Every finding on record at Riverside Lifelong Health & Rehab Smithfield

Based on information obtained during the resident group meeting, and observation, the facility staff failed to ensure that 4 of 4 residents in the group meeting knew the location of the required postings for the daily staffing.The findings included: On 5/28/26 at 9:30 AM a Resident Group meeting was held with the four residents. It was the consensus of all attending the meeting that they were unaware of where to locate the required posting of daily staff. On 5/28/26 at 10:33 AM, an interview was conducted with the recreation therapy director, stated that the residents may not have been aware of the daily postings. The director stated she would review what the posting meant and where they are located to the residents in the meetings. The Director of Nursing stated the posting is in plan site but that everyone may not know where to look for it in its current spot. On 5/28/29 the administrator interviewed stated that the daily staff posting is on the Nursing station door and acknowledges that the current posting location is not the most public place for it to be posted so that it is visible to residents, visitors and staff. On 5/28/26 at approximately 4:45 pm, a final interview was conducted with the Administrator, Director of Nursing, Regional Quality, and the Corporate Nurse Consultant. The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.

Based on family interview, staff interview and facility documentation review, the facility staff failed to notify the resident's Power of Attorney (POA) of a complaint of pain for 1 of 25 residents (Resident #38) in the survey sample.The findings included: Resident #38 was originally admitted to the facility 4/25/23 and readmitted on [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Chronic Diastolic Congestive Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Unspecified Osteoarthritis and Pain due to trauma. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/24/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #38 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goals) the resident was coded as requiring set up or clean-up assistance with eating, dependent with toileting hygiene, shower/bath self, lower body dressing, putting on/taking off footwear and personal hygiene.The person-centered care plan dated 9/12/25 read that resident has altered cardiovascular status relating to arrythmia, Atrial Fibrillation, hypertension, coronary artery disease and Congestive Heart Failure. The resident's Goal included: Resident will be free from complications of cardiac problems. The interventions for the resident included: Administer medications as ordered: Diuretic, Antiplatelet, Anticoagulant, Magnesium supplement, Potassium supplement, assess for shortness of breath and cyanosis as needed, Monitor VITAL SIGNS at least monthly or more often. Notify MD of significant abnormalities, Monitor/document/report PRN any signs/symptoms of coronary artery disease (CAD), chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap refill, color/warmth of extremities, notify provider for any changes in regimen.A review of a health note dated 9/09/25 at 9:27 AM, read: Resident complained of having chest pains and bilateral elbow pain but refused to go to the hospital. Residents vital signs were 98.3, 98, 18, 99/72, 98%. Resident stated that she didn't want to go to the hospital at this time and would like to try Tylenol first to see if it helps with the pain. This nurse educated the resident on the importance of notifying staff of any other new or worsening symptoms. Supervisor has been notified.A review of the Medication Administration Record (MAR) for September 2025 read Tylenol 325 mg give 2 tabs as needed for mild pain. On 9/09/25 Tylenol 325 mg 2 tablets were administered at 9:34 AM and at 10:24 AM with effectiveness.A review of the Medical Record did not reveal if the doctor or Power of Attorney (POA) were notified of the above incident concerning chest and elbow pain.A review of the Resident's profile revealed that the resident's family member was listed as the Emergency Contact #1.On 5/28/26 an interview was conducted at 7:55 PM, with Licensed Practical Nurse (LPN) #2. LPN #2 said that he remembers assessing Resident #38, concerning chest and elbow pain, but the resident said that she didn't want to go to the hospital but wanted to try Tylenol for chest pain and bilateral elbow pain. LPN #2 also said that he educated the resident to go to the hospital but realized that he couldn't make her go. LPN #2 said that he notified the supervisor but did not contact the doctor or the family member because the resident is her own Responsible Party (RP).On 5/29/26 a POA document was received by the facility administrator. The POA document revealed that the family member listed as the Emergency Contact #1 was also the POA since 9/29/23.On 5/29/26 at approximately 3:45 PM., a phone call was received from the Medical Director. The Medical Director said that because the resident didn't want to go to the Emergency Room, she didn't have to due to the patient having the right to refuse care. The MD also said that vital signs were taken and Tylenol was administered with effectiveness. The MD also said that if the pain issues were recurrent the staff should have notified him but the Tylenol was effective. The Medical Director also mentioned that we could have given the family an FYI.On 5/29/26 at approximately 4:55 PM, a brief interview was conducted with the POA concerning the above incident. The POA said that she didn't hear anything about her family member having chest or elbow pains They should have told me, I'm her POA. I would have asked why the doctor isn't looking at her.On 5/28/26 at approximately 8:50 pm., end of day meeting was conducted with the administrator, the Director of Nursing (DON) and the Executive Director of Nursing. No comments were made.

Based on observations and information obtain during the Resident Council interview, the facility staff failed to ensure residents of the facility were aware and knew the location of the list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups. The findings included: During the Resident Council interview conducted on 04/10/24 at approximately 01:38 PM four residents were present. All the residents in the interview were unable to verbalize the location of the list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups. Two random residents were also interviewed (residents not in the group interview). They were Resident #15 and #19. Resident #15's BIMS score was 14. He was interviewed on 4/10/24 at approximately 3:05 PM. The resident stated he was unaware of the listings. Resident #19 was interviewed on 4/10/24 at approximately 3:15 PM and he stated were not aware of he was unaware of the list. An interview was conducted with the Activity Director and the Assistant Activity Director after the Resident Council interview 4/10/24 at approximately 2:55 PM. The Activity Director stated she was unaware of the list of names and addresses and contact information, but she would get back with the Surveyor regarding the information. The Activity Director and the Assistant Activity Director informed the Surveyor that the listing was posted on the back hall near the rehabilitation department and going forward they would ensure to share the location of the information to residents and families. During the final interview with the Administrator, Director of Nursing and Administrative team members on 4/12/24 at approximately 10:00 AM the above findings were shared, and they voiced no concerns regarding the identified issues during the survey.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure 1 of 27 residents in the survey sample, (Resident #5) were given the opportunity to formulate an advance directive. The findings included: Resident #5 was originally admitted to the nursing facility on 09/25/21. Diagnosis for Resident #5 included but are not limited to Hypertension. The quarterly revised Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/06/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #5 cognitive abilities for daily decision making were intact. A review of the clinical record revealed that there was no advance directive for Resident #5. On 04/10/24 at approximately 11:48 AM., Registered Nurse (RN) #1 was approached for assistance in locating Resident #5's advanced directive. RN #1 looked through an advance directive binder for a hard copy and the Resident's medical record with no success. The RN failed to provide evidence that they offered the resident the opportunity to formulate an advance directive. On 4/11/24 at approximately 8:30 PM., a Do Not Resuscitate (DNR) order was received from Licensed Practical Nurse (LPN) #1. LPN #1 was informed that the DNR order did not meet the criteria for an advanced directive. LPN #1 said that no advance directive was found in the resident's medical record nor evidence that the resident was offered an opportunity to formulate one. On 4/12/24 at approximately 9:25 AM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on observation and staff interview, the facility's staff failed to ensure Enhanced Barrier Precaution signage was initiated to prevent the spread of infection and or hospitalization s for 3 of 27 residents (Resident #14, Resident #15, and Resident#16), in the survey sample. The findings included: 1. The facility staff failed to post precautionary signage alerting facility staff, visitors, and outside vendors of Enhanced Barrier Precautions (EBP) for Resident #14. Resident # 14 was originally admitted to the facility 10/24/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Chronic Kidney Disease. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/23/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00: This indicated Resident #14 cognitive abilities for daily decision making were severely impaired. Section K (Swallowing/Nutritional Status) coded the resident as having a Feeding Tube. According to the Infection Preventionist Resident #14 meets the criteria for EBP precaution due to having a feeding tube. 2. The facility staff failed to post precautionary signage alerting facility staff, visitors, and outside vendors of Enhanced Barrier Precautions (EBP) for Resident #15. Resident #15 was originally admitted to the facility 8/05/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Retention of urine. The quarterly revised Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/20/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #15 cognitive abilities for daily decision making were intact. In section H(Bladder and Bowel) the resident was coded as having an Indwelling catheter. An interview was conducted on 4/11/24 at approximately 2:05 PM., with the Infection Preventionist (IP). The IP said that because Resident #15 had an Indwelling catheter, EBP signage should have been posted. 3. The facility staff failed to ensure EBP signage was posted for Resident #16. Resident #16 was originally admitted to the facility 07/18/23 after an acute care hospital stay. The current diagnoses included; Chronic Kidney Disease, Stage 3 Unspecified. The quarterly revised Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/16/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated Resident #16 cognitive abilities for daily decision making were moderately impaired. An interview was conducted on 4/11/24 at approximately 2:05 PM., with the Infection Preventionist (IP). The IP said that Resident #16 was diagnosed with a Urinary Tract Infection (UTI). On 4/08/24 during the initial tour of the facility at approximately 7:30 PM to 8:30 PM., no Enhanced Barrier Signage was posted on the above Residents' door or wall. On 4/09/24 an interview was conducted with Certified Nurse's Assistant (CNA) #4. CNA #4 said that EHB precautions are used when providing care to the residents. CNA #4 pointed to an EBP signage that read: ENHANCED BARRIER PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Changing briefs or assisting with a toileting device care or use. Central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. On 04/11/24 at approximately 2:05 PM., an interview was conducted with the Infection Preventionist (IP) and Director of Education (DOE) concerning Enhanced Barrier Precautions (EHB's) for the above Residents. The IP said that EHB precautions should have been followed since April 1st (2024) with High-risk residents with portals for entrance. The IP also said that Resident #14, Resident #15, and Resident #16 should have had EHB precaution signage posted. On 4/12/24 at approximately 9:25 AM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities. Enhanced Barrier Precautions can be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO. Consistent with 2019-2020 CDC EBP interim guidance, examples of indwelling medical devices include central line, urinary catheter, feeding tube, and tracheostomy/ventilator; examples of high contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use, and wound care. https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html

Based on a family interview, staff interviews, and clinical record review, the facility staff failed to review and revise the person-centered care plan to include hospice services for 1 of 27 residents (Resident #11), in the survey sample. The findings included: Resident #11 was originally admitted to the facility 4/15/22 and the resident had never been discharged from the facility. The current diagnoses included dementia and dysphagia. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/5/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #11's cognitive abilities for daily decision making were intact. It was noted during the interview with Resident #11 that she would lose her train of thought and switch from subject to subject. In sections GG the resident was coded as dependent upon staff for most activities of daily living. She was also coded for set-up assistance only with eating. In section O (Special Treatments and Programs) at K1, the resident was coded for Hospice services. On 4/10/24 at approximately 12:25 PM an interview was conducted with the Family Member #3. Family Member #3 stated that Resident #11 had experienced weight loss and some decline physically therefore the Physician recommended hospice services which would allow the resident to receive additional assistance with meal consumption. Family Member #3 stated he was unsure of how often hospice was assisting the resident with meal consumption, but he felt Resident #11 was self-feeding much better and maybe she could come off the hospice services soon. An interview was conducted with Registered Nurse (RN) #1 on 4/11/24 at approximately 1:35 PM. RN #1 stated the resident was receiving hospice services and provided a hospice book which contained documents from the hospice agency. A review of the facility's person-centered plan of care failed to address hospice services within any identified problem. RN #1 stated the hospice personnel don't have a consistent schedule and they are not scheduled to assist the resident with any meals. An interview with the Administrator on 4/12/24 at approximately 11:25 AM revealed that currently the facility is without an MDS Coordinator and they have a Corporate person currently helping out. During the final interview with the Administrator, Director of Nursing and Administrative team members on 4/12/24 at approximately 10:00 AM the above findings were shared, and they voiced no concerns.

Based on observation and staff interviews, the facility staff failed to ensure a multi-dose vial of Tuberculin, a purified protein derivative was dated when opened, to ensure it was discarded in 30 days and did not remain available for administration. The findings included: The medication storage task was conducted on 4/11/24 at approximately 11:50 AM with Registered Nurse (RN) #2. Observations were made of opened biologicals in the medication refrigerator which included an opened bottle of Tuberculin, purified protein derivative. The date on the Tuberculin box label as sent from the pharmacy to the facility for house stock was January 2024. A further review failed to reveal the date the multi-dose vial of Tuberculin, a purified protein derivative had been opened. RN #2 stated she did not know when it had been opened or for whom it was opened for since neither the box nor the vial was dated. An interview was also conducted with RN #1 on 4/11/24 at approximately 12:30 PM. RN #1 stated she received information that the undated multi-vial of Tuberculin, purified protein derivative can be used up to 30 days once opened. RN #1 stated the biological would be removed from use and discarded because the date it was opened was unknown. During the final interview with the Administrator, Director of Nursing and Administrative team members on 4/12/24 at approximately 10:00 AM the above findings were shared, and they voiced no concerns. INDICATIONS AND USAGE - TUBERSOL Tuberculin Purified Protein Derivative (Mantoux), is indicated to aid diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease (https://www.fda.gov/media/74866/download). STORAGE - Store at 2 to 8 C (35 to 46 F). (20) Do not freeze. Discard product if exposed to freezing. Protect from light. Tuberculin PPD solutions can be adversely affected by exposure to light. The product should be stored in the dark except when doses are actually being withdrawn fromthe vial. A vial of TUBERSOL which has been entered and in use for 30 days should be discarded (https://www.fda.gov/media/74866/download).

Based on a family interview, staff interview, clinical record review, and review of the Hospice policy; the facility staff failed to a method of communication after visits were available to the facility staff and to ensure hospice services were coordinated to ensure hospice staff assisted with meal consumption for 1 of 27 residents (Resident #11), in the survey sample. The findings included: Resident #11 was originally admitted to the facility 4/15/22 and the resident had never been discharged from the facility. The current diagnoses included dementia and dysphagia. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/5/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #11's cognitive abilities for daily decision making were intact. It was noted during the interview with Resident #11 that she would lose her train of thought and switch from subject to subject. In sections GG the resident was coded as dependent upon staff for most activities of daily living. She was also coded for set-up assistance only with eating. In section O (Special Treatments and Programs) at K1, the resident was coded for Hospice services. On 4/10/24 at approximately 12:25 PM an interview was conducted with the Family Member #3. Family Member #3 stated that Resident #11 had experienced weight loss and some decline physically therefore the Physician recommended hospice services which would allow the resident to receive additional assistance with meal consumption. Family Member #3 stated he was unsure of how often hospice was assisting the resident with meal consumption, but he felt Resident #11 was self-feeding much better and maybe she could come off the hospice services soon. An interview was conducted with Registered Nurse (RN) #1 on 4/11/24 at approximately:35 PM. RN #1 stated the resident was receiving hospice services and provided a hospice book which contained documents from the hospice agency. RN #1 was unable to confirm that a member of hospice made themselves available to assist with at least a meal on the days they visited. RN #1 also stated the hospice representative did not always ensure they provided a report to the facility staff at the end of their visit and there was not a written method of communication that was left at or later sent to the facility after a hospice representative visited the resident. During the final interview with the Administrator, Director of Nursing and Administrative team members on 4/12/24 at approximately 10:00 AM the above findings were shared, and they voiced no concerns.

Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to convey the summary of goals of the comprehensive plan of care upon transfer/discharge for 1 of 20 residents (Resident #23) in the survey sample. The findings include: The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on [DATE] or as soon as possible to the actual time of transfer for Resident #23. Resident #23 was admitted to the nursing facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23's most recent Minimum Data Set (MDS) assessment was an Annual dated [DATE] and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 00 out of a possible score of 15 which indicated the resident was severely impaired in the skills for daily decision making. The nurse's notes dated [DATE] indicated the nurse was called to the room by other clinical staff members. Resident was sitting in a wheelchair in obvious distress. He was transferred back to bed via a Hoyer (brand name mechanical lift) and 2 person CPR started while 911 was called at approximately 7:31 a.m. Paramedics arrived at 07:45 a.m. and took over CPR. The daughter and physician was notified of the situation. Paramedics were able to get a pulse and the resident left the building to be transferred to (name of local hospital). There was no documentation in the clinical record that facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge or soon thereafter to the local hospital. On [DATE] at 9:30 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON). They stated that care plan goals and summary report should be sent with the resident if possible and if not be forwarded by email, but mostly faxed to the hospital in this case, but it wasn't and this is something we are going to fix through in-services. They said, When a resident is transferred to the ER or the hospital the nurse is prompted through a check list in the computer for the specific resident that in turn generates the transfer summary that includes the care plan summary with goals as well as the bed hold notice, but there is no way to confirm the documents was sent at the time of the transfer or that it was sent over to the ED or hospital soon after. The facility's policy titled Nursing Home Discharge/Transfer Policy dated [DATE] indicated that the hospital of receiving facility will be provided with all applicable state and federal notices at the time of transfer or as soon as possible for emergent discharges/transfers, including comprehensive care plan goals and discharge summary.

The findings include: The facility staff failed to include a bed-hold policy at the time of discharge to the local hospital on [DATE] or as soon as possible to the actual time of transfer for Resident #23. Resident #23 was admitted to the nursing facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23's most recent Minimum Data Set (MDS) assessment was an Annual dated [DATE] and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 00 out of a possible score of 15 which indicated the resident was severely impaired in the skills for daily decision making. The nurse's notes dated [DATE] indicated the nurse was called to the room by other clinical staff members. Resident was sitting in a wheelchair in obvious distress. He was transferred back to bed via a Hoyer (brand name mechanical lift) and 2 person CPR started while 911 was called at approximately 7:31 a.m. Paramedics arrived at 07:45 a.m. and took over CPR. The daughter and physician was notified of the situation. Paramedics were able to get a pulse and the resident left the building to be transferred to (name of local hospital). There was no documentation in the clinical record that facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge or soon thereafter to the local hospital. On [DATE] at 9:30 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON). They stated that the bed hold policy/notice in the case of Resident #23 who would have not been able to comprehend the notice, we would make sure the Resident Representative (RR) received our bed hold policy/notice and it was documented accordingly. They said, When a resident is transferred to the ER or the hospital the nurse is prompted through a check list in the computer for the specific resident that in turn generates the transfer summary that includes the care plan summary with goals as well as the bed hold notice, but there is no way to confirm the documents was sent at the time of the transfer or that it was sent over to the ED or hospital soon after. The facility's policy titled Nursing Home Discharge/Transfer Policy dated [DATE] indicated that the resident/representative will be provided with all applicable state and federal notices at the time of transfer or leave of absence as soon as possible including the bed hold policy.

Based on information gleamed during a complaint investigation, a complainant interview, staff interviews, and clinical record review, the facility's staff failed to communicate pertinent information to the resident and resident representative at the time of an anticipated discharge, for 1 of 20 residents (Resident #21), in the survey sample. The findings included: Resident #21 was originally admitted to the facility 4/24/20, and was discharged [DATE], return not anticipated therefore; a closed record review was conducted. Resident #21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/30/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with bed mobility, extensive assistance of one person with bathing, toileting and dressing, limited assistance of one person with transfers, walking in room and personal hygiene and independent after set-up with eating. During the interview with the complainant on 2/23/21 at 1:20 p.m., the complainant stated the facility's staff never notified her that Resident #21 had acquired a pressure ulcer while at the facility. The complainant stated on the day of discharge the resident was very uncomfortable and unable to sit on her behind when they arrived home from the facility therefore; she assisted her to undress and that was when she first learned of the open areas to her behind. The complainant stated the open area were uncovered and large. The complainant stated she immediately telephoned the facility to inquire of the open areas to the resident's behind and asked how to care for them but the staff didn't seem to care since the resident had been discharged . Review of Resident #21's clinical record revealed she was admitted without a open areas to her buttock. The Braden scale completed on 4/24/20 and 5/8/20 indicated the resident was a mild risk for development of a pressure ulcer. Nurses's notes stated the resident toileted and was mostly continent of her bladder and bowels but she required assistance with transfers and bed mobility because of the right knee limitations. Further review of Resident #21's clinical record revealed on 5/9/20 the staff identified an open area measuring 0.5 centimeters by 0.5 centimeters to the right lower buttock. An order was obtained to treat the open area. The order read; cleanse the right buttock gently with normal saline and pat dry. Apply an oil [MEDICATION(S)] dressing to the open area and a foam dressing every three days. Review of Resident #21's treatment record revealed the right buttock dressing change was performed 5/10/20 and 5/13/20. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 2/24/21 at approximately 3:40 p.m. LPN #1 stated she was the nurse who originally assessed the open area to Resident #21's buttock and she obtained the initial order for care. She further stated she hadn't been trained to determine types of wounds or staging therefore; a staff member trained in wound assessment was responsible to complete an in-depth assessment and determine the most appropriate treatment. An interview was conducted with the Director of Nursing on 2/25/21 at approximately 11:30 a.m. The Director of Nursing stated LPN #1 duties included to immediately assess and measure the wound, notify the provider and resident representative, start the ordered treatment, complete rCare documents, a nurses note, write the nursing care plan, notify nursing management, and the on-coming shift until the area was healed. The Director of Nursing further stated the next business day the nurse leader/wound champion's investigation report wasn't completed and the etiology wasn't determined. Neither was the Director of Nursing able to locate documentation the resident representative was notified of the original finding of the open area or documentation stating at the time of Resident #21's discharge that the resident representative was notified of the residents open wound and was made aware of orders to treat the open area. On 2/25/21 at approximately 3:00 p.m., the above findings were shared with the Administrator and the Director of Nursing. The Director of Nursing stated the expectation is for the nurse to explain important information from the discharge summary to the resident and resident representative and have the information written on the discharge summary so there is something to refer to if needed. The Administrator stated she understood the concern and had no additional information to offer. Complaint Deficiency

Based on information gleamed during a complaint investigation, a complainant interview, staff interviews, and clinical record review, the facility's staff failed to ensure a resident with pressure ulcers received necessary treatment and services to promote healing for 1 of 20 residents (Resident #21), in the survey sample. The findings included: Resident #21 was originally admitted to the facility 4/24/20, and was discharged [DATE], return not anticipated therefore; a closed record review was conducted. Resident #21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/30/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with bed mobility, extensive assistance of one person with bathing, toileting and dressing, limited assistance of one person with transfers, walking in room and personal hygiene and independent after set-up with eating. During the interview with the complainant on 2/23/21 at 1:20 p.m., the complainant stated the facility's staff never notified her that Resident #21 had acquired a pressure ulcer while at the facility. The complainant stated on the day of discharge the resident was very uncomfortable and unable to sit on her behind when they arrived home from the facility therefore; she assisted her to undress and that was when she first learned of the open areas to her behind. The complainant stated the open area were uncovered and large. The complainant stated she immediately telephoned the facility to inquire of the open areas to the resident's behind and asked how to care for them but the staff didn't seem to care since the resident had been discharged . Review of Resident #21's clinical record revealed she was admitted without a open areas to her buttock. The Braden scale completed on 4/24/20 and 5/8/20 indicated the resident was a mild risk for development of a pressure ulcer. Nurses's notes stated the resident toileted and was mostly continent of her bladder and bowels but she required assistance with transfers and bed mobility because of the right knee limitations. Further review of Resident #21's clinical record revealed on 5/9/20 the staff identified an open area measuring 0.5 centimeters by 0.5 centimeters to the right lower buttock. An order was obtained to treat the open area. The order read; cleanse the right buttock gently with normal saline and pat dry. Apply an oil [MEDICATION(S)] dressing to the open area and a foam dressing every three days. Review of Resident #21's treatment record revealed the right buttock dressing change was performed 5/10/20 and 5/13/20. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 2/24/21 at approximately 3:40 p.m. LPN #1 stated she was the nurse who originally assessed the open area to Resident #21's buttock and she obtained the initial order for care. She further stated she hadn't been trained to determine types of wounds or staging therefore; a staff member trained in wound assessment was responsible to complete an in-depth assessment and determine the most appropriate treatment. An interview was conducted with the Director of Nursing on 2/25/21 at approximately 11:30 a.m. The Director of Nursing stated LPN #1 duties included to immediately assess and measure the wound, notify the provider and resident representative, start the ordered treatment, complete rCare documents, a nurses note, write the nursing care plan, notify nursing management, and the on-coming shift until the area was healed. The Director of Nursing further stated the next business day the nurse leader/wound champion's investigation report wasn't completed and the etiology wasn't determined. Neither was the Director of Nursing able to locate documentation the resident representative was notified of the original finding of the open area or documentation stating at the time of Resident #21's discharge that the resident representative was notified of the residents open wound and was made aware of orders to treat the open area. Review of a Physician's progress note dated 5/16/21, revealed Resident #21 presented to the practice with two stage 2 pressure ulcers, one to each buttock, more superficial. No measurements were documented. New orders were obtained to keep the area clean and dry as possible with dry bandages, apply a light layer of [MEDICATION(S)] ointment to the affected areas three times per day and allow the area to air out if possible. On 2/25/21 at approximately 3:00 p.m., the above findings were shared with the Administrator and the Director of Nursing. The Director of Nursing stated the expectation was for the nurse to notify the nurse leader/wound champion so a through investigation and etiology could be determined and it appeared that didn't occur therefore; all wound care measures were not instituted. The Administrator stated she understood the concern and had no additional information to offer. Complaint Deficiency

Based on observations, staff interviews and clinical record review the facility staff failed to ensure one resident (Resident #15, in the survey sample of twenty Residents) who is unable to carry out activities of daily living receives the necessary services to maintain toenail care. The facility staff failed to ensure that podiatry services were provided to Resident #15. The findings included: Resident #15 was originally admitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was a quarterly revision with an Assessment Reference Date (ARD) of 01/19/21 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 6 which indicated cognitive impairment for daily decision-making. Resident #15 was coded to require extensive assistance of one staff with personal hygiene. During the initial tour on 2/23/21 at approximately 1:48 p.m., an interview was conducted with Resident #15. He was asked if he received toenail care. No response was made. He was then asked by the surveyor if she could see his feet. He stated, Yes. The Resident's nurse, LPN (Licensed Practical Nurse) #1 was asked to assist in removing the covers from off of the Resident's feet. An observation of the resident's toenails revealed they were long, thick and curving into the skin on all of his digits/toes (both feet) except for the right and left great toe. LPN #1 stated that she will put him on the podiatry list. A review of progress notes revealed that Resident #15 was seen by a podiatrist on 8/16/20. Resident received Electrical and Mechanical debridement of nails. Dystrophic toenails were debrided digits 1-10. The Care Plan revealed the following: Resident has had a decline in ADL (Activity of Daily Living) ability secondary to recent hospitalization S/P fall. Goals: Resident will increase his level of independence in ADL'S by working with therapy and with assistance of staff will have ADL needs met through next review. Interventions: Let Resident know that you are there to assist him with his ADL'S. An interview was conducted on 02/25/21 at approximately, 9:56 AM with CNA (Certified Nurse's Aide) #1 concerning care of resident #15 toenails. She stated, When we do ADL (Activities of Daily Living) care we check to see if they (Residents) need nail care then we let the nurse know. An interview was conducted on 2/25/21 at approximately, 10:45 a.m. with the DON (Director of Nursing) concerning podiatry services for Resident #15. She stated, Our podiatry is coordinated through the Podiatrist. If we have a concern about a resident we will send it to him and he will add to that list. He comes monthly but can only bill quarterly. She was asked if facility RN's could have provided podiatry care to the residents? She stated, Yes. I just asked Resident #15 if he wanted podiatry care. He said yes. The facility revised policy dated 02/2021 reads: Only a licensed nurse or podiatrist is allowed to cut the residents' toenails. CNA's are allowed to file the residents' toenails. Procedure: Cut or file the resident's toenails after bathing, if possible. Nails are soft and easy to trim after bathing. On 2/25/21 at 3:35 p.m. a Debriefing was held with the Administrator and DON concerning the above issues with podiatry care services. No comments were voiced. Onychomycosis: Fungus infection of the nail bed under the fingernails or toenails. Onychomycosis makes the nails look white and opaque, thickened, and brittle. It usually produces no symptoms other than a cosmetic problem. Reference: https://search.yahoo.com/yhs/search?hspart=pty&hsimp=yhs-pty_email¶m2= 702-4c31-4b0e-b504-1ff86be15a2c¶m3=email_~US~appfocus1~¶m4=d-ccc9-lp0-cp_ ilc-bb8-iei-oth-su~MSIE~onychomycosis+definition~D41D8CD98F00B204E 98ECF8427E~Win10¶m1= 108&us_privacy=1---&p=onychomycosis+definition&type=em_appfocus1_ie www.rxlist.com/script/main/art.asp?articlekey= #:~:text=Onychomycosis%3A%20Fungus%20infection%20of%20the%20nail%20bed%20under,produces%20no%20symptoms%20other%20than%20a%20cosmetic%20problem. Dystrophic nails are nails that become misshapen, thickened, or have a partially destroyed nail plate. Nails may become distorted by too much keratin in the nail plate and nail bed, causing the nail to lift off the underlying skin. Dystrophic nails are commonly caused by a fungal infection of the toenail, called onychomycosis. Other potential causes include psoriasis and trauma - either direct injury or chronic, repetitive microtrauma. Reference: https://www.bergdpm.com/dystrophic-nails.html#:~:text=Dystrophic%20nails%20are%20commonly%20caused%20by%20a%20fungal,athlete%E2%80%99s%20foot%29%2C%20and%20less%20commonly%20yeasts%20or%20molds.

Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 residents (Resident #2 and Resident #13) out of 20 in the survey sample. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #2 who was discharged from skilled services with Medicare days remaining. The findings included: 1. Resident #2 was admitted to the nursing facility on 11/16/20. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Minimum Data Set (MDS) an OBRA Admission Assessment with an Assessment Reference Date (ARD) date of 11/21/20 coded Resident #2 a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated no cognitive impairment. Review of the SNF Beneficiary Notification Review provided by the facility to surveyor, was noted that Resident #2 was not listed for having been issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice.). The resident had received a NOMNC (Notice of Medicare Provider Non-Coverage), however; no copy of the SNF ABN was provided. Resident #2 started a Medicare Part A stay on 11/17/20 and the last covered day of this stay was 11/27/20. Resident #2 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #2 had only used 12 days of her Medicare Part A services with 88 days remaining. Resident #2 should have been issued a SNF ABN and an NOMNC. Resident #2 was only issued an NOMNC. An interview was conducted with the Social Worker (SW) on 02/24/21 at approximately 2:45 p.m. He stated, I'm not sure what happened; I can't find a copy of the SNF ABN letter for Resident #2. When asked, if an ABN letter should have been issued to Resident #2, the SW replied, Yes. 2. Resident #13 was admitted to the nursing facility on 12/24/20. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's Minimum Data Set (MDS) an OBRA Admission Assessment with an Assessment Reference Date (ARD) date of 12/30/20 coded Resident #13 a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated no cognitive impairment. Review of the SNF Beneficiary Notification Review provided by the facility to surveyor, was noted that Resident #13 was not listed for having been issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice.) The resident had received a NOMNC (Notice of Medicare Provider Non-Coverage), however; no copy of the SNF ABN was provided. Resident #13 started a Medicare Part A stay on 12/26/20, and the last covered day of this stay was 01/25/20. Resident #13 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #13 only used 39 days of his Medicare Part A services with 61 days remaining. Resident #13 should have been issued a SNF ABN and an NOMNC. Resident #13 was only issued an NOMNC. An interview was conducted with the Social Worker (SW) on 02/24/21 at approximately 2:45 p.m. He stated, I'm not sure what happened; I can't find a copy of the ABN letter. When asked, if an ABN letter should have been issued to Resident #13 the SW replied, Yes. The Administrator and Director of Nursing DON) was informed during the debriefing on 02/25/21 at approximately 3:45 p.m. The facility did not present any further information about the findings. The facility's policy titled: Daily Skilled Review Procedure, revision date: 12/06/19. Purpose: To ensure interdisciplinary team (IDT) identifies and address skilled resident's needs from admission to discharge. -Procedure: Supplemental Guidance read in part: Date of NOMNC and ABN from Social Services or Business Office Liaison ([NAME].)

Based on information gleamed during a complaint investigation, a complainant interview, staff interviews, clinical record review, and review of facility documents, the facility's staff failed to notify the resident representative of a change in condition for 1 of 20 residents (Resident #21), in the survey sample. The findings included: Resident #21 was originally admitted to the facility 4/24/20, and was discharged [DATE], return not anticipated therefore; a closed record review was conducted. Resident #21's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/30/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with bed mobility, extensive assistance of one person with bathing, toileting and dressing, limited assistance of one person with transfers, walking in room and personal hygiene and independent after set-up with eating. During the interview with the complainant on 2/23/21 at 1:20 p.m., the complainant stated the facility's staff never notified her that Resident #21 had acquired a pressure ulcer while at the facility. The complainant stated on the day of discharge the resident was very uncomfortable and unable to sit on her behind when they arrived home from the facility therefore; she assisted her to undress and that was when she first learned of the open areas to her behind. The complainant stated the open area were uncovered and large. The complainant stated she immediately telephoned the facility to inquire of the open areas to the resident's behind and asked how to care for them but the staff didn't seem to care since the resident had been discharged . Review of Resident #21's clinical record revealed she was admitted without an open area to her buttock. The Braden scale completed on 4/24/20 and 5/8/20 indicated the resident was a mild risk for development of a pressure ulcer. Nurses' notes stated the resident toileted and was mostly continent of her bladder and bowels but she required assistance with transfers and bed mobility because of the right knee limitations. Further review of Resident #21's clinical record revealed on 5/9/20 the staff identified an open area measuring 0.5 centimeters by 0.5 centimeters to the right lower buttock. An order was obtained to treat the open area. The order read; cleanse the right buttock gently with normal saline and pat dry. Apply an oil [MEDICATION(S)] dressing to the open area and a foam dressing every three days. Review of Resident #21's treatment record revealed the right buttock dressing change was performed 5/10/20 and 5/13/20. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 2/24/21 at approximately 3:40 p.m. LPN #1 stated she was the nurse who originally assessed the open area to Resident #21's buttock and she obtained the initial order for care. She further stated she hadn't been trained to determine types of wounds or staging therefore; a staff member trained in wound assessment was responsible to complete an in-depth assessment and determine the most appropriate treatment. An interview was conducted with the Director of Nursing on 2/25/21 at approximately 11:30 a.m. The Director of Nursing stated LPN #1 duties included to immediately assess and measure the wound, notify the provider and resident representative, start the ordered treatment, complete rCare documents, a nurses note, write the nursing care plan, notify nursing management, and the on-coming shift until the area was healed. The Director of Nursing further stated the next business day the nurse leader/wound champion's investigation report wasn't completed and the etiology wasn't determined. Neither was the Director of Nursing able to locate documentation the resident representative was notified of the original finding of the open area or documentation stating at the time of Resident #21's discharge that the resident representative was notified of the residents open wound and was made aware of orders to treat the open area. On 2/25/21 at approximately 3:00 p.m., the above findings were shared with the Administrator and the Director of Nursing. The Director of Nursing stated the expectation is for the nurse to notify the resident representative of changes in condition and when the algorithm is utilized it guides the nurse to ensure all necessary measures are met. The Administrator stated she understood the concern and had no additional information to offer. Complaint Deficiency

Based on clinical record review, staff interviews, and facility document review the facility staff failed to notify the office of the State Long-Term Care Ombudsman in writing of applicable discharges for 1 of 20 residents in the survey sample (Resident #23). The findings included: The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #23's discharge to the hospital on [DATE]. Resident #23 was admitted to the nursing facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23's most recent Minimum Data Set (MDS) assessment was an Annual dated [DATE] and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 00 out of a possible score of 15 which indicated the resident was severely impaired in the skills for daily decision making. The nurse's notes dated [DATE] indicated the nurse was called to the room by other clinical staff members. Resident was sitting in a wheelchair in obvious distress. He was transferred back to bed via a Hoyer (brand name mechanical lift) and 2 person CPR started while 911 was called at approximately 7:31 a.m. Paramedics arrived at 07:45 a.m. and took over CPR. The daughter and physician was notified of the situation. Paramedics were able to get a pulse and the resident left the building to be transferred to (name of local hospital). On [DATE] at 2:30 p.m., the Admission's Coordinator presented the Transfer/Discharge Notice that indicated the State Long-Term Care Ombudsman was notified of Resident #23's transfer to the hospital on [DATE] at 2:22 p.m. She stated, I am supposed to do this, but I missed some and this is one I missed, but I at least I informed them after you asked me for it. We normally send out as soon as we can or at least a monthly notification to the Ombudsman. This one should have been sent by the end of [DATE]. On [DATE] at 9:30 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON). They stated that the Admission's Coordinator is responsible to maintain a list of transfers and discharges from the facility to be sent to the Ombudsman either as soon as they are transferred, but at least on a monthly basis. The Administrator stated she would audit any that were missed and ensure notification to the Ombudsman in timely. The facility's policy titled Nursing Home Discharge/Transfer Policy dated [DATE] indicated that all applicable state and federal notices to include emergent transfers or discharges to the hospital and to home (immediate or 30 day as applicable) will be forwarded to the State Ombudsman.

Based on observation, staff interviews, and review of the facility's policy, the facility staff failed to ensure the food was prepared, distributed and served under sanitary conditions. The finding included; On 03/06/19 at approximately 6:55 PM an initial tour was conducted with Other Staff # 4. She stated that she was scheduled to get off at 7 PM, but will stay until the Food Service Director arrives. The following was observed during the tour. 1. Food substances on the floors, counters, carts, stoves, burner, steam craft machine and refrigerator throughout the main kitchen. 2. Tilt Skillet grill with moderate amounts of hardened cheese drippings down the side. 3. Cell phone on the counter plugged in beside the three compartment sink. 4. Located in the salad bar refrigerator were two separate packs of American single cheese with use by dates of 02/19/19 and 02/18/19 and 1 stick of butter with use by date of 03/02/19. 5. Paper towel dispenser located over open box of plastic wrap. (Due to the location, water dripping from wet hands fall inside of the plastic wrap used to cover food). On 03/07/19 at approximately 10:14 AM an inspection was conducted with the Food Service Director (FSD) present. The following was observed: 1. Food substances were still on the floors, counters, carts, stoves, burner, steam craft machine and the refrigerator throughout the main kitchen. 2. While inspecting the walk in refrigerator, 1 gal. unopened milk with expiration date of 03/06/19 and 1 pint of milk with an expiration date of 03/04/19. 3. A plastic bottle filled with a brownish, liquid substance was on the shelf of the walk in refrigerator. (The bottle was without a name, date and label). The FSD (Food Service Director) stated that it was a bottle of tea that belongs to one of her kitchen staff. She said that they keep their drinks in the refrigerator because they would have too far to walk. 4. Lid left open on a Kosher salt box. (Located on shelf in the main kitchen). A review of the facility's policy titled Dating and Labeling Food Supplies, effective revision date of 10/25/17. Under the Ready To Eat TCS Foods section states: Products will be labeled by using a Use By Date. Foods that are not labeled, or exceeds the expiration date will be discarded. The section under Monitoring/Subheading Outcomes Monitoring states: A designated employee shall be responsible for checking refrigerators daily to verify that foods are date marked and that foods exceeding the determined time period are not being used or stored. On 03/08/19 11:16 AM a brief interview was conducted with the Food Service Director (FSD) and the Administrator concerning the kitchen inspection. FSD states that the staff is designated to clean and mop the kitchen. The FSD also commented on employee having an unlabeled, unnamed bottle of tea in the walk in freezer saying that's where we keep our drinks to keep from walking too far. No other comments were made. On 03/08/19 A review of the facility cleaning scheduled dated from 03/03/19 and 03/06/19-03/07/19 showed no one checked off on sweeping and mopping the kitchen. On 03/08/19 at approximately 4:45 PM a pre-exit interview was conducted. Present were the Administrator, The Director of Nursing, The Nurse Executive and The Director of Facility Operations and Compliance.

Based on observations, staff interviews and facility document review the facility staff failed to follow infection prevention practices to ensure a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections during the dispensing of ice to residents. The facility staff follow infection control practices to ensure a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections during the dispensing of ice to residents on 3/7/19. The findings included: On 3/7/19 at approximately 10:00 AM two facility volunteers were observed passing ice to the residents. The ice was contained in a large blue cooler on top of a rolling cart with a shelf noted at the bottom. On the bottom shelf of the ice cart there was a one gallon open empty zip-lock bag. While the volunteers were in a room the ice cart was opened and the ice scoop was observed sitting straight down in the ice with the handle up. The two volunteers were observed 3 times opening the ice cart, placing the ice scoop back in to the ice and shutting the ice cart. During one of the observations the Director of Facility Operations and Compliance was standing beside the surveyor and also observed the two volunteers obtaining the ice and placing the ice scoop back into the ice chest. Director of Facility Operations and Compliance was asked if she saw anything wrong with the way the ice was being passed. The Director of Facility Operations and Compliance stated, They are putting the ice scoop back into the ice, it should be placed in the bag, its an infection control issue. On 3/7/19 at approximately 10:45 AM the Director of Activities who oversees the volunteers was interviewed. The Director of Activities was asked if the two volunteers passing ice to the residents had been inserviced on proper infection control practice while passing ice. The Director of Activities stated, I give each volunteer a Lifelong Health Center Volunteer Handbook before they start working with the residents. In the handbook we review infection control and preventing the spread of infection, but there is no specific education provided for passing ice. One of the volunteers was trained over at the hospital over [AGE] years ago. The facility policy titled Food and Nutrition Services Ice Preparation and Use Policy last revised 8/30/17 was reviewed and is documented in part, as follows: POLICY STATEMENT: Ice is prepared, stored and used in a manner consistent with good sanitation practices. To ensure proper methods are used to prevent contamination in making, storing and dispensing ice. 2. Ice is dispensed as needed, either automatically or using a clean scoop which is placed in covered containers located near the ice machine. On 3/8/19 at 4:46 PM a pre-exit conference was held with the Administrator, the Director of Nursing, the Nurse Executive, and the Director of Facility Operations and Compliance were the above information was shared. No further information was provided prior to exit .

Based on observation, resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to provide the appropriate care and services to prevent indwelling catheter complications for 1 of 17 residents (Resident #5), in the survey sample. The facility staff failed to assure Resident #5's indwelling catheter was anchored/secured. The findings included: Resident #5 was originally admitted to the facility 8/31/18, and readmitted [DATE] after an acute care hospital stay. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/28/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring set-up with eating, extensive assistance of 1 person with locomotion and personal hygiene, extensive assistance of 2 people with bed mobility and dressing, and total care of 2 people with transfers, toileting, and bathing. In section H Bladder and Bowel, the resident was coded as having an indwelling catheter and always incontinent of bowels. A physician's orders [REDACTED]. Cath care two times daily. Empty catheter bag and record output two times daily. The current care plan dated 11/27/18 had a problem which read at risk for infection related to an indwelling catheter. (name of resident) has retention. He failed the voiding trail and the Foley had to be put back in. The care plan goal read (name of resident) will remain free of Urinary Tract Infections [MEDICAL CONDITION] during period of catheterization. The interventions included; Clean around Foley with soap and water. Keep tubing below the level of the bladder and free of kinks and twist. Record output per shift. Report any signs of infection (temperature, pain, urine that looks cloudy, dark or with blood). Wash hands before and after procedure. Foley catheter as ordered. Voiding trial as ordered. Administer medications for [MEDICAL CONDITION] as ordered. On 3/6/19, at approximately 8:05 p.m., Resident #5 was interviewed while in bed. The catheter bag and drainage bag were observed on the lower frame of the bed. It was draining clear yellow urine. On 3/8/19 at approximately 10:30 a.m., another interview was conducted with Resident #5. The resident stated I have never had the catheter tubing attached to my thigh/leg or body. An interview was conducted on 3/8/19 at approximately 1:40 p.m., with the Director of Nursing, she stated the expectation is for the resident's indwelling catheter to be anchored. Guidance for care of the catheter was provided by the facility from https://point-of-care.elsevierperformancemanager.com. It was titled Urinary Catheter: Indwelling (Foley) Catheter Care, published: (MONTH) (YEAR). Adapted from Perry, A.G., Potter, P. A. Ostendorf, W.R. (Eds). (2018). Clinical nursing skills and techniques (9th ed.). St Louis: Elsevier. At 19c; the guidance read; Resecure the catheter in the catheter securement device. Avoid pulling on or tension on the catheter. On 3/8/19, at approximately 4:30 p.m., the above findings were shared with the Administrator, Director of Nursing and two corporate consultants. No additional comments were made regarding the indwelling catheter.

Based on family interview, staff interview, clinical record review and facility document review the facility staff failed to implement fall interventions consistent with the resident's needs and plan of care to reduce the risk of an avoidable accident for 1 of 14 residents in the survey sample, Resident #3, that resulted in a fall with subsequent fracture requiring surgical intervention. Resident #3 was identified as requiring two staff for positioning, two staff for safe transfers and the use of a total body lift (Maxi lift) transfer device to reduce the risk of accidents. On 8/5/17 during the preparation of a transfer from the bed to a wheelchair the facility staff failed to implement the use of two persons for positioning, two staff for transfers and failed to implement the correct transfer device. As a result the resident was repositioned to sit on the edge of the bed by one staff. The certified nurse aide (CNA #1) stepped back from the resident to maneuver a sit to stand lift; not the required Maxi lift device. The resident was not physically able to maintain a sitting position on the edge of the bed and started sliding off. CNA#1 caught the resident under both arms and straddled the resident while placing the call bell on. The resident's lower body was completely off the bed. The CNA was not able to get the resident back on the edge of the bed and lowered the resident to the floor. As a result of the assisted fall Resident #3 sustained a spiral fracture to the right leg. The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) with an assessment reference date of 7/13/17 coded the resident as having highly impaired hearing and impaired vision. The resident scored a 5 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident had severely impaired cognition. The resident exhibited cognitive inattention. Under Functional Status activities of daily living the resident was coded as being dependent on two staff for transfers and required extensive assistance of two staff for bed mobility. Under Balance During Transitions and Walking the resident was coded as not steady, only able to stabilize with staff assistance during surface-to-surface transfer (transfer between bed and chair or wheelchair). The resident was identified with functional limitation with range of motion impairment to one upper extremity and both lower extremities. On the Fall Risk Evaluation dated 1/11/17 the resident scored a 16; a total score of 10 or above equals high risk. On the back of this form under transfer the box was checked for two persons. The comprehensive person centered care plan effective from 11/14/16 to 8/5/17 identified the resident was at risk for falls due to loss of balance and requirement of staff assistance for transfers. The goal was not checked. Two of the interventions to be implemented to reduce the resident's risk for falls included two staff for transfers and the use of a Maxi lift device. These two interventions were communicated to the staff by way of a STOP sign placed inside the resident's bathroom and listed on the Resident Profile. The STOP sign that was current and in use at the time of the fall on 8/5/17 instructed the staff that the resident's transfer method was to use a Maxi lift, two staff with transfers and two staff for proper repositioning. The Resident Profile available for direct care staff to include CNAs and licensed staff at the time of the fall on 8/5/17 alerted the staff that the resident was a fall risk. The resident's transfer needs of two staff with the use of a full body lift was clearly identified. The Clinical Notes Report dated 8/5/17 read that the nurse was called into the resident's room by CNA #1. The nurse observed the resident sitting on the floor next to the bed on her bottom with her feet towards the head of the bed. The CNA stated she had helped the resident sit up on the side of the bed after she had dressed her. When she turned the resident's legs off the bed to assist the resident to get up using the lift, the resident began to slide off the edge of the mattress. At that point the CNA was not able to keep the resident on the bed and lowered the resident to the bed. The resident was assessed for pain and injury and did not exhibit any. The resident was transferred to the wheelchair using a Maxi lift and taken to the dining room for breakfast. At lunch time the resident complained of pain to the right leg. The physician was notified and an order for [REDACTED]. The X-ray dated 8/5/17 resulted in a moderately displaced fracture through the distal shift of the femur. The resident was transferred to the emergency room for evaluation. The Hospital Discharge Summary Note evidenced the resident was admitted with a non-displaced spiral fracture of the right femur shaft (1). The resident underwent [REDACTED]. On 9/6/17 at 3:45 pm, inside the resident room the resident was observed sitting up in a wheelchair. The resident's daughter and son in law were visiting and a family interview was conducted. The resident was inattentive, did not engage in the conversation, acknowledge this surveyor nor made eye contact during the interview. The daughter stated she was concerned with the resident's safety as the resident had several falls at the facility, two prior falls resulted in fractures (a refracture of the hip and a fracture of the elbow). She stated she insisted on the resident having assistance of two staff when getting up out of the bed. She stated she was told that during the last fall (8/5/17) the resident was placed on the side of the bed and slid off the bed. The lift was two feet away from the resident. On 9/6/17 at 4:30 pm, the Nurse Mentor was interviewed about the fall. She stated this occurred on a Saturday morning. She stated the CNA (CNA #1) was labor pool. The Nurse Mentor stated the resident was sitting on the edge of the bed and began to slide off. She stated the CNA was preparing the resident for transfer using a sit to stand lift. On 9/7/17 from 12:30 pm to 1:15 pm, the Director of Nursing (DON) was interviewed. The DON was asked what was the root cause of the fall based on her investigation. She stated, She (CNA #1) did not properly prepare the resident for the appropriate transfer .she (CNA #1) should have looked at the STOP sign to be made aware of the proper method of transfer (two person assist with Maxi lift). The DON stated a QAPI (Quality Assurance Performance Improvement) Action Plan was developed in response to this fall. The DON was asked if there were any other residents who experienced a fall resulting in an injury caused by the staff failure to implement appropriate preparations or devices during transfers after the Action Plan was implemented, she stated, No. On 9/7/17 at 1:30 pm, CNA #2 assigned to care for Resident #3 was interviewed. She was asked how was Resident #3 supposed to be prepared for transfer prior to the fall on 8/5/17. She stated, two person using the Maxi lift. When asked why, she stated, Because that is what she was screened for. A pre-exit meeting with the Administrator, the Manager of Clinical Services and the Director of Nursing was conducted on 9/7/17 at 5:30 pm. The question was asked, Are residents sat on the edge of the bed when preparing for a total lift transfer? The response from the Manager of Clinical Services was, No, we already established that. When asked what led to the fall, they stated, She (CNA #1) was attempting to transfer incorrectly. The QAPI Corrective Action Plan with completion date of 8/18/17 was reviewed and accepted on 9/7/17 and included: Correction: 1. The resident was assessed for correct method/assistance of transfer on stop sign and profile sheet. 2. 100% audit of all residents stop sign and residents profile sheet related to transfer. 3. Audit of residents using a sit to stand lift. 4. Re-educate nursing staff on transfers, residents profile sheets, and stop signs. 5. Nursing staff to demonstrate on the ability to operate the mechanical lifts and the ability to safely transfer. 6. Nursing staff to demonstrate the ability to read the resident stop sign and profile sheet. Other Potential: All residents are at risk that does not transfer independently. System changes: 1. Audit/Observe 2 different residents being transferred by nursing staff on each shift weekly times 3 weeks, then one resident on each shift for 3 weeks, then 2 residents monthly. Monitoring/ QA Oversight: Outcomes will be communicated in the weekly at risk meeting, re-eval referral to therapy as needed, and to QA Committee for on-going recommendations. (1.) Non-displaced spiral fracture of the right femur shaft: Femur fractures vary greatly, depending on the force that causes the break. The pieces of bone may line up correctly or be out of alignment (displaced), and the fracture may be closed (skin intact) or open (the bone has punctured the skin). Spiral fracture: The fracture line encircles the shaft like the stripes on a candy cane. A twisting force to the thigh causes this type of fracture. A lower-force incident, such as a fall from standing, may cause a femoral shaft fracture in an older person who has weaker bones. http://orthoinfo.aaos.org/topic.cfm?topic=A (aaos-American Association of Orthopedic Surgeons)

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure one of 21 residents in the survey sample (Resident # 3) was first assessed for the use of a mechanical device (Sara-Lift) by PT (physical therapy) before using and the staff failed to assess Resident #3 for tiredness and her wish not to be transferred. A Sara-Lift was used for the first time to transfer Resident #3, who complained of being tired, and had never been transferred with the help of this device before. During the transfer Resident #3 became un-cooperative, letting go of the device with her hands, then falling back onto the straps of the lift. The resident later complained of pain to her shoulder. She was noted to have swelling of the arm, an XRAY was ordered and performed, which confirmed a fracture of the left clavicle (collar bone). The findings included: Resident # 3, an [AGE] year old was originally admitted to the facility on [DATE]. Resident # 3's [DIAGNOSES REDACTED]. Resident # 3's most recent MDS (minimum data set) with an assessment reference date of 7/10/12 was coded as a significant change assessment. The resident was assessed and was coded a score of 4 ( a score of 0 - 7)denotes severe cognitive impairment) for the BIMS (brief interview for mental status). She was coded as feeling tired and having little energy. Her functional status was coded for extensive assistance required in bed mobility, dressing, toileting and hygiene; with two person assistance. She was assessed and coded totally dependent for transfers with two person physical assistance. There were no physician's orders for the use of a Sara Lift prior to the incident of 7/3/2012. The Care Plan dated 6/19/12 documented a problem for Resident # 3, unsteady gait, loss of balance requiring staff assistance for transfers. Goals: Resident will not experience significant injury (i.e., requiring ER (emergency room ) visit or hospitalization ). Approaches: Provide rest periods as needed and or tolerated. Provide assistive mobility devices as recommended by therapy; report unsafe use to therapy." Additional review of the care plan did not specify the use of a Sara- Lift or any other device to use. On 7/5/12 (a few days after the fracture) an approach was added as follows: "Do not use Sara-Lift secondary to fracture left clavicle. " Resident # 3 was initially observed on 7/24/12 at 2:55 p.m. She was in her room, in bed asleep. The head of the bed was elevated at 45 degrees. A blue arm sling was observed on her left arm. Resident # 3 was observed to be obese. She weighed 206 pounds and was 5 foot 6 inches tall. Resident # 3 was again observed on 7/25/12 at 7:56 a.m. She was in her room, in bed asleep. The blue splint remained on the left arm. Review of a Facility Incident Report forwarded to the OLC (office of licensure and certification) dated 7/5/2012 documented an incident of July 3, 2012 involving Resident # 3. The clinical record of Resident # 3 was reviewed and evidenced the following about this incident: "7/3/2012, 1000 (AM) nurse informed me that resident c/o (complained of) left shoulder pain. The left shoulder was swollen. Spoke to NP (nurse practitioner) and she gave the order to obtain an X-Ray of (L) left shoulder. I spoke with PT (physical therapist) and asked if the resident c/o (complained of) shoulder pain yesterday during therapy. They told me no. I asked the 3-11 CNA (certified nursing assistant) if there were any issues last night. The CNA told me that when she was transferring the resident from wheelchair to bed; she had to use the Sara-Lift. The Sara-Lift was brought in because the resident stated she was "too tired to get up." The Sara-Lift was then applied and when the CNA started to lift the resident up; the resident threw her hands up in the air and said she "could not do it." The resident was lowered back down into her chair. The CNA (certified nursing assistant) stated that the resident was able to transfer herself with assist of two CNA's. The 3-11 nurse stated that resident was resting quietly in her bed for the duration of her shift. Resident did no (sic) c/o of pain. The 11-7 nurse stated that resident rested quietly and did no (sic) c/o of pain on her shift. I also questioned the resident's roommate and she said "all her roommate does is sleep." I asked the resident's roommate did she c/o of pain and the resident said no. Attempt to call RP (responsible party) X 3(times 3), left 3 messages. Will continue to call RP. " Review of a SBAR (Situation, Background, Assessment and Request) Report documented: SITUATION - "Resident complaining of left shoulder pain. Started last night that has gotten worse. Moving arm, putting pressure on. Not moving arm. Swelling in the shoulder. " BACKGROUND- Pain level 9. ASSESSMENT- (RN) or Appearance (LPN). Nothing was documented. Review of a Progress Note located on the back of this SBAR Form documented: Was informed by CNA res. (resident complaining of (L) Left shoulder pain. Assessed and noticed swelling in shoulder area. Informed (nurse practitioner name). New order for X-Ray to left shoulder. Will monitor. REQUEST -New orders-X-RAY." The X-Ray report of 7/3/2012 was reviewed and revealed: "Results: There is a fracture of the mid clavicle with superior displacement of the left shoulder." An interview with CNA (certified nursing assistant) Employee #3 was conducted on 7/26/2012, from 3:33 to 3:45 p.m. She stated that Resident #3 did not fall. When interviewed about the other CNA, Employee #7 who was not available for interview, as she was out of town on vacation. She stated that she and the other CNA Employee #7 decided to use the Sara-Lift. We put her in the Sara-Lift and when we started to lift her. She let go, threw up her arms and said "she could not do this anymore." The CNA stated that Resident # 3 was lowered back down into the wheelchair at that time. The CNA, Employee #3 was interviewed about having been trained on the use of the Sara-Lift for Resident # 3. She stated that it was never used for her (Resident #3) because she could stand and pivot. The CNA stated that Resident #3 was new to the James Unit, as she recently transferred from the skilled unit. She stated that they had not used the Sara-Lift on Resident # 3 before 7/3/12 because Resident # 3 could stand and pivot. Review of an Investigative Report completed by the DON (director of nursing) regarding this incident documented: "INVESTIGATION AND FINDINGS 7/3/2012, 10:45 a.m., interviewed all staff members from previous shifts. Resident (Resident # 3) had Physical Therapy on the 7-3 shift on day of 7/2/12. Therapist reports that resident had no complaints of pain or no problems noted with left shoulder. The 3-11 CNA's working 7/2/12 were interviewed and reported when they went to transfer resident to bed the night of 7/2/12 she was too tired to do her stand pivot transfer from the wheelchair to bed. Since she would not stand for them they attempted to use the Sara- Lift. This lift has a strap that goes behind the back under the Axilla (under the arm) and the resident grips the handles out in front of them. When they start lifting her up off the wheelchair Ms._________ (name of resident) flapped her arms back and dropped her body down on the strap. She was lowered back into her wheelchair and then she helped with a stand to pivot and use of gait belt. On the morning of 7/3/12 the CNA providing am care noted that resident had discomfort and complained of pain in left shoulder. After thorough investigation and interview of staff and residents there is no evidence of abuse. It is determined that the downward force of her weight onto the strap under the axilla is directly related to the fracture." On 7/27/12 from 10:04 to 10:20 a.m., an interview was conducted with the Physical Therapist, Employee #1 along with the DON (director of nursing) Employee #2 and the Unit Manager, on the James Unit, Employee #5. It was stated by the Physical Therapist, Employee #1 that prior to Resident # 3 moving from the other unit, she was capable of standing and pivot to transfer. It was stated that staff on the James Unit had not been assessed on the use of the Sara-Lift for Resident # 3. It was stated that they could have waited to transfer her if Resident # 3 said she was tired. A request of the Manufacturer's Operational Instruction for the Sara-Lift was obtained on 7/27/12 from the Physical Therapist, Employee #1. The Instructions "CAUTION" A professional assessment should be carried out before lifting patients who are non-weight bearing. This also applies to patients who have limited shoulder movement or cannot hold on with one or both hands." A Plan of Care for Physical Therapy dated 6/29/12 was reviewed and documented a treatment [DIAGNOSES REDACTED]." Goal, "the patient will increase standing balance to hold for 1 minute in order to increase endurance." Further review of Physical Therapy Notes documented that Resident # 3 was discontinued from therapy on 7/15/12. On 7/27/2012 from 10:04 to 10:20 a.m., Resident # 3 was observed transferred using a Maxi-Lift (a full body pad lift) by two CNA's, Employees #1 and #2. When interviewed at 10:21 a.m. both CNA's said that the Sara-Lift was no longer used.

Based on observations, record review, staff interview and family interview, it was determined that the facility staff failed to ensure 1 of 21 residents in the survey sample (Resident #6) did not receive an unnecessary medication, [MEDICATION NAME] to which she had a known allergy/adverse reaction. Resident #6 subsequently experienced a fall and sustained a C2 cervical spine [MEDICAL CONDITION] process as result. The findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6 was administered a medication [MEDICATION NAME] in which she was allergic. A 5/4/11 Re-entry Minimum Data Set (MDS) assessed this resident as having hearing difficulty and impaired vision. In the area of Activities of Daily living -Bed Mobility this resident was assessed as needing extensive assistance with two person physical assist. In the area of transfer this resident was not able to perform. In the area of Range of Motion this resident was assessed as having impairment on one side for upper and lower extremity. She is assessed as having a history of falls secondary to an unsteady gait and out turned foot. She is coded as poor in decision-making skills and has a history of physical and verbal abuse with family and staff. In the area of Medications: this resident was assessed as having received antipsychotic medications within the last seven days. A Care Plan dated 4/21/11 indicated: "Problem- Resident is at risk for side effects related to use of psychoactive medications PRN antipsychotics and antidepressants; Goal- Resident will achieve desired effect from ordered medications. Resident will experience no negative effects from medication use as ordered. Approach- Administer medications as ordered; observe for effect and side effects, Assure that psychoactive drug orders includes medical [DIAGNOSES REDACTED]. Problem- At risk for health complications related to known allergy to [MEDICATION NAME]. Goal- Resident will have no health complications attributable to exposure to known allergens. Approach- Screen for known allergens medication orders, Monitor response to new medications and diet changes , Assure known allergies [REDACTED]. A history and physical admission record indicated: "Special instructions -Allergy- [MEDICATION NAME]." A review of current physician orders [REDACTED]. A nursing note dated 5/2/11 at (0100) 1:00 A.M. indicated: " Patient woke up and was very confused, aides were in room attempting to work with roommate and (Resident #6) ran them all out and told them to get 'get out of my house.' Then she began talking about calling 'Boots' (husband) to come here right now or never come again. He's partying and having a lot of people all over my house. I called (husband) so that he was aware of Resident #6's state of mind at this time. He spoke with her on the phone. [MEDICATION NAME] 2 (mg) milligrams was administered P.O. at (0050) 12:50 A.M. patient keeps getting out of bed and pacing. Informed 11-7 nurse and aides to keeps patient sitting as much as possible for fall prevention." A nursing note dated 5/2/11 at (0215) 2:15 A.M. indicated: "Paging physician patient still confused and very agitated. Ordered [MEDICATION NAME] 2 mg IM now, one time only. Administered (0200) 2:00 A.M.. LPN and aide staying with patient till she sits down or goes to bed. LPN will continue to monitor." A nursing note dated 5/2/11 at (0600) 6:00 A.M. indicated: Pharmacy called, patient allergic to [MEDICATION NAME] was given by 3-11 Nurse Manager and doctor was notified of med error. Doctor said to monitor resident for falls and to get her vital signs throughout the day." A nursing note dated 5/2/11 at (1415) 2:15 P.M. indicated the reisdent had 2 falls as was as follows. "VS 17/86, 81, 76, 18, 96.9 fall #1 this A.M. then fell about 10:00 A.M. Heard patient screaming and found resident laying on left side next to bed. Cut on forehead and right thumb. Found blood on floor used lift to get her in bed cleaned her up and used steri strips. Called husband and let (NP) know. Started neuro check about 11:30 A.M. called 911 and patient was taken to hospital. A hospital Radiology report dated 5/2/11 at 2:38 P.M. indicated: " Findings: There is an acute incomplete nondisplaced [MEDICATION NAME] fracture through the base of th odontoid process consistent with a type 2 odontoid fracture. There is straightening of the cervical lordosis. There persists multilevel disk height loss and marginal osteophyte formation. Impression: 1. Nondisplaced acute type 2 odontoid fracture. 2. Moderate to severe [MEDICAL CONDITION] change, stable." A physician's re-admission assessment dated [DATE] indicated: " Resident #6 with dementia is readmitted after C-spine surgery for [REDACTED]. Currently she is in a C-spine collar and denies neck pain, UE tingling, numbness, weakness. She also broke right thumb. She states that she is doing well and denies anorexia, [MEDICAL CONDITION], fatigue." A nurse practitioner (NP) assessment dated [DATE] indicated: "Resident #6 presents with a chief complaint of fall, forehead and thumb laceration 3 sutures, very agitated during night and received [MEDICATION NAME] early am, sustained a fall just after 10 am and has laceration to left temple/eyebrow area and to right thumb. Husband is present at bedside. Patient is more sleepy and slower to respond. allergies [REDACTED]. Assessment- Altered mental status- Assessed as deteriorated. During an interview on 5/27/11 at 2:30 P.M. with Resident #6's husband, he became very distraught and tearful over the fall and subsequent injury Resident #6 incurred. The husband stated, before the injury, his wife would be waiting for him and walk the halls of the facility with him. He stated, since the fall and injury, she does not recognize him and she is confined to a Geri chair. During the survey Resident #6 was observed seated in a Geri chair with chair alarm and seat pad alarm. The husband was observed to come and visit his wife two times a day. During an interview on 5/27/11 with the Director of Nursing (DON) she stated that the nurse in question was terminated. The DON stated this staff did not follow policy and have been reported to appropriate state agency. A review of a Facility Reported Incident dated 5/6/11 indicated: "On 5/2/11 stated Nurse called a physician about a patient in his care. She informed him about the events of the night and asked him for guidance. After speaking with the physician, Stated Nurse administered [MEDICATION NAME] to the patient in question however the physician denies giving an order for [REDACTED]." The report indicated that during an interview with the Stated Nurse, she denied the physician's claim he didn't give the order. She was asked if she re-read the order back to the physician she said she did. When asked if she looked at the patient's allergies [REDACTED]. When asked why she didn't call the pharmacy as protocol to open the stat box for the [MEDICATION NAME] to which she stated she didn't have time to wait on an actual signature (pharmacy approval) for the order and borrowed the medication from another resident. A review of the clinical records indicated: " a telephone order with Resident #6's name, facility, date 5/2/11, medication-[MEDICATION NAME], strength-2 mg, route IM, frequency-now, one time only, faxed and noted by Stated Nurse time (0200) 2:00 A.M." During an interview on 5/27/11 at 11:15 A.M. with the DON she stated, "The doctor did not order [MEDICATION NAME] he ordered a PRN dose of [MEDICATION NAME]. The DON stated, family had informed facility of her history to [MEDICATION NAME] which is increased agitation." Resident #6 was administered [MEDICATION NAME] contraindicated by clinical records that she was allergic/had adverse reaction to the medication.

Based on observation, record review, staff and family interviews, facility staff failed to ensure 1 of 21 residents in the survey sample (Resident #6) was free of accident hazards. Resident #6, who had a known history of falls and a known allergy to Ativan (antianxiety medication with sedative qualities), was administered an Ativan injection without a valid physician's orders [REDACTED]. The findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6 was administered a medication Ativan in which she was allergic resulting in a fall and several fractures. A 5/4/11 Re-entry Minimum Data Set (MDS) assessed this resident as having hearing difficulty and impaired vision. In the area of Activities of Daily living in the area of Bed Mobility this resident was assessed as needing extensive assistance with two person physical assist. In the area of transfer this resident was not able to perform. In the area of Range of Motion this resident was assessed as having impairment on one side for upper and lower extremity. This resident has a history of falls secondary to an unsteady gait and out turned foot. She is coded as poor in decision-making skills and has a history of physical and verbal abuse with family and staff. In the area of Medications: this resident was assessed as having received antipsychotic medications within the last seven days. A Care Plan dated 4/21/11 indicated: "Problem- Resident is at risk for side effects related to use of psychoactive medications PRN antipsychotics and antidepressants; Goal- Resident will achieve desired effect from ordered medications. Resident will experience no negative effects from medication use as ordered. Approach- Administer medications as ordered; observe for effect and side effects, Assure that psychoactive drug orders includes medical [DIAGNOSES REDACTED]. Problem- At risk for health complications related to known allergy to Ativan. Goal- Resident will have no health complications attributable to exposure to known allergens. Approach- Screen for known allergens medication orders, Monitor response to new medications and diet changes , Assure known allergies [REDACTED]. Problem-Resident at risk for falls and/or history of falls related to unsteady gait, short term memory loss, requires reminders to call for assistance, requires staff assistance for transfers; Goal- Resident will not experience fall; Approach- keep bed in low position, keep bed wheels locked, keep frequently used items in reach and/or close proximity, obtain vital signs per physician order, check vital signs at time of fall, sitting blood pressure, apply personal alarm bed-chair, keep eyeglasses clean and ensure use, keep corridors and areas of resident use uncluttered, report changes in health condition. A review of the clinical record indicated: Resident #6 had falls on 12/10/10, 12/27/10, 1/27/11, 2/17/11, 2/22/11, 3/10/11, 3/12/11, 5/1/11, 5/2/11, and 5/14/11. A nursing note dated 5/1/11 at (1430) 2:30 P.M. indicated: "Resident informed nurse that she fell on floor beside her bed on 11-7 shift. Resident states nobody knew about it so she stood up and got herself back in bed. Resident states she didn't tell anyone about fall. Resident has no injuries or bruises noted at this time ROM (wnl) with in normal limits, neuro checks wnl vital signs taken, (RP) responsible party present MD notified. A nursing note dated 5/2/11 at (0100) 1:00 A.M. indicated: " Patient woke up and was very confused, aides were in room attempting to work with roommate and (Resident #6) ran them all out and told them to get 'get out of my house.' Then she began talking about calling 'Boots' (husband) to come here right now or never come again. He's partying and having a lot of people all over my house. I called (husband) so that he was aware of Resident #6's state of mind at this time. He spoke with her on the phone. Haldol was administered P.O. at (0050) 12:50 A.M. patient keeps getting out of bed and pacing. Informed 11-7 nurse and aides to keeps patient sitting as much as possible for fall prevention." A review of the Medication Administration Record (MAR) indicated this resident received a (2 milligrams) IM Intra-Muscular dose of Haldol at (0050) 12:50 A.M. on 5/2/11." A nursing note dated 5/2/11 at (0215) 2:15 A.M. indicated: "Paging physician patient still confused and very agitated. Ordered Ativan 2 mg IM now, one time only. Administered (0200) 2:00 A.M.. LPN and aide staying with patient till she sits down or goes to bed. LPN will continue to monitor." A nursing note dated 5/2/11 at (0600) 6:00 A.M. indicated: Pharmacy called, patient allergic to Ativan, Ativan was given by 3-11 Nurse Manager and doctor was notified of med error. Doctor said to monitor resident for falls and to get her vital signs throughout the day." A nursing note, dated 5/2/11 at (1415) 2:15 P.M., indicated the reisdent had 2 falls as was as follows. "VS 17/86, 81, 76, 18, 96.9 fall #1 this A.M. Then fell about 10:00 A.M. Heard patient screaming and found resident laying on left side next to bed. Cut on forehead and right thumb. Found blood on floor used lift to get her in bed, cleaned her up and used steri strips. Called husband and let (NP) know. Started neuro check about 11:30 A.M. called 911 and patient was taken to hospital." A hospital Radiology report dated 5/2/11 at 2:38 P.M. indicated: " Findings: There is an acute incomplete nondisplaced transverse fracture through the base of the odontoid process consistent with a type 2 odontoid fracture. There is straightening of the cervical lordosis. There persists multilevel disk height loss and marginal osteophyte formation. Impression: 1. Nondisplaced acute type 2 odontoid fracture. 2. moderate to severe degenerative change, stable." A physician's re-admission assessment dated [DATE] indicated: " Resident #6 with dementia is readmitted after C-spine surgery for [REDACTED]. Currently she is in a C-spine collar and denies neck pain, UE tingling, numbness, weakness. She also broke right thumb. She states that she is doing well and denies anorexia, insomnia, fatigue." A nurse practitioner (NP) assessment dated [DATE] indicated: "Resident #6 presents with a chief complaint of fall, forehead and thumb laceration, very agitated during night and received ativan early am, sustained a fall just after 10 am and has laceration to left temple/eyebrow 3 sutures to area and to right thumb. Husband is present at bedside. Patient is more sleepy and slower to respond. allergies [REDACTED]. Assessment- Altered mental status- Assessed as deteriorated." During an interview on 5/27/11 at 2:30 P.M. with Resident #6's husband, he became very distraught and tearful when speaking about the fall and subsequent injury Resident #6 incurred. "He stated, since the fall and injury, she does not recognize him and she is confined to a Geri chair. Resident #6's husband stated, he does not know how she fell . They have told me about three different stories. Because I was not here, I can't say for certain. Some say she was getting up. Some say she fell in bathroom. Some say after getting the wrong medication at 1:00 o'clock med- error or something. She was doing so well until that fall. I was so proud of her. She would walk and meet me here every time I came. I come twice a day. Since the fall she has just been going down -down -down- and it has been so hard to watch her. I don't know what exactly happened, she keeps going down." During the survey Resident #6 was observed seated in a Geri chair with chair alarm and seat pad alarm. The husband was observed to come and visit his wife two times a day. During an interview on 5/27/11 with the Director of Nursing (DON) she stated that the nurse in question was terminated. The DON stated this staff did not follow policy and have been reported to appropriate state agency. A review of a Facility Reported Incident dated 5/6/11 indicated: "On 5/2/11 stated Nurse called a physician about a patient in his care. She informed him about the events of the night and asked him for guidance. After speaking with the physician, Stated Nurse administered Ativan to the patient in question, however, the physician denies giving an order for [REDACTED]. He also doesn't recall Stated Nurse calling the order back to him to validate the correct medication and dosage." The report indicated that during an interview with the Stated Nurse, she denied the physician's claim he didn't give the order. She was asked if she re-read the order back to the physician; she said she did. When asked if she looked at the patient's allergies [REDACTED]. When asked why she didn't call the pharmacy as protocol to open the stat box for the Ativan to which she stated she didn't have time to wait on an actual signature (pharmacy approval) for the order and borrowed the medication from another resident. The DON stated during their investigation and questioning of nurse, it was determined the stated nurse did not call the pharmacy as protocol to open the stat box for the Ativan order and borrowed the medication from another resident. The DON stated, the doctor never ordered the Ativan and had the nurse followed protocol she would have been stopped by pharmacy because the notice for Allergy to Ativan is a part of her record."