 2:00 PM, the Assistant Director of Nursing (ADON) reported Resident #4's heel wounds were considered to be caused by trauma. The ADON reported the facility thought the areas developed due to Resident #4 causing friction and shearing to the back of his heels when trying to move in his wheelchair. On 12/31/25 at 8:30 AM, the Director of Nursing (DON) reported the staff were supposed to come up with a new skin intervention when a new skin issue had been identified. The DON verified additional skin interventions were not implemented when Resident #4's left heel ulcer was identified on 10/9/25.A facility policy titled Documentation of Wound Treatments dated 2025 documented the facility to complete accurate documentation of wound assessments and treatments, including response to treatment, change in condition and changes in treatment. The policy documented additional wound documentation to include effectiveness of current interventions and modification of interventions.

Based on observations, record review, staff interviews, and policy review, the facility failed to change oxygen tubing and water humidifier for 1 of 1 residents reviewed (Resident #12) for respiratory services. The facility reported a census of 43 residents. Findings Include: Resident #12's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD)(progressive lung condition) and congestive heart failure (heart inability to pump blood causing fluid build up). The MDS documented Resident #12 received oxygen while a resident within the last 14 days. A Physician order dated 11/7/25 directed Resident #12 to wear oxygen per nasal cannula to keep oxygen saturation above 90% as needed related to COPD. The order directed no more than 3 liters of oxygen for diagnosis of COPD.The Care Plan with a target date of 2/25/26 documented Resident #12 had altered respiratory status and required continuous oxygen. The care plan directed staff to administer oxygen via nasal cannula as ordered. The care plan lacked direction on when to change the oxygen tubing or water bottle. On 12/29/25 at 1:36 PM, observed Resident #12's oxygen concentrator running at 2 liters. The oxygen cannula/tubing was hanging from the shelf on the wall. Resident #12 reported that he only wore the oxygen during the day when his oxygen levels were below 90%. He said he wore the oxygen at night routinely. Observed the oxygen tubing and water bottle dated 12/5/25 and the water bottle was empty/dry. Review of the November and December 2025 Medication Administration Record (MAR) or Treatment Administration Record (TAR) lacked direction on how often to change the oxygen tubing and water bottle. On 12/30/25 at 10:00 AM, the DON reported she expected the oxygen tubing to be changed weekly and documented on the MAR. She said the tubing was normally changed on Fridays. She said Resident #12 had not been utilizing his oxygen when he first came to the facility so the order to change the tubing might have been missed. When asked how often the water bottle should be changed and water added to the bottle, she said she did not have a good answer for that. She said she would have to look at the policy. She said she would expect staff to add water to the bottle as needed. The facility policy titled Oxygen Concentrator dated 2025 documented the care of the concentrator included changing the oxygen tubing and mask/cannula weekly and as needed if it became soiled or contaminated and to change the humidifier bottle when empty, or weekly.

Based on observation, staff interviews, the Centers for Disease Control and Prevention (CDC) and the facility policy review, the facility staff failed to follow infection control practices in order to prevent and control the onset and spread of infection within the facility by not wearing the required personal protective equipment for 1 of 2 residents (Resident #4) reviewed for catheter care. The facility also failed to keep dirty linens off the floor. The facility reported a census of 43 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #4's MDS included diagnoses of benign prostatic hyperplasia (enlargement of prostate gland), renal (kidney) disease and obstructive uropathy (blockage in urinary tract preventing normal urine flow). The MDS revealed Resident #4 had an indwelling catheter (thin tube used to drain urine). The Care Plan with a target date of 12/31/25 documented Resident #4 required enhanced barrier precautions (EBP) due to the presence of an indwelling catheter. On 12/30/25 at 3:05 PM, observed a EPB sign posted on the back of Resident #4 door. The sign directed everyone must clean their hands, including before entering and when leaving the room. The sign directed providers and staff to wear gloves and a gown following high-contact resident care activities which included device care or use related to urinary catheters. On 12/30/25 at 3:32 PM, observed Staff A, Licensed Practical Nurse (LPN) and Staff B, Certified Nursing Assistant (CNA) empty Resident #4's urinary leg bag and perform cares to the suprapubic catheter site. Staff A and Staff B did not wear a gown when completing any of the catheter cares. Staff A and Staff B acknowledged that they did not wear a gown during catheter care. Staff A and B reported they had forgotten but were aware they were supposed to wear the gown. On 12/30/25 at 4:14 PM, the Director of Nursing (DON) reported she expected staff to wear gowns during high-contact activities which included taking care of the catheter. The facility policy titled Enhanced Barrier Precautions dated 3/25/24 documented EPBs are utilized to prevent the spread of multi-drug resistant organisms (MDR0s) to residents. The policy documented EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of a gown and gloves include indwelling device care or use such as a urinary catheter. 2) On 12/30/25 at 8:40 a.m. noted dirty linens (bedding) on the floor in room [ROOM NUMBER]. The resident was not in the room, and no staff were in the room. On 12/31/25 at 10:20 a.m. the DON confirmed dirty laundry and linens should not be on the floor. The undated facility policy for Handling Soiled Linen documented linen should not be allowed to touch the uniform or the floor.

Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 42. Findings include: A direct observation on 01/12/2025 at 10:23 AM of the kitchen revealed an open container of cottage cheese with a discard date of 01/11/2025. It also revealed an unmarked, undated meat product stored in the freezer in a single sheet of plastic cling wrap. The Dietary Manager identified the item as roast beef, and stated it had been prepared within a day or two of the observation. A direct observation on 01/14/2025 at 09:33 AM of the kitchen dining service Staff A, Cook, was observed wearing the same pair of disposable vinyl gloves while prepping three unique food items, touching different utensils, the walls, as well as other contaminated surfaces before returning to prepare ground meat for the lunch service. During the same observation, Staff A was witnessed coughing into the same pair of vinyl gloves without changing them. While preparing the ground meat, Staff A removed a paper menu from the wall and placed it on the clean preparation surface, then used the menu to place utensils used for preparing food on the menu. After having placed the utensils on the menu, and without having sanitized them, Staff A scooped freshly ground meat from the blender into the storage container. When the utensil Staff A was using proved to be too big to get all of the food out of the blender, Staff A utilized her soiled gloves from the above observation to scoop the remaining ground meat from the blender. Only then did Staff A change gloves and sanitize their hands. A direct observation on 01/14/2025 at 10:56 AM revealed Staff A coughing into ungloved hands. She did not perform hand sanitation, and continued to prepare food for lunch service. A direction observation of the lunch dining service on 01/14/2025 at 11:27 AM revealed the Assistant Director of Nursing (ADON) made direct ungloved contact with a pudding style dessert, then placed a lid on the dessert and carried it to a resident. While walking down the hall pudding could be observed on the ADON's ungloved hands. A direct observation of the lunch dining service on 01/14/2025 at 11:30 AM revealed the Director of Nursing (DON) holding resident plates with her thumbs on the top of the plate, this occurred again at 11:32 AM. In an interview on 01/14/2025 at 11:44 AM with the Registered Dietician, she acknowledged she had seen the same issues with dining service as the surveyor had. She stated the ADON should have replaced the food she made contact with, and the DON should not be touching the top of a plate being served to a resident. In an interview on 01/15/2025 at 01:23 PM with the Dietary Manager, she stated she had seen the ungloved contact with food occur on 01/14/2025 as well. She stated the food should have been disposed of and a fresh one offered to the resident. She stated it is prohibited to make ungloved contact with a resident's food. She acknowledged she had also seen the DON carry at least one plate by the top serving side, and confirmed that this action is also prohibited based on her knowledge of food safety protocol. She stated gloves have been an issue in the past with the facility, but staff should change gloves every time they switch to a new task. Gloves should have been disposed of and hand hygiene performed after coughing into hands. She acknowledged that placing serving utensils on soiled surfaces was prohibited, as was using soiled gloves to scoop food out of the blender. In an interview on 01/15/2025 at 01:47 PM with the Director of Nursing, she acknowledged she had made a mistake touching the top serving surface of several plates during lunch service the prior day. She stated she was kicking herself, and noted she does not normally serve food to residents but was attempting to assist her team during the survey process. She informed the surveyor that proper protocol is to hold a plate only from the bottom, avoiding any surface that a resident will eat from. Review of a facility provided document titled Food Preparation and Service, with a last revised date of October 2017, stated in a section labeled Food Service/Distribution, subsection four; food and nutrition service staff, including nursing services personnel, will wash their hands before serving food to residents. It further stated in subsection five staff must be free of communicable disease. It continued in subsection six to state bare hand contact with food is prohibited. Review of a facility provided document titled Food Receiving and Storage, last revised in July of 2014, stated all foods stored in the refrigerator of freezer will be covered, labeled, and dated.

Based on clinical record review, staff interviews, and facility policy review the facility failed to verify the resident's advanced directive choice for 1 (Resident #46) of 12 residents reviewed. The facility reported a census of 42 residents. Findings include: The Clinical Census Sheet dated [DATE], documented Resident #46 admitted to the facility on [DATE] and Code Status, Advanced Directive of Do Not Resuscitate (DNR). Observation on [DATE] at 10:38 AM, resident's hard chart with sticker Full Code (initiate cardiopulmonary resuscitation (CPR) in the event resident is not breathing and has no pulse) on the outside of the chart and the inside of the chart lacked an IPOST (Iowa Physician's Order for Scope of Treatment) (document that allows a person to communicate their preferences for key life-sustaining treatments). The resident's electronic health record, revealed an Order Summary Report, dated [DATE], with a physician's order dated [DATE] for DNR. Interview on [DATE] at 10:39 AM, Staff B, Certified Medication Aide, stated when looking for a resident's code status she looks at the sticker on the outside of the chart or the inside of the chart for the IPOST. The resident's Care Plan initiated [DATE] documented resident requests code status of DNR. The facility policy Advance Directives revised ,d+[DATE], documented the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Interview on [DATE] at 4:50 PM, the Director of Nursing (DON) confirmed the resident's outside of the chart had sticker for Full Code, no IPOST in the chart and had an order in the electronic health record for a DNR order. The DON stated her expectation for all documentation to match and be correct representing the resident's wishes.

Based on clinical record review, resident and staff interview the facility failed to followed a physician's order for 1 resident (Resident #1) of 12 residents reviewed. The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) for Resident # 1, dated 12/19/24, documented she scored 15 on the Brief Interview of Mental Status indicating intact cognition. The MDS included diagnoses of cerebral palsy, and documented received a scheduled pain medication regimen with frequent pain or hurting over the last 5 days. Interview on 1/14/25 at 10:22 AM, resident stated she is to receive a Lidocaine pain patch on her left shoulder every day and then removed at bedtime. The resident further stated the patch was not available today and there were also 2 weekends in December that the facility did not have the patch to apply to her. The resident stated the patch helps a lot with the shoulder pain. Review of the resident's Medication Administration Records documented the Lidocaine pain patch not available on the following dates in the past 3 months: a. 11/9, 11/10, 11/11,and 11/15/24 b. 12/4, 12/6, 12/7, 12/8, 12/9, and 12/10/24 c. 1/14/25 Interview on 1/14/25 at 3:30 PM, Staff C, Licensed Practical Nurse stated the resident's patch was not available today so she ordered it from the pharmacy and the patch will arrive later today. Staff C further stated there have been several times the patch was not available. Staff C stated the patch is usually ordered through the facility with stock medications but if the facility is out the patch can be ordered from the pharmacy. Staff C stated she did not notify the physician that the ordered medication was not available and does not normally notify the physician if the medication is an over the counter medication. Interview on 1/14/25 at 4:30 PM, the Director of Nursing stated her expectation was if the medication was not available at the facility, the staff need to order from the pharmacy and administer when delivered, to follow the physician's orders, and notify the physician when the patch was not administered.

Based on observation, record review, staff interviews, and facility policy review the facility failed to ensure a person that assisted a resident to eat was a certified paid feeding assistant for 1 (Resident #36) of 15 residents reviewed. The facility reported a census of 42 residents. Findings include: The MDS for Resident #36, dated 12/23/24, indicated a Brief Interview for Mental Status score of 99, indicating the resident was unable to complete the interview, indicated severe cognitive impairment for decision-making. Observation on 1/13/25 at 12:00 PM, in the dining room with the Assistant Director of Nursing present, the resident was assisted to eat by another resident's wife. Facility policy Assistance with Meals revised March 2022, documented facility staff will serve resident trays and will help residents who require assistance with eating. Interview on 1/13/25 at 3:57 PM the Director of Nursing stated expectation for family/visitors to not assist non-family member residents to dine.

Based on pharmacy interview, staff interviews, policy review and clinical record review the facility failed to keep accurate account of narcotic medications for 2 of 3 residents. On 8/12/24, staff discovered that Resident #1 had 8 milliliters (ml) of morphine missing, and Resident #2 had 12 ml missing. Staff admitted that they did not always look at the bottles at shift change before documenting the amount of remaining liquid morphine. Documentation of narcotics administered was inconsistent between the paper chart and the electronic chart for Resident #1 and #2. The facility reported a census of 39 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #2 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits). She required substantial assistance with dressing and showering, and was totally dependent for transfers. The census tab showed that Resident #2 was admitted to Hospice services on 5/2/24. A Progress Note dated 8/12/24 at 9:31 PM, showed that Resident #2 passed away at 7:45 PM that evening. The Care Plan for Resident #2, revised on 6/12/24, showed the she had impaired cognitive function and impaired ability to understand related to dementia. Staff were to administer medications as ordered and monitor for side effects. She was at risk for pain and discomfort related to a fractured ankle. Her diagnosis included: dysphagia, at risk for aspiration pneumonia, airway obstruction and dehydration. She elected to receive hospice care due to a terminal condition. The electronic Medication Administration Record (MAR) for Resident #2 showed an order dated 5/3/24 at 11:00 AM, for morphine sulfate solution 20 milligrams per milliliter (mg/ml) give 0.25 ml every 4 hours as needed (PRN) for pain or shortness of breath. According to the Individual Residents Controlled Substance Record (RCSR) for Resident #2, 30 ml of morphine was delivered to the facility (the document lacked date of delivery.) The RCSR showed that Resident #2 had 8 doses in May, none in June, 1 dose in July and 15 doses in August. The electronic MAR showed that no morphine had been given in the month of July, and just 14 doses in the month of August. According to the RCSR, on 8/12/24 at 7:30 PM, there was 24 ml remaining in the bottle of morphine (date of the residents passing). The Disposition of Remaining Doses showed that 12 ml had been destroyed by two nurses, the documentation was not dated. 2) The MDS assessment dated [DATE] for Resident #1, showed that she was admitted to the facility on [DATE]. She had a BIMS score of 0 (severe cognitive deficit). The resident was totally dependent on staff for eating, showering, dressing and transfers. She was receiving hospice services and had diagnosis that included; coronary artery disease, Alzheimer's Disease, cerebrovascular accident (CVA), Parkinson's Disease and bipolar disorder. The Care Plan for Resident #1, updated on 6/21/24, showed that the resident was at risk for discomfort related to contractures, stiffness in joints and Parkinson's. Staff were directed to administer pain medication and evaluate for effectiveness. Resident #1 elected for hospice care due to a terminal condition. The MAR for month of July 2024 showed Resident #1 had an order dated 12/17/2021 for morphine sulfate solution 5 mg/ml, give 0.25 ml every 4 hours PRN for breakthrough pain as resident allowed. On 9/10/24 at 12:01 PM a representative from the pharmacy said that they delivered one bottle of 30 ml morphine on 7/8/24 for Resident #1, and that was the first time they sent morphine to the facility for that resident. The RCSR for Resident #1 showed that the morphine was used 7 times in July and 1 time in August. The MAR for July showed that the morphine had been administered 6 times in July and not at all in August. The Individual RCSR for Resident #1 showed that after a dose of morphine was administered on 8/11/24 at 9:15 AM, the bottle contained 28.00 ml. On 8/12/24 at 2:30 PM, Staff F, Licensed Practical Nurse (LPN) and Staff E, Assistant Director of Nursing (ADON) signed a note that stated: bottle spilt and corrected with 20 ml remaining. On 9/11/24 at 8:05 AM, the Administrator displayed the used morphine bottle for Resident #1 and it was found to have 19-20 ml of fluid remaining. The label indicated that it had been delivered on 7/8/24. According to the facility investigation titled DIA (Department of Inspections and Appeals) Report, on 8/12/24 Staff F was on the north wing caring for Resident #2 and went to draw up a 0.25 ml dose of morphine. She double checked the bottle and found that there was 12 ml in the bottle, and according to the RCSR, there should have been 24.25 ml. The ADON looked at the MAR, compared it to the RCSR and concluded that the medication had been given enough times to account for the difference of 12 ml. Upon investigation on 8/13/24, the Administrator discovered that Resident #1 had 8 ml less in the bottle than what was documented and the ADON assumed that some had been spilled so she signed the narcotic sheet saying that some of the liquid had spilled. Further investigation revealed that 5 out of the 6 nurses that worked on that medication cart that was missing the morphine, admitted that they did not look at the bottle at shift change when they completed the narcotic count. On 9/10/24 at 8:55 AM, Staff F said that she administered medication on 8/12/24 and discovered that 2 of the bottles of morphine were off by large amounts. She told the ADON, they look at bottles together and she left it with the ADON to deal with from there. On 9/10/24 at 1:37 PM, the ADON said that Staff F brought it to her attention that there was morphine missing. She said that she just thought that it was a matter of nursing mistakes in documentation and not a possible drug diversion. She decided to correct the count on the narcotic sheet for Resident #1 to indicate 8 ml less, assuming that some must have spilt. She acknowledged that she should not have entered wrong documentation and that she had been disciplined for those actions. On 9/10/24 at 3:22 PM, Staff B, LPN acknowledged that she worked on 8/10, 8/11 and 8/12/24. She said that on Sunday (11th), she noticed the morphine was low for Resident #2, but didn't compare the measurements. She said it was a busy day with a resident fall, and there was only one aide to help. She said that the morphine bottles didn't have accurate measurements to begin with, so the nurses assume that it will be off. She said that she hadn't ever given morphine to Resident #1, because she didn't like to take medicine. On 9/10/24 at 3:28 PM, Staff C, LPN said that she witnessed Staff D, RN (was the DON at the time), at the beginning of her shift take all the scheduled narcotics for the residents and put them in one cup for the shift to administer later. There were about 8-9 tabs in the cup. She said that she didn't report this because she was my boss. On 9/10/24 at 4:26 PM, Staff A, RN said that she had given morphine to Resident #1 when she would express pain. The resident didn't like to take medication, she would tighten her lips or spit it out. Staff A said that she always looked at the medication and verified what was left in the bottle or bubble pack at shift change. Some may say it doesn't matter because the fluids were always off by a fraction, but she looked at it anyway, with a second nurse. She said there had been times where a nurse may say she already counted but Staff A insisted that they count them together. On 9/10/24 at 3:49 PM. Staff D, RN said that on the weekend of 8/11/24, there was a resident that was close to the end of life and was getting more morphine. She had worked the day shift; 6 AM - 6 PM, and on the 2-10 PM shift they were short staffed and she was the only one passing pills. She admitted that the job is stressful and she had tried to save time by preparing the scheduled narcotics at the beginning of the shift and putting them all in one cup. She acknowledged that this was not an accepted practice for medication administration, but she knew the residents well enough and what medicine they had. On 9/11/24 at 11:21 AM, the Administrator and the Nurse Consultant said that as soon as they learned about the missing morphine, they did a complete audit of the narcotic documentation going back to January. They said that they would do monthly audits of the narcotics, beginning with a report from the pharmacy on what has been delivered. According to a facility policy titled: Controlled Substances, dated 2012, the facility would comply with all laws regulations and other requirements related to handling, storage, disposal, and documentation of controlled substances. Nursing staff must count controlled medications at the end of each shift. They must document and report any discrepancies.

Based on observation, staff interview, policy review and clinical record review the facility failed to safely store liquid narcotic medications for 1 of 3 residents reviewed (Resident #3). Staff F left two liquid narcotic medications in the top drawer of the medication cart under a single lock. The facility reported a census of 39 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive deficit). She required substantial assistance with dressing, sit to stand and transfers. Her diagnosis included; diabetes mellitus, Alzheimer's disease, aphasia, cerebrovascular accident and fibromyalgia. The Care Plan for Resident #3, updated on 7/25/24, showed that she was at risk for elopement and was in the locked unit. She had elected for hospice care due to terminal condition and staff were to administer medications as ordered. On 9/10/24 at 8:06 AM a medication cart was sitting in the dining room area. Staff F, Licensed Practical Nurse (LPN) was on the opposite side of the room and then came over to the cart. When asked to count the narcotics and verify with the paper documentation, Staff F pulled a bottle of morphine out of the top drawer for Resident #3 and then pulled out a bottle of Ativan. The rest of the narcotics were in a separate, locked drawer in the cart. When asked why the two Scheduled medications for resident #3 were not double locked, she said that the resident was transitioning, so they were using them more often and it was more convenient. She acknowledged that they should have been double locked and then put them in the locked narcotic drawer. On 9/11/24 at 11:21 AM, the Nurse Consultant said that they would expect that the morphine and the Ativan for Resident #3 would be kept under two locks and not in the top drawer with other medication for convenience. A facility policy titled: Controlled Substances, revised in 2012, showed that the facility would comply with all laws, regulations and other requirements related to handling, storage, disposal and documentation of controlled substances. Controlled substance would be stored in the medication room in a locked container, separate from containers for any non-controlled medications. The container must remain locked at all times except when it was accessed to obtain medications for the resident.

Based on staff interview, record review and policy review, the facility failed to consistently count resident narcotics between shifts for 1 of 3 residents reviewed (Resident #7). Findings include: Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severely impaired cognition. The MDS included diagnoses of Alzheimer's disease, anxiety, and depression. Resident #7 received a scheduled pain medication. The Care Plan revised 10/25/23 reflected Resident #7 had a risk for alteration in comfort, had Alzheimer's and couldn't always effectively express her pain. The Care Plan included an Intervention for Resident #7 to take her medications as ordered. Resident #7's November 2023's Medication Administration Record (MAR) listed an order dated 8/13/23 for Hydrocodone-Acetaminophen 5-325 milligram (MG) 1 tablet by mouth 3 times a day for pain. The Incident Report dated 11/21/23 at 5:52 PM included a nursing description that the facility found a narcotic discrepancy found during the narcotic count. Resident #7 had 4 missing hydrocodone, after investigation, the facility located all tablets. The facility's Self-Report dated 11/22/23 at 2:27 PM described the facility discovered on 11/16/23. The facility's undated Investigation provided to the Department of Inspections, Appeals, and Licensing (DIAL) listed a date of incident as 11/16/23. The form indicated that during shift change on 11/16/23 Staff A, Licensed Practical Nurse (LPN), and Staff B, LPN, completed the narcotic count for Resident #7 when they discovered her 2 PM scheduled Hydrocodone (narcotic pain medication) card had 2 missing doses. The Director of Nursing (DON) interviewed Staff C, Registered Nurse (RN), who worked 6 PM to 6 AM on 11/15/23 who reported that she didn't count narcotics with Staff B at the start of the 6 AM to 6 PM shift on 11/16/23. Staff C's Written Warning dated 11/21/23 indicated she didn't complete the narcotic count between shifts as expected the morning of 11/16/23. The undated Narcotics, Controlled Substances, and Preventing Drug Diversion policy instructed the staff member responsible for medication completing his/her shift, and the staff member responsible for medication who is starting his/her shift, to count all narcotic medications at the end of each shift, and confirm that the amount on hand matches the amount listed on the Narcotic Count Sheet for each medication. Both staff members will sign a Narcotic Reconciliation Sheet to confirm an accurate count of narcotics on hand. During an interview 1/10/23 at 3:47 PM, the DON explained she expected the staff to count the narcotics at every shift change or when giving the keys to someone else. The facility corrected this concern on 12/14/23 with the following: a. Starting 11/22/23 the facility started audits b. Completed education on the Narcotics, Controlled Substances, and Preventing Drug Diversion policy with nurses and certified medication aides (CMA). c. Completed education on discarding and destroying medications with nurses and CMAs. d. Starting 12/14/23 the facility's nurses and certified medication aides called the Administrator, recorded a video, or got the Administrator for every narcotic count completed.

Based on staff interview, record review and policy review, the facility failed to ensure to resident narcotics were disposed of properly for 1 of 3 residents reviewed (Resident #7). Findings include: Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severely impaired cognition. The MDS included diagnoses of Alzheimer's disease, anxiety, and depression. Resident #7 received a scheduled pain medication. The Care Plan revised 10/25/23 reflected Resident #7 had a risk for alteration in comfort, had Alzheimer's and couldn't always effectively express her pain. The Care Plan included an Intervention for Resident #7 to take her medications as ordered. Resident #7's November 2023's Medication Administration Record (MAR) listed an order dated 8/13/23 for Hydrocodone-Acetaminophen 5-325 milligram (MG) 1 tablet by mouth 3 times a day for pain. The documentation indicated Resident #7 received all her hydrocodone. The facility's undated Investigation provided to the Department of Inspections, Appeals, and Licensing (DIAL) listed a date of incident as 11/16/23. The form indicated that during shift change on 11/16/23 Staff A, Licensed Practical Nurse (LPN), and Staff B, LPN, completed the narcotic count for Resident #7 when they discovered her 2 PM scheduled Hydrocodone (narcotic pain medication) card had 2 missing doses. Upon discovering the shortage, Staff B popped 2 hydrocodone out of the bubble pack and tossed them in the sharps container in what appeared to be an attempt to correct the count. When asked by Staff A why she did that Staff B responded, I was trying to correct the count. The Director of Nursing (DON) interviewed Staff C, Registered Nurse (RN), who worked 6 PM to 6 AM on 11/15/23 who reported that she didn't count narcotics with Staff B at the start of the 6 AM to 6 PM shift on 11/16/23. Interview conducted with Staff A indicated that she had witnessed Staff B throw 2 hydrocodone in the sharp's container. The Director of Nursing (DON) pulled the sharps container and checked it for hydrocodone, where she found 4 hydrocodone tablets. On 1/10/23 at 9:05 AM, Staff A reported she came in for her 6 PM to 6 AM shift on 11/17/23 and Resident #7's narcotic count was off by 2. Staff A stated she observed Staff B then throw 2 of Resident #7's hydrocodone in the sharps container during the narcotic count resulting in an off count of 4. Staff A stated she directed Staff B to take the narcotic bubble pack to the DON and tell her what she did. The following attempts to contact Staff B, no longer employed by the facility, remained unanswered: a. 1/10/23 at 10:23 AM - Left message to return call. b. 1/10/23 at 12:19 PM - Sent text message to return call. c. 1/11/24 at 8:36 AM - Left message to return call. The Incident Report dated 11/17/23 at 3:23 PM reflected the nurses who completed the narcotic count determined Resident #7 didn't receive her 2:00 PM hydrocodone as ordered. On 1/10/23 at 9:20 AM, the Administrator and the DON explained they didn't know if Staff B placed 2 additional hydrocodone in the sharps container prior to the observation of placing 2 in the container to correct the count. The Administrator and DON explained Staff B did not acknowledge that she placed a total of 4 hydrocodone in the sharp's container during their investigation. On 1/10/23 at 2:15 PM, the DON reported the facility didn't complete a separate investigation related to the 2 additional hydrocodone found in the sharp's container. On 1/10/23 at 3:45 PM, the DON said she expected the nurses or CMAs document on the narcotic sheet the disposal and/or destruction of the narcotic medication. In addition, she expected 1 nurse and 1 witness destroy the narcotic medication together and dispose of the narcotic medication in the drug buster. The undated Narcotics, Controlled Substances, and Preventing Drug Diversion policy instructed the staff member responsible for medication completing his/her shift, and the staff member responsible for medication who is starting his/her shift, to count all narcotic medications at the end of each shift, and confirm that the amount on hand matches the amount listed on the Narcotic Count Sheet for each medication. Both staff members will sign a Narcotic Reconciliation Sheet to confirm an accurate count of narcotics on hand. The facility corrected this concern on 12/14/23 with the following: a. Starting 11/22/23 the facility started audits b. Completed education on the Narcotics, Controlled Substances, and Preventing Drug Diversion policy with nurses and certified medication aides (CMA). c. Completed education on discarding and destroying medications with nurses and CMAs. d. Starting 12/14/23 the facility's nurses and certified medication aides called the Administrator, recorded a video, or got the Administrator for every narcotic count completed.

Based on clinical record reviews, observations, resident, and staff interviews, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 2 of 2 residents reviewed (Residents #18 and #10) for falls. 1. Resident #18 fell two times and the facility failed to either put an intervention in place or put an inadequate intervention in place to prevent future falls. After Resident #18 fell on [DATE], the facility requested a urinalysis on 7/12/23. The facility collected and received the results on 7/14/23 that revealed a urinary tract infection. The provider ordered to wait for the culture and sensitivity (C&S) results then update them with the results. Resident #18 attempted to get up on her own multiple times, with the staff intervening to prevent her from falling. On 7/18/23 a staff member left Resident #18 unattended in the bathroom with the call light and instructions to pull it when she was ready. Without using the call light, Resident #18 attempted to get to bed by herself and fell . The next day, Resident #18 complained of pain in her ankle and an assessment revealed a moderate amount of swelling in her left ankle. An x-ray revealed a fracture to the two lowest bones in her leg. The facility failed to have the C&S results until 11/7/23, the identified an infection of Proteus mirabilis. Following the fall, Resident #18 went from an assist of one person for transfers to needing a full-body mechanical lift (Hoyer) with two persons for transfers. 2. Resident #10 fell on [DATE], the facility implemented an intervention to clip a call light to her, so it pulled when she got up without assistance. Resident #10's bathroom door had a sign that instructed her to use the call light and wait for assistance. Observations of Resident #10 on 11/6/23 revealed her sitting in her recliner while her call light sat on an end stand approximately 5 feet away starting at 10:39 AM. The call light remained on the end stand even after she fell at 3:38 PM. Findings include: 1. Resident #18's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS identified Resident #18 had signs and symptoms of delirium (a temporary mental state characterize by confusion, anxiety, incoherent speech, and hallucinations) with inattention with behavior present, fluctuates. Resident #18 required extensive assistance of one person with bed mobility, transfers, ambulation and toilet use. The MDS indicated Resident #18 required a walker and wheelchair for mobility. A balance during transitions and walking identified Resident #18 as not steady, only able to stabilize with staff assistance with the following: moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfers. The MDS documented Resident #18 had frequent incontinence of bowel and bladder. Resident #18's MDS included diagnoses of anemia (low blood iron), hypertension (high blood pressure), chronic kidney disease, stroke, diabetes mellitus, and adjustment disorder. The Facility Incident Reports (IR) documented in July 2023 revealed Resident #18 fell on the following dates: 7/8/23 7/18/23 Resident #18's Fall Risk Evaluations documented the following scores and fall risk (A score greater than 10 or more represent high risk for falls): 3/8/23=15 7/12/23=21 7/20/23=19 The Care Plan revised 6/28/23 reflected that Resident #18 had a risk for falls related to impaired balance, poor safety awareness, neuromuscular/functional impairment and the use of medications that may increase fall risk. The Care Plan Interventions included the following: a. Call light in reach when in room - 1/24/23 b. Clean and apply glasses daily as appropriate; ophthalmology (eye doctor) referrals as deemed necessary - 1/24/23 c. Encourage proper footwear when out of bed - 1/24/23 d. Encourage to ask for assistance if weak/tired - 1/24/23 e. Ensure safe environment, free of clutter, with adequate lighting, and clean spill promptly - 1/24/23 f. Fall assessment on admission, quarterly and with changes or falls - 1/24/23 g. Neurological checks per facility protocol for any/suspected head injury - 1/24/23 h. Notify MD/family/responsible party of changes as needed - 1/24/23 i. Obtain labs as ordered - 1/24/23 j. Possibly limit number of blankets on bed or use only lightweight blankets - 3/8/23 k. PT/OT evaluation and treat as needed - 1/24/23 l. Recheck urinalysis post fall - 7/12/23 m. Review medication every quarter and as needed - 1/24/23 n. Rule out medical complications with increased falls - 1/24/23 o. Skid strips next to bed - 1/24/23 p. Clip call light to walker with break-away lanyard - 7/19/23 q. Assist of 1 with ADL's (activities of daily) and assist of 2 with Hoyer with transfers - 8/23/23 An IR dated 7/8/23 at 8:02 AM identified an unwitnessed fall in Resident #18's room. Staff observed Resident #18 on the floor next to her bed. Resident #18 stated that she wanted to get to her chair. The IR lacked an immediate intervention put in place following the fall. A Progress Note titled Fall - initial dated 7/8/23 at 8:35 AM documented the fall occurred at 6:15 AM. The progress noted indicated that staff found Resident #18 in her room on the floor lying on her left side beside the bed. The note revealed Resident #18 had mild back pain and last went to the toilet at 5 AM. According to the note, Resident #18 did not have their call light on at the time of the fall. The progress note lacked any new or additional interventions to prevent falls. A Progress Note titled IDT Note dated 7/12/23 at 10:09 AM documented IDT (Interdisciplinary Team) reviewed Resident #18's fall from 7/8/23. The progress note documented the facility would recheck a urinalysis (UA) due to ongoing increased confusion. A Progress Note dated 7/14/23 at 3:39 AM documented Resident #18 noncompliant with call light. The note revealed Resident #18 was holding the call light in her hand (also clipped to her pajama collar) and voided in her bed. The note further documented that later, Resident #18 continued with the call light in her hand and had an extra, extra-large diarrhea in her bed requiring two complete bed changes. Resident #18 stated to the CNA (certified nursing assistant), I don't know why you pooped my pants, I haven't had supper yet so it couldn't have been me. A Progress Note dated 7/14/23 at 12:38 PM indicated a urine sample was obtained from Resident #19 and sent to the laboratory (6 days after the fall). A Progress Note dated 7/15/23 at 2:19 AM documented the facility received the UA lab result and faxed it to the Physician. The UA results dated 7/14/23 at 4:46 PM documented the following abnormalities: positive for blood in the urine, 3+ leukocyte esterase (white blood cells) in the urine, and WBC lumps (increased mucus) are present in the urine. The abnormalities are indicative of an inflammation or bacterial infection in the urinary tract system. A Progress Note dated 7/16/23 at 12:23 AM documented Resident #18 as combative with HS (hour of sleep) cares, hitting and punching the CNA while the CNA attempt to dress her for bed. Resident #18 stated her family was here and was going with them, without putting clothes on first. A Progress Note dated 7/17/23 at 10:11 AM documented the PCP (Primary Care Physician) responded regarding UA results. The PCP directed the facility to wait for the culture and sensitivity results (C&S) and to send results when received. A Progress Note dated 7/18/23 at 4:30 AM documented Resident #18 screamed with cares whether being touched or not. The note further documented Resident #18 had multiple attempts to get out of bed on her own and had the call light clipped to her pajama collar. An IR dated 7/18/23 at 8:45 PM identified an unwitnessed fall in Resident #18's room. Staff observed Resident #18 lying on the floor on her back next to her bed. Resident #18 stated she was going to her bed. According to the IR, approximately 15 minutes before the fall, staff assisted Resident #18 to the bathroom and instructed her to use the call light when finished. The IR lacked an immediate intervention put in place following the fall. A Progress Note titled Fall - Initial dated 7/18/23 at 8:45 PM documented an unwitnessed fall in Resident #18's room. The progress note revealed staff observed Resident #18 lying on the floor on her back next to her bed with her walker next to her. The note documented that Resident #18 did not have her call light on but had it within her reach when in the bathroom. The progress notes further documented Resident #18 transferred from the toilet to her bed when she fell . The progress note lacked any new or additional interventions to prevent falls. A Progress Note titled IDT Note dated 7/19/23 at 9:39 AM documented the IDT team reviewed Resident #18's fall from 7/18/23 and determined that Resident #18 attempted to ambulate with her walker from bathroom to bed. Staff observed Resident #18 lying on the floor next to her bed with her pants down around her ankles. The progress note documented that Resident #18's forgets to use the call lights due to her cognition. The new fall intervention listed as to add a break away lanyard on call light and attach to the walker. A Progress Note dated for 7/19/23 at 10:22 AM revealed Resident #18 had pain in her left ankle with a moderate amount of swelling. The facility notified Resident #18's PCP, who ordered a 3 view portable x-ray of the left ankle and no weight bearing until the completion of the x-ray. An X-ray report dated 7/19/23 documented the findings of the portable images of the left ankle revealed a nondisplaced fracture of the distal fibula and a nondisplaced transverse fracture of the medial malleolus. The PCP directed the facility to send Resident #18 to the emergency room (ER) for the left ankle fracture. The ER report dated 7/19/23 at 1:37 PM documented Resident #18 arrived at the ER with complaints of a fracture of the left ankle. The ER assessment revealed tenderness to palpation to the left ankle, swelling with signs of injury present. The ER completed a 3 view x-ray of the left ankle which showed fractures involving the distal fibula (lower leg bone) and the medial malleolus of the distal tibia (lowest part of the big bone in the lower leg). The ER report indicated Resident #18 would be discharged back to the facility with a urinary catheter in place due to the fracture, along with no weight bearing and to follow up the following week for surgery. The ER note documented the application of a long leg splint to the left lower extremity. The ER final diagnosis listed bimalleolar fracture of left ankle (a fracture of the bony projections at the end of the lower two bones in the leg). A Progress Note dated 7/19/23 at 6:00 PM documented Resident #18 returned from the ER by ambulance accompanied by her daughter. The progress note documented Resident #18 had an OCL splint (a plaster splint) to the left lower extremity. In addition, she received Dilaudid (narcotic pain medication) 1 mg (milligram) intramuscular (IM) while at the ER. Resident #18 received new orders for Tramadol every 6 hours as needed for pain and an insertion of a urinary catheter at the ER. The Clinical Record lacked the urine C&S results received and sent to the PCP from the UA done on 7/14/23. On 11/7/23 at 11:51 AM, after an inquiry, Staff E, RNC (Regional Nurse Consultant), provided the C&S results from 7/14/23. The results indicated the report got generated on 11/7/23 at 11:27 AM. The clinical record lacked follow up to obtain the C&S results and lacked Physician notification. Resident #18 did not receive any orders related to the C&S results. The C&S results dated 7/17/23 at 10:20 AM revealed the culture grew out greater than 100,000 CFU (colony forming units) per ML (milliliter) of Proteus Mirabilis (gram negative bacteria) indicating Resident #18 had an acute infection at the time of the fall on 7/18/23. On 11/7/23 at 1:17 PM, Staff E reported that she called the hospital lab and spoke to a lab employee. Staff E stated the lab employee confirmed the hospital did not send the C&S report to the facility. Staff E reported even if the facility had received the culture back, she is not sure one dose of antibiotics would have made a difference in the fall. Staff E reported she could not say if the facility called the lab to follow up on the culture results. On 11/7/23 at 2:30 PM, Staff F, LPN (Licensed Practical Nurse), reported when she went into the bathroom to check on Resident #18, she was not done. Staff F stated she handed the call light to Resident #18 and told her to use it. Staff F reported that she had not worked four days prior to the fall. Staff F stated she did not recall any urinary symptoms and did not recall/remember if there was a urine culture pending. Staff F reported she observed Resident #18 lying on the floor right next to the bed. She stated she did not see any injuries. Staff F stated she put the bed in the lowest position. Then Staff G, CNA, and herself lifted Resident #18 into the bed. Staff F stated Resident #18 assisted in the transfer and did not complain of any pain at the time. On 11/7/23 at 7:56 PM, Staff G recalled working the night Resident #18 fell . Staff G stated as she got Resident #18 ready for bed, she liked to sit on the toilet to have a bowel movement after supper and before bed. Staff F stated that the nurse and herself checked on Resident #18 while she sat on the toilet and she was not done. Staff G stated when she went in the room she saw Resident #18 on the floor lying by the recliner and the TV stand right outside the bathroom door. Staff G stated she heard Resident #18 would self-transfer on the overnight shift at times. Staff G stated no one reported a possible infection. On 11/9/23 at 1:53 PM, the Director of Nursing (DON) reported with an acute change such as increased behaviors and confusion, she expected the staff to stay with the resident while using the toilet. She expected the staff to follow up on culture results in a timely manner. The DON expected the staff to call to get the lab results if the facility did not receive the results. A facility policy titled Falls and Fall Risk, Managing revised March 2018 instructed based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The policy documented the resident conditions that may contribute to the risk of falls include: a. Fever b. Infection The policy further documented that the staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remained relevant. 40905 2. Resident #10's MDS assessment dated [DATE] identified a BIMS score of 2, indicating severely impaired cognition. The MDS identified that Resident #10 needed limited assistance of 1 person for bed mobility, transfers, walking, and toilet use. The MDS documented Resident #10 had a prior fall. The MDS included diagnoses of Alzheimer's Dementia, arthritis and depression. Resident #10's Care Plan initiated 8/30/23 reflected that Resident #10 had a risk for falls related to impaired balance, poor safety awareness, neuromuscular/functional impairment and/or the use of medications that may increase falls risks related to the diagnosis of Alzheimer's disease. The Interventions initiated on 8/30/23 included the following: a. On 7/14/23 Resident #10 received an injury after falling, staff to ensure her walker is in place. b. Encourage to ask for assistance when wanting to transfer/ambulate c. Sign on wall to remind Resident #10 to use the call light. Resident #10 likes to tear it down, replace as needed. The Fall-Initial Note dated 10/27/23 at 3:00 AM, reflected that Resident #10 fell while getting up to go to the bathroom. The intervention/prevention to prevent recurrence listed to clip a call light to Resident #10 so it pulls when She get up without assistance. On 11/6/23 at 10:39 AM observed Resident #10 sitting a in recliner in their room with the call light on the end stand, approximately 5 feet from her, not within reach. A sign on bathroom door instructed to please pull call light and wait for assistance. On 11/6/23 at 12:43 PM observed Resident #10 in the recliner while the call light remains on the end stand. On 11/6/23 at 3:38 PM witnessed Resident #10 on the floor in the bathroom doorway, as the call light remains on the end stand. On 11/6/23 at 3:38 PM, the DON confirmed the call light sat on the end stand and not within reach of Resident #10 when in the recliner. On 11/6/23 at 3:50 PM, Staff D, CNA, said she observed Resident #10 sitting in the recliner shortly before taking another resident to the shower and then heard Resident #10 yelling. When she went to Resident #10's room, Staff D found her on the floor. Facility policy, Answering the Call Light, revised March 2021, instructed that when a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. On 11/9/23 at 2:06 PM, the DON stated She expected the call light to be within reach of the resident.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 4 out of 14 residents reviewed (Resident #29, #18, #30, #37). The facility reported a census of 38 residents. Findings includes: 1. Resident #29's Minimum Data Set (MDS) assessment dated [DATE] identified Brief Interview for Mental Status (BIMs) score of 7, indicating moderately impaired cognition. The MDS identified Resident #29 required substantial/maximal assistance with bed mobility, transfers, and toilet use. Resident #29's MDS included diagnoses of anemia, heart failure, hypertension, diabetes mellitus, non-alzheimer's dementia, anxiety disorder and post traumatic stress disorder. Resident #29 received insulin for 7 out of 7 days in the lookback period. Resident #29's November 2023 Medication Administration Record (MAR) included an order dated 4/1/23 for Levemir (long acting insulin) FlexPen Subcutaneous Solution Pen Injector 100 units/ml (milliliters) inject 18 units subcutaneously (underneath the skin) one time a day for type 1 diabetes mellitus. On 11/8/23 at 7:19 AM, observed Staff J, LPN (Licensed Practical Nurse), prepare to give Levemir insulin to Resident #29. When asked to see the medication name on the insulin pen, the label said Lantus (long acting insulin). Staff J reported a shortage of insulin and the facility had a hard time getting it. Staff J reported that she would verify the physician order for the insulin and did not give the Lantus. On 11/8/23 at 10:50 AM, Staff J reported that she found Resident #29's physician order for Lantus. Staff J reported when the order changed it did not get transcribed to the electronic MAR (EMAR). Staff J reported she changed the order on the EMAR and gave the Lantus. Resident #29's Medication Change Request dated 9/20/23 from the Pharmacy documented a request to change the the insulin order from Levemir to Lantus or similar due to the pharmacy inability to get Levemir insulin from the wholesaler. The Replacement Therapy section listed an order from the Advanced Registered Nurse Practitioner (ARNP) on 9/21/23 to administer Lantus Flexpen 100 units/ml Inject 18 units subcutaneously daily. The Administering Medications policy revised December 2012 instructed that medication shall be administered in a safe and timely manner, and as prescribed. The Medication Orders policy revised November 2014 described the purpose of the policy as to establish uniform guidelines in the receiving and recording of medications orders. The policy further documented that a current list of orders must be written and maintained in chronological order. 2. Resident #18's MDS dated [DATE] assessment identified a BIMS score of 10, indicating moderate cognitive impairment. The MDS identified Resident #18 had signs and symptoms of delirium (a temporary mental state characterize by confusion, anxiety, incoherent speech, and hallucinations) with inattention with behavior present, fluctuates. Resident #18 required extensive assistance of one person with bed mobility, transfers, ambulation and toilet use. The MDS indicated Resident #18 required a walker and wheelchair for mobility. A balance during transitions and walking identified Resident #18 as not steady, only able to stabilize with staff assistance with the following: moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfers. The MDS documented Resident #18 had frequent incontinence of bowel and bladder. Resident #18's MDS included diagnoses of anemia (low blood iron), hypertension (high blood pressure), chronic kidney disease, stroke, diabetes mellitus, and adjustment disorder. A Progress Note titled IDT Note dated 7/12/23 at 10:09 AM documented IDT (Interdisciplinary Team) reviewed Resident #18's fall from 7/8/23. The progress note documented the facility would recheck a urinalysis (UA) due to ongoing increased confusion. A Progress Note dated 7/14/23 at 12:38 PM indicated a urine sample was obtained from Resident #19 and sent to the laboratory. A Progress Note dated 7/15/23 at 2:19 AM documented the facility received the UA lab result and faxed it to the Physician. The UA results dated 7/14/23 at 4:46 PM documented the following abnormalities: positive for blood in the urine, 3+ leukocyte esterase (white blood cells) in the urine, and WBC lumps (increased mucus) are present in the urine. The abnormalities are indicative of an inflammation or bacterial infection in the urinary tract system. A Progress Note dated 7/17/23 at 10:11 AM documented the PCP (Primary Care Physician) responded regarding UA results. The PCP directed the facility to wait for the culture and sensitivity results (C&S) and to send results when received. The Clinical Record lacked the urine C&S results received and sent to the PCP from the UA done on 7/14/23. On 11/7/23 at 11:51 AM, after an inquiry, Staff E, RNC (Regional Nurse Consultant), provided the C&S results from 7/14/23. The results indicated the report got generated on 11/7/23 at 11:27 AM. The clinical record lacked follow up to obtain the C&S results and lacked Physician notification. Resident #18 did not receive any orders related to the C&S results. The C&S results dated 7/17/23 at 10:20 AM revealed the culture grew out greater than 100,000 CFU (colony forming units) per ML (milliliter) of Proteus Mirabilis (gram negative bacteria) indicating Resident #18 had an acute infection at the time of the fall on 7/18/23. On 11/7/23 at 1:17 PM, Staff E reported that she called the hospital lab and spoke to a lab employee. Staff E stated the lab employee confirmed the hospital did not send the C&S report to the facility. Staff E reported even if the facility had received the culture back, she is not sure one dose of antibiotics would have made a difference in the fall. Staff E reported she could not say if the facility called the lab to follow up on the culture results. On 11/9/23 at 1:53 PM, the Director of Nursing (DON) reported that she expected the staff to follow up on culture results in a timely manner. The DON expected the staff to call to get the lab results if the facility did not receive the results. 3. Resident #30's MDS assessment dated [DATE] identified a BIMS score of 8, indicating moderately impaired cognition. Resident #30 required extensive assistance from one person with bed mobility and extensive assistance from two persons with transfers and toilet use. Resident #30's MDS included diagnoses of anemia (low blood iron), hypertension (high blood pressure), kidney disease, wound infection, Alzheimer's disease, and cutaneous abscess (skin infection) of the right lower limb. Resident #30's September 2023 Medication Administration record (MAR) directed the staff with the following: a. From 9/2/23 to 9/6/23 to pack her wound on her right thigh with iodoform 1 inch packing and cover with dressing daily and as needed. May use 1/2 inch regular packing until iodoform arrives every day shift for wound care. On 9/4/23, Staff C, Certified Medication Aide (CMA), signed the administration section indicating she completed the order. b. From 9/7/23 to 9/30/23 to pack the wound to the right thigh with iodoform 1/4 inch packing and cover with dressing daily and as needed. The record reflected that CMAs signed the order indicating they completed the dressing change on the following dates: - Staff A, CMA on 9/12, 9/26, 9/27 - Staff B, CMA on 9/7 - Staff K, CMA on 9/20 The October 2023 MAR directed staff from 10/1/23 to 10/31/23 to pack the wound to the right thigh with iodoform 1/4 inch packing and cover with dressing daily and as needed. The record reflected that CMAs signed the order indicating they completed the dressing change on the following dates: - Staff C, CMA, on 10/2, 10/28 - Staff A on 10/26 The November 2023 MAR directed staff starting 11/1/23 to cleanse the wound with normal saline, appy 4% topical lidocaine to the wound bed prior to procedure. Then pack wound to right anterior thigh with iodoform 1/4 inch packing and cover with bordered foam dressing daily and as needed every day shift for wound care. The record reflected that Staff A signed the order on 11/4 and 11/6 indicating they completed the dressing change. A Progress Note dated 9/14/23 at 2:17 PM indicated that the Nurse did not get to the dressing change that day. A Progress Note dated 9/28/23 at 5:44 PM indicated that the Nurse unable to do the dressing change that day. A Progress Note dated 10/24/23 at 4:05 PM indicated that the Nurse did not do the dressing change on 6 AM - 6 PM shift. A Progress Note dated 10/25/23 at 2:37 PM, indicated that the Nurse did not do the dressing change on 6 AM - 2 PM shift. The Clinical Record lacked documentation of completion of the dressing changes at a different time or by a different nurse. On 11/8/23 at 6:45 AM, Staff A reported there are times the dayshift nurses can not do the dressing change. She stated the evening nurse would do the dressing change if the day shift could not do it. She explained that she did not know where the dressing change would be documented. Staff A reported that she signed off the dressing change on the EMAR when the nurses did it. She reported that the Nursing Administration told her that she could sign off medications and treatments for the nurses on the EMAR as long as she documented it in the progress notes who had completed it. On 11/8/23 at 2:15 PM, Staff L, CMA, reported the nurses complete the treatments and the CMAs sign them off on the MAR/TAR (Treatment Administration Record) for the nurse. Staff L reported she tried to document who completed the treatment in a progress note. On 11/8/23 at 3:37 PM, Staff C reported that she signs off on the MAR and TAR treatments that she did not complete or administer. She stated the nurse did the treatments and she usually observed them. Afterwards, she signs on the TAR and tries to write a progress not on which nurse completed the treatment. Staff C stated the management instructed her to sign the MAR/TAR for treatments given by nurses and write a progress note with who completed the treatment. On 11/8/23 at 5:00 PM Staff E, RNC (Regional Nurse Consultant), verified CMAs cannot document for the nurses. On 11/9/23 at 9:00 AM, Staff J, LPN, acknowledged that CMAs sign/document the dressing changes she completed on the MAR. Staff J reported she received training that the CMAs could document for the nurses and make a progress note. On 11/9/23 at 1:53 PM, the Director of Nursing (DON ) reported she expected the nurse to complete and document the dressing changes in a timely manner by the person who actually completed the order. The Certified Nurses Aide/Medication Aide Job Description directed that a CMA could administer regularly scheduled medication to residents via oral, eye, ear, rectal, inhalant and topical routes under the direction and supervision of an LPN or RN (Registered Nurse). The policy further revealed the CMA documents after administration the date, time, dosage and method of administration of all medications or reason for not administering the medication as ordered, including signature of the nurse or physician who is authorized to administer or observe. The policy directed the CMA to recognize limits of knowledge, skills, experience; facilitate situations beyond the CMA's competency. 4. The MDS for Resident #37 dated 9/4/23 assessment identified a BIMS score of 15, indicating intact cognition. Resident #7 's MDS included diagnoses of fracture of lower end of left femur, type 2 diabetes, hypertension and anemia. The October and November [DATE] directed staff to administer/inject Basaglar insulin (long acting insulin) 12 units subcutaneously one time a day for diabetes. The insulin was documented as completed by a CMA on the following days: -Staff A, CMA on 10/11, 10/24, 10/25, 10/26, 10/30, 11/4 and 11/5 -Staff C, CMA on 10/2. The October and November [DATE] directed staff to inject Novolog insulin (short acting) 100 units per ml per sliding scale subcutaneous (underneath the skin) before meals and at bedtime for diabetes: -If 150-199= 1 unit -200-249= 2 units -250-299= 3 units -300-349= 4 units -350- 399= 5 units -400 or greater= call Physician The sliding scale insulin was documented as completed by a CMA on the following days: -Staff A, CMA a. 10/10/23 1 unit at 4:30 PM b. 10/11/23 1 unit at 4:30 PM c. 10/27/23 1 unit at 4:30 PM d. 11/4/23 1 unit at 6:30 AM -Staff C, CMA a. 10/2/23 3 units at 11:30 AM and 1 unit at 4:30 PM -Staff M, CMA a. 10/13/23 1 unit at 11:30 AM and 4:30 PM On 11/8/23 at 2:15 PM, Staff L, CMA reported nurses administer insulin and CMAs sign off the insulin on the MAR for the nurse. Staff L reported that she tried to document in a progress note which nurse administered the insulin. On 11/8/23 at 3:37 PM, Staff C, CMA reported she signs off on the MAR medications(insulin) that she is not completing or administering. Staff C stated she was instructed by management to sign the MAR for medications given by nurses and put in a progress note which nurse completed it. On 11/9/23 at 9:00 AM, Staff J, LPN verified and acknowledged the CMAs sign/document insulin administration that she completed on the MAR. Staff J reported she was trained that the CMAs could document for the nurses and make a progress note. On 11/9/23 at 1:53 PM, the DON reported she expected the nurse who administers the insulin to document the administration, not a CMA.

Based on clinical record review, staff interviews, and policy review, the facility failed to label individualized insulin pens with a resident identifier, date open vial of tuberculin (TB) solution and had expired treatment supplies in the cupboard and medication cart. The facility reported a census of 38 residents. Findings include: On [DATE] at 7:19 AM observed Resident #29's Novolog and Lantus insulin pens stored in a clear plastic tube (toothbrush holder). The clear plastic tubes included the residents' name with a black marker. When the staff removed the insulin pens from the plastic tube, the insulin pen lacked resident identifiers. On [DATE] at 5:00 PM, the Director of Nursing (DON) and Staff E, RNC (Regional Nurse Consultant), reported the pharmacy sends 5 insulin pens in a box and the box is labeled with the resident identifier, not the individual pens. On [DATE] at 8:36 AM observed in the front nurses' station refrigerator an open vial of TB solution with no open date or a date to discard on vial or on the box. Staff J, Licensed Practical Nurse (LPN), verified the TB solution did not have a date and discarded the bottle. On [DATE] at 8:38 AM observed the following expired dressings in the cupboard at the front nurses' desk: a. Hypafix retention sheets - Expired ,d+[DATE] b. Calcium Alginate dressing - Expired [DATE] c. Exuderm Hydrocolloid Dressing - Expired [DATE] On [DATE] at 8:40 PM observed the following expired items in the medication cart in the locked unit. a. 6 fluid (fl.) ounce (oz.) Skin protectant cream - Expired ,d+[DATE] b. 4 fl. Oz. antifungal cream - Expired ,d+[DATE] On [DATE] at 8:40 AM, Staff L, Certified Medication Aide (CMA), verified the expired creams in the medication cart in the unit and discarded them. On [DATE] at 1:53 PM, the DON reported that she expected each insulin pen to have a label with resident information. The Administering Medication policy revised [DATE] instructed the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multidose container, the date opened shall be recorded on the container. The policy further documented insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse will verify that the correct pen is used for that resident.

Based on observation, policy review, and staff interview, staff failed to prepare and serve food under sanitary conditions and failed to properly thaw meat to reduce the risk of contamination and foodborne illness. The facility reported a census of 38 residents. Findings include: 1. On 11/8/23 at 10:00 AM and 11:16 AM observed 2 beef pot roasts in the sink submerged in standing water, without any water running into the sink. 2. On 11/8/23 at 10:00 AM observed Staff H, Cook, wash their hands, apply gloves, and then touch the pans, tongs, foil, and a scale. Staff H proceeded to use the tongs to place meat on the scale, the meat fell off the scale onto the counter. Staff H placed the meat back onto the scale with tongs and touched the meat with her gloved hands. Staff H removed their gloves and wiped the counter with a cloth from the sanitizer bucket and proceeded to place utensils on the wiped counter. Staff H tested the sanitizer bucket water, with the strip remaining orange, indicating 0 parts per million (ppm) of sanitizer. Staff H removed their gloves, washed the robot coupe (machine to pureed food), touched the robot coupe, foil, and a pan, then scooped broccoli into the robot coupe. When Staff H's bare hand they pushed the broccoli into the robot coupe off the top of the blade with her bare hand. 3. During a continuous observation of the meal service on 11/8/23 starting at 11:24 AM, Staff H washed their hands, applied gloves, and pushed the steam cart to the north dining room. After serving the residents using tongs and scoops, Staff H removed their gloves, pushed the steam cart to the south dining room. Without completing hand hygiene, Staff H applied gloves then touched plates, scoop handles. Staff H without changing gloves got a hot dog bun and placed it on a resident's plate. Staff H continued to serve plates. Without changing their gloves or completing hand hygiene, Staff H took a piece of aluminum foil, touching the middle of the foil with their gloved hands and then placed the foil on a plate of food with the foil touching the food. 4. During a continuous observation of the meal service on 11/8/23 starting at 11:24 AM - 12:07 PM, Staff I, Dietary Aide, served plates to residents, assisted residents by touching their silverware to cut up food, then proceeded to serve and assist other residents cutting up food, touching cups, without completing hand hygiene between residents. The Food Preparation and Service policy revised October 2017, instructed that foods will not be thawed at room temperature and thawing procedures include submerging the item in cold running water. The Preventing Foodborne Illness-Employee Hand Hygiene and Sanitary Practices policy revised October 2017, directed that employees must wash their hands after handling soiled equipment or utensils. Contact between foods and bare (ungloved) hands is prohibited. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The Sanitization policy revised October 2008, directed that sanitizing of environmental surfaces must be performed with 150- 200 ppm quaternary ammonium compound (sanitizing solution) and between uses cloths and towel used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. On 11/9/23 at 10:45 AM, the Dietary Supervisor said they expected the staff to complete hand hygiene between serving resident plates, wash their hands before and after applying gloves, only wear their gloves for 1 time, use only if having to touch a food item, no touching food items with their bare hands, sanitizer buckets for cleaning cloths to be changed every 2 hours, and maintained at 200 parts per million, and when thawing food, the food should be under continuous running water. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, includes the following requirements: 1) Single-use gloves are to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation, 2) prohibits food employees from bare hand contact with ready-to-eat food (unless washing fruits and vegetables) and requires food employees to wash their hands immediately before engaging in food preparation, including before donning gloves for working with food, in order to prevent cross contamination when changing tasks.

Based on staff interview, resident interview, and facility policy review, the facility failed to provide care for 1 of 14 residents reviewed (Resident #37) in a manner to promote dignity and respect. The facility reported a census of 38 residents. Findings include: Resident #37's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #37's MDS included diagnoses of fracture of lower end of left femur, type 2 diabetes, hypertension (high blood pressure) and anemia (low blood iron). On 11/6/23 at 10:38 AM, Resident #37 described the facility as short staffed. Resident #37 stated she has waited 30-45 minutes for her call light to be answered. She has become incontinent of bowel due to having to wait so long. Resident #37 reported it happened in the morning before breakfast. Resident #37 reported being horrified and really upset as it is not normal for her. A facility policy titled Quality of Life-Dignity revised August 2009 directed the facility to care for each resident in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The policy further documented demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by promptly responding to resident's request for toileting assistance. On 11/9/23 at 1:52 PM, the Director of Nursing (DON) reported she expected staff to treat residents with respect and dignity.

Based on clinical record review and staff interviews, the facility failed to notify the Physician when a resident refused to take sliding scale insulin at bedtime and failed to report blood sugars below 70 mg/dl (milligrams per deciliter) for 1 of 1 resident reviewed (Resident #37) for insulin administration. The facility reported a census of 38. Findings include: Resident #37's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #37's MDS included diagnoses of fracture of lower end of left femur, type 2 diabetes, hypertension (high blood pressure) and anemia (low blood iron). The Care Plan revised 9/11/23 indicated that Resident #37 had a diagnosis of diabetes mellitus and had a risk for frequent infections, alteration of skin, visual impairment, hyper/hypoglycemia (low/high blood sugar), renal failure and cognitive/physical impairments. The Care Plan directed staff to monitor/check blood glucose levels as ordered and follow protocol per facility for low blood sugar. Resident #37's September 2023 Medication Administration Record (MAR) included an order dated 8/31/23 to monitor her blood sugar four times a day for diabetes and call the physician for blood sugars (BS) below 70 or above 400. The MAR documented on 9/6/23 at 4 PM a BS of 69 and on 9/22/23 at 4 PM a BS of 67. The clinical record lacked any assessment, follow up, or physician notification regarding the blood sugar under 70 mg/dl. A Progress note on 10/10/23 at 5:32 AM documented that Resident #37 reported her BS at approximately midnight decreased to 68 mg/dl. The progress note described Resident #37 as not diaphoretic (sweating heavily). Resident #37 ate a snack and drank one of her cokes provided by a CNA (certified nursing assistant). Approximately 1 hour later, the recheck of Resident #37 BS had a result of 80 mg/dl, she experienced no further hypoglycemic signs. The clinical record lacked notification to the Physician of Resident #37's low blood sugar. The September 2023, October 2023, and November 2023 MARs included the order dated 9/22/23 to inject Novolog insulin (short acting) 100 units per milliliters (ml) per sliding scale subcutaneously (underneath the skin), as listed, before meals and at bedtime for diabetes: - If 150-199 = 1 unit - 200-249 = 2 units - 250-299 = 3 units - 300-349 = 4 units - 350- 399 = 5 units - 400 or greater = call Physician The MAR documented Resident #37 refused sliding scale insulin at bedtime on the following dates: -September 2023: 9/24, 9/25, 9/26, 9/27, 9/28 and 9/30 -October 2023: 10/1, 10/2, 10/3, 10/4, 10/10, 10/13 to 10/26 and 10/29 to 10/31 -November 2023: 11/1, 11/2 and 11/6. The Clinical Record lacked documentation that the facility notified the Physician that Resident #37 refused the sliding scale insulin at bedtime. On 11/9/23 at 11:19 AM, Staff E, RNC (Regional Nurse Consultant), verified that the physician did not get notified of Resident #37's blood sugars below 70 and the refusal of her sliding scale insulin. On 11/9/23 at 1:53 PM, the Director of Nursing (DON) reported that she expected the staff to notify the Physician according to the set blood sugar parameters and of insulin refusals. A facility policy titled Nursing Care of the Resident with Diabetes Mellitus revised December 2015 documented the reference range for mild hypoglycemia (low blood sugar) are 55-70 mg/dl. The policy directed staff for asymptomatic and responsive resident with hypoglycemia (less than 70 mg/dl or less than the physician ordered parameter): a. Give Resident an oral form of rapidly absorbed glucose (4 oz juice or 5-6 ounces of soda); b. Recheck blood sugar in 15 minutes 1. If BS greater than 130 mg/dl, administer diabetic medications; 2. If BS less than 70 mg/dl repeat oral glucose and recheck BS in 15 minutes; or 3. If no improvement, notify Physician for further orders. A facility policy titled Change in a Resident's Condition or Status revised May 2017 documented that the facility shall promptly notify the resident's attending physician of changes in the resident's medical/mental condition and/or status. In addition, the policy directed the nurse to notify the resident's attending physician or physician on call when they refuse their treatment or medications two or more consecutive times or when there are special instructions to notify the Physician of changes in the resident's condition.

Based on clinical record review, observation, facility document review and staff interview, the facility failed to ensure that each resident received adequate supervision to prevent a resident's unplanned exit from the facility for one of four residents (Resident #1). The facility identified a census of 45 current residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with a brief interview for mental status (BIMS) score of 8, indicating moderate cognitive impairment. The resident experienced disorganized thinking which fluctuated in severity and inattention which did not fluctuate in severity. The assessment documented she wandered 4 to 6 days out of 7 and the wandering placed the resident at risk of getting into potentially dangerous places and significantly intruded on the privacy and activities of others. Resident #1 required supervision with transfers, walking in the room and corridor and off unit, eating, toilet use and bathing. A test for balance during transitions and walking revealed the resident was not steady but could stabilize without staff assistance. The resident had [DIAGNOSES REDACTED]. An Elopement Wandering Risk (MDS) data set [DATE] identified the resident had 1 to 2 elopement episodes in the past 6 months and as at risk for elopement. The resident resided in a secure unit. During interview on 11/7/18 at 4:16 p.m. regarding the 1 to 2 elopement episodes identified on the assessment, the MDS nurse stated Resident #1 didn't actually elope but she did push on the unit doors. The Care Plan dated 9/18/18 identified Resident #1 as at risk for alteration in mood/behaviors related to the resident's medical diagnosis, cognition and placement on the CCDI (chronic confusion and dementing illness) unit. The resident may be restlessness and wander and have unrealistic fears. The resident also spoke to unknown persons, often says she is having a baby and changes clothes frequently. The care plan directed staff to monitor the resident's whereabouts when the resident wandered and redirect as needed. An addendum to the care plan dated 10/28/18 revealed Resident #1 left the CCDI through the east exit door at 3:15 p.m. The resident walked around the building to the smoking area. Staff implemented interventions for 15 minute checks and physician and family notification. The facility investigation summary submitted to the State Agency recorded that on 10/28/18 at approximately 3:10 p.m. the east door alarm activated in the CCDI unit. Staff B CMA (certified medication aide) went to the door and found it slightly ajar. Staff B looked out the window and saw no one. She then told the two staff members in the unit, Staff C CNA (certified nurse aide) and Staff D CNA that it was OK and Staff C shut the alarm off. At approximately 3:15 p.m. Staff E CNA was taking residents out and found Resident #1 sitting in the lawn chair on the northeast side of the building. The resident was fully dressed in a long sleeved shirt, blue jeans, socks and shoes. The outside temperature was approximately 60 degrees, windy and sunny. Staff E asked Resident #1 to come back in and the resident said she knew the way. She walked back to the east CCDI exit door and could not enter. Staff E brought the resident back into the building and reported to Staff F RN (Registered Nurse); Staff F assessed the resident and did not identify injuries. Staff reported they last saw the resident around 3:05 p.m. in the building. Following the incident, staff implemented 15 minute checks and all staff on duty were re-educated about what to do if the door alarm sounds, including opening the door and searching around the building and completing a head count to ensure all residents are accounted for at the time an alarm sounds. All staff involved were disciplined regarding the incident. The facility investigation identified a distance of 95 feet from the exit door to the smoker's area. Departmental notes recorded the following information: a. 10/24/18 at 10:01 p.m. - Resident #1 paced and attempted to exit the unit at 9:45 p.m. Staff was able to redirect the resident back to the unit but she remained anxious and agitated. Staff administered PRN (as needed) [MEDICATION NAME] (anti-anxiety medication). b. 10/26/18 at 9:53 p.m. - The resident was very restless that evening, pushing on doors and pacing the halls. Staff could not redirect her and administered [MEDICATION NAME] with little improvement. c. 10/28/18 at 5:43 p.m. - At 3:15 p.m. staff reported the resident was outside sitting in one of the chairs visiting with a staff member and another resident. The staff member stated Resident #1 was sitting out there when staff went out to supervise residents who were going out to smoke. The resident sat there at least 20 minutes with staff supervising. Staff asked the resident about going in and the resident said she would show staff the way. When they got to the door it was shut and locked. The resident came back in the door coming into the north wing and back to the unit without problem, talking all the way back. The resident wore a 3/4 sleeve top, long pants and shoes. A head to toe assessment did not show any signs of abnormality or injury. Staff were re-educated on door alarms and what to do and 15 minute checks were started. d. 10/31/18, a late entry for 10/29/18 (no time identified) - The exit door alarm sounded. Staff observed Resident #1 standing inside the door in the hall and CNA beside her. Staff did a complete search of the grounds and a head count. It appeared the resident opened the door but did not exit and all residents were accounted for. During an interview on 11/7/18 at 1:04 p.m. Staff B CMA stated she worked as the medication aide on the southwest hall (The CCDI unit is the southeast hall). Staff B stated the alarm went off and she checked the southwest doors because she was not sure which door alarmed until she saw the 200 hall lit up on the alarm panel at the southwest nurses station. Staff B stated she didn't know a light came on to identify which door alarmed. She went into the CCDI unit and the east exit door was closed but the handle unlatched. Staff B pushed and pulled the door and thought maybe someone wiggled it and just didn't latch it. She looked out and didn't see anyone. She told the CCDI nurse aides the door wasn't latched who informed her Resident #1 was by the door a bit ago. The nurse aides weren't alarmed so Staff B thought they saw Resident #1 after they viewed her by the door. Staff B stated she just looked out the window because she thought she would be able to see someone. Staff B stated Resident #1 must have went to the side of the building and that must be why she didn't see her; she never thought of that at the time. Before leaving the unit, Staff B looked around and thought everything appeared normal. She stated staff has had training before but since the CCDI nurse aides weren't alarmed about anything, she thought they had just seen the resident. Staff C turned the alarm off and everyone went back to work. Staff B set up a couple treatments and walked to the north wing to tell Staff F RN she was going to lunch. They looked out and saw Resident #1 outside with Staff E, who took the smokers out. When Staff B got back from lunch, Staff F informed her that Resident #1 got out. On 11/7/18 at 12:30 p.m. Staff C CNA stated she was in the CCDI dining room with yelling residents and not hear the alarm. Staff B went to the door and Staff C went to the alarm panel. She stated that day, Resident #1 would look out the door and right before that she was in the bathroom. Staff B reported everything was OK so Staff C turned the alarm off. She stated Staff F later brought the resident back to the CCDI unit. Resident #1 said it felt good outside and thought it was funny. On 11/7/18 at 2:04 p.m. Staff D CNA stated she took a resident to the bathroom on the CCDI unit with the door shut and she didn't hear an alarm sound. Staff D heard that Staff B came in the unit and went to the exit door and asked Staff C if Staff C was the only one in the unit. Staff B said the door had been open a crack. Staff C shut the buzzer off after Staff B said the OK. They did not do a head count to ensure no missing residents. Staff D went to the north wing to get pads and saw staff bring Resident #1 in from the smoking door entrance/exit. Staff D stated she will never again trust a co-worker when they say its OK. Staff D stated the resident has gone to the door and opened it before. Review of Staff E's CNA written statement dated 10/28/18 revealed she took smoking residents out and saw Resident #1 sitting in a patio chair. When the smoking residents finished, she asked Resident #1 to go inside and the resident agreed. The resident said she knew the way in and walked to the CCDI east emergency exit. They could not enter through that door so Staff E and Resident #1 entered the facility through another door. On 11/8/18 at 10:13 a.m. Staff E CNA stated she took the residents to smoke. When she looked out no one was there. She turned around to get out cigarettes and then Resident #1 was there. When asked why her recollection differed today from the 10/28/18 written statement, she stated Staff F RN told her what to write and to say she saw the resident out there. On 11/7/18 at 2:47 p.m. Staff F RN stated staff took smokers out and brought them in. Staff F stated she looked out and saw Staff E sit with someone that looked like Resident #1. It was Resident #1. The resident got up and went to the southeast side of the building. When Staff F got outside, she saw the resident and Staff E return to the smoking area and Staff F helped the resident into the building and back into the unit. Staff F asked if staff knew how she got out and staff said no. She learned an alarm did go off and south staff shut it off. They said the door was open and everything was OK. There was no head count conducted because they didn't think anyone left. Staff in the unit didn't hear an alarm. Staff F stated if staff on north is in the dining room they can barely hear a south alarm. They can not hear it if they are in a room. Staff F was doing a treatment in a room on north when the south alarm activated and she did not hear it. After the resident returned into the facility, Staff F assessed her and found no injuries. The resident said she enjoyed it outside. It was windy out but not that cold. On 11/8/18 at 10:19 a.m. Staff F she did not tell Staff E what to write and was not around when Staff E wrote her statement. Observation on 11/7/18 at 9:34 a.m. showed Resident #1 asleep in a recliner. The resident wore a Wanderguard . At that time staff reported 9 residents resided in the CCDI unit and they all wore Wanderguard. On 11/7/18 at 9:40 a.m. the southeast exit door alarmed when staff opened it. The door also contained a local alarm which activated. The Administrator stated they added the extra alarm the day after the incident. All exit doors were checked by the surveyor with the Administrator and the alarms all functioned. Observation of the southeast exit showed the resident went north on the grassy area 95 feet to a small area with chairs where residents who smoke congregate. If Resident #1 would have went south she would have went to the front east side of the building which goes to a lightly traveled road with a speed limit of 20-25 mph (miles per hour). Policy: The facility door alarm policy dated 8/9/18, and in place when the incident occurred, revealed when a door alarm sounds all staff will immediately go to the door where the alarm is sounding. Staff will exit the door and start a search of the surrounding areas. Other staff will report to the charge nurse. The charge nurse will initiate room to room checks to verify residents are in the building. The charge nurse will verify census and if the resident is not found, staff will refer to the missing resident/elopement policy. The facility abated the immediate jeopardy on 10/28/18 prior to initiation of the investigation by implementing the following:. a. All staff on duty at 10/28/18 were re-educated about what to do when door alarms go off. b. Facility staff hung a notice in the breakroom and in the communication book and provided it to all departments on 10/28/18 regarding what to do when the alarm sounds. c. All staff involved in the incident received final written warning disciplinary actions on 10/28/18. d. All staff received copies on the reviewed policies on door alarms and missing resident/elopement procedures at in-service or via telephone education on 10/31/18. e. All residents were reassessed for elopement risk on 11/1/18 and Wanderguard bracelets placed on all assessed at risk. (All 9 residents in the CCDI unit have bracelets on and checked for placement and function every shift) f. Resident #1 was sent for an evaluation on 11/1/18 and returned 11/2/18 as no beds were available. g. Elopement and alarm drills are conducted every shift every month for 3 months and ongoing until 100% compliance is achieved. h. All door alarm functions are checked and documented weekly, ongoing. i. Locked covers were placed over alarm reset buttons and only nurses have keys/access to the reset button. j. Local alarm added to CCDI east exit door to increase alarm audibility placed 10/29/18.

Based on clinical record review and staff interview, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents reviewed (#2). The facility identified a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #2 with a brief interview for mental status (BIMS) score of 15, indicating no cognitive or memory impairment. The resident had occasional pain rated as 5, on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain. A Patient Information Report documented Resident #2 started Hospice care on [DATE] with admitting hospice [DIAGNOSES REDACTED]. The resident's Care Plan with a goal date of [DATE] documented Resident #2 had the risk of unidentified pain due to a [DIAGNOSES REDACTED]. The care plan recorded the resident need to take her medications as ordered. A telephone physician's orders [REDACTED].) 0.25 milliliter (ml.) sublingual (SL) every 4 hours as needed for pain and shortness of breath. An (MONTH) (YEAR) Medication Administration Record [REDACTED]./ml syringe 5 mg. (0.25 ml) SL every four hours as needed for pain/shortness of breath. The narcotic record identified the [MEDICATION NAME] as 20 mg/ml. On [DATE] at 10:03 a.m. the pharmacist stated the pharmacy sent liquid [MEDICATION NAME] 20 mg/ml. The pharmacist stated they do not make [MEDICATION NAME] 2 mg/ml. A Medication Error Report dated [DATE] at 11:15 a.m. recorded Staff A LPN (licensed practical nurse) administered 2.5 ml of [MEDICATION NAME] to the resident instead of 0.25 ml. Staff sent the resident to the emergency room (ER). Departmental Notes dated [DATE] at 11:37 a.m. documented Resident #2 received 2.5 ml (50 mg.) of [MEDICATION NAME] at approximately 11:15 a.m. The nurse recognized the mistake and immediately reported the error and sent the resident to the ER via ambulance. Review of ED (emergency department) notes dated [DATE] at 11:54 a.m. revealed the resident presented to the ED for evaluation of a drug overdose. The resident stated she had chronic knee and back pain. The resident's family identified the resident with constant bilateral thigh pain. They tried different ways to treat the pain but none were successful. [MEDICATION NAME] was recently introduced into the medication regimen and today instead of receiving 0.5 ml of [MEDICATION NAME] the resident accidentally received 5 mg. The [MEDICATION NAME] slowed the resident's breathing down and she was brought to the ED to reverse the effects of the medication. The clinical impression documented a [MEDICATION NAME] overdose, accidental or unintentional, initial encounter. The ED notes identified the resident received [MEDICATION NAME] twice to reverse the [MEDICATION NAME] overdose. ED staff then administered [MEDICATION NAME] IV (intravenous) to the resident with prompt improvement in back and thigh pain. Departmental Notes dated [DATE] at 11:16 p.m. recorded the resident returned to the facility at approximately 3:30 p.m. The resident responded and staff transferred her to a recliner. The resident appeared very lethargic the remainder of the shift and responded to stimuli but for no more than 30 seconds at a time. The resident could not eat or drink or take medications. The resident had a temperature of 99.3 degrees, pulse 75, respirations 16 and blood pressure ,[DATE] and her oxygen saturation measured 93% on 2 liters of oxygen. Departmental Notes dated [DATE] at 12:42 a.m. documented Resident #2 had a white to yellow frothy discharge from her mouth and her lungs had moist respirations. Facility staff informed hospice of the change. At 1:03 a.m. on the same date, staff found the resident with no pulse, respirations or blood pressure. A Death Certificate identified the immediate cause of death as [MEDICAL CONDITION] due to or as a consequence of [MEDICAL CONDITION] of 3 years due to or as a consequence of diabetes mellitus of 5 years. During an interview on [DATE] at 10:45 a.m. Staff A LPN stated when she went to administer the [MEDICATION NAME] to the resident, the medication syringe was missing so she used a plastic medication cup to measure the liquid medication. The medication cup had a marking for 2.5 ml and Staff A filled it to that line and administered it to Resident #2. Right after she administered it, she realized what she did and went for help. She stated it was a busy day and she felt tired and distracted. It was also emotional because the resident was related to her sibling. Staff A stated the resident had not needed or used the [MEDICATION NAME] other than a dose given the night before. Staff A stated she just completely looked at the medication dosage wrong and it dawned on her when she walked out of the room after giving it to the resident. Staff A stated she went to the ER with Resident #2 and she received [MEDICATION NAME]. The doctor ordered [MEDICATION NAME] again in the ER. The resident expired [DATE] and this had nothing to do with the overdose. An employee disciplinary action dated [DATE] revealed the Director of Nursing (DON) spoke with Staff A and what she could have done differently and they discussed the 5 right of medication administration and proper medication administration including proper dosage. The corrective action instructed that Staff A to double check orders and dosages before medication administration. In the employee comment section, Staff A wrote that she would check herself more when administering medications and she would only draw up [MEDICATION NAME] in a syringe. On [DATE] at 11:58 a.m. Resident #2's physician stated the [MEDICATION NAME] overdose had nothing to do with her death. When Resident #2 went to ER they gave her more [MEDICATION NAME] as well as [MEDICATION NAME]. She was on hospice for comfort care and the resident inadvertently received a larger dose of [MEDICATION NAME] than ordered. He stated the resident's [DIAGNOSES REDACTED]. A Major Injury Form dated [DATE] at 3 p.m. identified the incident was NOT a major injury and barring complications the resident would return to his/her previous functional status. The facility abated the immediate jeopardy on [DATE] prior to initiation of the investigation. On [DATE] at 12:45 p.m. the DON stated after the incident she monitored the narcotic records weekly but did not document it. A Nurses Meeting Form dated [DATE] identified the DON reviewed the 5 rights of medication administration/errors at the meeting. During the investigation on [DATE] the DON re-educated staff about the 5 rights of medication administration and co-signing insulin, liquid narcotics and pain patches. A new policy dated [DATE] directed 2 nurses and/or CMA (certified medication aide) to verify correct narcotic doses before administration to the resident.

Based on clinical record review, staff interviews and facility policy review, the facility failed to assure all residents were free from abuse for 1 of 8 residents reviewed (Resident #1). The facility identified a census of 46 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 11/10/16, Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident displayed severely impaired cognitive abilities, was usually understood and had the ability to understand others. The MDS documented the resident was dependent on 2 staff with transfers, required extensive assistance of 2 staff with bed mobility and toilet use, and extensive assistance of one staff with dressing and personal hygiene. A Care Plan with an onset date of 11/23/16, indicated the resident experienced short and long term memory deficits, a self care deficit as evidenced by a need for staff assistance with daily cares related to weakness and decreased mobility. The Care Plan documented the displayed cognitive loss from dementia, and was at risk for falls related dementia, incontinence, weakness and decreased mobility with a history of falls. The Care Plan interventions directed staff to do the following: a. Provide assistance of 1-2 staff members for dressing. b. Provide assistance of 1-2 staff members for grooming/personal hygiene needs. c. Provide assistance of 1-2 staff members to reposition. d. Provide assistance of 2 staff members to transfer with a Hoyer. e. Provide assistance of 1-2 staff members with toilet use. f. Apply 2 assist bars to the bed to assist with bed mobility and boundary identification. g. Ensure the resident's bed is in the lowest position when he/she is in it. A Fall Risk Data Set form dated 11/23/16, totaled 14 (high risk for falls). A Medication Administration Record [REDACTED]. A Departmental Notes entry dated 12/13/16 at 10:10 a.m., revealed staff yelled for help that morning in the the resident's room. At 6:55 a.m., staff found the resident in bed with the lower half dressed with an undergarment on the top half. The resident had a bruise on the left temple and right hand and was unresponsive. Staff attempted a sternal rub with no response, then called 911. Vital signs (VS) as follows: BP (blood pressure) 167/71, P (pulse) 61, (R) respirations 36 and labored, (T) temperature 98 degrees Fahrenheit, oxygen saturation (O2 sat) 93%. A Nursing Home to Hospital Transfer Form dated 12/13/16, documented the resident as non-responsive with vital signs as above. According to a ambulance report dated 12/13/16, the crew dispatched at 6:56 a.m. and arrived at the scene at 7:03 a.m. The crew found the resident unresponsive. When the crew transferred the resident to the cot he/she opened their eyes briefly but shut them again. Staff A informed the crew he/she had been in the room earlier and asked the resident about breakfast; the resident responded. Staff A reported she then left the room, returned and a few minutes later and found the resident unresponsive. The report revealed the resident remained unresponsive during transport. At 7:14 a.m., the resident's VS were as follows: B/P 190/85, P 78, R 36 and O2 sat 88%. The resident arrived at the hospital at 7:25 a.m. A History and Physical form dated 12/13/16 at 9:51 a.m., included the following documentation: The patient not able to give any information. The story differed from report to ambulance versus nurse to nurse report. The physician contacted the nurse at the facility for information. The patient had bruising as per below indicating a fall likely within the last 24 hours. However, both the night nurse and the morning (AM) nurse knew of no falls. The patient used a Hoyer lift for transfers and did not try to get up on their own. There was no fall reported by staff, but the facility planned to investigate. All nursing knew was the patient had been alert enough to give a breakfast order to the aide who was dressing him/her. Resident #1 then suddenly went unresponsive and they could not arouse the resident. On arrival to the emergency room , the resident opened his/her eyes initially to staff voice (however not to the physician shortly there after) and stuck out his/her tongue on command. The resident had been non-communicative at the hospital with no signs of infection per the facility staff and no recent medication changes. The resident's vital signs included the following: pauses in respirations and the initial B/P 210's/110's however presently 166/64, P 72, R 16, O2 saturation 92% and a T of 97.2 degrees. Bruising noted on both dorsal hands, the left hand noted after arrival to the hospital while still in the emergency room . An abrasion to the left lateral chest, possible new bruise to the left shoulder region, bruising on the left temple and an abrasion dorsum right hand near the 2nd joint. While the physician wrote orders for the patient, he/she woke up and had been a little more responsive. He/she had been able to follow some basic instructions like sticking out his/her tongue and telling the physician their name. The resident could not recall a fall, but had dementia that limited any history taking. The impression included the following: a. A traumatic subarachnoid bleed. b. Bruising/abrasion with no known fall. A family member asked if they could have been caused by a [MEDICAL CONDITION] in bed, however the resident had no [MEDICAL CONDITION] history. The physician discussed the head bleed could have certainly caused a [MEDICAL CONDITION]. A Computerized Axial Tomographic (CT) scan to head or brain without contrast dated 12/13/16 at 8:49 a.m., indicated the resident had an acute injury, bruising over the left eye and a small focus of a subarachnoid blood with no mass effect. Review of a typed statement dated 12/19/16, a different Physician documented the following information: Upon your request, I had a discussion with another physician at the Medical Center on (MONTH) 16, (YEAR) concerning Resident #1. The Physician could not determine a definitive cause for the patient's injuries. I have not seen or examined the patient since the incident and could not add to this determination. Due to the patient's advanced age of [AGE] years, even a minor injury could have serious long term consequences. During an interview 12/29/16 at 9:15 a.m., the Director of Nursing (DON) confirmed she would have expected Staff A, Certified Nursing Assistant (CNA) to have reported a fall or injury to a resident immediately to the charge nurse. During an interview 12/22/16 at 3:05 p.m., Staff A indicated at approximately 5:55 a.m. she and Staff B, CNA performed walking rounds and when they entered the resident's room the bathroom light was been on. They then walked to the sleeping resident's bedside and checked for incontinence. The resident had been dry and positioned to the right of the center of the bed (closest to the wall). The staff finished rounds and at approximately 6:30 a.m., went to the room to get the resident up. Staff A retrieved the resident's clothes and Ted hose. The staff member raised the resident's bed, uncovered and dressed the resident's bottom half with pants, socks, shoes. The staff member left the resident's pants approximately thigh high and put on the resident's undergarments. The staff member rolled the resident towards her (on the resident's left side), connected the undergarment and pulled up the resident's pants. At that point, Staff B called for assistance in another resident's room so she covered the resident with a shirt, put the bed down, and elevated the head of the bed (HOB) a little as the resident stated he/she wanted oatmeal and scrambled eggs for breakfast. Staff A left to assist Staff B and returned to the resident's room. She raised the resident's bed and noted the resident's eyelids fluttered, his/her eyes rolled back and his/her head slumped and tilted towards the left. The staff member said the resident's name with no response so she asked Staff B to check the resident. Staff B came and put the resident's HOB down because he/she had been having difficulty breathing. At that time, the resident's breathing changed again and staff raised the HOB. Then, Staff C arrived Staff A stated she had been standing at the resident's bedside to the left and observed the temple area had been a little raised and red. Staff B said, what was that and Staff A said she did not know. Staff A also noted a purple bruise on the resident's right hand around the knuckle area. Staff C assessed the resident and said to call 911. Staff A indicated Staff C assisted to sit the resident up and put on his/her shirt. The ambulance showed up and transferred the resident to the gurney. When they told the resident they were transferring him/her, the resident opened his/her eyes but did not respond. Staff A denied having witnessed the resident fall and/or hit his/her head during cares. The staff member confirmed up until 2 months ago, she sat the resident on the edge of the bed (EOB) to dress him/her but now the resident had been unable to sit up by him/herself due to contractures and a functional decline in the past couple months so she dressed the resident in bed. During an interview 12/21/16 at 1:10 p.m., Staff B confirmed she once witnessed Staff A position the resident on the EOB to dress him/her. The staff member indicated Resident #1 required total assistance of staff with cares and required a Hoyer lift device for transfers. Staff B indicated she dressed the resident's bottom half in bed, transferred him/her to the wheel chair with a Hoyer and finished the dressing process. On the morning of 12/13/16 while Staff A assisted Resident #1, she assisted another resident across the hall who required a Hoyer lift to transfer. When she was ready she called for the assistance of Staff A who responded within minutes. They transferred the resident and Staff A left the room. Staff B stated it had not been long and Staff A started screaming for her to come to the room of Resident #1. Staff C, LPN also heard the the yelling and yelled down the hall and questioned if she had been needed at which time Staff B said yes. When Staff B entered the resident's room she saw the resident positioned on his/her back to the left side of the bed (closest to the door), not up against the positioning bar, wearing pants and a bra, not covered up and with the bed at waist level. The resident had been non-responsive with his/her eyes rolled back in bed and weird breathing further described as it sounded like the resident was going to vomit. Staff A then pointed out a lump on the left side of the resident's head, red in color with no bruising however the staff member could not recall the size. Staff B elevated the HOB when Staff C arrived and directed Staff B to go call 911. As she went down the hall she observed Staff D, Registered Nurse (RN) and Staff E, LPN and asked them to call 911 as she had more residents to get up. Staff B then offered that Staff A told her the resident requested breakfast like he/she did every day and that had been when he/ became non-responsive. A typed statement dated 12/16/16 from the facility as a result of their interview with Staff B included the following documentation: a. When she entered the resident's room, he/she was non-responsive and Staff A had been acting confused and did not know what to do. Staff B stated Staff A usually had been the leader and always the one to tell staff what do do and what to do it in that type of situation. b. Staff B denied hearing any type of noise prior to Staff A yelling for help or her entering the resident's room and to her knowledge they were the only staff members down the hallways. c. Staff B stated Staff A routinely sat the resident on the EOB and dressed the top half of the resident's body once the bottom half had been dressed. During an interview 12/27/16 at 1:55 p.m., Staff B stated she observed Staff A position the resident on the EOB to dress since he/she had been moved from the 400 hallway to the 500 hallway. During an interview 12/21/16 at 1:39 p.m., Staff C indicated on 12/13/16 when she received report, Resident #1 had been fine and there was nothing new to report. She had not observed the resident prior to the event but as she stood by the nurse's station she heard Staff A say something. Staff C asked if they needed assistance and they said yes. Staff C entered the resident's room and observed the resident positioned flat in the bed. She could not recall where the resident had lain in conjunction with the mattress, but knew his/her head was not up against the positioning bar and the bed was waist high. The resident wore pants, shoes and undergarments with no Hoyer sling device under him/her. The resident had been non-responsive with an approximate 1 inch thick mark on the left temporal area, oblong in shape, red on top and blue toward the bottom. The mark appeared fresh. The resident also sustained a 25 cent sized purple bruise on the right hand between the 1st and 2nd knuckle. The staff member went to the resident, said his/her name, attempted a sternal rub and yelled for staff to call 911 as she checked the resident's vital signs (VS). At some point, Staff D entered the resident's room and attempted a sternal rub and checked the resident's pupils. Staff C left the resident's room to process the paperwork and told someone to say with the resident. The staff member indicated the resident was not known to have non-responsive spells and for his/her age she seemed in overall good health. The staff member recalled Staff A said the resident had been talking about breakfast and then became non-responsive. Then later that day, Staff A said she left the resident's room for a transfer of another resident and when she returned that had been when she found the resident non-responsive. She also remembered Staff A stated she had not observed a bruise on the resident's head. During an interview 12/22/16 at 10:41 a.m., Staff C indicated a physician called her after the resident arrived in the emergency room and asked if she knew what happened. The staff member informed the physician she had been told the resident had been talking and went non-responsive at which time the physician informed Staff C it appeared the resident had fallen and they better look into the situation. Staff C then asked Staff D if the resident fell and the staff member said no. During an interview 12/22/16 at 3:35 p.m., Staff C indicated the resident had not experienced a significant change in functional status recently, but in her opinion the resident had no ability to sit up on his/her own since admission to the facility. The staff member also clarified the resident had not been covered when she initially entered the room, and she did not assist with finishing to dress the resident prior to the ambulance arrival. She added she noticed the area on the resident's head right when she entered the resident's room, but Staff A stated she had not noticed it. During an interview 12/21/16 at 3:56 p.m., Staff D confirmed she worked 12/12/16 from 6 p.m. to 6 a.m. at which time she observed the resident as she participated in an activity between 8 p.m. and 9 p.m., however she had no further contact with her the rest of the night. The staff member denied having observed the resident fall and/or lay on the floor at any time. The staff member described the resident as dependent on staff who would have required assistance to get the resident off the floor if he/she had fallen. The staff member indicated no staff reported to her that night the resident had hit their head. The staff member had been present during the event as she had been sending another resident to the hospital. At around 7 a.m., she heard Staff C yell, call 911, at which point all she knew was the resident had been non-responsive with a bump on his/her head. Staff D went to the resident's room and found him/her positioned flat in bed closer to the left side of the bed. His/her back did not touch the positioning bar (further described as not centered in the bed by any means), wearing shoes, socks, pants and undergarments with the bed raised. Staff D raised her voice trying to stimulate a response, performed a sternal rub and checked the resident's pupils which had been round and reactive. Staff D remained with the resident until the ambulance crew arrived and indicated when the resident had been moved from the bed to the cot, his/her head had not been hit and/or bumped. Staff D stated she later received a call from the hospital who requested to speak with the nurse in charge of the resident. Staff D handed the telephone to Staff C. Upon completion of the conversation on the telephone Staff C told her there had been reasonable suspicion to believe the resident had fallen because of the bruising of the shoulder and side as well as what had already been described. During an interview 12/16/16 at 10:55 a.m., the Director of Nursing (DON) confirmed discrepancies with statements provided by Staff A and other staff members and the facility suspended Staff A pending the investigation. One discrepancy had been Staff A stated the resident had been positioned on the far right side of the bed (towards the wall) while Staff B stated the resident had been positioned on the far left side of the bed. During a re-enactment of the event 12/16/16 at 11:40 a.m., the DON indicated Staff A informed her the resident's bed had been to the floor when she initially entered the resident's room for morning cares. Staff A raised the bed to her height with the HOB raised approximately 15 degrees, the knees slightly raised and the bed up against the wall. The staff member informed the DON she dressed the resident's lower and rolled the resident toward her (resident's left side) when Staff B yelled for help so she lowered the resident's bed and left to assist the staff member. Staff A informed the DON she had been gone long enough to assist Staff B with another resident and when she returned the resident remained in the same position as when she left, however she noticed a goose egg on the left side of the resident's head. Staff B noticed redness when she entered the resident's room and Staff C noticed a plum sized, oblong reddish purple area on the left side of the resident's head and a quarter sized bruise on the resident's right hand. Staff C described the resident as non-responsive so she attempted a sternal rub, called for 911 and sent the resident to the hospital within 10 minutes. During an interview 12/21/16 at approximately 3 p.m., the DON described Staff A as a very strong CNA who would have had the capability to pick the resident up from the floor. The DON indicated on 12/13/16 around 10 a.m., she went to the hospital and observed a baseball sized area on the left side of the resident's face, bruising on the right hand and a light blue bruise on the left shoulder that appeared new. During an interview 12/22/16 at 12:25 p.m., the DON stated she felt Staff A sat the resident on the EOB and the resident fell to the left side and hit his/her head on the positioning bar, their right hand got caught in the the bar and the bruise on the shoulder may have occurred while sitting the resident up. The DON felt the bruise/hematoma on the left side of the resident's had was oblong so it would correlate with the shape of the siderail. The DON felt the resident could not have sat on the EOB alone due to the lack of upper body strength. A typed statement dated 12/29/16 included the following information from the DON: At approximately 10:15 a.m. the DON went to examine the resident at the hospital. The resident had been awake, eyes open and responding to questions. The DON asked the resident if he/she had fallen and the resident said no, not that he/she know of. The DON asked the resident if he/she hit her head and the resident stated no, not that he/she knew of. The resident had a reddish bruise on the left temporal region starting at the eyebrow level back to the hairline and oblong in appearance. The hematoma had been raised approximately 1/4 of an inch and approximately 2 inches wide and 3 inches long. There was also bruising present on the cheek in the shape of a horseshoe, on the right hand between the 1st and 2nd knuckle the size of a nickel, and a softball sized (very faint blue) area with no swelling on the left shoulder. The 4th digit on the left hand was swollen and the entire finger had been black and blue and red under the nail bed. The frontal portion of the 5th digit (little finger) on the left hand was also bruised. During an interview 12/21/16 at 3:47 p.m., Staff F, CNA confirmed she worked 12/12/16 from 10 p.m. to 6 a.m. and there had been nothing different about the resident. When the staff checked and changed him/her on rounds at 3 a.m. and 5 a.m. the resident just looked at them. The staff member denied seeing the resident fell or hit his/her head during cares. During an interview 12/22/16 at 4:17 p.m., Staff F, CNA indicated she never witnessed any bruising or abnormalities on the resident when she provided cares on 12/21/16. The staff member could not recall if they entered the resident's room for walking rounds that morning but she knew the resident had not been checked for incontinence during walking rounds at 6 a.m., because the resident had just been checked during 5 a.m. rounds. The staff member also could not recall any lights on during walking rounds. During an interview 12/22/16 at 4:05 a.m., Staff G, CNA confirmed she worked 12/12/16 from 10 p.m. to 6 a.m. The staff member entered the resident's room around 3 a.m. with Staff F, turned on the over bed light and proceeded to check and change the resident. The staff member denied having observed any abnormalities on the resident's face and/or person and described the resident as his/her normal self. At 5 a.m., the staff members checked and changed the resident again, but Staff G only observed the resident's legs at that time. The staff members then positioned the resident on his/her back, a little towards the left side of the bed. The staff member indicated the resident had not fallen or hit his/her head during any cares. During an interview 12/27/16 at 1:28 p.m., Staff H, CNA/restorative aide stated she did not know if the resident could hold him/herself up but she did not think so. Staff H indicated she never positioned the resident on the EOB to dress him/her. The staff member confirmed she witnessed Staff A position the resident on the EOB which she described as the normal routine for Staff A, because she dressed all of the residents independently and then would call for staff assistance for transfers. Staff H indicated she had not witnessed any functional changes in the resident in the last several months. During an interview 12/29/16 at 12:10 p.m., Staff H indicated she witnessed Staff A position the resident on the EOB when s/he lived on the 400 hallway. During an interview 12/22/16 at 2:38 p.m., Staff I, CNA indicated on 12/12/16 she assisted Staff J, CNA with HS (hour of sleep, bedtime) cares for the resident partially while positioned in the wheel chair with the remaining cares provided while the resident lay in bed. The staff member denied having witnessed any bruising and/or abnormalities and denied the resident fell or hit his/her head. Staff I confirmed the resident could not sit up independently. During an interview 12/22/16 at 2:29 p.m., Staff J, indicated on 12/12/16 she and Staff I assisted the resident with HS cares, did not place the resident on the edge of the bed to complete cares/dressing and denied having witnessed any bruising and/or abnormalities. Staff J denied she positioned the resident on the EOB denied the resident fell or hit his/her head, and confirmed the resident as unable to sit up independently. During an interview 12/27/16 at 2:20 p.m., Staff K, CNA confirmed she provided HS cares for the resident on 12/12/16 on the 2 p.m. to 10 p.m. shift. Staff K undressed the resident's upper body in the wheel chair, placed on a hospital gown, removed the resident's shoes and socks and called for assistance because she had not been able to transfer the resident per facility policy due to the resident's age. The staff members completed the undressing process while the resident was in bed. The staff member confirmed the resident could not sit up independently and denied she had positioned the resident on the EOB or seen staff members the resident on the EOB and confirmed the resident's functionality had not changed in the past several months. During an interview 12/27/16 at 1:18 p.m., Staff L, CNA indicated when she cared for the resident she dressed the resident in bed. The staff member confirmed the resident as unable to set up by him/herself and/or any staff members setting the resident on the EOB and confirmed the resident's functionality as unchanged in the past several months. A Resident Room Change Form dated 10/18/16, indicated that Resident #1 moved from the 400 hallway to the 500 hallway. A Incident & Accident Process form revised 10/15, documented the purpose of an Incident and Accident Process as to ensure the facility environment had been free from accident hazards over which the facility had control and that each resident received adequate supervision and assistive devices to prevent avoidable accidents according to equal guidelines. The process included the following: a. Unusual occurrence events, incidents and accidents noted by facility staff would have been reported to the nurse caring for the resident.

Based on record review and interviews with staff and the Advanced Registered Nurse Practitioner, the facility failed to provide adequate supervision to prevent accidents (Resident #1). The sample consisted of 4 residents and the facility reported a census of 55 residents. Finding include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 7/9/15. The assessment identified Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident had a BIMS (Brief Interview for Mental Status) score of 6. A score of 6 identified the resident with a severe cognitive impairment. The MDS reflected the resident required extensive assistance of 2 staff members to physically assist the resident with bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. The Care Plan identified the resident at risk for falls with significant injuries on 7/23/15. The Care Plan identified the risk for falls as evident by a history of falls, with weakness, incontinence, and the use of medications, including psychotropic medication. The care plan included interventions for staff to: 1) The resident needs medical complications [REDACTED]. 2) Staff to notify resident's provider of abnormalities. 3) Resident needs medications reviewed periodically. 4) Staff are to ensure the resident is in a safe environment, free of clutter and hazards with adequate lighting and spills cleaned promptly. 5) Resident needs assist of two staff members to transfer and walk with a gait belt. Resident frequently uses a wheel chair for mobility with staff assistance to propel it. 6) Resident to have nonskid strips present by my bed and in front of my chair. 7) Staff are to assess resident for fall risk every quarterly and as needed. 8) Staff are to observe resident's vital signs for changes from baseline. 9) Staff are to ensure resident's call light is within reach at all times when in room with reminders to use it when needed. 10) Staff to provide 1 to 2 person assistance to complete resident's toileting needs, 2 staff members if resident is transferring in and out of bed or on and off the toilet. 11) Resident is to have nonskid strips on bathroom floor. 12) Resident is to have a mat on the floor next to the bed, when in bed. 13) Resident needs gripper socks when in bed. 14) Resident to wear glasses per the resident's choice, staff to assist to wear them, and keep them clean and in good repair. 15) Resident may need referral to therapy as needed. 16) Resident to have labs reviewed as ordered. 17) Staff are to do a head to toe assessment weekly. 18) Staff are to observe for areas of concerns when assisting with cares. 19) Resident can become physically combative and aggressive, staff are to observe resident after incidents of combativeness 20) If resident refuse/reject care/interventions, assure resident's safety and leave immediate area, reproach resident in 5-10 minutes or provide alternate caregiver. Staff are to document response. 21) Staff are to use a Hoyer lift (mechanical lift) with the assistance of 2 staff members as needed. The Care Plan identified the resident at risk for impaired skin integrity related to weakness, incontinence and the use of Plavix and Coumadin (lengths blood clotting time). Review of the Wound Assessment Report dated 7/27/15, identified Resident #1 had the following bruises: a. Right lower quadrant; right side of abdomen, measurement of 4.3 cm (centimeters) in length and 7.5 cm in width, bruise is dark purple/blue in color, new wound, and cause is documented as accident/other trauma, staff will continue to monitor, physician notified. b. Right lateral thigh-front; right upper outer thigh, measurements 4.5 cm in length and 8.5 cm in width, bruise is dark purple/blue in color, new wound, and documented cause as accident/other trauma, staff will continue to monitor, physician notified. c. Right buttock; right outer buttock, measurements 2.5 in length and 5.0 in width, bruise is dark purple/blue in color, new wound, and documented cause is accident/trauma, staff will continue to monitor, physician notified. d. Right upper forearm; right antecubital, measurements 3.0 cm in length by 5.5 cm in width, bruise is dark purple/blue in color, new wound, and documented cause is accident/other trauma, staff will continue to monitor, physician notified. On 7/25/15, a facility registered nurse sent a fax (facsimile) to the ARNP (Advanced Registered Nurse Practitioner). The concerns communicated with the ARNP, were the weekly skin check completed on the resident. The nurse noted bruising to the right side of the abdomen, buttock, thigh, due to delayed bruising from prior fall, resident noted to have bruising to right antecubital area from a blood draw, skin remains intact, no swelling nor warmth noted, will monitor area until resolved. On 8/4/15, the physician responded with no new orders. Review of the record reflected this to be the only notification to the physician assistant, physician or ARNP about the resident's bruise injuries from falls. Review of the Incident Reports revealed the following: On 7/7/15 at 1:30 a.m., staff observed Resident #1 lying on the floor next to the bed with head at foot of bed and feet at the head of the bed. The resident stated he/she tried to get up out of bed to go to the bathroom and slipped. The resident became incontinent of urine. An assessment determined the resident had no apparent injury noted. The staff assisted the resident to a chair and cleansed the resident. Gripper strips were placed in front of the bed. The staff notified the physician and family. On 7/8/15 at 9:46 a.m., a housekeeping staff member reported Resident #1 lying on the floor. Upon entering the room, the resident was noted to wear slipper socks on feet and the floor appeared dry and clear of debris. The resident stated he/she didn't know how got there nor what he/she was doing. The resident had a history of [REDACTED]. An assessment was performed and showed no apparent injury. Three staff assisted the resident with the use of a gait belt and ambulated the resident with a slow and steady gait. The nurse notified the physician and family. On 7/17/15 at 1:30 a.m., staff heard a walker crash to the floor. The staff observed the resident sitting on the floor behind the recliner in room with roommate's walker behind the resident. The floor was wet with urine. The resident ' s feet were positioned towards the door. The nurse performed an assessment and identified no apparent injury (Department Notes reflected the resident was assisted by two staff members to a standing position). The nurse notified the physician and family. The facility staff put gripper socks on the resident ' s feet and applied a brief for incontinence. On 7/24/15 at 11:00 p.m., the nurse noted the resident on the toilet having a bowel movement. The nurse went to check on several other residents and upon returning, the resident ' s roommate came into the hall and informed the nurse that Resident #1 had fallen. The nurse observed the resident sitting on the bathroom floor next to the toilet, pants still down. An assessment identified no injuries and three staff members returned the resident to the bed via a Hoyer lift (mechanical lift). The nurse notified the physician and family. The facility placed nonskid strips on the bathroom floor. On 7/25/15 at 10:30 p.m., staff observed Resident #1 sitting on the floor in front of the recliner. The resident ' s legs extended out in front of the resident. The floor appeared dry and the resident wore plain socks and no shoes. The nurse performed an assessment and identified no apparent injury. (Department Notes reflected the bruises continue from previous fall). The staff applied gripper socks and will obtain UA (urinalysis). On 8/3/15 at 4:50 a.m., Resident #1 ' s roommate alerted the nurse that Resident #1 laid on the floor. The nurse was found lying on the left side and perpendicular to the bed. The bed spread was pulled over the resident and newspapers were under resident's head. The resident could not tell what had happened but going to the bathroom. An assessment identified no injuries present. The staff moved the resident from the floor to the bed with the use of a Hoyer lift. Neurological checks initiated. The nurse notified the family and physician after performing an assessment at 6:00 a.m. by the oncoming first shift nurse. (Departmental Notes reflected the resident was sent to the emergency room at 6:00 a.m. due to abdominal pain). A post-incident action: will determine when resident returns from emergency room . Review of the Departmental Notes dated 8/3/15 at 6:50 a.m., revealed at 4:50 a.m. Resident's #1 ' s roommate alerted the nurse that the resident laid on the floor. Resident found lying perpendicular to bed on his/her left side with bedspread over the resident and newspapers under the resident's head. Resident unable to say what happened and said he/she was going to the bathroom. The resident could move all extremities without difficulty. The resident states I just hurt all over the place. Vital signs blood pressure 138/92, pulse 155 (normal 60-100), respiration 20 (normal 16-20), and temperature of 95.5 (normal 98.6). Resident rolled on to back and three staff members lifted the resident with a Hoyer lift. The resident tolerated the procedure well. The nurse started neurological checks. The nurse started neurological checks. The nurse identified no bruising or red areas to the head from the fall. The blood sugar registered 147 (elevated). At 5:40 a.m. the pulse nurse identified the resident ' s pulse at 162 beats per minute (elevated). The nurse left a message for the ADON (Assistant Director of Nursing). Review of the next entry of the Departmental Notes dated 8/3/15 at 10:19 a.m., identified the nurse performed an assessment at 6:00 a.m. The assessment reflected the resident vital signs to be the following: temperature 97.9, blood pressure 163/78, pulse 173 (elevated), respirations 28 (elevated), oxygen saturation 93% (normal value is 95-99) on room air. The resident voiced abdominal pain. The nurse called the on call staff person and left a message for the ADON. The nurse contacted the PA (Physician ' s Assistant) and received orders to send the resident to the emergency room for further evaluation. The resident left the facility at 6:45 a.m. The nurse called the hospital and told the resident would be admitted into the hospital due to tachycardia (increased heart rate) and urinary retention. Review of the emergency room Provider Notes dated 8/3/15 at 8:20 a.m., reflected Resident #1 came to the hospital after a fall from the bed at the facility and now having pain located in the abdomen. The resident had an irregular heart rate rhythm and tachycardia (rate above 100). The resident had a very distended bladder. Multiple areas of bruising noted as detailed in the nurse ' s notes. However, an INR (lab test for blood thinning medications) as very elevated. The hospital Discharge Summary dated 8/4/15, reflected Resident #1 had [DIAGNOSES REDACTED]. Bruising noted and documented upon arrival. An INR registered 7.1 upon arrival and now 1.6. Review of the hospital Progress Notes, revealed the resident presented with 45 bruises in varied sizes and in different stages of healing, and body areas that included right and left arms, right hip, right leg, left side, left thigh, and right thigh. The bruises ranged in size from the smallest being 0.5 cm by 0.5 cm to 11 by 7.5 cm. The color of the bruises ranged from faded purple/yellow to appearing new and blue in color. On 8/20/15 at 3:18 p.m., Staff D, Certified Nurse Aide (CNA), was interviewed and stated she had seen bruising on Resident #1 prior to 8/3/15. Staff D stated the bruises were under the left arm, left side and thigh. Staff D stated when she reported the bruising, she was told the bruising came from the resident's falls. During an interview on 8/26/15 at 2:05 p.m., Staff A. Licensed Practical Nurse (LPN), reported she came into work on the day shift on 8/3/15 and received a report from the off going nurse. Staff A stated the 3rd shift nurse reported to her that the Resident #1 had a fall and the resident to have increased heart rate. Staff A stated she went right to the resident, at 6:00 a.m., and did an assessment and noted the resident to have a very high heart rate of 173 and the resident complained of abdominal pain. Staff A stated she contact the physician and transferred the resident to the emergency room . Staff A stated she did not have time to do an assessment of the resident's skin prior to resident going to the hospital. Staff A stated she did recall the resident to have some bruising to the left side/arm prior to 8/3/15 which appeared like older bruising. Staff A assumed the bruising came from the resident's fall a week or so ago. Staff A stated she calls the physician and family when there is a noted change or abnormal viatal signs. On 8/28/15 at 8:45 a.m., Staff E, Registered Nurse (RN) was interviewed and stated she worked the night on 8/2/15 and into the morning of 8/3/15. Staff E stated she was assigned to care for Resident #1 and responded to the resident's fall at 4:50 a.m. Staff E stated she did an initial assessment and noted the resident's heart rate to be 153 beats per minute. Staff E stated she thought the resident's heart to be high due to the fall. Staff E stated there were no injuries to the resident from the fall. Staff E stated she checked the resident's pulse two more times and noted it had gone up. Staff E stated she gave report to Staff A around 5:30 a.m. regarding the resident's fall and increase heart rate, and that is when we decided to send the resident to the emergency room . Staff E stated she recalled the resident to have old bruising on the upper right thigh prior to this fall. Staff E stated the old bruising was caused by the resident's prior falls. Staff E stated she does not recall staff reporting any bruising prior to this fall. On 8/21/15 at 11:10 a.m., Staff C, CNA stated she worked on 8/3/15 and was assigned to Resident #1. Staff C stated the resident always had a little bruising prior to 8/3/15. Staff C identified the resident to be very lethargic on the morning of 8/3/15. Staff C stated she was instructed to go and assist the ambulance with transferring the resident from the bed to the cot. On 8/19/15 at 4:45 p.m. and 8/21/15 at 10:30 a.m., Staff B, LPN (Licensed Practical Nurse) was interviewed and stated she worked on 8/3/15 when Resident #1 was sent to the emergency room . Staff B stated she assisted with the transfer papers for the resident. Staff B stated she did not do a skin assessment on the resident prior to resident going to the emergency room that morning. Staff B stated she does weekly skin assessments on residents and she last did a skin assessment on 7/27/15. Staff B stated on 7/27/15, she noted the resident have only 4 areas of bruising on the right arm, right outer buttock, thigh, and abdomen. Staff B stated she only notifies the physician with any initial wound assessment and if wound gets worse. Staff B stated she has never seen more bruises on the resident then that prior to the resident going to the hospital on [DATE]. Staff B stated she did an assessment on the resident's skin when the resident returned to the facility the next day, 8/4/15 and noted 13 areas of bruising, 9 new bruises plus the 4 noted on 7/27/15. Staff B stated she notified the physician of the bruising on 7/27/15 and the bruising from prior falls. On 8/17/15 at 3:10 p.m., the Director of Nursing (DON) was interviewed and stated the resident had bruises prior to 8/3/15. The DON stated the resident had bruises on the back of his/her hands and antecubital area of arms due to blood draws (for laboratory tests). The DON stated the resident had lots of bruises from his/her multiple falls. The DON stated the resident came back from the hospital on [DATE] with more bruises then what had been present prior. On 8/21/15 at 1:00 p.m., the Advanced Nurse Practitioner (ARNP) was interviewed and stated she had no concerns of the bruising noted at the hospital as far as mistreatment or abusive treatment from staff. The ARNP stated she would have expected the staff to call and notify her of the multiple falls the resident experienced and the bruising that resulted from the falls. The ARNP stated she would want to be notified of this by phone

Based on record review, staff and medical provider interviews, review of facility policy/procedures the facility failed to assess and timely intervene when a resident has an onset of adverse symptoms which represent a change in physical condition (Residents #1,#5). The sample consisted of 8 residents and the facility reported a census of 59 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 5/21/15. The MDS identified the resident ' s [DIAGNOSES REDACTED]. The heart rate is usually between 160 and 200 beats per minute), depression and [MEDICAL CONDITION] (malfunction or disease of the nerves). The assessment documented the resident had a BIMS (Brief Interview for Mental Status) score of 15. A score of 15 identified no memory or cognition problems. The Care Plan with a target date of 3/5/15, identified the resident required assistance for activities of daily living related to shortness of breath (SOB) due to [MEDICAL CONDITION], hypertension and cardiac arrhythmia. The Care Plan directed the staff on 7/23/15 to assist with oxygen needs, and would require more assistance with flare ups of the [MEDICAL CONDITION], remind the resident to ask for assistance. The Care Plan reflected the resident as at risk for communication related to the [MEDICAL CONDITION] and altered raspy voice that makes speaking ineffective and may need to use gestures to communicate. The physician order [REDACTED]. The resident's Departmental Notes documented the following: On 7/12/15 at 4:45 a.m. Staff D, LPN documented the resident complained of SOB, leaned over the side of the bed, helped to lay back, nebulizer treatment given, oxygen saturation obtained and measured 45%, with increase to 88% after treatment. Staff D documented she placed an oxygen mask (on the resident) due to the resident mouth breathing. Staff D documented the resident's respirations at 25 breaths per minute, deep and even with pulse rate of 118 (normal 60-100). The note reflected the nurse planned on monitoring the resident. The staff did not notify the physician or medical provider of the decline in the resident's condition. At 5 a.m., Staff D documented the resident as resting. The nurse documented the lung sounds as faint expiratory wheezes and the resident's oxygen saturation measured 90%. The resident did not have a cough. On 7/12/15 at 6:26 p.m. Staff E, RN documented the oxygen saturations of 88 - 91% on 2 liters of oxygen per nasal cannula. The resident complained of shortness of breath at rest, denied dyspnea, refused morning medications and required extensive assistance with all activities. On 7/13/15 at 00:57 a.m. Staff D documented the resident rested in bed, continued to remove the oxygen mask and then would ask staff to replace it. The resident had an oxygen saturation of 92% on 2 liters and experienced SOB with exertion. On 7/13/15 at 12:24 p.m. Staff E, RN documented she checked on the resident at 6:00 a.m. related to a report the resident had a decline in condition over the weekend. The resident's vital signs showed a blood pressure at 146/101, a pulse rate of 129, respirations at 20 and labored, and oxygen saturation at 66% on 5 liters. Staff E documented she turned the oxygen down to 3 liters, with oxygen saturation improved to 73%. The resident complained of SOB and staff administered a nebulizer treatment with no relief. Staff E documented the resident's skin color as pale/gray and the resident showed mottling on the resident ' s legs. Staff E documented the resident refused to go to the emergency room when asked the first couple of times and upon further talks, the resident agreed to be sent. The staff documented she called the PCP (primary care provider) and received a telephone order to send the resident out and resident left facility at 8:00 a.m. per ambulance to the hospital. Review of the emergency room notes dated 7/13/15 at 9:15 a.m. revealed the resident arrived to the emergency room with complaints of constant worsening SOB that had gradually increased in severity for 2 days. The patient indicated she/he had received nebulizer treatments at the facility without much relief, with oxygen saturations measuring 66% to 40% with 2 liters of oxygen over the weekend. In route to the emergency room the patient ' s oxygen saturation measured 66% with 4 liters per nasal cannula and diaphoretic and SOB. The physical examination in the emergency room revealed a blood pressure of 148/85, pulse rate of 134, respirations of 24 and oxygen saturation of 93%. The resident appeared in distress, diaphoretic and dyspneic. The patient had expiratory wheezes and rales in bilateral lower lobes. A chest x-ray revealed right pleural effusion (excess fluid in the pleural cavity). The listed [DIAGNOSES REDACTED]. The resident entered the general floor of the hospital at 12:55 p.m. then transferred to a higher level of care hospital at 5:45 p.m. On 7/29/15 at 12:40 p.m. the resident's PCP stated they did not utilize a standing order to use an oxygen mask for [MEDICAL CONDITION] residents. The PCP stated they do have an order for [REDACTED]. The facility policy for oxygen administration with a revised date of 10/10 instructed staff to verify there is a physician's orders [REDACTED]. The procedure instructed staff to assess vital signs, lung sounds, arterial blood gases and oxygen saturation and or other laboratory results if applicable. 2. Resident #5 had a MDS assessment with a reference date of 5/14/15. The MDS reflected Resident #5 had a BIMS score of 0. A score of 0 identified the resident had severe memory and cognitive impairment. Resident #5 required the assistance of two staff with bed mobility and toilet use and the assistance of one staff for locomotion, eating and personal hygiene. The resident's [DIAGNOSES REDACTED]. The Care Plan identified a problem on 5/7/15 due to a self- care deficit related to cognition loss as a result of dementia. The Care Plan identified a problem with the resident exhibiting signs of [MEDICAL CONDITION] at times due to dementia. The approaches directed the staff to observe the resident for acute illness as the cause for any changes. The Care Plan also documented a problem of the resident's risk for adverse effects related to use of black box medications and directed staff to observe the resident's vital signs for changes from baseline. The Departmental Notes dated 6/1/15 at 10:49 a.m. noted staff received an order to refer the resident to hospice for evaluation and treatment. The Department notes dated 6/2/14 at 3:13 p.m. documented Resident #5 was admitted into hospice services. The Departmental notes dated 6/3/15 at 10:29 p.m. documented a CNA (Certified Nursing Assistant) called the writer (Staff G) into the resident's room at 8:05 p.m. Resident #5 had no respirations or heartbeat and Staff G notified hospice. On 7/28/15 at 11:20 a.m. Staff G, RN stated she worked on 6/3/15 on the evening shift when one of the CNAs notified her that Resident #5 had been found not breathing. Staff G stated she went into the room and checked the resident. Staff G noted the time as sometime after supper, around 6:30 or 7:00 p.m., or it may have been later. Staff G stated she went immediately to the room to check on the resident and Resident #5 had no respirations and/or heartbeat. She stated she had given the resident medications prior to the CNA finding the resident and there had been no family present On 7/29/15 at 12:40 p.m. the resident's PCP stated she received a call from an area hospital and received notice of the resident's death. The PCP had not been informed by the facility staff. The PCP stated she called the facility and the DON stated the nurse working on the evening/night shift had not checked on Resident #5 immediately after being informed the resident had been found unresponsive for several minutes and that the front line staff was upset. The PCP who had been on call stated she had not been informed of the resident's death until 9:15 p.m. On 7/30/15 at 8:30 a.m. the facility's Director of Nursing stated she expected staff nurses to notify the PCP whenever the resident showed a change in condition and then document in the resident's chart any orders or comments made to them regarding the resident. On 8/3/15 at 12:00 p.m. Staff H, CNA stated she worked on 6/3/15 on the evening shift. Staff H stated she found Resident #5 unresponsive around 7:30 p.m. so she went to tell the nurse. She stated the nurse had been passing medications and did not go into the resident's room for several minutes after she received notice of Resident #5's death. Staff H stated she did not know why the nurse waited to go check the resident. On 8/3/15 at 3:50 a.m. Staff I, CNA stated that on 6/3/15, she went into Resident #5's room with another staff member after supper around 7:30 p.m. and they found the resident unresponsive and not breathing. Staff I stated the nurse had been passing the supper medications and one of the aides went to tell the nurse. Staff I stated several minutes passed before the nurse decided to check on the resident and when the nurse arrived to the room, she made a comment that she thought the resident had not been breathing when the nurse went in the room earlier. When asked if the resident had been cold when found, Staff I stated the resident did not feel cold but Staff I could tell the resident had not just taken their last breath. Staff I stated the front line staff were appalled at the nurse's comments. The facility policy titled Death of a Resident instructed staff to check apical pulse for one minute, wait a few minutes and check again, chart condition prior to the death, contact the doctor in office during day hours and the doctor on call after hours, leave a note to contact the primary doctor the next day in the doctor on call was used.

Based on record review and staff interviews, the facility failed to provide adequate supervision to protect against hazards during a transfer (Resident #1). The sample consisted of 6 residents and the facility identified a census of 64 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 8/28/14. The MDS reflected Resident #1 required the assistance of one staff person with bed mobility, transfers and ambulation. The resident had problems with an unsteady balance and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, moving from one surface to another surface (bed to chair) transfer. The resident had no history of falls. The MDS identified the resident had [DIAGNOSES REDACTED]. The Care Plan dated 6/19/14 identified a problem with self- care due to needing assistance with activity of living skills. The approach directed the staff to assistance the resident with 1 to 2 staff members for transfers and ambulation with the walker. Review of the Departmental Notes dated 8/27/14 at 8:26 p.m. revealed a 5 by 6.5 centimeters dark purple bruise to the left bilateral left extremity shin during afternoon cares. The resident denied pain to the area. The note reflected there was no warmth or swelling noted to the area. Review of the Departmental Notes dated 8/31/14 at 2:28 a.m. revealed the resident continued to have a bruise located on the shin which remained purple without warmth or swelling. The resident denied pain to the area. Review of the Departmental Notes dated 9/2/14 at 2:26 PM revealed staff received approval (from the physician) to have an x-ray of the resident's ankle on 9/3/14. On 9/3/14 at 1:24 PM the resident went to the hospital for an x-ray of the ankle. At 2:53 PM, the document reflected a fracture to the right fibula with directions to ice the right ankle 10 minutes every shift for 10 days, no weight bearing for 4 weeks, use a Hoyer lift for transfers and call if the resident had poor pain control. Review of the Radiology Transcription Report dated 9/3/14 revealed the resident with an obliquely oriented fracture of the distal fibula of the right ankle. The AP (Anterior Posterior) view appeared to have some mild asymmetric widening of the medial aspect of the ankle mortise (pivot movement) that questioned a history of trauma. Review of the facility Witness Statement dated 9/8/14 revealed Staff A transferred the resident when her/his foot got caught on the wheelchair. Staff A documented the resident had pivoted with the transfer and didn ' t notice the resident ' s foot was caught until she set the resident on the bed. The resident didn ' t appear to be in anymore pain than the usual stiffness with transfers. During an interview with Staff A, CNA on 9/26/14 at 10:55 AM, she stated that she transferred the resident to bed from the wheelchair. The foot pedals were swung back and the resident's feet planted on the floor. She noticed the resident's foot caught, but she did not know which foot caught. The resident voiced pain, but the resident always did that with any transfers. Staff A asked the resident if she/he felt OK (alright) and the resident settled down. Staff A stated she looked at the resident's ankle and did not see anything. Staff A did not hear a pop or anything else and did not realize the significance. Staff A stated she did not tell a nurse about the incident. The facility Witness Statement, written by Staff B, certified nursing assistant, reflected Staff A transferred the resident from the chair to the bed. As Staff A went to turn and position the resident in bed, she did not notice the resident ' s foot stuck behind the wheel of the wheelchair. As Staff A continued to turn, the foot remained stuck behind the wheel. During an interview with the Director of Nursing on 9/26/14 at 1:00 PM she stated that she did expect CNAs to report to the charge nurse right away and she felt this incident should have been reported to the nurse. During an interview with Staff B, CNA on 9/26/14 at 4:00 PM she stated that she witnessed Staff A transfer the resident from the wheelchair to the bed. The wheel chair had been positioned to face the bed approximately 1 1/2 feet away. She further stated staff normally positioned the wheel chair next to the bed. The resident's right foot became stuck behind the wheel of the chair. Staff B stated she asked the resident if she/he was alright and they looked at the ankle. The ankle had no bruise or swelling. On 9/26/14 at 3:45 p.m. Staff C, certified nursing assistant, was interviewed and stated she has helped the resident transfer. Staff C stated she would have placed the wheelchair (resident) next to the bed to pivot transfer the resident into bed. Staff C stated she would not take steps to transfer the resident.

Based on observation, clinical record review and staff interviews, the facility staff failed to provide adequate supervision and implement care plan interventions for one of seven residents reviewed. Resident #1 sustained a right shoulder fracture after a fall and at the time of the fall no safety intervention had been utilized. The facility reported a census of 56 residents. Findings include: According to the MDS (Minimum Data Set) assessment with a reference date of 5/30/11, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident's Brief Interview for Mental Status as 8, indicating the resident had moderately impaired mental status. The assessment documented Resident #1 as totally dependent on staff for transfers with a 2 person physical assist. Resident #1 had no history of falls. A review of the CAT Worksheet Problem Area: 11. Falls, documented the resident with difficulty maintain sitting balance and difficulty maintaining a standing position. The medications antipsychotics section showed anti-anxiety agents were checked. The worksheet documented the resident with a decline in functional status, incontinence, muscle weakness, chronic or acute condition resulting in instability and anemia. The section titled Analysis of Findings listed the resident at risk for falls related to increased weakness from current infection and recent hospitalization , use of psychotropic medications, and need for assistance with transfers. The document revealed the resident was non-ambulatory by direct care staff. The resident stands and ambulates with therapy at this time. The Care Plan Considerations documented: Notes, A care plan will be developed to state interventions in place to prevent future occurrence of falls. The Care Plan dated initiated on 6/2/11 documented Resident # 1 at risk for falls and directed staff to use a Hoyer lift with assist of 2 staff members to transfer at all times. The Care Plan documented that the resident had a pressure alarm present at all times to alert staff when the resident tried to get up without assistance and directed staff to check alarm for placement and function every shift. On 6/16/11, nursing staff updated the Care Plan and documented the resident had fallen. On 6/16/11 the Care Plan directed staff to also use a pull alarm at all times and to check the alarm for placement and function every shift. a. A Resident Incident Report dated 6/16/11 at 9:00 a.m. documented a Certified Nursing Assistant (CNA) found Resident #1 on the floor next to a bed rolled up in blankets with their wheelchair and personal alarm on the wheelchair next to the resident's bed. The form documented that the nurse competed a physical assessment, notified the physician and a family member. The form did not identify whether the pressure alarm sounded. The recommendation to prevent further falls indicated pressure alarm in wheelchair and in bed. The Skilled Daily Nurses Notes dated 6/16/11 at 9:00 a.m. documented staff found Resident #1 laying on floor next to bed, rolled in blankets and their wheelchair next to bed with their pull alarm in the chair. Staff completed an assessment, noting no injuries other than general soreness and administered as-needed Tylenol and Ativan given per restlessness. The nurse documented educating staff on the need to make sure the pressure and pull alarms intact at all times. A review of a fax dated 6/16/11 sent to Resident #1's primary care provider documented Resident #1 shut off their personal alarm and transferred self to bed. The resident rolled out of bed and staff found him/her on the floor. The resident reported general soreness and staff gave as-needed Tylenol given. The physician responded on 6/17/11 directing staff to proceed as planned; nothing further at this time. A review of an untitled document dated 6/20/11 at 11:30 a.m. reported that during skin checks Resident #1 had a 10 centimeter by 3 centimeter yellow, green, and purple bruise on the left shoulder, documented on the form under Resident Statement 'It was from my fall'. The facility notified the physician and the physician ordered an x-ray, which occurred on 6/21/11. The rational for the X-ray indicated pain in the resident's right shoulder and that he/she fell out of bed on 6/16/11. The X ray dated 6/21/11 revealed a right distal clavicular fracture and that this had occurred since the prior check x-ray from May 31, 2011. The physician directed placement of the resident's arm in a sling for 1 week, then physical therapy to evaluate and treat for range of motion exercises. The Progress Note dated 6/28/11 and dictated by the primary care physician reported that Resident #1 had sustained a right shoulder injury 6 days ago with a mechanism of injury a history of falling at the nursing home. In an interview on 7/14/11 at 1:30 p.m. Staff D CNA stated that on 6/16/11 between 9 or 9:30 a.m., she heard Staff E say that she needed a nurse and that Resident #1 had fallen on the floor. Staff D said she got the nurse. Staff D said she did not hear an alarm going off. In an interview on 7/14/11 at 11:43 a.m. Staff E CNA said, on 6/16/11 at 7:15 a.m. Staff O CNA and she transferred Resident #1 with a walker and a gait belt and then transported Resident #1 to breakfast. After breakfast, Staff E said they toileted the resident at 8:30 a.m. and returned him/her to a wheelchair to look out a window. Staff E said later while passing ice she witnessed Resident #1 on the floor curled up on their left side and wrapped in a blanket. Staff E stated the wheelchair sat next to the bed with the pressure alarm in the wheelchair and the pull alarm attached to the wheelchair. Staff E stated that Staff O went to get the nurse while she stayed with the resident. In an interview on 7/28/11 at 1:15 p.m. Staff B LPN (licensed practical nurse) said staff found Resident #1 lying on the floor, wrapped in a blanket. Staff B said the pull alarm sat on the wheelchair, not sounding. Staff B said the resident had taken off his/her shirt and transferred to bed. Staff B said she completed an assessment and the resident denied pain and she noted no bruising. Staff B said she notified the doctor and the resident's family. Staff B said the fall happened after breakfast and that she worked until 6:00 p.m. that day. Staff B said the resident did not complain of pain and continued to wheel him/herself around the facility. Staff B said they put the pull alarm in a different position and put a pressure alarm on the wheel as an intervention. Staff B said Resident #1 had a pressure alarm on the bed but the bed had been stripped to be washed. Staff B said if the bed had been made, the pressure alarm would have been on the bed. In an interview on 7/14/11 at 6:27 a.m. Staff J CNA said that Resident #1 will try to reposition him/herself and the pressure alarm would sound. Staff J said Resident #1 could not take steps without assistance. Staff J said that she had not observed Resident #1 to take off his/her pressure alarm. In an interview on 7/14/11 at 10:16 a.m. Staff K LPN said that on 6/20/11 while she completed skin checks she noted a bruise on Resident #1's right shoulder and noted that Resident #1 complained of pain to the area at rest and with movement. Staff K reported the findings to the North Charge Nurse. The North Charge Nurse directed Staff K to send a fax to the physician with findings and request an x-ray. In an interview on 7/26/11 at 2:12 p.m. Staff C LPN said she did not work with Resident #1 on 6/16/11. Staff C said that Resident #1 would set the alarms off because s/he would try to transfer without assistance. Staff C said she worked with Resident #1 on 6/17/11 and s/he complained of shoulder pain but had range of motion and did not yell out or exhibit behaviors. Staff C said she spoke with Staff A LPN and asked if she should send Resident #1 to see the doctor or wait. Staff C said that Staff A told her to wait another day, as the resident could move. In an interview on 7/26/11 at 2:55 p.m. Staff A LPN said she heard about Resident #1's fall the next day during the morning meeting. Staff A said she had not been notified of previous attempts to remove his/her alarms. Staff A said she spoke with Staff C Registered Nurse about the resident's complaints of pain to the shoulder area 1-2 days after the fall. Staff A said Staff C reported the resident had full range of motion to their extremities and no deformities or bruising with her assessment and the resident continued to propel self in the wheel chair without difficulty. Staff A said the following day Staff K notified her that Resident #1 had a bruise to the shoulder area with limited range of motion to the extremity. The resident complained of moderate pain off and on and received as-needed pain medication. Staff A said she sent a fax to the physician requesting an x-ray. Staff A said the resident went to a local emergency room and returned to the facility with a sling in place. In an interview on 7/27/11 at 3:57 p.m. Staff M LPN said she did not work at the time that Resident #1 fell . Staff M said Resident #1 has removed the alarm while in bed and then sat on the side of the bed. The resident had tried to get out of bed but has never transferred without assistance and sometimes the resident will not stand at all. Staff M said staff checks the alarms every shift and she usually double checked the alarms to make sure they were positioned correctly. Staff M said there were a couple of times that Resident #1's pull tab alarm did not work and not positioned right and therefore Resident #1 could take it off. On 7/26/11, the surveyor contacted the resident's primary care physician's office and spoke with the officer manager. The officer manager stated " I asked him (physician) if the fall caused the injury and the physician responded, absolutely. " b. An observation on 7/13/11 at 12:41 p.m. revealed 2 nursing staff members used a front wheeled walker and a gait belt to assist Resident #1 to a standing position from a wheel chair to provide peri-care. When the staff returned Resident #1 to the wheel chair the pressure alarm made a beeping sound. At the request of the surveyor the nursing staff members stood the resident up a second time and the alarm did not sound. Staff N CNA (certified nursing assistant) said the alarm had a time delay. Staff A, Assistant Director of Nursing, stated that the alarm should not be on a time delay. An observation on 7/14/11 at 9:56 a.m. revealed Staff K LPN, Staff F LPN and Staff O CNA stood Resident #1 up in the hallway from a wheel chair with the assistance of 2 and a gait belt. The resident's pressure alarm did not sound until after a 2 second delay. A review of the instructions for the Voice Attendant Pressure Pad Alarm revealed the alarm pad did not use an on/off switch so the alarm could never be accidentally turned off. The instructions directed the alarm had a 3-position delay adjustment: 0, 1 and 2 seconds. If pressure was restored within the timeframe, no alert would sound. In an interview with Staff G CNA on 7/13/11 at 5:02 p.m. Staff G said on 7/11/11 she toileted Resident #1 and noticed that the alarm did not work properly as it did not sound until the resident had finished toileting. Staff G said when they transferred the resident back to the wheel chair the alarm beeped. During interview on 7/14/11 at 10:16 a.m., Staff K, LPN stated on the morning of 7/14/11 Resident #1's alarm had a short delay before sounding. c. During interview on 7/13/11 at 3 p.m., the facility's Director of Nursing and Nursing Consultant stated that on 7/5/11 the facility self identified a problem with the AccuNurse computerized care plan and the comprehensive care plan not matching. The computerized care plan and the Exception reports, provided by the facility to the certified nursing assistants to use as pocket care plans, lacked directions as to what kind or the number of alarms a resident had nor the directive for the number of staff to assist with resident transfers.