Every finding on record at Rolling Green Village Care Center

Based on clinical record review, facility document review, resident interview, staff interviews, and policy review, the facility failed to assess and intervene when a resident reported a new complaint of rib pain in a timely manner for 1 of 3 residents reviewed (Resident #1) for assessment and intervention. Resident #1 continued to have pain in her chest when coughing or taking deep breaths for approximately 2 days. After Resident #1 went to the emergency room for the reports of pain, the hospital admitted her with a diagnosis of an acute (new) left 9th and right 10th rib fractures. The facility reported a census of 38.Findings include:Resident #1's Minimum Data Set (MDS) assessment completed on 6/17/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 entered the facility on 5/13/26 due to a fractured femur (thighbone). Active medical diagnoses included chronic pain syndrome, Crohn's disease (digestive disorder), end stage kidney disease requiring dialysis (medical procedure removing waste products and extra water), heart failure, and osteoporosis (brittle bone disease). Resident #1 maintained a right nephrostomy tube (tube placed through the skin of the back directly into the kidney to drain urine). The Care Plan Focus with target date of 8/13/26 indicated Resident #1 had complaints of pain related to right femur fracture and feet/legs, ribs bilaterally, chronic pain syndrome. The Skilled Note created 6/7/26 at 9:26 PM for 6/6/26 at 9:03 PM labeled LATE ENTRY written by Staff C, Licensed Practical Nurse (LPN), documented Resident #1 had regular breath sounds with clear lung sounds on the left and right. The note lacked a pain assessment. The Orders - Administration Note dated 6/7/26 at 6:50 AM written by Staff G, Certified Medication Aide (CMA) documented they gave Resident #1 oxycodone 5 milligrams (pain medication) for rib pain. The clinical health record lacked follow-up from a nurse regarding Resident #1's rib pain. The Orders - Administration Note dated 6/8/26 at 8:01 AM indicated staff provided pain medication to Resident #1 for leg pain. The Skilled Note dated 6/8/26 at 10:32 AM documented by Staff J, Registered Nurse (RN), reflected Resident #1 had regular breath sounds with clear lung sounds on the left and right. The note lacked a pain assessment. The General Progress Note dated 6/8/26 at 8:00 PM documented Resident #1 complained of chest and left rib cage pain when coughing or taking deep breaths. Resident #1 reported they felt a pop in the rib cage area 2 days before during a transfer, describing it as a stabbing pain and rating it as 7 to 8 out of 10, indicating moderate to severe pain. The General Progress Note dated 6/8/26 at 8:15 PM reflected the facility received a physician's order to send Resident #1 to the emergency room. The General Progress Note dated 6/9/26 at 1:34 AM identified Resident #1 admitted to the hospital. A Nurse Practitioner Progress Note dated 6/8/26 at 8:24 PM detailed a phone call from the facility's LPN updating the practitioner regarding Resident #1's significant chest pain. The note documented Resident #1 had pain present for the past 2 days. They described the pain as stabbing and rated it 7 to 8 out of 10 with deep breaths or coughing, and less severe with small breaths. The note documented Resident #1 felt a pop near the rib cage area under the left breast during a transfer 2 days prior. A Chest X-Ray completed 6/8/26 at 10:04 PM showed Resident #1 had acute nondisplaced fractures to the left 9th and right 10th ribs. The hospital's History and Physical admission report dated 6/8/26 at 11:26 PM documented a facility staff member grabbed Resident #1 in a bear hug and lifted Resident #1 2 days before. The report documented Resident #1 felt a pop with sudden pain and had ongoing pain occurring since the incident when coughing or inhaling. Resident #1 reported they had chills but didn't have a fever prior to her recent hospitalization. She had a fever of 101.8 degrees Fahrenheit (F). The plan directed to give Tylenol for fever, check labs, await blood and urine cultures, continue empiric Zosyn (antibiotic). The Assessment reflected Resident #1 had acute right 10th and left 9th rib fractures due to trauma from a bear hug by a staff member at the nursing home. An untitled facility document dated 6/9/26 at 1:44 PM confirmed Staff C worked as the nurse assigned to Resident #1's hall on 6/6/26 and 6/7/26. The document indicated staff reported nothing directly to Staff C regarding increased pain or transfer issues. An untitled facility document dated 6/9/26 indicated the Administrator, Director of Nursing (DON) and MDS Coordinator interviewed Staff B, Certified Nurse Aide (CNA) regarding any involvement in resident cares on 6/6/26. Staff B indicated she assisted Resident #1 with a transfer form the chair to the bed. Staff B reported Resident #1 said she transferred by a bear hug and stood on the staff's foot so she didn't put pressure on her right foot (non-weight bearing). Staff B said she heard Resident #1's back crack and indicated she didn't complain of pain then or any other time in the shift. On 8/5/26 at 9:15 AM Staff B acknowledged they transferred Resident #1 on 6/6/26 using a bear-hug pivot transfer. Staff B explained they placed their arms under Resident #1's shoulders while Resident #1 placed arms under Staff B's waist. Staff B recalled they heard a crack from Resident #1's back while lifting and transferring her to the bed. Staff B stated they told Staff C after completing cares, noting Staff C responded with OK and didn't seem totally engaged in the conversation. On 8/5/26 at 1:15 PM Staff D, Certified Nursing Assistant (CNA), explained they had a good working relationship with Resident #1. Staff D recalled Resident #1 shared she had pain since 6/7/26 when a staff member using a bear-hug transfer. Staff D stated they told the nurse working the hall after they learned of the incident, but couldn't recall the specific nurse. On 8/5/26 at 12:00 PM Resident #1 recalled the incident leading to her hospitalization on 6/8/26. Resident #1 explained when a staff grabbed Resident #1 from the wheelchair on 6/6/26, they heard a pop in her chest area. Resident #1 stated both Resident #1 and the staff member acknowledged the popping noise. Resident #1 noted pain over the next 2 days and recalled telling staff, including a couple of aides, prior to going to the hospital, but couldn't recall their names. On 8/5/26 at 4:30 PM Staff G, Certified Medication Aide (CMA), acknowledged providing pain medication to Resident #1 on 6/7/26 for rib pain. Resident #1 explained a staff member transferred Resident #1 to bed using a bear-hug transfer and then heard a pop. Staff G reported they told the nurse working the hall that day, but couldn't recall which nurse, noting they didn't work with that nurse since. On 8/6/26 at 1:00 PM the DON acknowledged Staff C worked as the nurse assigned to Resident #1's hall on 6/6/26 and 6/7/26. The DON stated Staff C remained adamant staff didn't approach Staff C regarding concerns surrounding Resident #1. The DON noted Staff C no longer worked at the facility. The DON explained when a resident notifies a CNA of a concern, that staff member should complete a Stop and Watch form, sending one copy to the nurse for follow-up and one copy to the DON. The DON stated the nurse updates the form after addressing the issue and returns it to the DON to ensure timely resolution, a procedure in place since January 2026. The DON confirmed they didn't receive a Stop & Watch form for Resident #1 from 6/6/26 or 6/7/26. The Notification for Change of Condition policy dated June 2023 directed staff to provide care to residents and provide notification of resident changes in status. The policy instructed staff to immediately inform the resident and consult the physician when an accident involving a resident results in injury with potential for requiring physician intervention.

Based on clinical record review, facility document review, resident interview, staff interviews, and policy review, the facility failed to transfer a resident, as outlined in their Care Plan for 1 of 4 residents reviewed (Resident #1) for transfer technique. The staff failed to transfer Resident #1 with an assistance of 2 staff and transferred her with a bear hug instead. While transferring with the bear hug technique, Resident #1 and the staff member heard a loud pop. Approximately 2 days after the incident, Resident #1 admitted to the hospital due to rib fractures. The facility reported a census of 38.Findings include: Resident #1's Minimum Data Set (MDS) assessment completed on 6/17/26 documented an admission date of 5/13/26 due to a fractured femur (broken thighbone). Resident #1's MDS documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1's MDS documented Resident #1 required moderate staff assistance for transfers. Resident #1's MDS listed active diagnoses including chronic pain syndrome (long-lasting pain), Crohn's disease (digestive tract inflammation), end stage kidney disease requiring dialysis (kidney failure requiring blood filtering treatment), heart failure (heart pumping weakness), and osteoporosis (brittle bone disease). Resident #1's MDS documented a right nephrostomy tube (kidney drainage tube). The Care Plan Focus initiated 5/13/26 identified Resident #1 needed assistance with activities of daily living (ADLs). The Intervention dated 5/13/26 directed 2 staff members to stand and pivot Resident #1 to a wheelchair for transfers. The General Progress Note dated 6/8/26 at 8:00 PM documented Resident #1 complained of chest and left rib cage pain when coughing or taking deep breaths. Resident #1 reported they felt a pop in the rib cage area 2 days before during a transfer, describing it as a stabbing pain and rating it as 7 to 8 out of 10, indicating moderate to severe pain. The General Progress Note dated 6/8/26 at 8:15 PM reflected the facility received a physician's order to send Resident #1 to the emergency room. The General Progress Note dated 6/9/26 at 1:34 AM identified Resident #1 admitted to the hospital. A Nurse Practitioner Progress Note dated 6/8/26 at 8:24 PM detailed a phone call from the facility's LPN updating the practitioner regarding Resident #1's significant chest pain. The note documented Resident #1 had pain present for the past 2 days. They described the pain as stabbing and rated it 7 to 8 out of 10 with deep breaths or coughing, and less severe with small breaths. The note documented Resident #1 felt a pop near the rib cage area under the left breast during a transfer 2 days prior. The Orders - Administration Note dated 6/8/26 at 8:32 PM indicated Resident #1 received oxycodone for sternum pain. A Chest X-Ray completed 6/8/26 at 10:04 PM showed Resident #1 had acute nondisplaced fractures to the left 9th and right 10th ribs. The hospital's History and Physical admission report dated 6/8/26 at 11:26 PM documented a facility staff member grabbed Resident #1 in a bear hug and lifted Resident #1 2 days before. The report documented Resident #1 felt a pop with sudden pain and had ongoing pain occurring since the incident when coughing or inhaling. Resident #1 reported they had chills but didn't have a fever prior to her recent hospitalization. She had a fever of 101.8 degrees Fahrenheit (F). The plan directed to give Tylenol for fever, check labs, await blood and urine cultures, continue empiric Zosyn (antibiotic). The Assessment reflected Resident #1 had acute right 10th and left 9th rib fractures due to trauma from a bear hug by a staff member at the nursing home. An untitled facility document dated 6/9/26 at 1:44 PM confirmed Staff C worked as the nurse assigned to Resident #1's hall on 6/6/26 and 6/7/26. The document indicated staff reported nothing directly to Staff C regarding increased pain or transfer issues. An untitled facility document dated 6/9/26 indicated the Administrator, Director of Nursing (DON) and MDS Coordinator interviewed Staff B, Certified Nurse Aide (CNA) regarding any involvement in resident cares on 6/6/26. Staff B indicated she assisted Resident #1 with a transfer from the chair to the bed. Staff B reported Resident #1 said she transferred by a bear hug and stood on the staff's foot so she didn't put pressure on her right foot (non-weight bearing). Staff B said she heard Resident #1's back crack and indicated she didn't complain of pain then or any other time in the shift. On 8/4/26 at 4:30 PM Staff A, Certified Nursing Assistant (CNA), acknowledged they transferred Resident #1 without additional staff assistance, utilizing a gait belt and walker from a wheelchair to the bed prior to Resident #1's hospitalization on 6/8/26. Staff A reported they didn't know Resident #1 required assistance from 2 people to transfer. On 8/5/26 at 9:15 AM Staff B, CNA, acknowledged they transferred Resident #1 on 6/6/26 using a bear-hug pivot transfer without checking Resident #1's Care Plan or Kardex (care summary sheet) beforehand. Staff B reported Resident #1 stated other staff members used the same transfer method to limit pain. Staff B explained they placed their arms under Resident #1's shoulders while Resident #1 placed their arms under Staff B's waist to transfer between wheelchair, toilet, and bed. Staff B recalled hearing a crack from Resident #1's back while transferring to bed, and Resident #1 acknowledged hearing the noise, stating feeling fine and breathing better. Staff B stated they told Staff C after completing cares, noting Staff C responded with OK without seeming totally engaged in the conversation. On 8/5/26 at 1:15 PM Staff D, CNA, explained they had a good working relationship with Resident #1. Staff D recalled Resident #1 shared she had pain since 6/7/26 when a staff member using a bear-hug transfer. Staff D stated they told the nurse working the hall after they learned of the incident, but couldn't recall the specific nurse. Staff D suspected other staff members transferred Resident #1 using this method previously based on resident comments. On 8/5/26 at 10:30 AM Staff E, CNA, acknowledged they transferred Resident #1 using a bear-hug on one occasion, without recalling the exact date. Staff E reported Resident #1 explained staff transferred them using that method. Staff E stated feeling the transfer felt unsafe and didn't perform it again with Resident #1. On 8/5/26 at 12:00 PM Resident #1 recalled the incident leading to hospitalization on 6/8/26. Resident #1 noted one staff member transferred them on 6/6/26, but felt 2 staff members should've assisted. Resident #1 explained staff grabbed Resident #1 tightly from the wheelchair, and Resident #1 heard a pop in the chest area when lifted. Resident #1 stated both Resident #1 and the staff member acknowledged the popping noise. Resident #1 noted limited movement the rest of the day and soreness the following day. Resident #1 reported they told staff about the incident before going to the hospital, but couldn't recall specific names, noting the staff performed bear-hug transfers previously. On 8/5/26 at 12:35 PM Staff H, Physical Therapist (PT), and Staff I, Occupational Therapist (OT), explained when Resident #1 entered the facility she had a right femur fracture and remained non-weight bearing. Both noted Resident #1 stayed motivated but lacked carry-over from therapy sessions to floor staff. Staff H recalled floor staff approaching them approximately two weeks prior to the incident to discuss transfers. Staff H and Staff I stated they didn't know the floor staff used a bear-hug pivot transfer, noting they wouldn't recommend that method. Staff H and Staff I reported the staff typically fill out the whiteboard in the resident's room with transfer status, including required equipment and number of staff. On 8/5/26 at 3:05 PM Staff F, CNA, recalled Resident #1 complained of rib area pain early in the morning on 6/7/26, noting Resident #1 hadn't complained of similar pain previously. On 8/5/26 at 4:30 PM Staff G, Certified Medication Aide (CMA), acknowledged providing pain medication to Resident #1 on 6/7/26 for rib pain. Resident #1 explained a staff member transferred Resident #1 to bed using a bear-hug transfer and heard a pop. Staff G reported they told the nurse working the hall that day, but couldn't recall which nurse, noting not working with that nurse since. On 8/6/26 at 1:50 PM the Administrator reported they didn't know about Resident #1's rib fracture until reviewing medical records the day after she transferred to the hospital. The Administrator reported the hospital records indicated staff performed a bear-hug transfer, prompting an internal investigation that identified Staff B as the CNA who performed the incorrect transfer method. The Administrator acknowledged staff didn't follow Resident #1's Care Plan. The Care Plan policy dated March 2025 directed staff to implement Baseline Care Plans within 48 hours of admission to address resident care, including initial goals and therapy services. The policy instructed staff to implement person-centered care plans outlining care after completing comprehensive assessments, and directed the interdisciplinary team to review and revise care plans after completing MDS assessments or when changes warrant revision.

Based on clinical health record review, resident interviews, staff interviews, and policy review, the facility failed to offer and provide bathing for 2 of 3 residents reviewed (Residents #2 and #5) for activities of daily living (ADLs). The facility reported a census of 38.Findings include:1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 1, indicating severely cognitively impaired. Active diagnoses included dementia (memory loss) and depression (mood disorder). Resident #2 required staff assistance for bathing and toileting. The Care Plan with a target date of 8/12/26 noted Resident #2 needed at least 1 staff member for bathing assistance. The Care Plan Intervention directed staff to adjust grooming and bathing schedules per resident's desire related to dementia behaviors. A record review of the April 2026 and May 2026 Documentation Survey Report v2 for Showers outlined to offer Resident #2 bathing two times per week on Tuesdays and Fridays. Between 4/17/26 and 5/3/26, Resident #2 received only 2 out of 4 scheduled showers. A record review of Resident #2's Clinical Record lacked documentation regarding rationale for missed showers or whether staff made additional attempts to provide bathing. 2. Resident #5's MDS assessment dated [DATE] documented a BIMS score of 15, indicating intact cognition. Active diagnoses included neurogenic bladder (loss of bladder control), quadriplegia (loss of movement and feeling in upper and lower body), and a stage 4 pressure injury of the sacral region (deep open wound to the tailbone exposing muscle or bone). Resident #5 depended on staff for bathing and toileting. The Care Plan with a target date of 10/15/26 outlined Resident #5 required 1 to 2 staff members for bathing. The Care Plan directed staff to offer bathing on Wednesdays between 4:00 PM and dinner time, and on Sundays between 2:00 PM and 4:00 PM. A record review of the April 2026 and May 2026 Documentation Survey Report v2 for Bathing indicated Resident #5 preferred bed baths offered two times per week. Between 4/1/26 and 5/23/26, Resident #5 received 6 bed baths out of 15 scheduled bed baths. A record review of Resident #5's Clinical Record indicated Resident #5 declined 3 baths, but lacked documentation whether staff offered alternative times. The record also lacked rationale for the other 4 missed baths and whether staff made additional attempts to provide bathing. On 8/4/15 at 12:00 PM Resident #5 reported the staff didn't provide bed baths as scheduled. On 8/6/26 Resident #5 explained staff don't reapproach or offer an alternative day or time if they didn't provide the bath as scheduled. Resident #5 acknowledged they didn't approach the staff if staff didn't offer bathing. Resident #5 reported the staff know the scheduled bath times and Resident #5 shouldn't have to ask. On 8/6/26 at 1:00 PM the Director of Nursing (DON) acknowledged the missed showers and baths for Resident #2 and Resident #5 weren't acceptable. The DON explained staff might've missed showers for Resident #2 due to an increase in Resident #2's behaviors. Regarding Resident #5, the DON believed certain staff members might not reoffer baths due to a history of mistreatment by Resident #5. The DON noted nursing staff might not maintain active involvement with day-to-day resident bathing refusals. The Bathing policy dated May 2025 instructed residents maintain the right to choose the time and frequency of bathing. The policy directed staff to reapproach at a later time or offer another day if a resident refuses.

Based on clinical record review, written staff statement, staff interviews and policy review, the facility failed to provide adequate nursing supervision related to a fall and failed to ensure appropriate steps were taken after a fall to ensure resident safety for 1 of 3 residents reviewed for falls (Resident #2).The facility corrected the noncompliance prior to the start of the survey on 3/13/26 by completing the following:3/13/26: The facility started educating their employees on falls.3/13/26: The facility started educating their employees on the fall occurrence policy. 3/13/26: The facility started educating their employees on abuse prevention.3/13/26: The facility began using the audit tool on new falls to ensure the staff followed the occurrence policy and understood the fall policy.The facility reported a census of 48 residents.Findings include:Resident #2's Minimum Data Set (MDS) assessment, dated 3/16/26, documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impaired cognition. Resident #2 had diagnoses to include fractures, multiple trauma, renal insufficiency, arthritis, and osteoporosis.The Care Plan for Resident #2, initiated 3/10/26, included a focus area for complaints of pain related to osteoporosis, bursitis of both knees, and a history of a wedge compression fracture. The goal was for Resident #2 to state that the pain level's tolerable at a score of 0 or that she had relief with interventions. Interventions included notifying the Medical Doctor (MD) if pain relief's inadequate or if the complaint's a significant change from past experiences. An additional focus area noted Resident #2's at risk for falls. Interventions included assisting Resident #2 with ambulation and transfers, using a gait belt, and using a standard walker. The plan required a substantial or maximum assist of two staff members for walking.The Fall Occurrence policy, dated February 2024, instructed staff to ensure residents are evaluated for fall risks and to implement interventions to minimize injury. The policy directed a nurse needed to complete an incident report each time a resident fell. It further required a licensed nurse assess residents prior to being moved after a fall. The nurse must notify the physician and the resident's representative.Review of the Electronic Health Record (EHR) revealed a Physical Therapy (PT) report dated 3/12/26. Staff D, Physical Therapist (PT), documented that after he explained the agenda, Resident #2 stated, I cannot, my knees are so painful. Resident #2 reported she fell the previous night while a staff member changed her brief. Staff D asked the charge nurse, Staff C, Registered Nurse (RN), about the fall, but Staff C explained no one told them about a fall in report. When Staff D notified the Administrator, they reported Resident #2 would have x-rays that day. They documented pain with movement as a 7 out of 10 in both knees, indicating severe pain level.Review of a facility investigation report, completed 3/20/26, outlined the investigation into the fall. The facility determined Staff E, Certified Nursing Aide (CNA), worked the overnight shift on 3/11/26. Camera monitors showed Staff E entered Resident #2's room at 4:46 AM and exited at 5:04 AM. Staff E told the Administrator she observed Resident #2 sitting in a lift chair and used a gait belt to assist her to the floor because of her sliding out. Staff E stated she didn't view this as a fall and didn't report it to the nurse. When the Administrator follow-up with Resident #2 told them the staff member assisted her to the floor and she landed on her knees. Resident #2 stated the staff member helped her up alone without equipment. She didn't believe the nurse knew of her fall.A written statement from Staff F, Human Resources (HR) Director, dated 3/12/26, documented an interview with Staff E. Staff E stated it wasn't a fall, but that she lowered Resident #2 to the floor because she wasn't in a safe position. Staff E confirmed she didn't report the incident to the nurse because she assisted Resident #2 the entire time.The General Progress Notes dated 3/12/26 at 4:25 PM confirmed a mobile X-ray company arrived at 4:00 PM to x-ray both of Resident #2's knees. The X-Ray Report dated 3/12/26, identified Critical, significant findings for the right knee x-ray. The Impression indicated Resident #2 had an apparent comminuted fracture (a severe injury where a bone breaks into three or more pieces) involving the central patella (kneecap). The x-ray report listed a faxed date stamp of 3/13/26 at 12:36 AM. The Diagnostic Test Result Note dated 3/13/26 at 12:36 AM indicated the left knee x-ray showed arthritic changes but no fracture.The Physical Therapy Treatment Encounter Note dated 3/13/26, signed at 1:41 PM by Staff D. The Note reflected Staff D informed Resident #2, the staff would transfer her with a full-body mechanical lifting device due to a fracture and non-weight bearing status. Additionally, he documented educating Staff J about the lift. Resident #2 rated their pain at a 6 out of 10, indicating moderate pain. She described the pain as constant and intermittent (coming and going) to her right knee, adding it ached and felt dull.On 4/13/26 at 4:07 PM, the Administrator stated Staff B, Licensed Practical Nurse (LPN), received the fax and sent a text message with a screenshot of the fracture result to the on-call management phone at 2:01 AM. The Administrator reported she thought she was the person on-call that night. She explained she didn't hear the text at 2:01 AM as she was sleeping and needed her sleep. The Administrator noted Staff B didn't call the on-call provider to inform them of the fracture. The Administrator called the provider at 9:41 AM on 3/13/26 and received an order to send Resident #2 to the Emergency Department (ED). The facility didn't send Resident #2 to the hospital until 3:15 PM.Review of text messages to the on-call phone revealed Staff B sent a picture of the results at 2:01 AM and another text at 5:37 AM asking, did you see this? The response, saw this now, was followed by Staff B asking if she should chart it in the nurses' notes or wait for them to arrive. The on-call manager asked if Staff B did an incident report, and Staff B responded no one told her Resident #2 fell.The hospital report dated 3/13/26 for the ED visit documented Resident #2 fell onto her knees while a staff member helped her out of a recliner. The hospital confirmed Resident #2 had a comminuted fracture of the patella with a new x-ray and placed her in a knee immobilizer. The hospital directed to follow-up with orthopedics.On 4/14/26 at 7:50 AM, Staff B stated she went into the room at 5:00 AM on 3/12/26. Resident #2 asked for pain medication and said her legs hurt, but didn't mention a fall. Staff B remembered giving her something for pain, but couldn't remember when. Staff B confirmed Staff E didn't report a fall. Staff B admitted she should've called the on-call provider after receiving the fracture results on 3/13/26 but didn't. She documented the fracture in a communication book but didn't recall telling the oncoming shift in person.On 4/14/26 at 8:15 AM, Staff G, Occupational Therapist (OT), stated she performed a toileting session with Resident #2 on the morning of 3/13/26. Staff G assisted Resident #2 out of her chair with a gait belt and Resident #2 walked to the bathroom, placing weight on her right knee. Resident #2 complained of pain in her back as 8 out of 10 on the pain scale, indicating severe pain but described it as an ache. Resident #2 didn't mention any pain in her knees. Staff G stated she didn't know Resident #2 had a fractured knee. Staff H, RN, came into the room during the session but didn't mention a fracture. Staff G noted the Director of Nursing (DON) didn't email her about the fracture until 9:45 AM, after completion of the session. Staff G reported if she knew about the fracture, she wouldn't have walked her due to her impaired cognition and difficulty reporting pain or events.The Treatment Encounter Note, completed by Staff G, OT on 3/13/26 identified they walked Resident #2 to the bathroom using a 2-wheeled walker (2WW) with contact guard assistance (CGA). Resident #2 rated her pain with movement at an 8 out of 10. Staff G notified Staff H of Resident #2's pain. Resident #2 had constant pain in her bad that she described as an ache. Resident #2's March 2026 Medication Administration Record (MAR) included orders for acetaminophen (over the counter pain medicine) and hydrocodone-acetaminophen (prescription pain medication). On 3/12/26, Resident #2 rated their pain at dinner a 7. On 3/13/26 at 5:28 AM, Resident #2's received as-needed pain medication for a pain rating of 4 with movement.On 4/14/26 at 9:55 AM, Staff H stated she didn't get a report of the fracture when her shift started at 6:00 AM on 3/13/26. She didn't see the report in the chart and didn't tell the staff not to transfer Resident #2. She stated a resident shouldn't put weight on a fracture.On 4/14/26 at 10:10 AM, Staff D stated Resident #2's hesitant to say what happened because she didn't want to get staff in trouble. He stated Resident #2 eventually reported she fell on her knees near the recliner and a staff member lifted her up alone. Staff D confirmed he notified Staff C, who stated she knew nothing about a fall. Staff D didn't do a session with Resident #2 because of her knee pain. She reported her pain as a 7 with movement, but none at rest. On 4/14/26 at 10:35 AM, the DON explained she was the person on-call the night the results came in but didn't hear the 2:30 AM text. She heard the 5:30 AM text and spoke with Staff B at 7:00 AM. The DON acknowledged she didn't immediately call the provider or notify therapy. She confirmed Resident #2 shouldn't have put weight on her knee.The Communication with Physician Note dated 3/13/26 at 9:41 AM, completed by the Administrator documented they called the provider regarding the x-ray results for Resident #2. The provider requested to see if an ortho doctor could immediately see Resident #2. If they couldn't, the provider directed to Resident #2 to the emergency room for evaluation and treatment of their right knee fracture. On 4/14/26 at 11:15 AM, Staff C stated when she started her shift at 6:00 AM on 3/13/26 no one reported Resident #2 fell in the night. After Staff D asked her about Resident #2 falling, she tried to figure out what happened as she didn't have any documentation of a fall. Staff C confirmed she texted Staff B, who replied later in the day that she didn't know about a fall.On 4/14/26 at 11:45 AM, Staff I, Certified Medical Assistant (CMA), reported she worked 3/12/26 at 6:00 AM, no one reported Resident #2 fell in the night. On 3/13/26 when started at 6:00 AM, no one reported Resident #2 had fracture. She the staff transferred Resident #2 that morning and she put weight on her knee before and after breakfast. Staff I explained if a resident fell, they are supposed to call the charge nurse right away so they can assess the resident and document the fall. She noted the staff aren't supposed to pick residents up alone after a fall.On 4/14/26 at 1:45 PM, Staff K, CNA, reported she worked on 3/13/26 starting at 6:00 AM, but she didn't care for Resident #2 that day. No one reported about Resident #2 having a fracture that day. She stated the facility sent a message in their application about Resident #2's non-weight bearing status but not until 9:44 AM.On 4/14/26 at 2:00 PM, Staff L, CNA/CMA, stated no one advised her that Resident #2 fell in the night when she started on 3/12/26. The PT asked her about it and explained the situation. She heard Resident #2 had an x-ray but no one reported she had a fracture when she started her restorative shift on 3/13/26.The review of the facility's message application sent on 3/13/26 at 9:44 AM instructed Resident #2 couldn't bear weight on her right leg.On 4/14/26 at 2:15 PM, Staff J, CNA, stated she saw Resident #2 early in the shift around 10:40 PM on 3/11/26. After Staff E made it to work, she didn't ask Staff J for help with a fall on the night of 3/11/26. She didn't work again until 3/13/26 and when she returned no one reported Resident #2 had a fracture and attempted to transfer her for lunch with full weight-bearing. Staff D walked by and stopped her before she transfer her. Staff D informed her of Resident #2's injury.On 4/15/26 at 6:00 AM, Staff M, CNA, stated she worked Resident #2's hall on 3/12/26 on the overnight shift. She did hear she fell, but no one told her about Resident #2's right knee fracture during her overnight shift on 3/12/26. Staff M explained she did call for Resident #2 but didn't have to get her up as she slept. She only learned of the injury a day or two later.On 4/15/26 at 10:24 AM, Staff D stated he saw Staff J in the room and warned her not to put weight on Resident #2's knee. Staff J told him she didn't know about the fracture. Staff D reported the facility administration never emailed him about Resident #2's x-ray results or her non-weight bearing status on the morning of 3/13/26. He explained he only saw the hospital x-ray with their discharge instructions. Staff D stated that placing weight on a patella fracture could cause significant separation of the bone and increased pain.

Based on clinical record review, family interview, staff interviews and policy review, the facility failed to immediately notify and inform a family member (Resident #1) and the resident's physician (Resident #2) of a change in status for 2 of 3 residents reviewed for notification. The facility reported a census of 48 residents.Findings include: 1. The Minimum Data Set (MDS) assessment, dated 3/30/26, documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident had diagnoses to include medically complex conditions, heart failure, arthritis and respiratory failure. The Care Plan initiated 3/24/26, included a Focus that indicated Resident #1 required assistance with Activities of Daily Living (ADL's). The goal listed Resident #1 would receive assistance with ADLs as required. The interventions included:a. Encourage participation on ADL's. b. Gait belt with transfers and ambulation. c. Provide sufficient time for completion of ADL tasks.d. Staff will allow resident independence to the best of their ability with ADL task completion. The Incident Report Note dated 3/30/26 at 3:48 AM, written by Staff A, Registered Nurse (RN), reflected Resident #1 fell during an assisted transfer in her bathroom. The note reflect Staff A notified Resident #1's daughter and physician. Resident #1 Clinical Resident Profile reviewed 4/13/26 listed her daughter as her emergency contact #1. During an interview on 4/13/26 at 12:00 PM, Resident #1's daughter, emergency contact, stated she received a call from Staff A on 3/30/26 at 11:00 AM advising her of a fall Resident #1 sustained earlier that morning around 8:00 AM. Staff A advised her the facility was sending Resident #1 to the hospital due to unmanaged pain. Resident #1's daughter stated she asked Staff A why they didn't notify her right after the fall happened that morning and Staff A replied they were trying to manage her pain. During an interview on 4/14/26 at 11:30 AM, Staff A recalled the morning of 3/20/26 when she learned Resident #1 fell in the bathroom, hitting her head on the wall. Staff A stated Resident #1 sustained a skin tear on her leg and complained of pain in her back. Staff A notified the on-call physician right away, around 8:00 AM, and obtained an order for pain medication and orders to treat the skin tear. Staff A reported she contacted the on-call physician again around 11:00 AM due to Resident #1 still complained of pain in her back. They gave an order to send Resident #1 to the hospital. Staff A explained she didn't call the daughter, until around 11:00 AM. Staff A stated she contacted the family approximately 3 hours after the fall. She acknowledged they are supposed to contact the family, emergency contact, as soon as they can. 2. The MDS assessment, dated 3/16/26, documented Resident #2 had a BIMS score of 12, indicating moderate cognitive impairment. The MDS included diagnoses of fractures and other multiple trauma, renal insufficiency, arthritis, osteoporosis and other fracture. The Care Plan initiated 3/10/26 included the following Focuses:a. Resident #2 had complaints of pain related to osteoporosis, bursitis of both knees and history of wedge compression fracture of T11-T12 (area of the middle of the back protecting the spine) vertebra. The goal listed Resident #2 stated their level of pain is tolerable at (0) or has relief with interventions. The interventions included: i. Notify MD (doctor of medicine) if inadequate pain relief as indicated. ii. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from past experience of pain. b. Resident #2 had a risk for falls and had an actual fall. The goal listed to minimize risk for falls throughout next review. The interventions included: i. Assist resident with ambulation and transfers as needed. ii. 3/12/26: Urinary Analysis (UA), labs, x-ray of right knee. The Physical Therapy (PT) report dated 3/12/26 documented Resident #2 reported a fall in the night. Resident #2 stated she couldn't complete PT that morning due to pain in her knees related to the fall. The PT report documented Resident #2 had x-rays ordered that day. The General Progress Note dated 3/12/26 at 4:25 PM indicated the mobile x-ray company arrived at 4:00 PM to take x-rays of Resident #2's bilateral (both) knees. The X-Ray Report dated 3/12/26, listed Critical, significant findings for the right knee x-ray. Under the Impression section: There is an apparent comminuted fracture (a severe injury where a bone breaks into three or more pieces) involving the central patella (kneecap). The x-ray report was faxed to the facility with a date stamp of 3/13/26 at 00:36 AM (12:36 AM). During an interview on 4/14/26 at 7:50 AM, Staff B, Licensed Practical Nurse (LPN), stated she worked the overnight shift on 3/12/26, beginning at 10:00 PM and ending at 6:00 AM on 3/13/26. Staff B recalled they received the fax from the mobile x-ray company a little after midnight. She read the fax and noted the fracture to Resident #2's right knee. Staff B explained she sent a text to the management phone number; however, she didn't call the on-call provider/physician. Staff B reported they have a provider on-call at all times and acknowledged she didn't call the on-call provider to notify them of the fracture to Resident #2's right knee to get direction for treatment. Staff B acknowledged she should have contacted the provider. During an interview on 4/14/26 at 10:35 AM, the Director of Nursing (DON) reported being the management staff on call during the night of 3/12/26 into the morning of 3/13/26. The DON stated Staff B sent her text message on 3/13/26 around 2:30 AM and again at around 5:30 AM regarding the x-ray result. The DON explained she only responded to the 5:30 AM text, however she couldn't recall what she said. The DON stated she arrived at the facility around 7:00 AM and didn't know no one notified the provider of the x-ray result indicating Resident #2 had a fracture to her right knee. The DON acknowledged she didn't notify the provider upon arrival to the facility and not until approximately 9:40 AM by the Administrator. The Communication with Physician Note dated 3/13/26 at 9:41 AM, completed by the Administrator documented they called the provider regarding the x-ray results for Resident #2. The provider requested to see if an ortho doctor could immediately see Resident #2. If they couldn't, the provider directed to Resident #2 to the emergency room for evaluation and treatment of their right knee fracture. During an interview on 4/15/26 at 1:15 PM, the Administrator stated she expected the staff to call the family as soon as possible, within an hour, of Resident #1's fall and change in status. Additionally, the Administrator expected the staff to notify the on-call provider immediately of a significant change in condition. The facility should have immediately notified the on-call provider of the fracture to Resident #2's right knee. The Administrator acknowledged this didn't happen. Review of the facility policy Notification for Change of Condition, revised June 2023, instructed the facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: a. An accident involving the resident which results in injury and has the potential for requiring physician intervention; b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or d. A decision to transfer or discharge the resident from the facility as specified in S483.12(a).

Based on observation, interviews, record reviews and policy the facility failed to assess and treat a pressure ulcer for 2 of 2 residents observed with pressure ulcers (Residents #9 and #50). Resident #50 documentation indicated the facility found their pressure wound on 11/1/24. Interviews determined hospice found the pressure wound before that date. The facility, hospice staff, and Resident #50's family had a meeting before the facility documented the pressure ulcer. At the meeting, hospice reported the got an order for heel protectors for Resident #50. Resident #50's clinical record lacked documentation of the order. When the facility reported the concern to the physician, the directed to monitor the wound. Resident #50 reported she didn't like the boots because they made her feet hot. Resident #50's heel pressure ulcer declined and the facility failed to intervene to prevent the decline. Resident #9 had a pressure ulcer to their buttock. The nurse failed to provide clean technique while completing the wound treatment. The facility reported a census of 47 residents. Findings included: 1. Resident #50's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of anemia (low iron levels in the blood), atrial fibrillation (abnormal heart rate), hypertension, and demyelinating disease of the central nervous system (protective tissue surrounding special cells are damaged and disrupting the transmission of signals). The MDS indicated Resident #50 had a risk for a pressure ulcer, but didn't have one at the time of assessment. The Care Plan Focuses with a target date of 1/16/25 indicated: a. Resident #50 elected hospice services. The Interventions directed the following: i. Coordinate her care with hospice services to keep her as comfortable as possible. ii. May experience expected skin breakdown due to terminal disease process, poor nutrition, weight loss and decreased mobility, may be diagnosed with a Kennedy ulcer (occurs is some near final weeks of life) due to my terminal diagnosis. Skin issues are not expected to heal due to terminal disease process, poor nutrition, perfusion and decreased mobility. b. Resident #50 had a risk for alteration in skin integrity related to falls from terminal restlessness, altered skin integrity related to a terminal diagnosis of demyelinating disease, limited mobility and the use of a mechanical lift. Updated 11/8/24 Left calf medial aspect 4.0 by 2.0 centimeters (cm), left cheek bruising 5.0 by 5.0 cm extends down along left jawline, bruising is yellow and fading, and right medial heel measures 4.0 by 5.0 cm dark red center stage 2 pressure ulcer - hospice notified. Resident #50 had heel boots present but she often removed them. The Goal indicated Resident #50 would not develop skin alterations out of her disease process and skin impairment would heal without complications. The Interventions directed to use pillows/position devices as needed. The Skin Condition Note dated 11/1/24 indicated Staff E, Licensed Practical Nurse (LPN) completed Resident #50's weekly skin check, which revealed a right medial heel stage 2 pressure ulcer measuring 2.5 by 2.0 cm. The physician responded to continue to monitor. The Skin Condition Note dated 11/8/24 reflected Staff E completed the weekly skin check which revealed Resident #50's right heel stage 2 pressure ulcer measured 4.0 x 5.0 cm with a dark red center. Resident #50 remained on hospice level of care, heel boot present but she removed them often. Staff E placed a mepilex (dressing) to her right heel for protection and she alerted hospice to provide more. The Physician responded on 11/11/24 to continue to monitor. On 11/13/24 at 3:05 PM Staff C, Registered Nurse, reported they checked the Treatment Administration Record (TAR), and remarked it didn't have a treatment for Resident #50's right heel pressure ulcer. During an interview on 11/13/24 at 3:24 PM Resident #50's Power of Attorney (POA) voiced they had a meeting about two weeks before (10/30/24) with family, hospice, and the facility staff. They discussed the heel concern and hospice brought heel protectors. The POA reported she understood they had something new on order since Resident #50 wouldn't wear the heel protectors. On 11/13/24 at 3:25 PM Resident #50 acknowledged she didn't like to wear the heel protectors, as they made her feet hot. Resident #50 added that it would be nice if a doctor looked at her heel. She couldn't recall if it had a covered dressing or treatments. During an observation on 11/13/24 at 3:30 PM Staff C, Registered Nurse (RN), measured Resident #50's heel wound and reported it measured 1.5 by (x) 2.2 x 0.1 cm depth. They cleansed the wound and covered it with a mepilex dressing. Staff C said the TAR should include the heel boots, but it didn't. Staff C stated the previous Sunday they recalled the heel as dry with a darkened area, flat and reported the measurements in the skin book are much larger. They didn't appear accurate from their recalled comparison. Staff C explained the wound opened, they didn't have a treatment order and they should. During an interview on 11/14/24 at 1:35 PM Staff E stated they first saw the heel wound on 11/1/24. At that time, they measured, documented left medial heel, 2.5 x 2 cm stage 2, indicated the wound as open, notified the physician via fax, and alerted Staff D, Hospice RN, verbally. Staff E reported they didn't get any treatment orders and the Physician, directed to continue to monitor. Further interview, record review and discussion on 11/14/24 at 1:38 PM with LPN, Staff E included review of weekly skin record. LPN, Staff E acknowledged had measured the wound again on 11/8/24 noted increased size, stage II (two) measured 4.0 x 5.0 centimeters, dark red center, recorded placed mepilex (dressing) on for protection and alerted hospice to provide more direction. LPN, Staff E relayed, should not of staged the wound, is not qualified to do so as an LPN, relayed had staged as two since wound was open. Relayed updated Physician, Staff F and responded again to the updated measurements on 11/11/24 continue to monitor. During an interview on 11/14/24 at 3:00 PM, Staff D reported they documented in her hospice notes and acknowledged the following: a. On 10/29/24 suspected deep tissue injury, deep purple, obtained a physician order for the protective heel boots. b. On 10/31/24 met with family, the heel was intact, reddened, ensured a written order to the facility nurse for the heel protectors that didn't get transcribed to the TAR. c. On 11/11/24 obtained an order to cover wound with mepilex dressing, gave the order to the nursing facility staff, and again not transcribed to the TAR, and the order couldn't be located. d. On 11/12/24 measure the heel wound at 3 x 2.5 x .0.2 cm depth. e. On 11/14/24 at 3:05 PM, Staff D acknowledged the wound depth increased. They thought the facility should have transcribed the orders to the TAR. During an interview on 11/13/24 at 3:50 PM the Assistant Director of Nursing (ADON) acknowledged they only monitored the Stage 2 pressure ulcer weekly per the weekly skin book. The ADON verified Resident #50 had heel boots in her room, but no treatment orders. During an interview on 11/13/24 at 3:50 PM the Administrator acknowledged Resident #50 had a stage 2 pressure ulcer to her heel. They added the physician ordered to just monitor the wound and they wouldn't override a doctor's order. On 11/14/24 at 3:13 PM the ADON stated they have a process, when hospice got an order they give the written note to a facility nurse. Two nurses verify the order and add it to the electronic TAR. The ADON couldn't explain why the orders didn't get transcribed for the heel protectors or the mepilex dressing. The ADON expressed she trusted Staff D gave the orders to the facility nurse. The facility didn't provide a policy for pressure ulcer treatments. 2. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of heart disease, respiratory failure, metabolic encephalopathy (brain dysfunction due to problems with the metabolism) and depression. The MDS documented Resident #9 had a pressure ulcer. Resident #9 November 2024 TAR included an order dated 11/13/24 apply a Hydrofiber (soft, absorbent material that transforms into a gel on contact with wound fluid) with bordered foam dressing to change on Monday, Wednesday and Friday for skin healing. On 11/13/24 at 9:40 AM, observed Resident #9 lying on her side. Staff C explained they sanitized their hands, put on gloves, and removed the coccyx dressing. Staff C cleansed the coccyx wound with dermal (skin) cleanser, cut the hydro fiber, and placed it on the wound, labeled the dressing with a pen and applied it to Resident #9's coccyx. During the treatment, Staff C didn't complete hand hygiene between removing the old dressing and applying the ordered treatment. In an interview on 11/13/24 at 10:32 AM following Resident #9's coccyx wound treatment, Staff C reiterated the treatment process and verified they should have sanitized their hands before placing the new dressing on. In an interview on 11/13/24 at 3:00 PM the ADON acknowledged hand hygiene is standard practice after removing an old dressing, after taking off gloves, and prior to putting on gloves. The Infection Prevention and Control policy revised 7/31/24 instructed staff to perform hand hygiene before and after direct patient contact and after each situation that necessitates hand hygiene. To complete the hand hygiene, they will use an alcohol -based hand rub or hand washing for 20 seconds.

Based on clinical record review and staff interviews, the facility failed to develop and implement a comprehensive person centered Care Plan for 1 of 14 residents reviewed for Care Plans (Resident #8). The facility reported a census of 47 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated they had symptoms of feeling down, depressed or hopeless for several days during the lookback period. The MDS included diagnoses of medically complex conditions and depression. The MDS reflected Resident #8 took an antidepressant during the lookback period. Resident #8's Medical Diagnoses reviewed on 11/14/24 listed diagnoses of major depressive disorder, recurrent, in partial remission. Resident #8's November 2024 Medication Administration Record (MAR) included the following orders: a. Bupropion HCI ER (antidepressant) oral tablet 150 milligrams (mg) related to Major Depressive Disorder b. Fluoxetine HCI (antidepressant) oral capsule 40 mg, related to Major Depressive Disorder c. Risperidone (antipsychotic) oral tablet 0.5 mg, two times daily, related to Major Depressive Disorder. Resident #8's Care Plan with a target date of 1/15/25, lacked information related to their mood or antipsychotic medications. During an interview on 11/14/24 at 8:00 AM, the MDS Coordinator explained they expected the Care Plan contain a Focus and Interventions for Resident #8's antidepressant medications, mood, and behaviors. The MDS Coordinator stated the Care Plan should include that, but verified it didn't. During an interview on 11/14/24 at 8:13 AM, the Administrator stated the facility didn't have a policy on Care Plans, as they followed standard practices.

Based on clinical record review, staff interviews, and policy review the facility failed to revise a Care Plan for 1 of 15 residents reviewed (Residents #47). The facility reported a census of 47 residents. Findings include: Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #47 required set up or clean up assistance with eating. Resident #47's MDS included diagnoses of hypertension (high blood pressure), traumatic brain injury, and dysphagia (difficulty with swallowing). The MDS documented Resident #47 received a mechanically altered diet that required a change in texture of food or liquids. A Physician diet order dated 7/22/24 directed staff to administer a mechanical soft diet with pureed meats with all solids cut into bite size pieces, only soft canned vegetables or fruit, no lettuce or cabbage unless pureed and honey consistency liquids. The Share Negotiated Risk Agreement dated 10/21/24 documented Resident #47 received a pureed diet with thickened liquids. Resident #47 requested to have a regular diet with no thickened liquids. The form indicated Resident #47 and the Power of Attorney (POA) knew he would have a risk for aspiration (food, liquid, or other material accidentally enters a person's airway or lungs) and death by not following the speech recommended diet. The form documented the final agreement as Resident #47 to receive a regular diet with regular consistency liquids per his request. Resident #47 signed the form, POA, facility Administrator on 10/21/24. The Physician documented a hand-written note on the form dated 10/24/24 that Resident #47 was at a very high risk of aspiration and rehospitalization . The Physician recommended to stay on speech recommended pureed diet and thickened liquids. The Care Plan Focus with a target date of 12/25/24 reflected Resident #47 had a potential for nutritional risk related to dysphagia (difficulty swallowing) and the need for a mechanical altered diet. The Care Plan Interventions directed staff to administer a mechanical soft diet with puree meats, lettuce, and cabbage. In addition, the Care Plan directed the staff to cut all of his food into bite sized pieces, serving only canned fruit/vegetables, and honey thickened liquids in a nosey cup (cup with a cut out allowing it to tip farther without hitting the face). The Care Plan lacked information related to the shared negotiated risk agreement. On 11/14/24 at 8:35 AM, the MDS Coordinator verified the Care Plan didn't address the Shared Negotiated Risk Agreement, but she would update the Care Plan. On 11/14/24 at 8:45 AM, the Nurse Consultant reported the facility didn't have a Care Plan policy. She stated the facility followed the standard nursing practice and the Resident Assessment Instrument (RAI) manual when updating the Care Plan.

Based on clinical record review, resident and staff interview, the facility failed to meet professional standards of quality for services provided during medication administration for 1 of 1 resident reviewed (Resident #51). The facility reported a census of 47 residents. Finding include: Resident #51's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions, anemia (low iron levels in the blood), atrial fibrillation (abnormal heart rate), hypertension (high blood pressure), renal insufficiency (poor kidney function), diabetes mellitus, hyperlipidemia (elevated type of cholesterol), seizure disorder, respiratory failure and metabolic encephalopathy (brain dysfunction due to problems with the metabolism). The Incident Report - Medication Event dated 11/2/24 at 7:21 PM identified Resident #51 received another resident's (Resident #46) supper and hour of sleep (HS) medications. During an interview on 11/13/24 at 1:45 PM, the Administrator stated she completed an internal investigation regarding Resident #51's medication error. The Administrator provided a copy of the internal investigation. The Administrator stated Staff K, Certified Medication Assistant (CMA), who gave Resident #51 the incorrect medications no longer worked at the facility. She left the faciity on her own on the night of the incident. The Administrator explained Staff K was in training and only worked at the facility for a few days. Staff L, CMA, who trained her, still worked at the facility. They gave her a written disciplinary action, required her to take additional training on medication administration, and the Assistant Director of Nursing (ADON) conducted a medication audit. Staff L worked at the facility for approximately one year. During an interview on 11/14/24 at 10:25 AM, the Administrator stated Resident #51's medication error, identified a concern with the broken process of Staff L providing orientation to Staff K and her not knowing her training or following professional standards with the 5 rights. Staff L should have given the medications as she is the one who got them ready, or she should have gone into the room with Staff K to observe her give the medication. The Administrator stated they expected the right resident received the medication as prescribed. The Administrator stated they didn't have a policy for medication administration, as they followed professional standards. During an interview on 11/14/24 at 11:07 AM, Staff K, Certified Medical Assistant (CMA), explained it was only her second day in training at the facility and when Staff L, another CMA, trained her, they worked the 2 PM to 10 PM shift. Staff K stated she started the shift by observing Staff L pass medications. Around supper time Staff L started having Staff K give residents their medications. Staff L put the medications in the cup, then told Staff K to go and give it to the resident. She told Staff K who the resident was and where they were. Staff K stated because she didn't know the residents, she felt uncomfortable with this process as Staff L didn't go with her to give the medications. Staff K stated she gave some residents their medications while they were in the dining room. Staff L told her what color of hair they had and to find them based on their hair color, name, and where they sat. Staff K stated she got frustrated and concerned because she wasn't the one putting the medications in the container and she didn't know the residents. Staff K stated Staff L seemed frustrated with her because she kept asking questions. She added she didn't know the residents and Staff L didn't go with her. Staff K no longer worked at the facility as that was her last night at the facility. During an interview on 11/14/24 at 11:30 AM, Resident #51 and her husband recalled the night of 11/2/24 when Resident #51 received another resident's medication. A CMA, whom they never met before, came into the room then went up to Resident #51 and said she had her medications. The CMA didn't ask Resident #51 her name. Resident #51 said she asked the CMA what the medications were as she hadn't got medications that looked like that before. The CMA said she didn't know what the medications were. The CMA gave Resident #51 the medications with just water. Resident #51 said she had a hard time swallowing them as she usually got her medication with applesauce. Resident #51 said she started to gag on the medications and the CMA patted her on the back, then went to get her applesauce. The CMA came back to the room with the applesauce and then tried to give Resident #51's husband a cup of medications. Resident #51's husband said he told the CMA he wasn't a resident there and then she left the room. Resident #51 and her husband stated they feel the facility administration handled the incident well after finding out what happened. They said this never should have happened and said it is their policy for the person who signed out the medication be the person who gave the medication. During an interview on 11/14/24 at 12:00 PM, Staff L reported she trained Staff K on the night of 11/2/24. She added that night was Staff K's second night working at the facility. She trained Staff K the first night, and Staff K shadowed her that night. When asked to talk about the training process and how she trained Staff K, Staff L stated she didn't want to talk about it. She said she messed up, made a mistake, and learned a valuable lesson. She said she didn't follow the 6 rights and she should have. Staff L stated she gave Staff K medications to give to residents, without having Staff L put the medications in the cup herself and didn't go with her to ensure she gave the medication to the correct resident. Staff L stated she gave Staff K several resident medications that night, however couldn't give a specific number of residents she gave medication for Staff K to give. Staff L stated they were in the [NAME] hallway and she gave Staff K medication to at least one resident in the dining room, telling her what the resident looked like, but didn't go with her to give the resident the medication. Staff L stated she knew she didn't follow what she was supposed to follow and made a mistake. She said she put the medications for a resident in a cup with Staff K standing next to her, then gave the cup to Staff K. Staff L told her where to find the resident. Staff L stated she didn't feel like she needed to hold Staff K's hand. Staff L stated she didn't want to talk any further about the incident when asked what training she received before and after the incident. During an interview on 11/14/24 at 12:30 PM, Staff M, CMA, recalled working the night of 11/2/24. She recalled Staff L trained Staff K and it was Staff K's second night in training. Staff M stated at one point in the evening, before and around super time, she and Staff L had their medication carts side by side by the beauty shop in the hallway. Staff M heard Staff K say she wasn't ready to put the medications in the cups herself or give them herself, as she wanted to observe more with Staff L. Staff M stated Staff L showed Staff K the Medication Administration Record (MAR) and Staff K stood next to Staff L, when Staff L put the medication in a cup for a resident. Staff M stated Staff L gave Staff K medications for residents while they were still in the dining room and wouldn't go with her to give the medication to the resident. However, Staff L gave Staff K a description of the resident and she saw their picture on the MAR. Staff L would write the name of the resident on the medication cup. Staff L also gave Staff K medication to give to residents in their room in the [NAME] hallway. Staff L told Staff K the name of the resident and their room number. Staff M heard Staff L talk to Staff K about Resident #46's medication, that she was in room [ROOM NUMBER], and married. Staff L didn't go with Staff K to room [ROOM NUMBER] to give Resident #46 her medication. Staff M heard about Staff K giving Resident #51 the medication meant for Resident #46.

Based on observation, record review, facility policy review, resident, and staff interview the facility failed to keep a resident's environment free from accidents and hazards by not storing the resident's smoking materials in a secured location for 1 of 1 resident reviewed for smoking (Resident #30). The facility reported a census of 47 residents. Findings include: Resident #30's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #30 used a wheelchair for mobility. The MDS further documented the resident had diagnoses to include diabetes, arthritis, Parkinson's disease, chronic obstructive pulmonary disease (COPD), and pulmonary fibrosis. Resident #30 reported shortness of breath with exertion and while lying flat. The MDS described Resident #30 as a current tobacco use. The Care Plan Focus with a target date of 12/26/24 indicated Resident #30 preferred to smoke. The Goal reflected Resident #30 would follow the facility guidelines for smoking in designated smoking areas and wouldn't sustain significant smoking related injuries. The Care Plan Interventions identified Resident #30 could exit and re enter the facility independently. They stored his smoking supplies at the nurse's station. If Resident #30 failed to let staff keep his smoking supplies at the nurse's station he could lose his smoking privileges. Resident #30 had a history of being non-compliant at times with the smoking practices outlined in the Care Plan. He would move the extinguishing receptacles and smoke beyond the boundaries of the designated smoking area. If staff observe those issues, they should intervene and ask him to comply. A Smoking assessment dated [DATE], indicated the facility educated Resident #50 about the risks of smoking. Resident #50 could light his cigarettes safely, hold the cigarette safely, put ashes in the ashtray, extinguish the cigarette safely, exhibited safety awareness when smoking, didn't have burn holes in clothing, and had no evidence of blisters or burns on his fingers. The facility approved his smoking privileges and allowed Resident #50 to smoke independently. He could exit and enter the facility independently. In addition, Resident #50 needed to store his smoking materials at the nurse's station, especially important because of oxygen in his room. Failure to keep the smoking supplies at the nurse's station may result in loss of his smoking privileges. On 11/13/24 at 10:20 AM, observed Resident #30 seated in his recliner in his room, remove his oxygen, ambulate to his motorized wheelchair, and put on his coat to go outside to smoke. Resident #30 independently exited the facility out the front door and located himself by the smoking receptacle. He removed a pack of cigarettes from his pocket in the front of his bib overalls. The pack of cigarettes contained several cigarettes and a lighter. Resident #30 removed 1 cigarette, the lighter, and safely lit the cigarette. He returned the pack of cigarettes back to the pocket in his bib overalls. He smoked the cigarette, ashed, extinguished, and placed the butt in the receptacle appropriately. Resident #30 re entered the building independently and returned to his room. Resident #30 didn't obtain his smoking materials from the nurse's station nor did he return them to the nurse's station after he finished smoking. In an interview on 11/12/24 at 3:17 PM, Resident #30 reported he smoked 4 5 cigarettes per day and could smoke independently. He stated he either smoked out front or in the back of the facility, as both had smoking receptacles. He reported he used his motorized wheelchair to get to and from the smoking areas. He added he removed his oxygen in the room prior to going out to smoke. Resident #30 stated he kept his cigarettes and lighter in his possession. He reported the facility would like him to obtain and relinquish his smoking supplies to the nurse's station when he smoked but he felt he had to wait too long for the staff to get them so he rarely turned his supplies in. In an interview on 11/14/24 at 7:28 AM, Staff G, Certified Nursing Assistant (CNA), stated Resident #30 went to the nurse's station to get his smoking supplies and returned the smoking supplies to the nurse's station after he finished. Staff G stated Resident #30 didn't specifically ask her for the smoking supplies, he just asked whomever happened to be at the nurse's station at the time. Staff G stated Resident #30 did at times forget to turn in his smoking supplies. If the staff saw him come in without turning the supplies in, they stop him and ask him for them to return them to the nurse's station. In an interview on 11/14/24 at 7:33 AM, Staff H, Certified Medical Assistant (CMA), stated Resident #30 theoretically had to get his cigarettes and lighter from the nurse's station. She reported he didn't comply and kept his cigarettes on his person most of the time. Staff H stated the Director of Nursing (DON) and Administrator knew but Resident #30 was just non compliant most of the time. In an interview on 11/14/24 at 11:18 AM, Staff I, CNA, stated Resident #30 smoked independently and obtained his supplies from the nurse's station when he wanted to go out to smoke. Then he was to turn the smoking supplies back in after he finished smoking. Staff I stated she didn't know Resident #30 ever kept his cigarettes on him and didn't witnessed that behavior from him. In an interview on 11/14/24 at 1:07 PM, the Administrator stated any resident who smoked must have a Smoking Assessment completed. Resident #30 had to go to the nurse's station to obtain his cigarettes and lighter, then turn them back into the nurse's station when finished. They talked to Resident #30 about other options such as a lock box but he needed to store his smoking materials at the nurse's station at that time. In a facility provided policy titled Smoking Policy Notification with a revision date of September 2023 instructed the facility requested their cooperation in observing the facilities smoking policy, as it was a NON SMOKING facility. The authorized area(s) in the facility for permitted smoking is/are: The facility had no notations behind any of the above options.

Based on clinical record review, policy review and staff interview, the physician failed to respond to gradual dose recommendations (GDR) for 1 of 5 residents reviewed (Residents #9). The facility reported a census of 47 residents. Findings included: 1. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of heart disease, respiratory failure, metabolic encephalopathy (brain dysfunction due to problems with the metabolism) and depression. The MDS documented Resident #9 received an antidepressant medication during the lookback period. The Care Plan Focus with a target date of 11/27/24 indicated Resident #9 used a psychotropic medication in the category of an antidepressant. The Intervention instructed to evaluate for GDR quarterly or as indicated. Resident #9's November 2024 Medication Administration Record (MAR) included the following psychotropic medications: a. Start date 3/25/24: Amitriptyline 25 milligrams (mg) tablet, by mouth one time a day for nerve pain. b. Start dated 3/26/24: Bupropion, 300 mg extended release 24-hour by mouth one time a day related to depression. The Pharmacy Review - GDR Request Psychotropic Medications dated 10/2/24 requested the provider access for possible GDR for amitriptyline 25 mg and Wellbutrin (bupropion) 300 mg. The physician responded they didn't agree with the recommendation and indicated they addressed this previously. Resident #9's clinical record lacked documentation of any other physician response to the GDR. On 11/14/24 at 2/26/24 PM the Administrator and the Assistant Director of Nursing (ADON) both acknowledged the facility should have documented a physician's response to pharmacy recommendations, but they couldn't locate the documents. The Medication Regimen Review policy, revised 8/16/24 directed the consultant pharmacist to review the medication regimen including psychotropic medication with considerations for dose reduction, potentially unnecessary medication usage, and required written communication intended for the attending physician. The facility would maintain the completed medication regimen consultation in the resident's clinical record. The facility is responsible for ensuring all clinical records are available for review.

Based on clinical record review, resident interview, staff interviews and policy review, the facility failed to ensure residents are free of significant medication errors for 1 of 1 resident reviewed (Resident #51). During the orientation of one Certified Medication Aide (CMA), Staff K, the trainer gave the person in training resident's medications without ensuring they gave the medications to the correct resident. Due to it only being Staff K's second day of training she didn't know the residents and gave Resident #51, Resident #46's supper and hour of sleep medications (HS). The facility reported a census of 47 residents. Findings include: Resident #51's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions, anemia (low iron levels in the blood), atrial fibrillation (abnormal heart rate), hypertension (high blood pressure), renal insufficiency (poor kidney function), diabetes mellitus, hyperlipidemia (elevated type of cholesterol), seizure disorder, respiratory failure and metabolic encephalopathy (brain dysfunction due to problems with the metabolism). The Incident Report - Medication Event dated 11/2/24 at 7:21 PM identified Resident #51 received another resident's (Resident #46) supper and HS medications. Resident #46 November 2024 Medication Administration Record (MAR) reflected their supper and HS medications as: a. Donepezil HCI oral tablet, 10 milligrams (mg), related to mild cognitive impairment. b. Calcium Carbonate Vitamin D oral tablet with minerals, 600 800 mg unit, for bone health c. Potassium oral tablet, 99 mg, for nutritional supplement. During an interview on 11/13/24 at 1:45 PM, the Administrator stated she completed an internal investigation regarding the medication error with Resident #51. The Internal Investigation File included a progress note completed by Resident #51's primary care physician (PCP), dated 11/5/24. Under Chief Complaint/Nature of Presenting Problem section the PCP documented an acute visit to follow up on emergency department visit for hyperkalemia (elevated level of potassium in the blood). Under History of Present Illness, the PCP documented on 11/2/24 Resident #51 received a potassium supplement pill inadvertently (accidentally). She had mildly high potassium level in the hospital and this had been improving on labs. Her potassium level in the emergency department was 5.8, she received IV fluids and Lasix. When her potassium level normalized to 4.9, she discharge back to the facility. During an interview on 11/13/24 at 2:30 PM, Staff J, Advanced Registered Nurse Practitioner (ARNP), stated she worked with Resident #51's PCP in the same office and is Resident #51's ARNP at the facility. Staff J recalled when Resident #51 received another resident's medication in error, which included a potassium pill. Resident #51 already had high potassium levels, they did have her go in for lab work the following morning to check her potassium levels, which were slightly elevated, however they cannot definitively say the slight elevation happened because of the medication error. Staff J stated Resident #51 went to the emergency room previously for elevated potassium and they treated her for this. Her levels are good now. Staff J described the resident as physically okay, she didn't have symptoms of high potassium, and didn't require additional medical treatment or admission to the hospital. Staff J stated the 3 medications Resident #51 received in error were a low risk medication error, and didn't place the resident at high risk or high level of harm or death. During an interview on 11/14/24 at 10:25 AM, the Administrator stated they expected the right resident received the medication as prescribed. The Administrator stated they didn't have a policy for medication administration, as they followed professional standards, but they did have a policy for following physician orders. During an interview on 11/14/24 at 11:07 AM, Staff K, Certified Medical Assistant (CMA) explained Staff K stated Staff L, CMA, put medications in a cup and told her to go give it to the lady in the room they were in before, the lady with the husband. Staff L didn't go with her, and stayed with the medication cart, she couldn't see down the hallway where Staff K was going. Staff K stated she went into the room where she thought she should go and gave the lady the medications. The lady (Resident #51) started choking a little, Staff K slapped her on the back to help her and she coughed up the pills. Staff K asked Resident #51 if she wanted some applesauce with the medications and she said yes. Staff K went back to the medication cart and got some applesauce. Staff L then gave her another cup of medications and said these are for the husband. Staff K went back to the room and gave Resident #51 the applesauce and she swallowed the medications. Staff K then told to Resident #51's husband she had his medications. He told her he wasn't a resident at this facility. Staff K realized at this point she was in the wrong room and just gave Resident #51 the wrong medication. She went to room [ROOM NUMBER] next door to Resident #51's room and gave the man in that room the medication that she just tried to give to Resident #51's husband. She stated she tried to find Staff L to tell her what happened but said she couldn't find her. Resident #51 later told the charge nurse what happened and the charge nurse came to talk to Staff K. During an interview on 11/14/24 at 11:30 AM, Resident #51 and her husband recalled the night of 11/2/24 when Resident #51 received another resident's medication. A CMA, whom they never met before, came into the room then went up to Resident #51 and said she had her medications. The CMA didn't ask Resident #51 her name. Resident #51 said she asked the CMA what the medications were as she hadn't got medications that looked like that before. The CMA said she didn't know what the medications were. The CMA gave Resident #51 the medications with just water. Resident #51 said she had a hard time swallowing them as she usually got her medication with applesauce. Resident #51 said she started to gag on the medications and the CMA patted her on the back, then went to get her applesauce. The CMA came back to the room with the applesauce and then tried to give Resident #51's husband a cup of medications. Resident #51's husband said he told the CMA he wasn't a resident there and then she left the room. Resident #51 and her husband stated they visited with their daughter at the time and their daughter said she thought Resident #51 just got the wrong medication. No one came to the room to talk to them about this and then approximately 30 minutes later the charge nurse came in to start the feeding tube. They told her they thought Resident #51 received the wrong medication. The charge nurse said it needed to be reported and looked concerned. They called the doctor's office and watched Resident #51 throughout the night. Resident #51 stated she didn't feel any side effects from receiving the wrong medications and felt okay. She went to the Emergency Department the next morning for a flush and they got her potassium down. During an interview on 11/14/24 at 12:00 PM, Staff L reported she trained Staff K on the night of 11/2/24. Staff L stated she put Resident #46's supper and hour of sleep (HS) medications into a cup and gave the cup to Staff K. She then told her to give Resident #46 the medication. She described Resident #46 as the one who was married and told her the room number. Staff K indicated she knew who Staff L was talking about. Staff L stated she didn't go with Staff K and couldn't see her from where she stood by the medication cart. Staff L stated she still stood by the medication cart when Staff K returned and said she needed applesauce. Staff L then gave Staff K a cup of medication that she prepared while Staff K was gone for her to take to Resident #46's husband, Resident #45. Staff L stated she didn't go with Staff K to give the medication. Staff L didn't recall talking to Staff K again that night. The Physician Orders policy, revised 8/16/24, instructed all resident medications must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders.

Based on observation and staff interview, the facility failed to discard expired stock medications to avoid compromising the integrity of the medications. The facility reported a census of 47 residents. Findings include: On 11/13/24 at 2:35 PM observed the medication room across from the nurses' station with Staff B, Licensed Practical Nurse (LPN). The room contained the following expired items: a. 1 unopened bottle of Rubbing Alcohol 70%, 16 fluid ounces with an expiration date of March 2024. b. 1 unopened box of Assure Prism Blood Glucose Monitoring System with an expiration date of 8/25/24 c. 2 unopened bottles of Geri Dryl (similar to Benadryl) Allergy Relief with an expiration date of September 2024. In an interview on 11/13/24 at 3:10 PM, the Assistant Director of Nursing (ADON) stated she didn't know if they had a facility policy related the prevention of expired stock medications in the medication storage area but she would implement one if they didn't. She stated she expected the staff to discard all expired medications, so the staff didn't use or give them to the residents. On 11/14/24 at 11:44 AM, the Administrator reported the facility didn't have a policy relating to expired medications.

Based on clinical record review, menu review, observations, staff interviews, and policy review the facility failed to provide residents food in a form to meet the needs of 2 of 6 residents (Resident #51 and #50). The facility reported a census of 47 residents. Findings include: A Physician diet order dated 10/24/24 for Resident #51 directed staff to administer a mechanical soft, ground meat diet. A Physician diet order dated 11/6/24 for Resident #50 directed staff to administer a mechanical soft texture diet. A facility menu titled Week 3 Wednesday documented the noon meal for a mechanical soft diet included a ground steak sandwich with grilled onion, potato salad with no raw vegetables, cooked broccoli cuts and maraschino cherry cake. On 11/13/24 at 11:20 AM, prior to the start of the noon meal service, observed the steam table didn't contain ground steak meat. The observation of the steak meat revealed various sizes of cut up meat. On 11/13/24 observations during the noon meal service revealed Staff A, Cook, prepared a steak sandwich with cut up meat for Resident #51. They served Resident #51 the non ground steak sandwich on a room tray. During the middle of the meal service, Staff A took several servings of the cut-up steak meat out of the steam table, grounded the meat using a robot coupe and returned the ground meat to the steam table. As the meal service continued, Staff A prepared and plated a steak sandwich with cut up meat (non ground) for Resident #50. Staff A placed it on a tray on the food cart. At 12:22 PM, the Dietary Manager intervened and stated she couldn't let the food trays leave the kitchen. She stated Resident #50's sandwich wasn't prepared with ground meat. Staff A removed Resident #50's plate from the food cart and acknowledged Resident #50's sandwich as prepared with cut up meat and not ground meat. Staff A prepared a new sandwich with ground meat for Resident #50. The Dietary Manager agreed if she didn't intervene Resident #50 would have received non ground meat. On 11/13/24 at 12:30 PM, the Dietary Manager reported she expected the staff to follow the menu and grind the meat as indicated on the menu. On 11/13/24 at 12:40 PM, Staff A reported she forgot to prepare the ground meat prior to the start of meal service. Staff A said when she prepared Resident #51's food tray she chopped up the food into small pieces in the pan before serving it. Staff A reported she made a mistake and overlooked the ground meat for Resident #50. On 11/13/24 at 12:45 PM, Resident #51 and her husband reported she had a sandwich with meat pieces for lunch. Resident #51's husband reported his wife shouldn't have a mechanically soft diet, as his wife could chew her meat with no problems. Resident #51 said she could chew her meat without difficulty. Resident #51's husband said he took his wife to a local restaurant the previous night and she ate chicken on the bone without difficulty. Resident #51 said she ate the chicken off the bone and didn't have any problems with chewing or swallowing. Resident #51 said she hasn't choked on her food. Resident #51 and her husband said a staff member comes to the room and provides supervision while she eats. Resident #51 and her husband said the meat was in smaller pieces that day for lunch. Resident #51 reported she ate all of her lunch, stating it was good and she had no difficulty swallowing or chewing. On 11/13/24 at 2:30 PM, the Dietary Manager provided a counseling form signed by Staff A on 11/13/24. The form indicated the problem was ensuring proper diets are prepared before meal service and to double check the correct diets are served. The form documented Human Resources would assign an online course to Staff A regarding proper food service procedures. The Altered Textured Diet Orders policy revised April 2012 instructed diet orders for residents requiring altered textures for chewing and swallowing problems, be written in a standardized language to specify the appropriate consistency of food and fluids to meet residents' safety, tolerance, and preferences.

Based on facility document review, and staff interviews the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 5 of 31 days reviewed (September 23rd through October 23rd). The facility reported a census of 37 residents. Findings include: Review of a facility provided document titled Nurse Dept (9/23/2023-10/23/2023) revealed the facility had no RN coverage on 9/24/23, 10/7/23, 10/21/23, and 10/22/23. The document further revealed that the facility only had 4.5 hours of RN coverage on 10/8/23. During an interview on 10/26/23 at 11:21 AM with the Administrator revealed that there was no RN coverage for 8 hours on 9/24/23, 10/7/23, 10/13/23, 10/21/23, and 10/22/23. The Administrator revealed there was RN coverage from 3:30 PM-8 PM only on 10/8/23. The Administrator further revealed her expectation is for RN coverage for 8 hours a day. During a follow up interview 10/26/23 at 1:40 PM with the Administrator revealed the facility does not have a policy for staffing RN's 8 hours a day, but that it's a regulation.

Based on clinical record review, observation and staff interviews, the facility failed to supervise administration of medication according to accepted standards of clinical practice for 2 of 6 residents reviewed for medication administration (Residents #15 and #188). The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #15 had a Brief Interview for Mental Status (BIMS) of 5 out of 15 indicating severely impaired cognition. The MDS further documented the resident had diagnoses to include non-Alzheimer's dementia. The Care Plan with a target date 12/14/23 documented Resident #15 had impaired cognition such as impaired short term/long term memory, being easily confused, disorientation to person, situation and needing assist with decisions. The Care Plan had a goal the resident would accept redirection when confused. Review of Resident #15's October 2023 Medication Administration Record (MAR) revealed the following order: a. Miralax Oral Powder 17/grams (GM) 1 scoop one time a day for constipation with a start date 9/8/23 at 7:00 AM. On 10/25/23 at 8:17 AM observed Staff B, Certified Medication Aide (CMA) turn around while administering medication to Resident #27 in the dining room and ask Resident #15 if he would drink more of his drink for her. Staff were not present at the table with Resident #15. At 8:18 AM after completing her medication pass to Resident #27 while exiting the dining room, Staff B revealed Resident #15 had been drinking Miralax. Observation 10/25/23 at 8:28 AM revealed 3/4 cup of Miralax mixture remained sitting in front of Resident #15 at the table in the dining room without staff present. Two other residents were also present at the dining room table. During an interview on 10/25/23 at 08:20 AM, the Director of Nursing (DON) acknowledged Resident #15 had been drinking Miralax unsupervised after seeing the Miralax mixture in the cup in front of the resident and stated the resident should have been supervised by the staff member that passed the medication. 2. The MDS dated [DATE] documented Resident #188 had a BIMS of 15 out of 15 indicating intact cognition. The MDS further documented the resident had a diagnosis of mild intellectual abilities and cerebral palsy. The Care Plan with a target date 12/07/2023 documented Resident #188 had impaired cognition and needed assistance with decisions, had difficulty in understanding/being understood and had some forgetfulness. Review of Resident #188's October 2023 MAR documented the following order: a. Arginaid two times a day for skin healing with a start date 10/20/23 at 2:00 PM. Observation on 10/25/23 at 8:08 AM revealed Staff B, CMA left 3/4 cup of water containing the Arginaid with Resident #188 at the dining room table with 3 other residents present. Staff B encouraged the resident to drink more of the mixture and then walked away from the table and left the dining room. No other staff were present at the table. Observation on 10/25/23 at 8:20 AM revealed 1/4 cup of Resident #188's Arginaid mixture remained at the dining room table and the resident was no longer present. After being shown the mixture the DON acknowledged the supplement particles present and planned to check on a policy with the corporate nurse. During an interview on 10/26/23 at 8:37 AM, the Administrator revealed residents should be supervised when administered medication. During an interview, on 10/26/23 at 8:43 AM the DON revealed any medicine broken or placed in water should be supervised by the person that passed the medication. During an interview on 10/26/23 at 10:51 AM the Nurse Consultant revealed the facility does not have a medication administration policy, does not have an audit form for medication administration, and does not have a form they use as part of orientation to audit staff for medication administration. The Nurse Consultant further stated the staff know how to pass medications by being trained by facility staff or nurse consultants coming in and observing the process.

Based on observation, record review, and staff interview the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice as the facility failed to obtain a physician's order for a continuous positive airway pressure (CPAP) and failed to ensure proper cleaning and storage of the CPAP machine, tubing, and mask for 1 of 3 residents (Resident #15) reviewed. Facility reported a census of 37 residents. Findings include: A Minimum Data Set (MDS) dated [DATE] for Resident #15, included diagnoses of Non-Alzheimer's Dementia and Obstructive Sleep Apnea. A Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicated severe cognitive impairment for decision making. Observation and interview on 10/24/23 at 2:48 PM, a CPAP, mask and tubing were sitting on Resident #15's end stand. The resident stated he wears the CPAP at night as the CPAP helps him sleep better, the staff have to help him put the CPAP on, and he denied that the staff clean the mask and tubing. Resident #15's Physician Orders lacked an order for a CPAP or cleaning and storage of a CPAP, tubing, and mask. Interview on 10/24/23 at 2:55 PM, Staff D, Certified Nurse Aide (CNA) stated she works the evening shift and Resident #15 wears a CPAP when he goes to bed. Staff D stated the resident puts the CPAP on or the nurse helps him with the CPAP. Interview on 10/25/23 at 11:12 AM, Staff E, CNA on day shift, stated Resident #15 wears a CPAP at night and removes the CPAP in the morning and places the CPAP on his end stand. Staff E stated day shift does not do anything with the CPAP, tubing or mask, the night shift cleans it. Interview on 10/25/23 at 4:00 PM, Staff F, Certified Medication Aide stated Resident #15 does wear a CPAP at night and she assists him with putting the CPAP on and fills the water. Staff F stated cleaning of the CPAP, mask and tubing is to be done on day shift. Interview on 10/25/23 at 4:08 PM, Staff C, Registered Nurse stated Resident #15 wears a CPAP at night and just got an order a few weeks ago as resident brought the machine in from home. Observation on 10/26/23 at 7:57 AM, Resident #15 in bed with CPAP on. Interview on 10/26/23 at 8:51 AM, the Director of Nursing confirmed Resident #15 did not have a physician's order or cleaning schedule for a CPAP and expectation to have a physician's order for the CPAP and cleaning to be completed.

Based on observation, staff interview, and facility policy review the facility failed to store food in accordance with professional standards for 37 of 37 residents. The facility reported a census of 37 residents. Findings include: On 10/23/2023 from 11:00 AM through 11:20 AM a continuous observation during the initial kitchen tour revealed: a. A 4 pound bag of Fajita Blend vegetables opened with approximately half of the vegetables gone with no open date in the double door freezer in the kitchen. b. A 4 pound bag of Country Blend vegetables opened with approximately half of the vegetables gone with no open date in the double door freezer in the kitchen. During an interview on 10/23/2023 at 11:10 AM with the Dietary Manager revealed her expectation is for opened items to have a date on the bags to show when they were opened. During an interview on 10/23/2023 at 12:43 PM with the Administrator revealed that her expectation is for items to be dated when opened in the kitchen. Review of a facility provided policy titled Frozen Food Storage, documented: Frozen leftovers will be labeled, dated and stored no longer than 6 months.

Based on clinical record review, observation, staff interview, facility policy review and skills checklist review, the facility failed to maintain proper infection control practices to prevent cross contamination and potential infection of residents when providing cares and treatments. (Resident #4 and #31). The facility reported a census of 37 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS indicated Resident #4 required an indwelling catheter. The MDS included diagnoses of obstructive uropathy, diabetes mellitus, anxiety disorder and depression. During an observation of catheter care and emptying of the catheter bag on 10/24/23 at 2:00 PM, Staff A, Certified Nursing Assistant (CNA) completed hand hygiene and donned appropriate personal protective equipment (PPE) for Enhanced Barrier Precautions prior to entering the resident's room. Resident #4 stood in the bathroom in front of the toilet for the catheter care. Staff A completed catheter care but did not change her gloves or complete hand hygiene upon completion. Using the same gloves, Staff A placed a basin with a graduate in it on the floor and proceeded to empty the catheter using appropriate technique. Once completed, Staff A removed her gloves but failed to complete hand hygiene prior to leaving the room. In an interview on 10/25/23 at 3:20 PM, the Director of Nursing (DON) stated the facility did not have a policy on catheter care or emptying a catheter bag but staff were to follow the Standards of Care for this process. The DON stated it was the expectation, staff wash their hands and don gloves before starting catheter care and in between catheter care and emptying of the catheter bag. Prior to leaving the room hand hygiene was to be completed. The DON stated the facility had a skills fair in June 2023 and catheter care was covered. A skills checklist was used for training purposes. Facility provided checklist titled Skills Checklist: Catheter Care directs staff to: a. Introduce self, identify tenant by name, and explain procedure b. Perform hand hygiene c. Assemble equipment d. Provide privacy e. Don gloves f. Complete incontinence care g. Cleanse around the meatus; using a clean area of washcloth with each stroke h. Hold the catheter near meatus to avoid tugging the catheter. i. Clean at least four inches of catheter nearest meatus. Move in only one direction, away from meatus. Use a clean area of cloth for each stroke. j. Dip a clean washcloth in water. Rinse at least four inches of catheter nearest meatus. Move in only one direction, away from meatus. Use a clean area of cloth for each stroke. k. Clean and put equipment away l. Doff gloves m. Perform hand hygiene n. Report any unusual observations to the RN Designee. 40905 2. The MDS assessment for Resident #31 dated 9/7/2023, included diagnoses of Diabetes Mellitus and Depression. The MDS documented the resident had a Stage 3 pressure ulcer (full thickness tissue loss). The MDS documented a BIMS score of 15 out of 15, indicting no cognitive impairment for decision-making. Resident #31's Treatment Administration Record for 10/1/23 - 10/31/23 documented a physician's scheduled order for betadine to right heel 2 times a day for skin breakdown. Observation on 10/24/23 at 12:37 PM, Staff C, Registered Nurse placed betadine in a cup and added sponges. Staff C applied gloves, entered Resident #31's room, and touched the end stand and removed resident's right shoe and sock. Staff C proceeded with the same gloved hands and applied betadine to wound area on right heel. Staff C then removed gloves and washed hands. Facility policy, Infection Prevention and Control Program Guidelines documented hand hygiene should be performed before and after changing a dressing. Interview on 10/25/23 at 10:47 AM, the Administrator stated the facility did not have a policy for catheter care, emptying a catheter bag, and hand hygiene/glove usage and the expectation was to use standards of care. Interview on 10/25/23 at 11:25 AM, the Director of Nursing stated expectation to complete hand hygiene and apply new gloves before completing a treatment.

Based on observations, record reviews, interviews, and facility policy review, the facility failed to provide respiratory services in accordance with the accepted standards of practice for 2 of 4 residents reviewed (Resident #137 and Resident #3) for respiratory services. Specifically: - The facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure proper cleaning and storage of the [CONDITION(S)] machine, tubing, and mask for Resident #137. - The facility failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure proper cleaning and storage of the [CONDITION(S)] machine, mask, and tubing for Resident #3. Findings included: A review of an undated facility policy titled, [CONDITION(S)] Machine and Equipment Cleaning Guidelines, revealed, Nursing staff will be responsible for cleaning resident's [CONDITION(S)] tubing, mask, humidifier, and headgear on a scheduled basis. The policy further indicated the following: - Nasal, full mask, tubing. Wash daily. Disinfect weekly. - [CONDITION(S)] Unit (clean as needed). - Humidifier. Wash daily. Disinfect weekly. 1. Resident #137's Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #137's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required limited to extensive assistance of one person for most activities of daily living (ADLs). A review of an undated Care Plan Detail revealed Resident #137 used a [CONDITION(S)] related to a hospital stay for respiratory failure. The goal indicated that Resident #127 wanted to have a restful night of sleep and not be tired throughout the day. The Care Plan Detail included the following interventions: a. Assist Resident #137 with cleaning and maintenance of the [CONDITION(S)] machine b. Please follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 8/2/22 at 9:33 AM, 10:27 AM and 1:05 PM revealed Resident #137's [CONDITION(S)] machine on the table next to her bed. The [CONDITION(S)] mask laid on the seat of the resident's recliner, incorrectly stored. Observations on 8/3/22 at 8:45 AM and 1:44 PM determined that the [CONDITION(S)] mask laid on the armrest of the recliner next to the bed without Resident #137 in her room. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order directed that Resident #137 should receive [CONDITION(S)] 16/8 Rate: 6 Oxygen: 55%. The directions instructed to apply at night and remove in the morning related to [CONDITION(S)]. The Orders for care and cleaning of the [CONDITION(S)] equipment had an order date of 8/3/22 during the survey. During an interview on 8/3/22 at 2:12 PM, Resident #137 stated that she sometimes used the [CONDITION(S)] machine at night. The staff put it on her, turned on the oxygen, and put water in the humidifier chamber. According to Resident #137, the staff never cleaned the mask, tubing, or humidifier chamber of the [CONDITION(S)] machine. During an interview on 8/3/22 at 2:18 PM, Staff A, Certified Nurse Aide (CNA), stated she would rinse out the water (humidifier) chamber and wipe down the mask. According to Staff A, she thought the nurses did something also but did not know for sure. Staff A stated she tried to store Resident #137's mask on a shelf in the closet but she didn't have a chance to do it yet. Staff A stated she did not document anything about the [CONDITION(S)] because it was a nurse thing. During an interview on 8/3/22 at 2:24 PM, Staff B, CNA, said the nurses provided the care for the [CONDITION(S)] machines. During an interview on 8/3/22 at 2:30 PM, Staff C, CNA, explained that she only made sure the [CONDITION(S)] machine had water in it while the resident wore it. Staff C reported that the person responsible to clean, sanitize, and store the [CONDITION(S)] mask as the nurse. In an interview on 8/3/22 at 2:37 PM, Staff D, Licensed Practical Nurse (LPN), stated she had two residents on her hall who used a [CONDITION(S)] or [CONDITION(S)] machine. She explained that she had to clean the equipment with mild soap and lay it out to air dry. Staff D reported that once it was air dried, it should be stored in a plastic bag. She stated she forgot to do this today. During an interview on 8/3/22 at 2:52 PM, Registered Nurse (RN) Staff E stated the [CONDITION(S)] machine should be cleaned daily and air dried. He stated the mask should be stored in the case, and the humidifier chamber should be cleaned when the mask was removed. On 8/3/22 at 3:00 PM, the Assistant Director of Nursing (ADON), who stated the mask and tubing for the [CONDITION(S)] machine should be cleansed with mild soap and water, hung up to dry, and then stored in a bag. She stated the machine should be cleaned weekly, including the humidifier chamber. According to the ADON, the nurses were responsible for doing those tasks. The ADON reported that Resident #137 should have an order that included the settings for the machine. On 8/3/22 at 3:19 PM, the Administrator stated she expected the staff to follow manufacturer's recommendations for the routine daily and weekly cleanings, along with the storage of the [CONDITION(S)] mask and tubing. 2. Resident #3's Admission Record reviewed on 8/3/22 at 3:39 PM included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #3's quarterly MDS assessment dated [DATE], BIMS score of 7, indicating severe cognitive impairment. Per the MDS, Resident #3 required supervision to limited assistance of one person for ADLs. The undated Care Plan Detail Focus identified that Resident #3 had impaired ADL and mobility independence related to a generalized decline while at home. The Care Plan listed an intervention that Resident #3 used a [CONDITION(S)]. Resident #3 could apply and remove the [CONDITION(S)] mask herself. Resident #3 needed assistance to fill the [CONDITION(S)] with water. Additionally, the Care Plan included documentation that Resident #3 refused to wear her [CONDITION(S)] at times. The intervention directed the staff to educate Resident #3 on the importance of wearing the [CONDITION(S)] while resting in bed. Resident #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 8/2/22 at 9:03 AM, Resident #3 laid in bed with a [CONDITION(S)] mask on. At 9:36 AM, with Resident #3 out of her room; her [CONDITION(S)] mask sat on top of the [CONDITION(S)] machine that sat on top of the nightstand. An observation showed a container of distilled water on the floor between the bed and the nightstand. At 10:26 AM and 1:06 PM, Resident #3's [CONDITION(S)] mask remained on top of the [CONDITION(S)] machine. During an observation on 8/3/22 at 11:28 AM, Resident #3 laid in bed with the [CONDITION(S)] mask on. At 1:41 PM, Resident #3 sat in her recliner in her room, and her [CONDITION(S)] mask laid on her pillow. Resident #3 stated that she put the [CONDITION(S)] mask on and usually added water to the humidifier. According to Resident #3, the facility staff never cleaned the mask, the tubing, or the humidifier chamber. During an interview on 8/3/22 at 2:18 PM, Staff A, CNA, stated she would rinse out the water (humidifier) chamber and wipe down the mask. According to Staff A, she thought the nurses did something also but didn't know for sure. Staff A reported that she tried to store Resident #3's mask, but she liked to keep it on the table next to her bed. Staff A explained that she did not document anything about the [CONDITION(S)] because it was a nurse thing. During an interview on 8/3/22 at 2:24 PM, Staff B, CNA, stated the nurses provided the care for the [CONDITION(S)] machines. During an interview on 8/3/22 at 2:30 PM, Staff C, CNA, acknowledged that her only responsibility with a [CONDITION(S)] machine was to make sure it had water in it when the resident wore it. According to Staff C, it was the nurse's responsibility to clean, sanitize, and store the mask. In an interview on 8/3/22 at 2:37 PM, Staff D, LPN, explained that she had two residents on her hall who used a [CONDITION(S)] or [CONDITION(S)] machine. She stated she was supposed to clean the equipment with mild soap and lay it out to air dry. Staff D reported that once it was air dried, it should be stored in a plastic bag. She stated she forgot to do that day. During an interview on 8/3/22 at 2:52 PM, Staff E, RN, said the [CONDITION(S)] machine should be cleansed daily and air dried. He stated the mask should be stored in the case, and the humidifier chamber should be cleaned once the mask got removed. On 8/3/22 at 3:00 PM, the ADON reported that the mask and tubing for the [CONDITION(S)] machine should be cleansed with mild soap and water, hung up to dry, and then stored in a bag. She stated the machine should be cleaned weekly, including the humidifier chamber. According to the ADON, the nurses were responsible for doing these tasks. During an interview on 8/3/22 at 3:19 PM, the Administrator stated she expected the staff to follow manufacturer's recommendations for the routine daily and weekly cleaning and storage of the [CONDITION(S)] mask and tubing.

Based on observation, record review and staff interview, the facility failed to ensure the residents received adequate supervision and assistance with transfer devices as needed to prevent accidents for one of four residents reviewed (Resident #1). Facility census was sixty-two (62) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 7/2/14 assessed Resident #1 with a brief interview for mental status (BIMS) score of 10 indicating moderate cognitive impairment. Resident #1 had the following signs and symptoms of delirium: inattention and disorganized thinking. The resident required extensive assistance of one staff member with transfers, locomotion on and off unit, dressing, toileting and bathing. The MDS identified Resident #1 as unable to ambulate. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance while: moving from seated to standing position, moving on and off toilet and surface to surface transfers (transfer between bed and chair or wheelchair). The MDS documented Resident #1 had functional limitations in range of motion to both lower extremities. The resident used a wheelchair for mobility. The resident denied pain during the pain assessment portion of the MDS. The resident did not have falls since the previous assessment. Resident #1 has a documented height of 61 inches tall and weighed 263 pounds. The care plan with an intervention dated 7/26/13 and updated 7/9/14 identified Resident #1, required assistance with ADLs (activities of daily living) related to cognitive loss, immobility in knees, chronic pain and obesity. The care plan directed staff to provide extensive assistance of 2 staff members and the EZ stand. Double check straps as resident has a history of unhooking harness. On 9/17/14 at 12:10 p.m. Staff A (unit manager and Registered Nurse) confirmed staff began using 2 and the EZ lift to transfer the resident on 7/26/13 and identified the use of 2 staff and EZ stand directive in place on 8/25/14 when the incident occurred. A progress note contained a late entry incident report dated 8/25/14 at 3:43 a.m. and written by Staff B (licensed practical nurse) revealed that a nurse aide paged for help in Resident #1's room. When Staff B responded to the call, she found Resident #1 sitting on the floor with legs outstretched in front of him/her. The resident leaned on the roommate's night stand just outside the bathroom door. The nurse aide (Staff C) reported she assisted the resident to the bathroom with the EZ stand when the waist belt buckle came undone and the right strap came off the EZ stand bar. Staff B noted the sling hung from the left side of the stand. The resident complained of right hip pain. The resident rated the pain as "9" out of a possible "10", with 10 as the worst pain. The entry identified the intervention of, assist of two for transfers, as in place when the fall occurred. Staff notified the physician of the resident's fall and pain on the same date at 3:52 a.m. An incident report dated 8/25/14 at 3:43 a.m. identified staff immediately provided written counseling to the nurse aide involved in the incident regarding the importance of following the care plan at all times and checking and double checking all straps and buckles. Progress notes dated 8/25/14 at 4:30 a.m. identified that the resident transferred to the emergency room for evaluation at 4:30 a.m. On the same date, progress notes identified the resident admitted to the hospital for pain control. A CT (computerized tomography) showed pelvic fracture. Progress notes dated 8/26/14 at 8:08 p.m. identified that the resident returned to the facility that day at 1:50 p.m. A hospital history and physical report dated 8/25/14 at 11:32 a.m. identified Resident #1 with [DIAGNOSES REDACTED]. The history and physical notes identified Resident #1 as non-ambulatory for the past 4 to 5 years due to osteoarthritis, spinal stenosis and obesity. The resident fell while transferring with the Hoyer lift at Rolling Green Village last night. Resident #1 could not move the right leg without pain. The resident transferred to the emergency room and evaluation identified a pelvic fracture on the right side. The assessment revealed pain control issues. The hospital admitted Resident #1 for pain control and physical therapy. X-ray dated 8/25/14 of the right hip, lateral and pelvis showed an acute non-displaced right superior and inferior pubic ramus fracture. The x-ray also showed osteopenia and an old healed fracture of the right proximal femur. Hospital transfer records dated 8/26/14 identified the resident returned to the facility with an order for [REDACTED].) every 6 hours as needed. On 9/4/14 at 6:25 p.m. progress notes identified increased pain in the resident's hip and back even after Norco (narcotic) administered. The physician ordered additionally ordered Fentanyl 25 microgram Patch and change every 3 days. History of prior falls for Resident #1: An incident report dated 7/11/14 at 2 a.m. identified that a nurse aide left Resident #1 on the toilet and left the room. The resident stood up and walked out of bathroom, taking the EZ stand with him/her. While standing, the resident unhooked the straps from around his/her waist and under arms causing the resident's support system to disappear. The resident fell down on bottom with legs stretched out in front of him/her. The resident did not yell or use the call light prior to getting up per self. Assessment showed no injury. Staff assisted the resident up with the Hoyer lift and 3 staff. The incident report identified the facility gave the nurse aide a written write up for the incident. A care plan with a target date of 10/9/2014 directed staff in the toilet use section of the care plan, DO NOT LEAVE UNATTENDED. Interview on 9/17/14 at 3:40 p.m. Staff H (licensed practical nurse) stated when Staff C was trained that she was told staff members are directed to use two people for transfers but use one person due to staffing. She stated staff had used one to transfer the resident with the EZ lift. Interview on 9/17/14 at 2:44 p.m. Staff I (licensed practical nurse) stated she had not seen anyone transfer Resident #1 with one staff member but she wouldn't doubt it was done that way. She never worked nights but stated there is only one aide down each hall at night. Interview on 9/17/14 at 12:20 p.m. the Administrator stated following the incident, maintenance checked the EZ stand and harness for malfunction or anything broken. There was nothing wrong with the lift or harness. Observation on 9/17/14 at 1 p.m. revealed two staff transferred, Resident #1 with the EZ stand. Staff ensured the buckles on the leg strap and harness strap snapped closed and placed a cover over the buckle. They placed the harness strap past the rubber stop on the arms bars of the EZ stand lift. Resident #1 then transferred safely to the bathroom. Observation showed on 9/18/14 at 5:20 a.m. in bed asleep with the television on. Interview on 9/18/14 at 5:33 a.m. Staff F (licensed practical nurse) stated prior to the incident, staff transferred the resident with one staff when they knew they should use 2. Staff may have done it due to staffing. Since the incident, staff uses 2 for transfers. Interview on 9/18/14 at 6:12 a.m. Staff G (nurse aide) stated there are times don't have enough staff to transfer the resident with 2 staff members as the care plan directs. So staff then goes ahead and uses one staff. Staff G stated she had transferred Resident #1 with one and probably all the other staff also transferred the resident alone. Interview on 9/18/14 at 6:40 a.m., Staff C (certified nurse aide) identified herself as the nurse aide involved in the 8/25/14 fall incident. She stated both residents in the room needed the bathroom so she took the resident's roommate first. After the roommate went to the toilet, Staff C got the EZ stand for Resident #1. Her pager indicated she had other call lights on so she decided she would take Resident #1 to the bathroom per self. Resident #1 stated he/she needed to toilet badly. Staff C stated she fastened the harness to the EZ stand and then around the resident. She did not hear a snap to indicate the buckle fastened properly. Staff C stated she did wonder about not hearing a snap but she was worried about the call lights. Staff C started towards the bathroom with Resident #1 up in the EZ-lift. When Staff C pivoted the lift to turn it towards the bathroom, Resident #1 fell . Staff C stated the top strap came off the EZ lift bar. She stated a failure to place the loop past the rubber stop on the bar and since she didn't hear the buckle snap/click into place, the buckle came apart and the resident fell to the floor. Staff C stated she had not been trained in how to use the lift. She stated it was her second week using the lift and the fall with the resident was the first time she used it alone. She stated she oriented on the north unit one night and did watch a transfer of the resident. She stated she watched less than 5 lift transfers. She stated she was given a 24 hour communication sheet that identified the resident required assistance of 2 staff but she did not look at it. Staff C stated when she trained on the resident's wing, Staff D (nurse aide) trained her and said Resident #1 transferred with one staff and the EZ stand. Staff D told her that is what she was told to do in orientation. When asked how the incident could be prevented, she stated this as her first nurse aide job and she needed better orientation. She stated she felt like since the facility knew it was her first nurse aide job that she should have more than one night of orientation on Resident #1's wing. She then stated she transferred the resident alone prior to the night of the incident and that time it went fine (after previously stating she had not). When asked who she told about not feeling as if she had enough training with the lift Staff C stated she informed other nurse aides but did not inform nurses or management. She stated she had a Walkie-Talkie that night that she could have used to call for another staff to assist her but since she was trained to transfer the resident with one staff, she went ahead and did it herself. Review of Staff C's personnel file revealed a hire date of 8/8/14. She was trained on the EZ lift/stand 8/27/14 (after the incident) A Certified Nurse Aide orientation checklist contained 6 pages. Only page one was completed to indicate another nurse aide trained Staff C. Page one did not include orientation for mechanical lifts. Mechanical lifts was on page 3 which was blank without initials to indicate orientation failed to be completed. Review of schedules and time cards revealed the facility scheduled Staff C for 12 days of orientation. Staff C ended up receiving 6 days of orientation with 3 of those days on Resident #1's wing. Interview on 9/28/14 at 2:35 p.m. Staff D (nurse aide) stated Resident #1 should transfer with 2 staff. She stated she was not sure and didn't know of anyone transferring the resident with just one staff. She denied training Staff C to use just one staff. She stated she worked at the facility for a couple months and no longer worked there. She stated she trained Staff C "a couple times". Interview on 9/28/14 at 2:46 p.m. Staff E (nurse aide) stated there were times staff transferred Resident #1 with one staff. She stated staff is expected to do things in a certain time frame and staff has done what they needed to do to accomplish that. Staff E stated she did not think Staff C received enough training prior to the incident and that Staff C's orientation was not completed when the incident occurred. The facility allows a lack of training due to staffing. Interview on 9/28/14 at 10:40 p.m. Staff B (licensed practical nurse) stated she was the charge nurse the night the incident occurred. She stated Staff C transferred Resident #1 by herself and the resident should have 2 for transfers. She stated she was not aware of staff transferring the resident with one staff. She stated the resident had a history of [REDACTED]. She stated she "absolutely" would have assisted Staff C if Staff C would have asked her for help with transferring the resident that night. She stated they worked with the usual number of staff that night. Interview on 9/30/14 at 9:55 a.m. Staff A confirmed the "DO NOT LEAVE UNATTENDED" intervention was in place for a while and when the fall occurred regarding Resident #1. Review of the Medication Administration record for Resident #1 revealed the following pain medications received after the fall and non-displaced right superior and inferior pubic ramus fracture. Resident #1 " s Methadone Hydrochloride (Norco) 10 mg(milligrams) orally 1 - 1.5 tablets or 15 mg administered 3 times daily for a total of sixteen doses between 8/26/14-8/31/14. Resident #1 ' s Hydrocodone with Tylenol 10mg/325mg 1 tablet by mouth every six hours as needed. Resident #1 received a total of eleven doses between 8/26/14 -8/31/14 for hip and pelvic pain.

Based on record review and staff and physician interviews, the facility failed to complete a timely resident assessment when a resident had a condition change that warranted the assessment (Resident #4). The sample consisted of 11 residents and the facility reported a census of 63 residents. Findings include: 1. Resident #4 had a quarterly Minimum Data Set (MDS) assessment, with a reference date of 12/18/13. The MDS reflected Resident #4 had a brief interview for mental status (BIMS) score of 10 which identifies the resident with a moderate cognitive impairment. The MDS did not identify a problem with the resident's ability to make self- understood or speech clarity. The resident spoke distinct intelligible words that staff understood. The MDS identified the resident to require limited staff assistance with transfers, bed mobility and ambulation. The resident had [DIAGNOSES REDACTED]. Review of the Interdisciplinary Progress Notes (IPN) dated 2/28/14 at 1:00 p.m., revealed a certified nurse aide, CNA came to the nurse ' s station and asked the charge nurse if she knew about the resident not acting as usual and not eating. The charge nurse went to the resident's room and observed the resident in bed with eyes closed. The resident awoke when the nurse called his/her name. Vital signs were blood pressure 69/52, pulse 52 (normal 60-100 beats per minute), respirations 18 (normal 16-20 per minute) and oxygen saturation 95% (normal 96-100 percent) on room air. The resident ' s eye pupils were nonreactive and the resident did not respond appropriately to questions. The resident's spoken words did not make sense; the resident did not know his/her name or place he/she was at. The resident's manual blood pressure was 101/56. The charge nurse notified the on-call physician and the resident left the facility at 2:00 p.m. for the emergency room and was admitted to the hospital. The IPN contained a late entry written on 2/24/14 and dated for 2/23/14 at 8:45 a.m., by Staff E, registered nurse, RN. The note revealed CNA's reported the resident acted strange. Staff E assessed the resident and documented the resident spoke clearly and appropriately. The resident took medications without difficulty and denied pain and discomfort. The resident questioned Staff E why she asked so many questions because he/she was fine. Vitals signs were blood pressure 112/72, pulse 72, respirations 18 and temperature 98.2 degrees. The resident ' s oxygen saturation level registered at 96%. A facility transfer form dated 2/22/14 (actual date of transfer was 2/23/14) identified the resident transferred to the hospital for confusion, [MEDICAL CONDITION], garbled talking and not eating. The transfer form identified the resident ' s speech as garbled and usually his/her speech was within normal limits, mental status as confused and resident was usually alert times three (person, place and time), resident required assistance of one staff with eating and usually feeds self. A consultation report from the hospital admitted d on 2/24/14 revealed the resident had a decline in speech on the 22nd and was brought to the emergency room the following day. The CT (computerized tomography) scan of the head showed a new left posterior middle cerebral artery stroke which was quite consistent with the resident's language and behavior problems. The neurological examination showed the resident was unable to follow verbal commands and not able to name and repeat. The resident spoke in a language sounding like Dutch or Scandinavian. Motor testing revealed the resident had some slight drift with the right upper extremity but otherwise showed good strength in all 4 extremities. Pupils were small at 3 millimeters (mm) and minimally reactive. The impression was left posterior middle cerebral artery stroke, presumed embolic in origin due to [MEDICAL CONDITION]. The Hospital physician progress notes [REDACTED]. The hospital notes identified the resident returned to the facility on [DATE]. On 3/24/14 at 2:15 p.m., Staff D, CNA stated the resident showed symptoms of stroke on her shift. When she put the resident to bed on 2/22/14 at 7:00 p.m. to 7:30 p.m. the resident was "different". Staff D stated the resident mumbled and only every couple words were understandable. Staff D stated she told the charge nurse (Staff B) right away that the resident mumbled and appeared confused. Staff D wrote it on the 24 hour report. Staff D stated the resident walked OK (alright) but stopped a few feet short of the toilet and acted like he/she did not know what to do. Staff D stated that was unusual because the resident was usually " with it " (new what to do). On 3/24/14 at 2:55 p.m., Staff B, licensed practical nurse, LPN stated Staff D informed her the resident had slurred speech. Staff B stated she assessed the resident and did notice the resident had slurred speech but the resident's vital signs were normal, grips equal and eyes OK (alright). The resident ate and walked like usual. Staff B stated she did not chart any of the information because everything seemed fine upon assessment. Staff B stated she reported the slurred speech symptom to the night shift. On 3/26/14 at 9:28 a.m., Staff J, RN stated she was not advised that anything unusual was going on with the resident the night of 2/22/14 in report or by the nurse aides working so she did not go out of her way to check on the resident. On 3/26/14 at 9:35 a.m., Staff L, CNA stated the resident was fine that night. Staff L was shocked when she heard the resident had a stroke. Staff L assisted the resident to the bathroom and did not notice anything different. On 3/25/14 at 2:04 p.m., Staff F, CNA stated the resident did not seem normal on 2/23/14. The resident talked gibberish versus the usual smile and clear words. Staff F stated once-in-awhile that day she could understand an "ok" or "thank you" but that was all. Staff F got the resident up between 7:00 a.m. and 8:00 a.m. on 2/23/14 and when she first saw the resident that day, the resident was like that. Staff F stated the night shift reported the resident was babbling when they walked the resident to the toilet. Staff F stated that morning the resident did not walk well. It was hard for the resident to stand up, the resident was wobbly. Staff F reported the information to Staff E, RN who left early. Staff M, LPN took Staff E's place and Staff F informed Staff M of their concern. Staff M went in right away and agreed the resident was not right. The resident went to the hospital after that. The resident needed help eating and could not get out what he/she wanted to say. For walking it took two staff instead of one and they basically had to just pivot transfer the resident. The resident could not really stand. On 3/25/14 at 1:25 p.m. Staff I, CNA stated she distinctly recalled getting the resident up for lunch on 2/23/14 and the resident pulled on her instead of standing so Staff I knew something was wrong. Staff I stated the resident did not make sense when he/she spoke. The resident went to the hospital later. On 3/24/14 at 2:33 p.m., Staff E, RN stated she got a report the resident acted strange and was not the usual self, speech slurred and not walking as well before lunch. Staff E stated she assessed the resident and checked vital signs. The resident spoke clearly and expressed annoyance at Staff E for asking. Staff E stated she did not hear anything in report about the resident. Staff E stated sometimes the resident acts that way and then he/she is better. Staff E stated she forgot to chart her assessment that day but she did chart it the next day. On 3/24/14 at 5:00 p.m., the Director of Nursing stated the hospital notes identified the resident was difficult to assess what was wrong and the resident always had periods of confusion. On 3/25/14 at 2:39 p.m., the resident's physician stated the facility should have notified the physician the evening of 2/22/14 when the resident experienced speech changes. The resident had a stroke. The physician stated they did not know if coming sooner would have changed anything and the resident was not a candidate for the clot dissolving drug.

Based on record review and interviews with the staff, physician and wound nurse, the facility failed to provide adequate supervision to ensure against hazards from self and the environment and the Health Service Supervisor failed to direct the nursing care services in order for nursing assistants to not perform treatments, including treatments not ordered by the physician (Resident #3). The sample consisted of 11 residents and the facility identified a census of 63 residents. The facility identified a census of 63 residents. Resident #3 voiced complaints of leg pain and the inability to sleep. A nursing assistant heated a heat pack and placed the pack between the resident ' s gown and pillow. The resident received a burn. There was not a physician's order [REDACTED]. Findings include: 1. Resident #3 had a Minimum Data Set (MDS) assessment with a reference date of 12/2/13, which reflected the resident with a brief interview for mental status (BIMS) score of 15. A score of 15 identified the resident with no cognitive impairment. The resident required extensive assistance for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The resident required limited assistance with ambulation. The MDS identified the resident with functional limitations in range of motion of both upper and lower extremities. The resident had [DIAGNOSES REDACTED]. The resident had almost constant pain that made sleep difficult and limited day to day activities. The MDS identified the resident with moisture associated skin damage. Interdisciplinary Progress Notes (IPN) dated 11/25/13 at 5:20 p.m. identified the resident as admitted to the facility. A skin sheet dated 11/25/13 identified a 3 or 4 centimeter (cm) by 3 cm bruise to the resident's left back. The IPN dated 11/26/13 at 2:30 a.m., revealed the resident complained of pain in the left leg from "sciatica" that prevented the resident from sleeping. Staff observed three fluid filled blisters on the residents left upper buttock/hip area in a straight line measuring 1 cm in diameter, 0.5 cm diameter and 1 cm diameter. The resident complained of discomfort. Staff started skin sheets and sent a facsimile to the physician. Interdisciplinary progress notes dated 11/26/13 at 9:00 a.m. revealed the resident reported their left upper buttock and hip area felt sore and burned. The resident stated he/she fell asleep with a hot pad and it burned him/her. The resident stated he/she received the hot pack around 10:00 p.m. when he/she went to bed. The assessment of the left upper buttock and left hip area identified a red dry area that measured 26.5 centimeters by 18 cm. The area was tender to the touch. The superior blister was intact and measured 3 cm by 1.5 cm by 1 cm The second blister measured 0.2 cm in diameter and was 0.2 cm in height. The 3rd blister measured approximately 0.8 cm-0.9 cm in diameter and 0.5 cm in height. All blisters appeared intact, withered and pink and felt slightly warm. On 11/27/13 the resident saw the physician. The physician directed staff to check the left hip burn daily until healed. Staff may apply Telfa if needed and staff may cleanse with wound cleanser with dressing changes. A resident status sheet (initial care plan) identified on 11/26/13 no ice or heat should be used due to sensitive skin. Review of a written statement dated 11/26/13, Staff K, certified nurse aide, CNA wrote the resident complained of pain on the left side. Staff K asked the resident if he/she tried heat. The resident had not, so Staff K positioned the resident on his/her right side with a body pillow under the resident's back and left side so the resident could avoid lying directly on the sore area. Staff K placed a bed buddy (hot pad) between the resident and body pillow positioning it from the resident's mid-back down to the tailbone area. The bed buddy was between a gown and a pillow and never coming in direct contact with the skin. The resident wore two gowns (one tied in back and one worn like a robe) so there were no gaps to touch the skin. The approximate times the resident used the bed buddy was shortly after 10:00 p.m. when Staff K answered the resident's call light and then it took approximately 30 to 45 minutes until she positioned the bed buddy. Staff K removed the bed buddy from the room between 12:00 to 12:30 a.m. Staff K wrote the bed buddy was not on the resident the entire time. The resident handed it to Staff K from the over bed tray table. Staff K did not know when the resident removed the bed buddy. Staff K stated she did not know the use of a bed buddy required a physician order. Staff K's written statement did not include information about how or how long she heated the bed buddy or if she shifted the contents of the bed buddy to check for temperature. The Bed buddy instructions directed staff to microwave the bed buddy in a clean microwave for 1 minute and 15 seconds. Staff should always touch test by shifting contents to check for hot spots before use. The instructions directed not to exceed 2 minutes total heat time. On 3/26/14 at 9:15 a.m., Staff K stated she did not recall the incident. Review of the Skilled Interdisciplinary Progress Notes dated 12/6/13 at 11:30 a.m., revealed the resident went to dialysis at 6:00 a.m. While out of the facility, the physician called and informed the facility that the resident was admitted to the hospital for uncontrolled pain. On 12/9/13, the Wound Nurse identified an open ulceration on the resident ' s left lower back/upper hip area. The resident reported staff applied a heating pad and as a result, the resident experienced a possible burn. The wound nurse questioned [DIAGNOSES REDACTED] (skin necrosis related to Stage 5 renal disease) versus burn. The resident identified the area was originally a blister but since opened. The base of the wound appeared purplish red. A central portion of the wound had a 20% slough tissue base. The wound nurse cleansed the area with normal saline to attempt to remove some of the slough tissue; however it was densely adhered and caused discomfort so the Wound Nurse stopped. The wound measured 13 cm by 19 cm by 0.1 cm. The periwound was intact without [DIAGNOSES REDACTED] present with a small amount of malodorous drainage on the dressing. The wound nurse assessed an area on the resident ' s left inner thigh that was identified as [DIAGNOSES REDACTED] versus shearing. The resident reported the wound appeared after a blister developed due to leg edema. On 3/26/14 at 11:56 a.m., the Wound Nurse stated the resident's nephrologist made the referral for the areas. There was some question if the left lower back/upper hip area wound was [DIAGNOSES REDACTED] versus burn. The Wound Nurse stated they can look similar and [DIAGNOSES REDACTED] was seen in residents with end stage renal disease (ERSD). In [DIAGNOSES REDACTED], there was a leathery eschar over the top of the wound and the resident's wound had that look to it. The wound nurse stated it was hard to determine which it was. The Wound Nurse identified the left inner thigh wound as most likely [DIAGNOSES REDACTED]. On 3/25/14 at 12:22 p.m., the physician who saw the resident on 11/27/13 stated the resident fell asleep on a heating pad and with that information; the physician thought the resident suffered a burn. The physician stated the resident had very poor skin quality and was morbidly obese so he/she was prone to develop blisters after heat pad use and blisters will open. The resident had medical problems that were not able to be treated well and that set the resident up for skin injury. On 3/25/14 at 8:55 a.m. the Director of Nursing stated the facility did not have a policy for the hot pad. On 3/25/14 at 3:26 p.m. the Director of Nursing stated the resident did not have an order for [REDACTED]. On 11/29/13, the Director of Nursing posted information for staff which reflected the CNA's could not heat bed buddies (hot pads) and this was the nurses ' job only.

Based on observation, record review, staff and family interviews, the facility failed to plan for and implement services to ensure Resident #9 received adequate supervision against hazards in the environment. Resident #9 sustained a fall with fractures to his/her hip and clavicle (collarbone) when he/she self-transferred. The resident's alarm sounded to alert staff of his/her self-transfer, however no facility staff could hear the alarm. The care coordinator and additional staff reported being aware that resident alarms are hard to hear however failed to implement services to address resident's safety needs. The facility reported a census of 68 residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 4/24/13 assessed Resident #1 with a brief interview for mental status score of "10" (moderate cognitive impairment). The resident did not have behavior symptoms identified. The resident required extensive staff assistance with bed mobility, transfers, ambulation, toileting and personal hygiene. A balance during transitions and walking test performed identified the resident as not steady and only able to stabilize with staff assistance when moving from a seated position, when turning around, when walking or when transferring from bed and chair. The resident had [DIAGNOSES REDACTED]. The resident did not have falls since the prior assessment and used a walker An alarm/monitoring screening tool reviewed with family on 5/9/13 identified the resident with a history of frequent falls. The form listed interventions the facility attempted and failed as: call light teaching, assist with transfers/walking, hi/lo bed, carpet in room, room in high traffic area and frequent checks. The reasons why the previously listed interventions failed were: forgets to use call light, impulsive and gets up without help, poor balance and safety awareness and moves fast. The reason for using the alarm was "Notify staff to change in position to decrease risk of fall and/or injury". The acknowledgement signed by the facility staff on 7/11/11 identified the resident had a personal/pressure alarm which was being used to alert staff of his/her attempts to self-transfer without assistance. The consequence of using the device was to decrease the risk of injury and falls; and noted the alarm may be annoying to the resident and peers. The alarm device would be evaluated on a monthly basis to identify a less restrictive device, a reduction in the use of the device or for the need to continue as. Condition change Prior to the 6/9/13 fall: Interdisciplinary progress (ID) notes dated 5/25/13 at 2 p.m. identified the resident returned from the hospital. A patient transfer form identified the [DIAGNOSES REDACTED]. On 5/30/13 at 5:30 a.m., the resident complained of dizziness while going to the bathroom and the resident complained of headache. At 2:45 p.m. of the same date, staff received physical therapy (PT) orders from a completed evaluation. Staff was to continue to use gait belt and walker for transfers and wheelchair when the resident appeared unsteady. On 5/31/13 at 11 a.m. ID notes identified the resident completed PT and could maintain balance with minimal assistance of one staff. The resident continued to experience headache pain. On 6/1/13 at 8 p.m., the resident appeared confused and complained of headache. Staff administered Flexeril (muscle relaxant) which helped somewhat. On 6/4/13 at 10:54 a.m. PT saw the resident. The resident completed PT with moderate contact guard assist of one staff. The resident had increased ambulation ability. On 6/6/13 at 10:45 a.m. the resident complained of a bad headache and not feeling well. On 6/7/13 at 3 a.m. the resident complained of severe headache and had an emesis. At 7 a.m. the resident had a moderate emesis. At 10:15 a.m., the resident refused PT due to not feeling well. At 1 p.m. the resident transported to the emergency room (ER) for change in condition. At 6:05 p.m., the resident returned to the facility with a new order for Percocet (narcotic pain reliever) At 9 p.m. the resident appeared very confused and leaned forward in the wheelchair. The resident required two staff to assist the resident to bed. On 6/8/13 at 1:30 p.m. the resident appeared very sleepy and stayed in room for breakfast. At 9 p.m. the resident still leaned to the side when up in the wheelchair. The resident did not seem to have the ability to form words and appeared a little confused. Fall: On 6/9/13 at 9:35 p.m. Staff I (licensed practical nurse) documented nurse aides called her to the North Hall STAT. She observed the resident on the floor on the left side with legs extended. Observation showed external rotation of the lower left extremity and the resident pointed to the leg and complained of pain. The resident wore shoes and the alarm functioned when the fall occurred. The resident did not use a walker and did not have the call light activated. The resident attempted to bring the facility portable phone back to the nurse ' s station and fell . The resident did not have pain prior to the fall. At 10:20 a.m., the resident transported to the emergency room (ER) for evaluation. At 1:30 p.m. the facility received information that the resident admitted to the hospital with [REDACTED]. Observation of the resident's room on 6/24/13 at 12 p.m. showed the resident's room 1/3 way down the north hall. A large lounge area separated the hall from the rest of the facility including the nurse ' s station. The Director of Nursing assisted the surveyor to measure the distance from the resident's recliner to where Staff I (licensed practical nurse) identified the resident laid in the hallway as approximately 9.5 feet. While measuring the distance, the Director of Nursing stated the resident probably started stumbling prior to the fall. (Based on the floor plan, Resident #1's room was three rooms away from where Staff A & Staff C were at during the time of the incident.) A hospital discharge summary identified the resident discharged from the hospital and back to the facility on [DATE] following open reduction and internal fixation surgery to the left hip. The resident also had a closed fracture of the distal clavicle. The resident had anemia likely due to blood loss from the hip fracture. The discharge summary identified the resident likely had osteopenia related to the multiple fractures that occurred on 6/9/13 and permanent atrial fibrillation. A care plan in place when the fall occurred identified the resident required assistance of one staff and gait belt and walker. The care plan identified the resident used a pressure alarm at all times due to care plan problem of history of multiple falls due to poor balance, decreased cognition and impulsive actions. Observation showed, on 6/20/13 at 9:27 a.m., the resident using a gait belt and standing at a bar with occupational therapy (OT) and physical therapy (PT). The alarm sounded when they stood the resident. When the surveyor informed the resident that she heard the resident had a fall, the resident replied, "I did?!" Staff Interviews: On 6/20/13 at 2:28 p.m., Staff A (certified nurse aide) stated she and one other staff (Staff C) worked on Resident #1's hall the day the resident fell . She stated they usually have 8 staff working but that day they had 6 staff on duty which meant two staff worked on Resident #1's hall. The other 4 staff worked down other halls. She worked the North hall with Staff C. She stated she thought lack of staff contributed to the fall because there was no one on the floor to answer call lights or alarms while she and Staff C worked in a room with the door closed. She stated they could not hear Resident #1's alarm sound while in the room with the door shut, TV on and while talking to the resident they worked with. She stated Staff C left the room to get a mechanical lift and saw Resident #1 on the floor. On 6/24/13 at 10:45 a.m., Staff A stated they worked in the room behind the closed door for approximately 15 minutes. In her written statement, Staff A wrote she and Staff C were the only 2 staff on the floor and they worked with a two assist resident. When Staff C went out of the room to get the mechanical lift, Resident #1 laid on the floor in the hallway. Resident #1's call light wasn't on and the alarm was muffled due to the alarm placement in the crack of the resident's chair. Staff A also stated the fall may have been prevented if staff could keep a closer eye on the resident because the resident was confused due to a condition change. On 6/23/13 at 2:54 p.m. Staff C (certified nurse aide) stated she worked in a room with the door shut when Resident #1 fell . She stated they worked in the room 40 minutes and she went out of the room to get the mechanical lift and that is when she saw Resident #1 on the floor. Staff C stated she couldn't hear the alarm until she got to the room next to Resident #1's. She stated either the alarm didn't work right or it was muffled. On 6/20/13 at 10:38 a.m. Staff I (licensed practical nurse) stated she sat at the nurse ' s station charting with door shut when staff called her to check Resident #1. She identified the resident's alarm as sounding but not loud enough for staff to hear. She stated the alarm could have laid on the speaker side which would muffle the sound. She stated she did not hear the alarm until she arrived at the entrance of Resident #1's hallway. She estimated the resident ambulated approximately 6 feet before falling. She stated she had given the resident the facility portable phone about 15 minutes prior to the fall. She stated 6 nurse aides worked which is normal weekend staffing. There wasn't a third staff on the floor. Maybe if the alarm sounded louder, staff may have heard it with the door shut. On 6/20/13 at 2:45 p.m. Staff E (licensed practical nurse) stated she worked the weekend of the incident. She stated there were only 2 staff down Resident #1's hall and they worked in a room with a resident that was 2 person transfer with the door shut. She stated staff can ' t usually hear alarms unless they are in a room right next to where the alarm sounds. On 6/20/13 at 3:35 p.m. Staff B (registered nurse and resident care coordinator) stated she was aware alarms are hard to hear when in a room with the resident door shut. On 6/20/13 at 10:05 a.m. the resident's responsible party stated the facility does not have enough help. The residents all require different things at the same time and Resident #1 is not patient. They tell the resident to stay put but the resident doesn't comply. During an interview with the DON on 7/8/13 at 11:08 a.m., she was informed that staff reported the alarms weren't audible behind closed doors, and whether she was aware alarms could not be heard. The DON replied no, and the facility tested the audibility after the surveyor left the facility. She stated according to their test if staff was in a room with the door shut, talking to a resident and with the commotions of the day shift noise, you couldn't hear it unless you were "really tuned in". However, the alarm wouldn't have prevented the fall.

Based on clinical record review and interviews, the facility failed to implement Resident #3's physician order [REDACTED]. In addition the facility did not recheck Resident #3's INR on 7/11/11 as the physician's orders [REDACTED]. Findings include: A Medication Discrepancy Report form dated 7/6/11, documented Resident #3 had been prescribed [MEDICATION NAME] 3 milligrams (MG's) or 6 mg 1/2 tablet by mouth every day. The report identified the actual medication that had been provided by the pharmacy had been an unbroken 6 MG tablet. The outcome for the resident had been an INR greater than 8.0 and the resident had been evaluated by a physician where the resident received Vitamin K immediately with an order to receive another dose of Vitamin K in 12 hour and to recheck his/her INR in the morning and to notify the physician. On 7/6/11 the physician directed the staff to give Vitamin K orally in 12 hours times 1 dose. The last dose had been given at 9:50 a.m. on 7/6/11 and to repeat the INR on 7/7/11. The incident report form dated 7/6/11 documented Resident #3 had an order for [REDACTED]. The report identified the medication cassette filled on 6/24/11 to 7/7/11 was filled with a full tablet rather than a ? tablet therefore the resident received 6 MG rather than 3 MG of [MEDICATION NAME]. Additionally, the medication had been removed from the medication cart. This form had been signed by the Director of Nursing, Administrator, Physician and Pharmacist. A record review of the Medication Administration Record (MAR) specified [MEDICATION NAME] 6 MG table ? tablet (3 mg) by mouth daily. The MAR showed staff signed off on administering the medication from 6/24/11 to 7/4/11, however the 7/5/11 dose had not been initialed on the MAR. During an interview 9/20/11 at 2:30 p.m., Staff A, Licensed Practical Nurse, confirmed the Coagucheck XS lab machine manufactured by Roche had not been able to register a direct read that may have been higher than 8.0 because that had been all the higher the machine would register. A Lab Report: INR MD Communication form dated 7/7/11 at 9:30 a.m., documented the residents INR lab value on this date had been 2.2 and his/her [MEDICATION NAME] had been on hold and he/she had received Vitamin K 5 MG times 2 doses in the past 24 hours. The physician directed the staff to give [MEDICATION NAME] 3 MG daily and repeat his/her INR on 7/11/11. Review of a INR Physician Communication form dated 7/7/11, documented a physician order [REDACTED]. The clinical record lacked any documentation the INR had been rechecked on 7/11/11. Review of a Lab Report: INR MD Communication form dated 7/18/11, documented the residents INR result as 1.6. During an interview 9/21/11 at 9:00 a.m., Staff A, LPN confirmed an INR level had not been drawn on 7/11/11 for Resident #3. Staff A notified the DON on 7/18/11, The DON directed Staff A not to worry about it as a medication error and/or an incident report form did not need to be filled out for a missed lab. The DON directed Staff A to draw the lab that day. During an interview 9/20/11 at 12:15 p.m., Staff A, Licensed Practical Nurse, confirmed it had been the facilities procedure to document a lab order on the calendar in the nurses station so he/she could check the calendar everyday and follow through with the appropriate physician ordered lab draws as directed. The staff member confirmed that Resident #3 had an order for [REDACTED]. When he/she checked the resident ' s INR level the results measured high. At that time this staff member and the charge nurse pulled the resident ' s medication cassette that contained the [MEDICATION NAME] pills and observed the cassette contained a whole [MEDICATION NAME] pill in the holding areas of the cassette not yet administered. The pharmacy had been contacted and described the pill in the cassette as a 6 MG [MEDICATION NAME] pill. Staff A then took the MAR and the cassette to the Director of Nursing and explained what had happened with the high lab value and the pills he/she had observed in the cassette. Staff A confirmed the Director of Nursing kept the medication cassette and said he/she would call the pharmacy. Staff A returned to the nurses station, called the physician who directed the staff member to bring the resident to his/her office. At the physician ' s office the resident had been administered Vitamin K and received an order to hold his/her [MEDICATION NAME] order, administer another dose of Vitamin K in 12 hours and re-check the INR on 7/7/11. During a re-interview 9/21/11 at approximately 9 a.m., Staff A, Licensed Practical Nurse, confirmed he/she had pulled the [MEDICATION NAME] cassette for the resident with Staff B, Licensed Practical Nurse, and could not remember the color of the pill but remembered there had been a #6 on the pill. Staff A stated he/she witnessed the Director of Nursing breaking the [MEDICATION NAME] pills left in the cassette for Resident #3 in half and placing them back in the resident ' s medication cassette. According to Staff A, the Director of Nursing stated staff would now know the pills were a 3 MG dose so the staff would not make the mistake again. At that time Staff A suggested to the Director of Nursing not to bother with breaking the pills because the [MEDICATION NAME] order may be different after the lab draw the following day. According to Staff A, the Director of Nursing made a sigh noise (deep breath) and stated that they could not send the [MEDICATION NAME] back to the pharmacy broken in half because the pharmacy would not know they had made a mistake. The Director of Nursing then left the nurses station with the cassette but Staff A did not think anything about it until he/she returned to the nurses station and told him/her the pills had been destroyed. During an interview 9/21/11 at 8:50 a.m., Staff G, Licensed Practical Nurse, confirmed he/she had removed the [MEDICATION NAME] cassette from the medication cart for the resident and gave it to Staff A, Licensed Practical Nurse but said he/she honestly could not remember any more information. During an interview 9/21/11 at 8:05 a.m., Staff B, Licensed Practical Nurse, confirmed he/she had observed the [MEDICATION NAME] pills in the cassette with Staff A, Licensed Practical Nurse, and observed what looked like a #6 on a whole pill but he/she could not remember the color of the pill. The staff member also confirmed he/she had witnessed the Director of Nursing destroying the pills in the bathroom. During an interview 9/21/11 at 7:40 a.m., the Director of Nursing stated that he/she did not have much memory about the incident except Staff A, Licensed Practical Nurse, had drawn an INR for the resident and it had been really high and that the staff member had made her aware of the situation. The Director of Nursing confirmed that she had been aware that Staff A and Staff B, had checked the residents cassette that contained the [MEDICATION NAME] medication and noted a #6 on the pills at which time he/she generated a Medication Discrepancy Report form and called the pharmacy. The Director of Nursing stated that if Staff A and Staff B had said he/she had destroyed the medications than she did and that she may have been thinking that he/she wanted to get the pills out of the facility. During an interview 9/21/11 at 7:45 a.m., Staff C, Registered Nurse, confirmed it had been the facilities protocol when passing medications to check the MAR with the cassette, administer the medication to the correct resident and then recheck cassette to MAR. During an interview 9/21/11 at 11:40 a.m., Staff A, Licensed Practical Nurse, confirmed that the facilities normal procedure when a medications had been discontinued and/or changed that the medication would have been crossed off the MAR and the cassette placed in the pharmacy box to be picked up. During an interview 9/23/11 at 10:40 a.m., Staff E, Registered Nurse, confirmed the facilities policy and procedure on proper medication administration had been to check the MAR, pull the cassette, compare the cassette to the MAR, place medication in a medication cup, recheck the cassette against the MAR and administer the medication. The RN confirmed that the facilities normal procedure to follow when a medication had been discontinued and/or changed would have been to put the discontinued cassette in the pharmacy box and reorder the medication even if there had been pills present in the cassette. During an interview 9/23/11 at 10:30 a.m., Staff D, Registered Nurse, confirmed the facilities policy and procedure on proper medication administration had been to match the patients name with the proper drawer of medications, compare the cassette to the MAR, place medication in a med cup, look at the medication and recheck the MAR, take medication to the resident, identify the medications and administer. The RN confirmed that the facilities normal procedure to follow when a medication had been discontinued and/or changed would have been to remove the cassette from the medication cart drawer and place it in the pharmacy box even if there had been medications present in the cassette. During an interview 9/23/11 at 10:35 a.m., Staff F, Registered Nurse, confirmed the facilities policy and procedure on proper medication administration had been to match to check the medication 3 times by opening the MAR, looking at the MAR and medication, open the medication cart drawer, remove the medication, check the cassette against the MAR, pop the pill, recheck the cassette then place the cassette back into the drawer. The RN confirmed that the facilities normal procedure to follow when a medication had been discontinued and/or changed would have been to remove the cassette from the medication cart drawer and place it in the pharmacy box, if the medication had been a controlled substance 2 nurses would be required to destroy the medication otherwise the medication would stay in the cassette and be returned to the pharmacy. During an interview 9/20/11 at 2:40 p.m., Staff H, Registered Nurse confirmed it had been his/her initials placed on the MAR on 7/4/11 which confirmed he/she had given the medication however he/she had not been able to recall what the pill may have looked like. . During an interview 9/20/11 at 2:45 p.m., Staff I, Licensed Practical Nurse, confirmed it had been his/her initials on the MAR on 7/1/11, 7/2/11 and 7/3/11 which confirmed he/she had administered the [MEDICATION NAME] however he/she had not been able to recall what the pill may have looked like. During an interview 9/20/11 at 3:20 p.m., the physician confirmed that if the cassette label read [MEDICATION NAME] 6 MG 1/2 tab every day than he/she would consider the situation to be an error on the facilities part. During an interview 9/21/11 at 9:30 a.m., the resident ' s physician confirmed the residents therapeutic level for his/her INR should be between 2.0 and 3.0. An observation 9/21/11 at 11 a.m., revealed a blue pharmacy tote in the medication room with 2 cassettes present in the box. During an interview at the same time, Staff D, Registered Nurse, confirmed the pharmacy picks up the box every night. During an interview 9/22/11 at 9:02 a.m., the pharmacist confirmed the normal procedure for the facility, when there had been a medication change and/or error, would have been to send the cassettes, containing the pills, back to the pharmacy and that the facility only destroy schedule II medications. The pharmacist also confirmed a delivery driver went to the facility 6 of the 7 days a week. Review of the facilities Medication Error and Medication Discrepancy Report revised 7/05, documented the policy had been to prepare and administer drugs and biological in accordance with the physician's order [REDACTED].