Every finding on record at Rockwell Community Nursing Home

Based on interviews, schedule review, and punch detail review, the facility failed to have a Registered Nurse (RN) on duty for at least 8 consecutive hours in a 24-hour period. On 3 different occasions, the facility had a full 24-hours without a RN on duty. The facility reported a census of 22 residents.Findings include:The review of the August 2025 and September 2025 nursing schedules identified the following:a. Staff A, RN, worked from 2 PM to 10 PM on: i. Friday 8/8/25 ii. Friday 8/22/25 iii. Friday 8/31/25.b. Staff B, RN, worked from 10 PM to 6 AM on: i. Saturday 8/9/25 ii. Saturday 8/23/25 iii. Saturday 9/1/25The schedule indicated Licensed Practical Nurses (LPN) covered the facility for the 3 shifts (10 PM to 6 AM, 6 AM to 2 PM, and 10 PM to 6 AM) in between the above dates and times.On 9/4/25 at 9:58 AM, the Administrator stated she talked with Staff C, RN, regarding the 8 consecutive hours of RN coverage in a 24-hour period. Staff C reported the facility had enough coverage because the night shift RN coverage counted as 8 consecutive hours of coverage. When shown the above days of concern, this Administrator acknowledged the concern. The Administrator stated she would get punch details for those days. In addition, she would look to see if the Director of Nursing (DON), came in to work on any of those days.On 9/4/25 at 11:15 AM, the Administrator and Staff C stated they worked under the assumption the night shift RN counted as the 8 consecutive hours in the 24-hour period. Staff C stated they did this for over a year. When talked about again how the hours need to be consecutive, and there are 3 shifts between the end of evening shift and the beginning of night shift on the above-mentioned dates that are covered by LPNs, they stated they understood. They would check with the DON to see if she worked any of the 3 shifts in between the above-mentioned dates. They would look for a policy. On 9/4/25 at 12:11 PM when shown the 5/30/25 schedule that the DON worked that day with no other RN on the schedule and on 5/31/25 at 10 PM listed the next time an RN worked, Staff C replied the DON probably worked 9 AM to around 5 PM on 5/30/25. She didn't really think the DON would have worked later than that. She stated so the facility went from 5 PM on 5/30/25 to 10 PM on 5/31/25 without RN coverage. Staff C again stated the past schedules would reflect a lack of RN coverage. Staff C didn't know if the facility had a policy regarding 8-hour consecutive RN coverage in a 24-hour period. The investigation determined the facility didn't have a policy regarding 8 consecutive hours of RN coverage in a 24-hour period.

Based on observation, clinical record review and staff interview, the facility failed to follow interventions for the comprehensive plan of care for 1 resident reviewed. (Residents #1) The facility identified a census of 23 residents. Findings include: A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), required extensive assistance of one (1) staff member with transfers and ambulation and had one fall with no injuries since admission or re-entry to the facility. A Care Plan with a problem initiated 3/12/20 indicated Resident #1 had a problem with mobility: The Resident transferred with assistance of 1-2 staff, a gait belt and walker. An Event/Episode Documentation Assessment form dated 8/4/20 at 7:48 p.m. indicated the Resident fell while she had been assisted from the bathroom to bed with 1 staff assist, a walker, gait belt and as she wore gripper socks. Staff A, Certified Nursing Assistant (CNA) left the resident stand while she opened the resident's bedding when the resident's right knee gave out which caused her to fall and land on her right side. The staff member witnessed the fall. The resident denied pain at that time and stated she just hurt her pride. Staff examined the resident and noted an abrasion to her right knee. The resident then complained of right knee discomfort. A Major Injury Determination Form signed by a Physician 8/6/20 at 10 a.m. indicated the resident sustained [REDACTED]. During an interview 12/3/20 at 12:43 p.m. Staff A confirmed she ambulated the resident from the bathroom with the use of a walker and gait belt. They stopped at the resident's bedside stand while the staff member left the resident to stand on her own and walked to the bed and pulled back the bedding with her back to the resident. As the staff member turned around she witnessed the resident fall to the floor on her right side. The staff member confirmed she should have maintained a grip on the the resident's gait belt.

Based on clinical record review and staff interview, the facility failed to care plan specialized services documented in Preadmission Screening and Resident Review (PASRR), and resubmit for a change of condition for two of four residents reviewed. (Resident #16 & #18) The facility census was 19 residents. Findings include: 1. The PASRR assessment dated [DATE], identified Resident #16's need for specialized services including psychiatry for medication management and behavioral health therapy for coping strategies. The care plan dated 7/1/19, did not identify when psychiatry and behavioral health therapy services began. 2. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #18 had [DIAGNOSES REDACTED]. The Care Plan updated 5/23/19 included a focus area for behavioral issues of frequent yelling, swearing, refusing cares and making inappropriate sexual comments and receives [MEDICATION NAME] for depression and [MEDICATION NAME] daily for impulse control. The interventions included to monitor for adverse side effects of the medications and report to physician as needed and to provide redirection if yelling and attention seeking. The care plan included further interventions to provide 1:1 attention as needed and allow him to express his feelings and point of views. The PASRR dated 1/7/15, identified Resident #18 did not take any [MEDICAL CONDITION] medications. The Clinical Record revealed during the resident's stay a new [DIAGNOSES REDACTED]. During interview on 7/2/19 at 11:33 a.m., the Director of Nursing (DON) acknowledged the resident had received [MEDICAL CONDITION] medication for some time and may not have been on them when he came in. The DON explained they should have submitted a new PASRR with the addition of [MEDICAL CONDITION] medication.

Based on clinical record review and staff interview, the facility failed monitor antidepressant side effects for two of five residents reviewed. (Resident #18 & #19) The facility census was 19 residents. Findings included; 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #18 had [DIAGNOSES REDACTED]. The Care Plan updated 5/23/19, included a focus area regarding behavioral issues of frequent yelling, swearing, refusing cares and making inappropriate sexual comments and receives [MEDICATION NAME] for depression and [MEDICATION NAME] daily for impulse control. The interventions included to monitor for adverse side effects of the medications and report to physician as needed and to provide redirection if yelling and attention seeking. The Care Plan lacked documentation of the type of side effects to monitor and report for the antipsychotic and antidepressant medications. During interview on 7/2/19 at 10:25 a.m., the Director of Nursing (DON) explained they monitor for side effects listed on the medication administration record. 2. The Medication Administration Record [REDACTED]. The care plan update on 5/23/19, indicated to monitor for side effects of [MEDICATION NAME] medication. The care plan and (MONTH) MAR indicated [REDACTED].

Based on observation, staff interview and facility policy review, the facility failed to ensure staff followed infection control practices for 2 of 9 active residents reviewed (Resident #2, #8, ). The facility identified a census of 29 current residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had [DIAGNOSES REDACTED]. The MDS documented the resident scored 15 on the Brief Interview for Mental Status (BIMS). A score of 15 identified no cognitive impairment. The MDS assessment documented the resident frequently incontinent of bladder and dependent on staff for extensive assistance with transfer, dressing and toilet use. The Care Plan focus area dated as initiated on 8/18/16 identified that Resident #2 required assistance with cares related to brain injury. The Care Plan directed assistance of one with peri care, and assistance of two for toileting. Observation on 1/24/17 at 7:05 a.m., revealed Staff H, Certified Nurse Aide (CNA) and Staff K, CNA prepared to assist the resident with peri-care as the resident reported had finished using the toilet. Staff H cleansed the resident's peri area using a wet washcloth, repeatedly utilized a front to back motion with the same wash cloth. Staff H failed to fold the wash cloth to expose a clean surface or obtain a new washcloth. Continued observation revealed Staff H dropped the washcloth in toilet the resident had just voided in and with gloved hand retrieved the washcloth from the toilet. With the same gloved hand Staff H obtained a new wet wash cloth and continued to provide peri-care. Staff H failed to remove contaminated glove. 2. The MDS assessment dated [DATE], revealed Resident #8 had [DIAGNOSES REDACTED]. The MDS documented the resident scored 3 on the Brief Interview for Mental Status (BIMS). A score of 3 identified severely impaired cognitive abilities. The MDS assessment documented the resident frequently incontinent of bladder and bowel and totally dependent on staff for transfer, and toilet use and required extensive staff assistance with dressing and hygiene. The Care Plan focus area dated as initiated on 11/29/16 identified Resident #8 experienced frequent urinary and bowel incontinence and with a history of UTI's (urinary tract infections). The Care Plan directed staff to provide peri care after incontinent episodes. Observation on 1/25/17 at 1:00 p.m., revealed Staff J, CNA, and Staff D, CNA, assisted the resident to transfer to the toilet. Staff J removed the resident's wet incontinence brief, and proceeded to cleanse the resident's peri area using an incontinence wipe in a front to back motion. Staff J continued to cleanse from the back as resident assisted to stand. Observed Staff J repeatedly utilize a front to back motion with the same incontinence wipe, with smearing of feces noted on the wipe. Staff J observed to remove gloves and assist Staff D to assist the resident to bed. Staff J obtained and donned gloves from bedside drawer and proceeded to wipe the resident ' s mouth with a disposable wipe. Staff J failed to wash hands after provided peri care, prior providing oral care. In an interview on 1/25/17 at 2:30 p.m. the Director of Nursing (DON) stated expectation that staff would remove gloves after retrieved wash cloth from toilet, wash hands before continued to provide care to the resident, and would expect staff to wash hands after providing peri care before provided oral care to resident. In an interview on 1/25/17 at 3:12 p.m. Staff M, Registered Nurse, Infection Control Nurse stated taught staff to sanitize or wash hands with glove change, change gloves after providing peri care and wash hands, not sanitizer before providing oral care, and would expect staff to remove gloves after retrieved wash cloth from toilet, and wash hands before continued to provide peri care to resident.

Based on observation, clinical record review and staff interview, the facility failed to provide complete incontinence care for 4 out of 6 residents reviewed (Resident #1, #2, #6 and #8). The facility reported a census of 29 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had [DIAGNOSES REDACTED]. The MDS documented the resident scored 15 on the Brief Interview for Mental Status (BIMS). A score of 15 identified no cognitive impairment. The MDS assessment documented the resident frequently incontinent of bladder and dependent on staff for extensive assistance with transfer, dressing and toilet use. The Care Plan focus area dated as initiated on 8/18/16 identified that Resident #2 required assistance with cares related to [MEDICAL CONDITION]. The Care Plan directed assistance of one with peri care, and assistance of two for toileting. Observation on 1/24/17 at 7:05 a.m., revealed Staff H, Certified Nurse Aide (CNA) and Staff K, CNA, prepared to assist the resident with peri-care as the resident reported had finished using the toilet. Staff H cleansed the resident's peri area using a wet washcloth, repeatedly utilized a front to back motion with the same wash cloth. Staff H failed to fold the wash cloth to expose a clean surface or obtain a new washcloth. Continued observation revealed Staff H dropped the washcloth in toilet the resident had just voided in and with gloved hand retrieved the washcloth from the toilet. With the same gloved hand Staff H obtained a new wet wash cloth and continued to provide peri-care. Staff H failed to remove contaminated glove. Staff H repeatedly utilized a front to back motion, again failed to fold the wash cloth to expose a clean surface. Staff H proceeded to cleanse the buttocks with the same wash cloth, utilized a back and forth motion. 2. The MDS assessment dated [DATE], revealed Resident #8 had [DIAGNOSES REDACTED]. The MDS documented the resident scored 3 on the Brief Interview for Mental Status (BIMS). A score of 3 identified severely impaired cognitive abilities. The MDS assessment documented the resident frequently incontinent of bladder and bowel and totally dependent on staff for transfer, and toilet use and required extensive staff assistance with dressing and hygiene. The Care Plan focus area dated as initiated on 11/29/16 identified that Resident #8 experienced frequent urinary and bowel incontinence, history of UTI's (urinary tract infections). The Care Plan directed staff provide peri care after incontinent episodes. Observation on 1/25/17 at 1:00 p.m., revealed Staff J, CNA, and Staff D, CNA, assisted the resident to transfer to the toilet. Staff J removed the resident's wet incontinence brief, and proceeded to cleanse the resident's peri area using an incontinence wipe in a front to back motion. Staff J continued to cleanse from the back as resident assisted to stand. Observed Staff J repeatedly utilize a front to back motion with the same incontinence wipe, with smearing of feces noted on the wipe. Staff H failed to fold the incontinence wipe to expose a clean surface. Continued observation revealed Staff J failed to cleanse the buttocks or either hip. In an interview on 1/25/17 at 2:30 p.m. the Director of Nursing (DON) stated expectation for all staff to use a new area of cloth for incontinence care, or use a new cloth. Also revealed would expect staff to cleanse all areas that come in contact with incontinence brief. The DON further clarified would expect staff to remove gloves after retrieved wash cloth from toilet, and wash hands before continued to provide care to the resident. In an interview on 1/25/17 at 3:12 p.m. Staff M, Registered Nurse and Infection Control nurse, stated taught staff to sanitize or wash hands with glove change, change gloves after providing peri care and wash hands, not sanitizer before providing oral care, and would expect staff to remove gloves after retrieved wash cloth from toilet, and wash hands before continued to provide peri care to resident. 3. The MDS with an assessment reference dated 11/13/16, documented Resident #6 with [DIAGNOSES REDACTED]. The MDS documented the resident with short and long term memory impairments, severely impaired decision making abilities, and required extensive assist of two staff for bed mobility and total dependence for transfers, dressing, toilet use and personal hygiene. The MDS documented the resident as frequently incontinent of bowel and bladder. The careplan with a target dated 2/9/17, had a focus area the resident with bladder incontinence. Staff to provide assist with toileting on routine basis. Wears incontinent brief. History of Urinary Tract Infections. Interventions included: a. Provide two assist with toileting on routine basis. b. If restless provide toileting first. c. Check and change system used on rounds on night shift. d. Wears incontinent brief. e. Provide per care after incontinent episodes. Observation on 1/23/17 at 4:05 p.m., revealed resident lying in bed. Staff A, CNA, and Staff B, CNA, transferred the resident from their bed to the bathroom by the EZ stand (mechanical stand). Staff A proceeded to pull down the resident pants and pulled the soiled brief from in between the resident legs and threw away in the garbage can. Staff A and Staff B proceeded to sit the resident down on the toilet. Resident #6 stated that they were finished on the toilet. Staff A and Staff B then proceeded to stand the resident. Staff B with gloved hands and a wet wipe cleansed the resident peri area in a back and forth scrubbing motion, from front to back and back to front. Staff B failed to change the position of the wet wipe during the incontinent cares and failed to cleanse the resident bilateral hips, thighs, coccyx and buttocks. Staff B stated the brief was soiled with urine in the groin area and buttock area. Observation on 1/24/17 at 7:20 a.m., revealed Resident #6 lying in bed. Staff C, CNA, and Staff D, CNA, provided incontinent cares on the resident. Staff D, with gloved hands and a wet wipe, cleansed the resident peri area using a back and forth motion three times and failed to use different parts of the wet wipe. Staff C stated that the brief was soiled in the peri area and not on the resident buttocks. 4. The MDS assessment dated [DATE], documented Resident #7 with [DIAGNOSES REDACTED]. The MDS documented the resident with extensive to total dependence on all aspect of activities of daily living and frequently incontinent of bladder. The plan of care with a focus area with target date of 1/26/17, documented resident with long history of urinary incontinence. Staff provides assist with toileting or check and change system. Frequently incontinent of urine occasionally incontinent of bowel. Wears incontinent brief. Interventions include: a. Provide two assist with toileting. b. Staff may assist to toilet as resident requests. c. Provide check and change system on 10-6 shift and other shifts. d. Provide peri-care after each incontinent episode. e. Wears incontinent product. Observation on 1/15/17 at 1:06 p.m., revealed Staff H, CNA, and Staff I, CNA, using the EZ stand to transfer the resident from their reclining geri chair to their bed. Staff I proceeded to pull down the resident slacks while in the EZ stand and remove a soiled brief. Staff H with gloved hands and a wet wipe cleansed the resident peri area, cleansing from back to front and front to back in a scrubbing motion. Staff H failed to use different parts of the wet wipe during incontinent cares and failed to cleanse the residents buttocks and coccyx area. Staff I confirmed the brief soiled with urine in the front and back over the buttocks and coccyx area.

Based on clinical record review, the 2017 Nursing Drug Handbook and staff interview, the facility failed to follow physician orders [REDACTED].#5) and failed to properly administer eye drops for 2 of 3 residents with a medicated eye drop (Resident #11 and #12) and failed to ensure staff utilized the five rights of medication administeration for one resident (Resident #12). The facility census was 29 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. A Medication Review Report dated 1/4/17, instructed staff to obtain a pulse for [MEDICATION NAME] (a medication for hypertension) and hold if pulse is lower than 55 and hold if systolic blood pressure below 100. The Medication Administration Record [REDACTED]. During interview on 1/25/17 at 10:20 a.m., the Director of Nursing (DON) confirmed the progress notes lacked documentation of the medication being held as directed. 2. Observation on 1/23/17 at 1:10 p.m., revealed Staff E, Registered Nurse, RN administered Dorzolamide/[MEDICATION NAME] 2% to the left and right eye of Resident #11. Staff E placed a Kleenex over the lacrimal sac for 6 seconds on each side. Staff A failed to apply pressure to the resident left and right eye for one minute or have the resident keep their eye closed for one minute. Observation on 1/24/17 at 11:30 a.m., revealed Staff G, LPN, administered [MEDICATION NAME] 1% to the left and right eye of Resident #11. Staff G placed their fingers in the corners of the residents eye for 35 seconds. Staff G failed to apply pressure to the resident left and right eye for one minute or have the resident keep their eyes closed for one minute. 3. Observation on 1/24/17 at 7:00 a.m., revealed Staff F, Licensed Practical Nurse, LPN administered Dorzolamide 2% to the left and right eye of Resident #12. Staff F held their fingers over the lacrimal sac for 44 sec on left eye and 51 seconds on right eye. Staff E failed to apply pressure to the resident's left and right eye for one minute or have the resident keep their eye closed for one minute. Review of the Nursing 2017 drug handbook instructed staff to apply light finger pressure on lacrimal sac for one minute after instilling to minimize systemic absorption on the above medicated eye drops. 5. Observation on 1/23/17 at 3:25 p.m., Staff L, LPN, removed two vials of [MEDICATION NAME] nebulizer from Resident #12 plastic tray. Staff L placed one vial in the left front pocket of their jacket and administered the other vial. Interview on 1/23/17 at 4:31 p.m., Staff L explained the vial of [MEDICATION NAME] was to be used later that night for the 9:00 p.m., medication administration. When interviewed on 1/23/17 at 4:31 p.m., the DON stated the nurse was to follow the patient 5 rights of giving medication and requested the nurse to throw the vial away.

Based on observation, clinical record review, policy review and staff interview, the facility failed to provide complete perineal care for one of six residents reviewed during personal cares with a history of urinary tract infections. (Resident #6). The facility census was 29 residents. 1. The Minimum Data Set (MDS) with an assessment reference date 11/13/16, documented Resident #6 with [DIAGNOSES REDACTED]. The MDS documented the resident with short and long term memory impairments, severely impaired decision making abilities, and required extensive assist from two staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS documented the resident as frequently incontinent of bowel and bladder. The careplan with a target date 2/9/17, had a focus area the resident has bladder incontinence. Staff provide assist with toileting on routine basis. Wears incontinent brief. History of Urinary Tract Infections. Interventions included: a. Provide two assist with toileting on routine basis. b. If restless provide toileting first. c. Check and change system used on rounds on night shift. d. Wears incontinent brief. e. Provide peri care after incontinent episodes. Observation on 1/23/17 at 4:05 p.m., revealed the resident lying in bed. Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, transferred the resident from their bed to the bathroom by the EZ stand (mechanical lift). Staff A proceeded to pull down the resident pants and pulled the soiled brief from in between the resident legs and threw away in the garbage can. Staff A and Staff B proceeded to sit the resident down on the toilet. Resident #6 stated they were finished on the toilet. Staff A and Staff B then proceeded to stand the resident. Staff B with gloved hands and a wet wipe cleansed the resident peri area in a back and forth scrubbing motion, from front to back and back to front. Staff B failed to change the position of the wet wipe during the incontinent cares and failed to cleanse the resident bilateral hips, thighs, coccyx and buttocks. Staff B stated that the brief was soiled with urine in the groin area and buttock area. Observation on 1/24/17 at 7:20 a.m., revealed the resident lying in bed. Staff C, CNA, and Staff D, CNA, provided incontinent cares on the resident. Staff D with gloved hands and a wet wipe cleansed the resident peri area using a back and forth motion three times and failed to use different parts of the wet wipe. Staff C stated the brief was soiled in the peri area and not on the resident buttocks.

Based on clinical record review, facility policy review and staff interview, the facility failed to report a suspected resident abuse to the Department as required for two of four residents reviewed. (Resident #1 & #2) The facility census was 29 residents. Finding include: 1. The minimum data set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. 2. The minimum data set (MDS) assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. During interview on 12/27/16 at 1:10 p.m., Staff A stated sometime in June she witnessed Resident #1 place his/her hands on the shoulders of Resident #2. Staff A stated Resident #1's hands rested on Resident #2's breasts. Staff A stated she reported the incident to a dietary staff who directed her to report to a nurse. Staff A stated she reported the alleged incident to a nurse, but did not recall if she had mentioned Resident #1 touched Resident #2's breasts. Staff A stated a second incident occurred in December when she witnessed Resident #1 walk by Resident #2 and touched and/or slightly grabbed Resident #2's breast. Staff A stated she reported the incident to the nurse (Staff B) but could not recall if she had mentioned that Resident #1 actually touched and/or grabbed Resident #2's breast. During interview on 12/29/16 at 11:30 a.m., Staff B stated Resident #1 was known to often place his/her hands on the shoulder of other resident's and/or staff. Staff B stated on the date of the alleged incident (12/17/16) Staff A was a distance away from Staff B when she yelled that Resident #1 was bugging Resident #2. Staff B stated she responded by locking the medication cart and as she started to walk toward where the residents were, she observed Resident #1 returning to his/her room. During interview on 12/27/16 at 10:52 a.m., the administrator stated the alleged incident between Resident #1 and Resident #2 was reported on 12/20/16. The administrator stated there were two different scenarios, one of Resident #1 was groping Resident #2's breast and the other was Resident #1 brushed Resident #2's breast. During interview on 12/29/16 at 12:16 p.m., the administrator stated she would have expected Staff A to immediately report the alleged incident to her supervisor and the supervisor in turn report to the administrator. The administrator confirmed the facility did not report the allegation of resident to resident contact to the State Agency, Department of Inspections and Appeals, as required. Review of the facility Abuse Prevention, Identification, Investigation and Reporting Policy (Rev. 8-16) revealed all allegations of Resident abuse should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Director of Nursing, Administrator, or designated representative.

Based on observation and staff and resident interview, the facility failed to maintain food temperatures at a safe and palatable temperature. The facility reported a census of 34 residents. Findings include: 1. On 2/3/16 at 12:20 p.m., observation revealed the facility staff passed room trays in Zone #1 and Zone #2. The surveyor requested a guest tray which was dished at 12:20 p.m. and placed on the cart for Zone #1. At 12:25 a.m., staff removed the last tray from the cart in Zone 1. At that time, the hamburger on the sample meal temped at 113 degrees Fahrenheit and the French fries at 103.9 degrees Fahrenheit. Residents #1 and #2 received room trays in Zone #2. At 12:27 p.m. Resident #1 reported the food was cold as ice. Resident #2 reported at 12:28 p.m., the French fries were not hot upon delivery. On 2/3/16 at 3:25 p.m., the Dietary Manager stated there had been a resident complaint about one and one half weeks ago about the room trays food not being hot.

Based on clinical record review and staff interview, the facility failed to ensure staff administered [MEDICAL CONDITION] medication as ordered and attempted alternative interventions before its administration for one of four residents reviewed with [MEDICAL CONDITION] medications. The facility census was 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance with bed mobility and transfer. The care plan dated 2/20/15, included a problem of psychosocial/mood. The problem included an intervention to administer medications per orders, monitor effectiveness and side-effects of medications. The problem also included the following alternative interventions: a. Observe for changes in eating, sleeping habits, tearfulness, withdrawal. Tender loving care and support as needed. b. Try walking resident when restless. Trey distractions with TV, socks, fabric, tinker toys, music, 1:1, conversations, etcetera when restless. c. Assist with phone calls to family as requests to help calm down. d. Offer coffee in lounge area when needing assist in redirecting attention. Provide gentle distraction when exhibiting behaviors. e. Offer rest periods out of room on sofa in lounge or recliner if restless. A physician order [REDACTED]. Nurse note dated 2/6/15 at 9:00 a.m., documented the resident complained of low back pain and leg pain and was given as needed [MEDICATION NAME] (pain medication) for comfort. Nurse note dated 2/6/15 at 11:30 a.m., documented the resident was crying at that time and was very confused and upset. The resident was given an as needed [MEDICATION NAME] for comfort. This did help calm down and relax the resident. Director of Nursing called and physician and received new order for resident. Lots of 1:1 time with resident today by several staff members. The Medication Administration Record, [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED] Nurse notes revealed no behavior at the time and no alternative interventions attempted prior to the administration of the medication. The MAR indicated [REDACTED]. The response indicated the medication was not effective. The MAR indicated [REDACTED]. The section for response to the medication was left blank. The MAR indicated [REDACTED]. The section for the response to the medication documented the medication was no help. During interview on 3/4/15 at 2:00 p.m., the Director of Nursing stated staff would be expected to attempt to relieve pain and administer pain medication prior to administering a [MEDICAL CONDITION], rather than administering a [MEDICAL CONDITION] before a pain medication. The DON stated the resident sometimes stated they did not have pain and then changed their mind, and may have asked for it that way.

Based on observation, review of State Fire Marshall guidelines and staff interview, the facility failed to utilize electrical equipment in a safe manner, failed to ensure medications were stored in a secured manner and failed to ensure shower rooms were well maintained to prevent accident hazards. The facility census was 33 residents. Findings include: On the Department website in the February 2004 Insight, the State Fire Marshal's Office documented clarification on use of surge protectors. The posted information documented the electrical surge protector shall be of metal or steel construction and approved by Underwriters Laboratories or another recognized laboratory. The paper documented items that could be used with an electrical surge protector and items prohibited from use with a surge protector that included clocks, lamps, personal grooming and care devices, battery chargers, and motor drive appliances. 1. On 3/3/15 at 11:30 a.m., the lounge area revealed a plastic surge protector with three fish aquarium pumps and a fish aquarium light plugged in to it. 2. On 3/3/15 at 1:30 p.m., observation revealed a plastic surge protector on a counter at the nurses station with computer equipment plugged in to it. 3. On 3/4/15 at 9:10 a.m., observation revealed two loose ceramic tiles on the lower portion of a shower room wall in the zone 2 shower room. The edges of the tile felt rough and jagged to touch. At the time the Maintenance Director stated the shower room needed to be updated. Observation revealed a bottle of Naproxen Sodium tablets in an locker with the door open, in an unlocked room near a facility entrance. Another open locker had a bottle of prescription medications. At the time the Administrator verified medications needed to be stored in a secured area. Observation revealed a plastic surge protector remained at the nurses station and in the cabinet under the fish aquarium with the same items plugged in to it.

Based on clinical record review and staff interview, the facility failed to complete a through assessment and attempt the least invasive intervention for one of seven residents reviewed. (Resident #6) The facility census was 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance with bed mobility and transfer. A physician order [REDACTED]. A review of the bowel record revealed the resident did not have a bowel movement from 1/29/15 until 2/3/15. The as needed Medication Administration Record [REDACTED]. A facsimile transmission to the physician dated 2/3/15, requested an order for [REDACTED]. Clinical record review revealed no assessment of bowel sounds completed, or of any other abdominal assessment. Nurse notes on 2/3/15 at 6:00 p.m., documented the resident was unable to sit and move their bowels so the as needed [MEDICATION NAME] ([MEDICATION NAME]) suppository was given at 4:45 p.m. without results. A saline enema was given per rectum at 5:45 p.m. with good results. The note included no assessment of bowel sounds or any other abdominal assessment. The bowel record documented the resident had a small formed stool on 2/3/15 and again on 2/5/15. Nurse notes dated 2/8/15 at 2:00 p.m., documented he resident stated they needed to have a bowel movement, but had been unable to go. Stool was noted after a rectal check. An as needed enema was given with a scant amount of stool removed at 10:15 a.m. Stool still remained after a rectal check. At 11:20 a.m., an as needed bowel jam was given. Good results from the as needed bowel jam/prune juice noted that afternoon. Nurse note included no assessment of bowel sounds or any abdominal assessment. During interview on 3/4/15 at 2:00 p.m., the Director of Nursing stated the facility had no policy to direct staff on the administration of medications for constipation, but they would expect the least invasive measure to be attempted first. During interview on 3/5/15 at 9:40 a.m., Staff B, licensed practical nurse, LPN stated that every 3rd day without a bowel movement a resident would receive something to help their bowels. Staff B stated on the 3rd day the resident would get bowel jam and they would contact the physician. Staff B stated sometimes they would have a dementia patient they had to do a rectal check on because they could not tell them. Staff B stated they would not do an enema first and that would be a last resort, unless there was a specific order to do it first. Staff B stated they would need to listen to bowel sounds as part of the bowel assessment. At 9:50 a.m., Staff B approached the surveyor and stated it would be different with a resident who had an order for [REDACTED].

Based on observation, clinical record review, staff interview and facility policy review, the facility failed to ensure one of four residents remained in a safe and secured environment. (Resident #1) The facility identified 6 residents as at risk for elopement. The facility identified a census of 39 residents. Findings include: According to a Minimum Data Set (MDS) assessment form dated 5/18/14, Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident had severely impaired cognitive skills, short and long term memory deficits, fluctuating inattention, altered levels of consciousness and psychomotor retardation, required extensive assistance of staff with all activities of daily living (ADL'S), as not stable and only able to stabilize with staff assistance with all movements. According to the most recent Care Plan dated 5/22/14, the facility failed to address the residents code alert alarm however according to a Resident Care Plan form dated 2/27/14, the resident had a problem with delirium, cognitive loss, communication and activities. The approaches included the following: a. 5/2/13 - Code alert alarm for safety and to remind not to go out door unattended . Offer assistance and/or encourage/redirect the resident to go outside in the garden area or in the porch. The alert bracelet had been placed on the right wrist. A nursing assistant pocket care plan dated 6/6/14, the facility failed to address the resident's code alert alarm. According to a Zone 1 form dated 5/27/14, the resident had not been allowed outside in the garden area unattended. (area fenced and alarmed). An Elopement Risk form dated 5/19/14, indicated the resident received a score of 2 and with a code alert alarm placed. (a score of above 3 and mobile staff had been directed to initiate elopement precautions). A Quality Improvement Tracking Form dated 6/6/14 at 7:30 p.m., indicated the resident last observed at 6:30 p.m. by Staff A, Registered Nurse (RN) wandering the halls in his/her wheel chair. At no time documented, the resident's code alert alarm sounded. Staff A and another unidentified staff member checked both doors and looked outside, with no resident observed. A Rockwell Community Nursing Home, INC form dated 6/6/14, documented the following: FYI (for your information): Resident found outside facility with a wheel chair in the grass next to the office window. Code alert went off, staff looked for the resident and had not seen him/her in the grass. Resident found sleeping in the wheel chair with no injuries noted. During an interview 7/9/14 at 12:06 p.m., a person who had been mowing the lawn indicated he had been mowing the grass just West of the visitor parking lot between the pavement and the trees and observed the resident sitting in the grass in a wheel chair with his/her back to him. He stated the resident was just North of the visitors parking lot; more or less just sitting there, but not very responsive. This individual indicated he had not mowed the portion of the lawn the resident had been sitting on until the next day and also reported he left the facility around 8 p.m. with the resident still outside. He had not told anyone because he thought someone had brought the resident outside. During an interview 7/9/14 at 8:35 a.m., a family member indicated at 7:30 p.m. to 7:45 p.m. on the night of the incident he/she came to the facility to visit his/her family member and noticed a man in a wheel chair sitting in the grass north of building. The family member thought it was weird because the resident did not turn and look when they pulled up to the facility. The family member went to the nurse's station and asked an unknown older gal and unknown younger gal if they had been aware of a man in a wheel chair outside. At that point the young gal ran down the hall. The family member observed the resident when he/she returned to the facility and felt he/she had not been in any distress. During an interview 7/8/14 at 1:40 p.m., Staff B, Certified Nursing Assistant (CNA) indicated she had been down hall 2 assisting Staff C, CNA with another resident's cares. Staff C stayed with the resident to finish the cares as she left the room and heard a noise. As she walked down the hallway around 7 to 7:10 p.m., she heard a code alert alarm sounding down the main entrance hallway, but had not known how long the alarm had been sounding. The staff member then tried to silence the alarm however she had not known the code. Staff A had also been present and after a few attempts, silenced the alarm. Staff B then went out the door and looked forward and then left and observed a person mowing the grass. The staff member indicated she had no peripheral vision because of the size of the frame of her glasses so could not see nor did she look to the right. Staff B then turned around to the left and went back into the building. The staff member confirmed she should have looked to the right, checked the parameters of the building and performed a resident head count. Staff B identified the facility's policy and procedure when a door alarm sounds as follows: a. Turn off the alarm b. Go outside and check for a resident however she thought the policy had been more in-depth but would have to get back to the surveyor with the answer. During an interview 7/8/14 at 3:45 p.m., Staff C indicated she vaguely heard the door alarm sound at around 7 p.m. to 7:30 p.m. the night of the incident because she had been in a resident's room and had not responded because that resident could not be left unattended. When she completed the resident's cares she observed Staff A and Staff B walking up the hall towards the nurse's station but they never said anything to her so she proceeded with resident cares. At around 8:30 p.m. she had been at the nurse's station when a family member of Resident #5 approached her and asked if she had been aware there had been a man outside in the grass. The staff member ran outside and observed the resident positioned in his/her wheel chair in the grass, sleeping, calm and in no distress. The staff member patted the resident's knee and aroused him/her. The staff member asked the resident if he/she had been tired and wanted to go to bed and the resident said that would have been nice. The staff member placed the foot pedals on the wheel chair and propelled the resident into the building. The resident had been wearing a cap, glasses, long sleeved shirt, a white T-shirt, gray sweat pants, white socks, shoes, a personal body alarm attached to his/her person and a code alert on his/her ankle. The staff member indicated there had been no apparent injuries and no grass stains on the resident's clothing however there had been wet grass on the wheel of the wheel chair but no tracks in the grass. The staff member propelled the resident into the building and approached Staff D, RN had been positioned at the nurse's station and told her what had happened. The staff members called Staff A to the nurse's station and also told her what had happened at which time she performed an assessment of the resident. This staff member indicated the facilities policy and procedure when a door alarm sounds as follows: a. Depended on which resident she had been assisting at the time. If she could leave the resident unattended she had been suppose to check on the alarm that had been going off. b. Check the door and if no one there start a head count of residents. c. If missing a resident staff were to go outside and search but leave a couple of CNA'S in the building. d. It had not been acceptable to shut of a door alarm prior to checking outside for a resident. According to a written statement dated 6/11/14, the Administrator's documentation included the following: a. A family member had been visiting his/her spouse and left the facility about 7 p.m. but no one had been observed sitting outside and he/she had not noticed anyone following him/her out the door , "but I was not really paying attention". The scene was re-enacted with Staff B and Staff A demonstrating how they responded when the code alert alarm sounded and where they stood once outside of the building. Staff C sat in the wheel chair at the location she found the resident. It appeared Staff B should have sen the resident sitting in the grass. A Rockwell Nursing Home Employee Guide to Emergencies form (not dated), documented the following information in relation to a missing resident: a. Report to the charge nurse as soon as any resident had been suspected of having been missing. b. Search the building and immediate grounds. c. Search the surrounding area. d. Call in off-duty personnel and/or emergency services to assist in the search. e. Notify family/responsible party. f. Notify the physician. All of the facility outside doors and the garden gate had been alarmed. The front and back entrance doors have a key pad to bypass the alarm. The alarm panel had been located on the wall at the nurse's station and would wound when a door had been opened. The panel would tell you which door had been activated. Instructions for silencing and resetting had been on the wall at the panel. DO NOT SILENCE OR RESET UNTIL YOU HAVE CHECKED THE INDICATED EXIT TO MAKE SURE A RESIDENT HAD NOT LEFT THE BUILDING UNAUTHORIZED. The front and back entrance doors had been hooked into the code alert monitory system. Residents identified as having been possible wanderers wore a battery operated code alert band around their wrist and/or ankle to monitor their activity. The band activates an alarm when the resident passes through the door. AN ELOPEMENT HAD BEEN DEFINES AS WHEN A COGNITIVELY IMPAIRED RESIDENT LEFT THE FACILITY UNDETECTED, WITHOUT THE KNOWLEDGE OR AUTHORIZATION OF THE STAFF. that INCLUDED WANDERING THE FACILITY GROUNDS UNATTENDED. IF THE ALARMS WORK PROPERLY AND STAFF RESPOND TO THE ALARM AND REDIRECTS THE RESIDENT, THAT IS NOT CONSIDERED AN ELOPEMENT BECAUSE THE EXIT HAD BEEN DETECTED AND THE SYSTEMS WORKED PROPERLY.

Based on observation and staff interview, the facility failed to secure hazardous chemicals from cognitively impaired residents. The facility identified six residents with a code alert system. The facility census was 38 residents. Findings include: 1. Observation on 12/17/12 at 8:15 a.m., revealed an unlocked custodial closest on the northeast hallway with the following items accessible to residents: a. one bottle of ph-7 Ultra- one step disinfectant. Danger keep out of reach of children. b. 2 bottles of Clorox 409 cleaner, precaution statement- hazard to humans, call poison control center if ingested. c. 2 bottles of spray majestic carpet solution, cherry almond fragrance, Caution- do not take internally, keep out of reach of children. d. 1 bottle of chlorine bleach, keep out of reach of children, call poison control center. e. 1 bottle of instant odor control Elimo-Healthcare, keep out of reach of children, harmful if swallowed. During interview on 12/17/12 at 8:22 a.m., the Director of Nursing confirmed and verified the custodial closest was to be locked at all times.

Based on observation, staff interview and review of manufacturer guidelines, the facility failed to properly sanitize the glucometer after use to prevent the transmission of disease. The facility census was 38 residents. (Resident #6, #11 & #12) Findings include: 1. During observation on 12/17/12 at 11:12 a.m., Staff A, Licensed Practical Nurse, LPN completed a blood sugar check on Resident #6. At 11:17 a.m., Staff A cleansed the glucometer with a Microdot bleach wipe. The directions on the back of the wipe container indicated the item cleansed should remain thoroughly wet for five minutes. At 11:20 a.m., Staff A verified the glucometer was dry and placed it in a wheeled cart. At 11:22 a.m., Staff A completed a blood sugar check on Resident #11 using the same glucometer. At 11:26 a.m., Staff A cleansed the glucometer with a Microdot bleach wipe. At 11:28 a.m., Staff A verified the glucometer was dry. At 11:29 a.m., Staff A placed the glucometer in a wheeled cart. At 11:31 a.m., Staff A completed a blood sugar check on Resident #12 using the same glucometer. At 11:35 a.m., Staff A used a Microdot bleach wipe to cleanse the glucometer. At 11:37 a.m., Staff A verified the glucometer was dry and placed it in a wheeled cart. On 12/19/12 at 10:30 a.m., the Director of Nursing verified the manufacturer guidelines included directions to leave an item wet for five minutes to effectively sanitize equipment.

Based on clinical record review and staff interview, the facility failed to follow physician orders [REDACTED]. The facility census was 38 residents. (Resident #1 & #9) Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance with transfers, bed mobility, dressing and toilet use. A clinical laboratory note dated 6/26/12, documented Vitamin D 50,000 units by mouth weekly times eight weeks and re check Vitamin D level after eight weeks. A pharmacy review dated 7/25/12, documented Vitamin D laboratory to be repeated after the eight weeks of therapy per chart. Record review revealed no re check of the Vitamin D level was completed after eight weeks as ordered. 2. The MDS assessment dated [DATE], documented Resident #9 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance with bed mobility, transfers, ambulation, dressing, toilet use and personal hygiene. A nursing home correspondence dated 2/14/12, documented re check Vitamin D in three months per pharmacy recommendation and once per year after that time. Record review revealed no Vitamin D level completed as ordered after three months. During interview on 12/17/12 at 7:30 a.m., the Director of Nursing confirmed and verified the laboratory work was not in the chart for the two residents and was missed.

Based on clinical record review, physician and staff interview, the facility failed to notify the residents physician and interested family member when a condition change occurred for two of eight residents reviewed. The facility census was 38 residents. (Resident #5 & #7) Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required supervision and setup for eating. Nurse notes dated 12/6/12 at 5:00 p.m., documented the resident choked on a Calcium pill, turned red and required the [MEDICATION NAME] maneuver to be performed. The entry documented the resident coughed the pill up and was able to talk. Review of the clinical record revealed no documentation of physician or family notification of the incident. The facility Director of Nursing stated on 12/18/12 at 1:30 p.m., the expectation would be for an incident that involved the [MEDICATION NAME] maneuver be reported to the physician and family. On 12/19/12 at 10:15 a.m., the Director of Nursing stated the physician was notified earlier that morning of the incident and ordered a Speech Therapy consult for the resident. 2. The MDS assessment dated [DATE], documented Resident # 7 had [DIAGNOSES REDACTED]. The MDS documented the resident required supervision with setup for eating. Nurse notes dated 6/19/12 at 8:30 a.m., documented the resident was coughing and choking while eating breakfast. The note indicated the residents airway remained patent, however, the resident stated he/she did choke on scrambled eggs. The note documented the residents face turned red and the resident coughed a lot but had been able to clear it. The resident stated it scared them and reassurance and tender loving care was provided. The clinical record documented no notification of the residents family or physician. Nurse notes dated 7/16/12 at 8:00 a.m., documented the resident had two choking spells while he/she ate scrambled eggs. The note indicated the resident was able to maintain his/her airway but did cough and clear it both times. The resident was re-directed to eat slower and take smaller bites and the resident agreed. The note indicated staff would continue to observe, with no documentation of physician or family notification. A dietary note dated 8/7/12, documented the residents swallow and feeding abilities varied with no new concerns. Nurse notes dated 9/28/12 at 5:45 p.m., documented the resident had two choking spells while drinking. One spell at the dinner table and another while giving medication. The note documented the resident was asked if okay and the resident stated "uh huh". The note documented the resident would continue to be monitored, with no physician or family notification. Nurse notes dated 10/16/12 at 8:00 a.m., documented the residents physician was in with no major concerns reported and no new orders. The Director of Nursing stated on 12/19/12 at 8:20 a.m., he/she was not aware of the choking episodes and the physician and family should have been notified of the incidents. On 12/19/12 at 8:46 a.m., the resident's physician stated the expectation would be for the facility to notify the residents physician of a choking episode. The physician stated typically a speech therapy evaluation would be ordered.

Based on clinical record review and staff interviews, the facility failed to plan for and direct nursing care and services to ensure a resident received adequate supervision from hazards. Resident #1 fell and fractured his/her ankle after a staff left him/her unattended in the bathroom. Staff interviews revealed other staff had also left the resident unattended in the bathroom prior to the fall. The care plan for Resident #1 lacked any directives for staff to not leave them unattended in the bathroom. The resident sample consisted of five (5) residents with a census of thirty-nine (39) residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance of two for transfer and locomotion and total assistance of one with toileting. A test for balance determined Resident #1 unsteady and only able to stabilized with human assistance when moving from seated to standing position; when walking; when turning around; when moving on and off the toilet with surface to surface transfer. The plan of care with a review date of 9/22/11, documented a problem of falls which included an addendum dated 4/19/11, for the use of a bed strip alarm and mobility alarm. The problem included the following interventions: a. Provide resident an environment free of clutter. b. Have call light available, instruct/remind/encourage to use as needed, especially at night. c. Assist/remind to wear braces and shoes whenever out of bed. Gripper socks at night. d. Assure the floor is free of glare, liquids, foreign objects. e. Fall assessment and elopement assessment per policy. f. Code alert (alarm). g. Encourage participation in restorative program. h. Recliner on non-slip pad. i. Physical therapy recommends stand by assistance with ambulation, follow with wheel chair. j. Use wheel chair with auto lock brakes as needed. k. Seat belt alarm in wheel chair. l. Ambulate with assistance as resident allows, anticipate as possible. m. Toilet rails on toilet. n. Alarm in wheel chair. o. Bed strip alarm to bed. p. Toilet every two hours around the clock a possible. q. Respond to door alarms immediately. The plan of care with the same review date, documented a problem with activity of daily living. The problem included the following interventions: a. Provide/assist (total added, no date) with grooming, dressing, personal hygiene, oral care and perineal care as required. Encourage to be active in his/her own self-care (as able added, no date). b. Assist with toileting, arranging clothing when toileting-wears TENA (incontinent brief) and unable to do independently and perineal care following each incontinent episode. c. Assist with applying braces to feet/ankles as needed. d. Toilet resident per schedule before and after meals and activities, before bed and upon arising, awaken during night at least once for toileting and as resident requests. Toilet every two hours and around the clock as possible (added 4/19/11). Review of the nursing communication book revealed an entry dated 10/25/11, that directed staff to use assistance of two staff because of Resident #1 is a big person. Review of a staff assignment sheet dated 10/30/11, revealed a directive to ambulate the resident with assistance of one, and utilize a bed, chair and seatbelt alarm for the resident. A fall potential risk assessment dated [DATE], indicated the resident to be at a high risk for falls. A review of quality improvement tracking forms, revealed the resident had fallen on the following dates: a. 1/3/11, found on floor sitting in front of bed. b. 3/30/11, found sitting on the floor in front of bed and nightstand. c. 4/2/11, getting up from supper table and fell to the floor. d. 4/19/11, found sitting on floor in front of bed. The form included steps implemented to prevent reoccurrence was to toilet every two hours, ambulate with the resident, assist with all transfers and use a bed strip alarm and mobility alarm. e. 9/29/11, feet slipped out from under the resident during a transfer, lowered to the floor. Review of the staff communication book revealed an entry dated 4/19/11, indicating the resident had three falls in less than three weeks, and he/she needed to be toileted every two hours and needs anticipated so he/she did not try to get up alone. The entry directed staff to never let the resident walk alone, and if seen to do so assist, especially transfers. The entry directed staff to use a mobility monitor and bed strip alarm on the resident. Review of a quality improvement tracking tool, revealed Resident #1 sustained a fall in the bathroom on 10/30/11 at 5:25 p.m., and had been transferred to a local emergency room . The form included an additional comment/step to prevent reoccurrence implemented would be to not leave the resident alone while in the bathroom and possibly post in resident ' s room if up with one or two assistance and if could be left alone in the bathroom. The same section indicated the facility had many new staff or those that work infrequently. A radiology report dated 10/30/11, identified Resident #1 sustained a lateral malleolar (right ankle) fracture. During interview on 11/15/11 at 11:17 a.m., the Administrator stated employees can find specifics about resident cares in the nursing communication book and facility policy directed staff not to leave residents alone while in bathroom if the resident wore an alarm. The Administrator stated the facility had implemented a new procedure after the incident on 10/30/11, and placed a pink neon sign in resident bathrooms directing staff if they could not leave a resident alone in the bathroom. During interview on 11/16/11 at 7:30 a.m., Staff J stated she had taken the resident to the bathroom prior to his/her fall on 10/30/11. Staff J stated after transferring the resident to the toilet, she left the bathroom to check on (residents) call lights. Staff J stated she had directed the resident to use the call light when finished, and had been gone approximately five minutes. Upon returning the resident was still on the toilet and stated he/she was not done. Staff J stated she left the resident alone in the bathroom for approximately two minutes to help a resident to the dining room. Upon returning to the room, Staff J found the resident on the floor. Staff J stated she thought the facility had gone over not leaving a resident alone in the bathroom if the resident had an alarm during orientation, but he/she did not remember. Staff J stated employees kept up on resident cares and changes by reading the communication book when you come in for a shift. During interview on 11/15/11 at 2:15 p.m., Staff C, Registered Nurse stated he/she had been the nurse who responded when the resident fell on [DATE]. Staff C stated facility policy stated a resident with an alarm should never be left alone in the bathroom. Staff C stated the facility had a lot of newer and inexperienced staff and that it is hard to read something in the communication book and be expected to remember it in a split second. During interview on 11/15/11 at 2:40 p.m., Staff D, certified nurse aide, CNA stated facility policy had been not to leave residents alone if they have alarms. Staff D admitted she too had left Resident #1 alone on the toilet in the past to go and help other residents. During interview on 11/15/11 at 3:25 p.m., the Director of Nursing stated that if a resident such as Resident #1 had been in the bathroom and knowing he/she had not had a fall in the bathroom, she would leave the resident alone if another resident ' s alarm sounded. The DON stated as a general rule, residents with alarms should not be left alone in the bathroom. The DON stated Resident # 4 had an alarm but could be left alone in the bathroom. The DON stated that employees who work infrequently would be expected to ask in report who could and could not be left alone. During interview on 11/15/11 at 3:00 p.m., Staff E, CNA stated the facility had one resident who could be left alone in the bathroom with an alarm. Staff E stated the information for who could and could not be left alone in the bathroom would be found on the plan of care, and that you just had to know the residents. Staff E stated Staff J did not work in the facility often and did not know the residents well. Staff E stated some residents have a seatbelt alarm and could be left alone, that you had to know the resident and if the resident would try to get up. During interview on 11/15/11 at 3:10 p.m., Staff F, CNA stated staff knew which residents to stay with by reading the communication book and it would be very difficult for Staff J to keep up on things because he/she worked infrequently. During interview on 11/15/11 at 11:35 a.m., Staff B, Registered Nurse stated he/she orientated new aides. Staff B stated staff were told they need to go by the care plan for specific resident cares and there was a section in the orientation packet that told staff not to leave a resident alone in the bathroom unless it was specifically on the care plan. Staff B stated another resident (Resident #4) who had an alarm had been allowed to be left alone in the bathroom and that directives related to this could be found on the residents plan of care. Staff B stated an employee would be expected to go to the plan of care or ask another staff person if not sure how to care for a resident. (A review of Resident #4 ' s plan of care dated 8/25/11 revealed Resident #4 no specific instruction(s) that the resident could be left alone in the bathroom.) During interview on 11/15/11 at 3:45 p.m., Staff H, CNA stated they would not leave a resident alone in the bathroom if the resident had an alarm, except for Resident # 4. During interview on 11/15/11 at 4:00 p.m., Staff I, CNA stated if a resident had an alarm staff did not leave the resident alone in the bathroom. Staff I stated Resident #4 had an alarm and could be left alone in the bathroom and staff learned this from the training when hired, or from report. A facility policy for resident care dated 2010, included a nurse aide skills checklist that directed staff never to leave a confused, weak or resident with an alarm alone on the commode. The policy included a directive for the nurse aide to determine what the resident can do for themselves and provide safety throughout all procedures.