Every finding on record at Santa Fe Health & Rehabilitation Center

Based on observations, interviews and record review the facility failed to inform residents, both orally and in writing in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for 1 of 3 residents (Resident #1) reviewed for resident rights.The facility failed to maintain written acknowledgment that Residents #1 was informed prior to or at admission of their rights, the rules governing resident conduct, and their responsibilities during their stay at the facility This deficient practice could place residents at risk of not being aware of their rights, responsibilities, the facility's policies on admission.The findings included:Review Resident #1's face sheet, dated 03/10/26, revealed a [AGE] year-old female admitted on [DATE] with diagnoses of major depression (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems, heart failure, pulmonary hypertension (a condition characterized by abnormally high blood pressure in the arteries of the lungs, which can strain the right side of the heart and lead to heart failure and dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). Review of Resident #1's facility record revealed there was no signed acknowledgement that Resident #1 was informed of her rights and responsibilities.Observation and interview of Resident #1 revealed she was lying in bed. The resident was alert, oriented to name and place. She stated she did not know she was not receiving her major depression medication until the daughter informed her. She said the daughter felt her behavior changed and started asking questions about her medication. The Resident stated she did not have any interest in participating in activities because she was depressed.During interview on 05/06/26 at 11:25a.m, with Resident #1's RP, she stated she was the responsible party for Resident #1. She said Resident #1 was taking off her major depression medicine Lexapro without informing her. She stated the resident behavior was not normal. The RP stated Resident #1 was refusing meals, waking up at night and losing interest in everything. She stated she could not figure out what the problem was. She stated she requested the resident's medication list and found out Resident #1 was not taking her depression medication of Lexapro. She said the facility did not notify her before discontinuing the medication. She said she immediately informed the staff and medication was restored. The RP stated she did not receive notice of rights and services during admission either orally or in written form. She said she did not know her expectations and that of the facility. The RP stated she did not sign any admission documents as at the time of this interview.During interview with the ADM on 05/07/26 at 4:36p.m, he said there was no evidence that resident #1 was provided with written information regarding her resident rights on admission or after. He said they did not have any admission packet for Resident #1. The ADM stated the facility was working to ensure residents get their packets and their rights explained to them. He stated he was not aware that Resident #1 was not provided with her resident rights before admission to the facility. He said he looked and could not find Resident #1's packet. The ADM stated the facility admission was a work in progress and the facility is trying to get it right. Record review of the Facility policy on Resident Rights dated 02/23/16 reflected the following:Policy:The facility will inform the resident both orally and in writing in alanguage that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing.Policy Explanation and Compliance Guidelines:1. Prior to or upon admission, the social service designee, or another designated staff member, will inform the resident and/or the resident's representative of the resident's rights and responsibilities.2) Information about resident rights and responsibilities will be given to the resident both orally and in writing.3) Information about resident rights will be given to the resident in a language that the resident understands to the extent possible, considering impediments which may be created by the resident's health and mental status.

Based on interviews and record review, the facility failed to immediately notify the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was an accident involving the resident for 1 of 2 residents (Resident #1) reviewed for resident rights. The facility failed to inform the Resident #1 responsible party (RP) that her depression medications were discontinued.The Findings:Observation and interview of Resident #1 revealed she was lying in bed. The resident was alert, oriented to name and place. She stated she did not know she was not receiving her major depression medication until the daughter informed her. She said the daughter felt her behavior changed and started asking questions about her medication. The Resident stated she did not have any interest in participating in activities because she was depressed.Record review of Resident #1 MAR for April 1 through 30, 2026 revealed the resident started receiving Lexapro oral tablet 20 mg by mouth in the morning on 04/01/26. Record review of Resident #1 MAR for May 1 through 7, 2026 revealed the resident stopped receiving Lexapro oral tablet 20 mg by mouth in the morning on 05/07/26.During interview on 05/06/26 at 11:25a.m, with Resident #1's RP, she stated she was the responsible party for Resident #1. She said Resident #1 was taking off her major depression medicine Lexapro without informing her. She stated the resident behavior was not normal. The RP stated Resident #1 was refusing meals, waking up at night and losing interest in everything. She stated she could not figure out what the problem was. She stated she requested the resident's medication list and found out Resident #1 was not taking her depression medication of Lexapro. She said the facility did not notify her before discontinuing the medication. She said she immediately informed the staff and medication was restored. The RP stated she did not receive notice of rights and services during admission either orally or in written form. She said she did not know her expectations and that of the facility. The RP stated she did not sign any admission documents as at the time of this interview.During interview with DON on 05/07/2026 at 4:42p.m, she stated she was not aware Resident #1's RP was not informed when her depression medication was discontinued. She stated Resident #1 was transferred to hospice care. She said all Resident #1's medications were discontinued because hospice determines what medication is required for care moving forward. She stated she did not know if the hospice informed the RP. The DON stated the facility deferred to hospice after change in care status.

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #4) reviewed for wound care. RN G failed to use standard, proper technique and process while providing wound care for Resident #4. RN G did not cleanse the wound before applying physician ordered treatment. These failures placed residents at risk for the spread of infection.Findings included: Review of Resident #4's face sheet, dated 04/15/26, revealed the resident was a 63- year- old female admitted to the facility on [DATE] with diagnoses of urinary tract infection, drug induced subacute dyskinesia ( characterized by involuntary movements primarily affecting the face, tongue, often associated with prolonged use of antipsychotic medications), intermittent explosive disorder (characterized by sudden episodes of unwarranted anger and violent outbursts) and dementia (a syndrome characterized by a decline in cognitive functions affecting memory, thinking, behavior and the ability to perform everyday activities). Review of Resident #4's MDS assessment, dated 03/22/26, revealed Resident #4 required was dependent on staff assistance with most ADLs and one person assist with transfer. Resident #4 was always incontinent with bowel and bladder. Record review of Resident #4's care plan dated 04/14/26, revealed the resident was planned for pressure ulcer care. It stated Resident #4 has a pressure ulcer unstageable to distal medial foot and is at risk for infection, pain, and a decline in functional abilities. Its goal stated Resident #4 's pressure ulcer will show signs of healing through next review. Record review of Resident #4's physician orders dated 04/15/26 reflected as follows: Cleanse with wound cleanser unstageable to right medial distal foot then apply betadine to site every shift for wound care. Observation of wound care for Resident #4 on 04/15/26 at 10:02 a.m. revealed RN G washed hands and put on gloves before the start of care. RN G prepared a clean field on a medication tray. She removed the old dressing. A thin clear wound on the right distal medial foot was indicated. RN G changed gloves. She proceeded to apply betadine on the wound instead of first cleansing the wound and allowing it to dry. RN G doffed her gloves and washed hands before leaving Resident #4's room. In an interview on 04/15/26 at 4:50p.m. with RN G she stated she had been employed at the facility for 21 years. She stated she cannot remember the last time she received wound training. She explained she was made aware by DON that it was standard procedure to cleanse the wound before applying the treatment. She stated she was sorry for not following good infection control practice during Resident #4's wound care. RN G noted she has learnt from her mistake. During an interview with the DON on 04/15/26 at 4:46p.m. she stated she was aware of some of the concerns raised about RN G's wound infection control problems. The DON explained it was expected practice to always cleanse the wound before applying physician ordered treatment. She said it is expected that the nurse will prepare a clean field and cleanse the wound and apply treatment after drying the wound. The DON stated the staff receive training annually through the program. Review of the facility policy on skin prevention and management revised 02/14/22 reflected the following:Guideline statement:This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.Interventions for Prevention and to promote Healing:a. The initial plan of care is completed by the licensed nurse for patients with pressure ulcers. The goal of the care plan may include but not be limited to: promoting the prevention of pressure ulcer development, promoting the healing of pressure ulcers that are present, prevention of infection ofthe wound to the extent possible.b) The interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.c) Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to:1) Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.);2) Minimize exposure to moisture and keep skin clean, especially of fecal contamination.3) Provide appropriate, pressure-redistributing, support surfaces.4) Maintain or improve nutrition and hydration status, where feasible.5) Skin care interventions such as showers, incontinent care, barrier creams, moisturizers,repositioning devices/schedule and adaptive devices, etc. are used to reduce the risk ofpressure injury development and other alterations in skin integrity

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments on 2 of 8 (Medication Cart 100 and Medication Cart 200) medication carts reviewed for pharmacy services.The facility did not ensure medication carts 100 and 200 were secured and locked when unattended.This failure could place all residents at risk of drug diversion.Findings included:During an observation and interview on 4/14/2026 at 6:28 AM, medication cart 200 was found unlocked and unattended against the wall of hall 200 beside the entrance into the dining room. DON was present in the hallway at that time. There were no other staff in the area. She locked the cart and stated LVN D was responsible for that medication cart. DON stated this failure could result in medications being taken by someone who is not supposed to have them potentially causing harm. During an observation on 4/14/2026 at about 6:55 AM, medication cart 100 was found unlocked with a drawer partially opened outside of room [ROOM NUMBER]. The resident door was closed, and the medication cart was unattended. LVN D was observed exiting room [ROOM NUMBER]. LVN-D refused to be interviewed. She pushed the medication cart against the wall at the entrance of the 200 hall.During an interview on 4/14/2026 at 8:40 AM with ADMN, stated LVN-D had failed to meet and maintain facility policy and standards of storing and securing medications.Record review of a policy titled Medication Storage dated 1/20/2021 revealed the following:General Guidelines:All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperatures.Only authorized personnel will have access to the keys to locked compartments.During a medication pass, medications must be under the direct observation of the person administering the medication storage area/cart.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 3 residents (Resident #86) observed for infection control.Facility staff (CNA-C) failed to sanitize, wash hands, and/or change gloves while providing perineal care to Resident #86.This failure could place all residents at risk of infectionFindings included:Record review of Resident #86's Electronic Face sheet dated 04/15/26 revealed he was a [AGE] year-old male. He was admitted to the facility on [DATE]. Diagnoses included: Hemiplegia (Paralysis) and hemiparesis (weakness) following Cerebral infarction (Stroke) affecting left non-dominant side, Depressive episodes, Type 2 Diabetes Mellitus with hyperglycemia (elevated blood glucose), Morbid obesity, Dysarthria (speech disorder) and anarthria (loss of ability to articulate) , Malignant neoplasm of duodenum (cancer of the small intestines), and Frontal lobe and executive function deficit (damage to the part of the brain that controls memory and impulse control) following cerebral infarction.In an observation on 4/13/2026 at 2:56 PM CNA-C put gloves on without performing hand hygiene prior to providing incontinent care to Resident # 86. CNA-C applied gloves and assisted resident with positioning to lower his pants and remove the mechanical lift pad. CNA then used wet wipes to clean peri-area for brief change. There were no briefs available at bedside, and CNA-C went around the privacy curtain and opened a drawer of roommate's nightstand for a brief. CNA returned to bedside of Resident #86 and turned resident to properly position brief. CNA-C then stated to the resident he needed to go get something to dry him with and opened the resident door without removing gloves and walked through the hallway to a linen cart where with gloved hands retrieved washcloths and returned to bedside to complete incontinent care. CNA-C removed gloves when leaving the room to get a urinal for resident without using hand sanitizer or washing his hands.In an interview on 4/13/2026 at 3:37 PM with CNA-C, he stated he has worked at this facility for about 1.5 years. He stated he had training in infection prevention. He stated trainings are provided by the DON in person. He stated he should perform hand hygiene and change gloves maybe like when I move between patient. He stated he should have changed his gloves during observed incontinent care but I just didn't do it. He stated negative outcomes of poor hand hygiene could cause infection for the resident. He stated he should wash his hands when touching a patient and before touching someone else.In an interview on 4/13/2026 at 3:42 PM with the DON, she stated her expectation was for hand hygiene to be completed when entering or leaving a resident's room, in between tasks or when hands are dirty. She stated negative outcomes of poor hand hygiene practices could result in illness and residents getting sick.Record Review of Policy titled Infection Prevention and Control Program dated 10/24/2022 revealed [in part}:4. Standard Precautions:a. All staff should assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident services.b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. Record review of Policy titled Hand Hygiene dated 2/20/2020 and revised on 2/11/2022 revealed [in part}:Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility.6. Additional considerations:a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.Record review of document titled Incontinence Care dated 4/14/2014 revealed [in part]Procedure:1. Assemble equipment4. Wash hands5. Put on non-sterile, latex free gloves8. If feces present, remove with toilet paper or disposable wipe by wiping from front of perineum toward rectum. Discard soiled material and gloves. Wash Hands.9. Put on non-sterile, latex free gloves. 11. Cleanse peri-area and buttocks with cleansing agent wiping from front of perineum toward rectum. Turn patient side to side to cleanse entire affected area, as needed. Rinse with water, if needed or per incontinent product manufacturer's instructions.12. Dry peri-area and buttocks from front to back.13. Apply skin protectant products, if needed and, or as ordered, per manufacturer's instructions.15. Remove and discard gloves.16. Wash Hands.

Based on interviews and record reviews, the facility failed to ensure that the activity program was directed by a qualified professional who completed a training course approved by the state for 1 of 1 (AD) activity director reviewed for training. The facility Activity Director (AD) failed to take her annual 8 hours of continuing education course work for Activity Director through the state AD training website. These failures could place residents at risk of inadequate activities from incompetent/untrained staff. The findings included:Record review of personnel files on 04/15/2026, revealed that the AD, with a hire date of 04/02/2023, did not receive/provide the facility with her 8-hour annual CE training.In an interview on 04/15/2026 at 4:25 PM AD stated she does not currently have her 8 CE hours for Activity director. She said she thought her {facility online training} hours from the facility trainings would cover those hours and was just told yesterday bherse CE credits did not count towards her AD continuing education hours. She stated she is currently searching for an online program to attain the CE credits she needs. In an interview on 04/15/2026 at 4:34PM HRD was made aware yesterday that the AD did not have her yearly 8 hours when she asked her for the copy of her 8 hours. HRD stated that when you take the certification class you are told about needing 8 hours a year and given instructions on what website to use.In an interview on 04/15/2026 at 4:55PM ADMN, stated he is the AD's direct supervisor, and he expects the staff to keep up with what training they need for their certifications whether it be AD, nursing, the aides, anyone. He stated he will dig into why this happened and make sure it gets done. He stated that it is not acceptable for staff not to complete their training and in-services. The {facility online training} in-services are logged and notify the facility leadership about incomplete assignments. This 8-hour training course is with her certification and is required outside the facility training. He denied having a policy for staff completion of required training, Record review of the Job Description for the AD, undated, reflected the staff development: Attend and participate in training, educational activities, and staff meetings, assist with orientation and training other staff. Qualifications reflect: Successful completion on a state approved and certified course of instruction in patient activities.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 09/18/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including methicillin susceptible staphylococcus aureus infection (bacterial infection), methicillin resistant staphylococcus aureus (bacterial infection), constipation, bacteremia (presence of live bacteria in the bloodstream) and personal history of malignant neoplasm of breast (breast cancer). Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 required dependent assistance with most activities of daily living (ADLs). Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's Care Plan revised 07/30/25 revealed he had bowel and bladder incontinence. The goal stated Resident #1 will be clean and odor free through the next review date. Observation of incontinence care for Resident #1 on 09/17/25 at 11:14 a.m., revealed CNA A washed her hands prior to putting on gloves. CNA A removed Resident #1's brief that was soiled with urine. CNA A wiped the resident from front to back. She did not change gloves but continued to clean the resident. Her gloves were visibly soiled with urine. CNA A did not wash her hands, change gloves, or perform hand hygiene before placing the clean brief underneath the resident. CNA A retrieved the old, soiled brief and placed on a trash can. CNA A removed her gloves and picked up the trash. She washed her hands before leaving Resident #1's room. In an interview on 09/17/25 at 11:14 a.m. with CNA A, she stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she has been in the facility for 2 years and received infection control training during orientation. She said cross contamination was going from clean to dirty. CNA A noted the resident could acquire an infection when she did not follow good infection control practices including changing gloves before retrieving the clean brief. CNA A stated she did not change her gloves because she was put on the spot and was nervous. During the interview on 09/18/25 at 1:30 p.m., the DON acknowledged being aware of some of the concerns raised about infection control practice. She stated ADON B was responsible for infection control in the facility. The DON stated employees receive training in infection control monthly. She explained that the facility conducts spot checks and training with return demonstrations, and monitors staff with return demonstration periodically. The DON stated the aides were expected to follow standard precautions including washing hands and changing gloves while providing care. Review of the facility's infection control policy revised 04/12/23 reflected:Policy:This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines.Standard Precautions:a) All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted while providing resident care services.b) Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.c) All staff shall use personal protective equipment (PPE) according to established facility policy.d) Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility practices.e) Environmental cleaning and disinfection are performed routinely with high touch cleaning proceduresf) All staff have responsibilities related to reporting cleanliness issues in the facility to the Administrator/designee and housekeeping

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs for 1 of 5 residents (Resident #5) reviewed for pharmaceutical services, in that: RN A failed to reorder medication for Resident #5 before his supply was depleted. These failures could place residents who receive medications at risk for a decline in health and of not receiving the intended therapeutic benefit of the medications. The findings included: Record review of Resident #5's face sheet dated 08/07/2025, revealed a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with the following diagnosis: diabetes mellitus with high blood sugar (a condition in which the is improper metabolism of carbohydrates resulting in too much sugar in the blood). Record review of Resident #5's admission MDS dated [DATE] revealed Section-C Cognitive Patterns Resident #5 had a BIMS score of 13, meaning mild cognitive impairment. Section N revealed he received insulin injections one time in the last 7 days. Record review of Resident #5's physician orders revealed start date 07/27/25, Monjarno Subcutaneous solution, Auto-injector 5 mg/ml (Tirzepatide) every Monday inject one application subcutaneously ( refers to the deepest layer of the skin. containing a layer of fat cells and collagen) in the morning. Daily Blood sugar monitoring was ordered at 8:00 Am daily. Record review of the medication administration record on 08/06/2025 at 3:30 PM for July 2025 and, August 2025 revealed Resident #5 had not been administer his Monjarno since 07/28/25 . It had not been administered for the entire month of August as of 08/06/2025. One dose of Monjarno was ordered weekly. Review of the Care Plan revised 06/25/25 for Resident #5 revealed, Resident #5 has a diagnosis of diabetes and is at risk for hypo/hyperglycemia. Interventions: Administer diabetic meds per MD order. Monitor blood sugars as ordered. During an Interview on 08.06.2025 at 1:00 PM Resident #5 stated that he had not received His Monjarno injection weekly on Monday as ordered by his physician. He stated A nurse told him that they were out of the Medication on 08/04/2025 and it needed to be ordered. He stated he did not know her name, but she told him that she would order it and she was here now and he still had received the medication. He stated he just wanted his medication because he needs it. He stated his blood sugars was 136 this morning. During an Interview with RN A at 4:00 Pm on 08/06/2025, she stated she gave the Monjarno to the resident on 07/27/2025. She stated there must have been one syringe left in the box or she would have reordered the medication at that time. She stated on Monday 08/04/2025 she went to administer the Monjarno, and the box was empty. She stated she ordered the medication at that time. She stated she should have notified the physician that the Monjarno was not available, but she was busy, and she just let it slip her mind. She stated she worked on 08/05/2025 and on 08/06/2025 and the medication still had not come in. She stated she threw the box away when she ordered the medication on 08/04/2025, which she should not have done until the new medication came in. She stated that by failing to administer the medication when the medication was ordered and not notifying the physician that it was not available could have caused an adverse effect for the resident. The resident could have had an increase in his blood sugar and not received the appropriate treatment that he needed. During an interview with the NP 4:30 PM on 08/06/2025 the NP stated she was not aware until today that Resident #5 had missed a dose of his Monjarno. She stated he told her when she saw him today (08/06/2025) that he hadn't received the medication since last week. She stated that Resident #5's blood sugars were normal for him today at 147 and that the delay in him receiving his Monjarno was not detrimental to his health or likely to cause serious illness. She stated she would address the matter, contact the pharmacy, and make necessary treatment changes if indicated. She stated she did expect the nurses to notify her if a resident was not taking their medication or that medication was not available from the pharmacy. During an Interview at 4:40 PM with RN B she stated resident #5 was not administered Monjarno on Monday, Tues, or Wednesday. Resident had just completed a treatment for Mr. [NAME] at the time just prior to the interview. There was no documentation In an interview and observation of the medication cart with the DON and ADON on 08/06/2025 at 3:30 PM, the DON reported she expected the Monjarno to be ordered when the last dose is used, and her expectation was that resident's should not run out of their medications. She stated that there were medications in the emergency kit that could be administered, but due to the price of the Monjarno, it was not a medication that was available in the emergency kit. She stated failure to receive medication as ordered could be detrimental to a resident's health. She confirmed the medication could not be found and stated it had been re-ordered today. She stated the physician had been notified of the missed dose and that the medication was re-ordered again today. She stated a complete cart audit and medication reconciliation was conducted on all carts to ensure that that all residents' ordered medications were available for administration and all staff were in-serviced on the proper procedure for reordering medication by herself and the regional nurse . She stated she believed the failure occurred because there was not a designated person responsible to order the medications and no one was designated to monitor the carts and spot check behind the nurses prior to this. She stated she and the ADONs would be responsible for auditing the medication carts for medication availability weekly and the night nurses were responsible for ordering medications on Monday and Thursday nights. She stated that carts would be checked 3 times a week with this new process. Record review of facility policy titled, Medication Treatment Administration and Documentation dated January 2014 stated in part: Verify labels accurately reflect the physicians orders on the MAR or TAR prior to administering medication and treatments. Verify and provide medication or treatment focused assessment such as Wound status B/P or as indicated by physician orders, Administer the medication according to the physicians orders, document and sign for medications and treatments when administered immediately following administration. Medications or treatments that were not administered should be documented as not administered on MAR/TAR with the reason for no administering the medication and the physician notified . Check the emergency box for availability for medication not available provide the physician with a list of medication available and physician response, notify the physician when medication and treatments will be available, document omission on the 24 hour report of med not available with a summary of medication or treatment administration issues to on-coming charge nurses or CMA during the shift to shift report.

Based on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurate for 1 of 5 (Resident #5) residents reviewed for resident records. RN A failed to ensure she documented treatment orders on the MAR or progress notes when not administered for Resident #5. This failure could place residents at risk of having errors with their care and treatment. Findings included: Record review of Resident #5's face sheet dated 08/07/2025, revealed a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with the following diagnoses: dermatitis (a condition in which the skin becomes red, swollen and sore, with small blisters forming caused from irritation or allergic reaction), diabetes mellitus with high blood sugar (a condition in which the is improper metabolism of carbohydrates resulting in too much sugar in the blood). Record review of Resident #5's physician orders revealed start date 07/30/2025 Clotrimazole Cream 1 percent apply to face and ears two times a day for fungal involvement of face and ears for 14 days. For 2 weeks. Record review of Resident #5's MAR for August 2025 revealed the Clotrimazole 1 percent Cream was applied at 9:00 AM on 08/01/2025, at 9:00 AM on 08/02/2025, and at 9:00 AM 08/03/2025. There was no documentation on 08/04/2025 of Clomitrazole cream administration, and there was documentation on 08/05/2025 at 9:00 AM only and 08/06/2025 at 9:00 AM only. Record review of Resident #5's physician orders revealed start date 07/30/2025 Triamcinolone Acetonide Cream 0.1 percent, apply to both arms 2 times a day for dermatitis for 2 weeks. Monitor for effectiveness x 1 week and may continue 1 more week if needed not to exceed 2 weeks. Record review of Resident #5's progress notes and the MAR/TAR for August of 2025, revealed no evidence of Triamcinolone Cream administration or monitoring for effectiveness per physician order on 08/01/2025 thru 08/06/2025. Record review of Resident #5's active orders for August 2025 revealed: start date 08/01/25 Lotrisone1-0.05 percent cream apply to penis two times a day for fungal infection. Record review of Resident #5's MAR for August 2025 revealed the Lotrisone1-0.05 percent cream apply to penis two times a day cream was applied 2 times at 9:00 AM and 5 PM on 08/02/2025, and 2 times at 9:00 AM and 5 pm on 08/03/2025, There was no documentation on 08/04/2025 , and there was documentation on 08/05/2025 of one administration at 9:00 AM and one administration on 08/06/2025 at 9:00 AM . During an interview on 08.06.2025 at 1:00 PM Resident #5 stated that he had not received the 3 creams that the physician ordered for his dermatitis since Saturday 08/02/2025). Resident stated he had a rash that was on his face, ears, and his penis. He stated he thought he had not received the medication because his regular treatment nurse was on vacation starting 08/01/25. He stated he hadn't received his cream 2 times a day since then. He stated he told a couple of nurses, but he did not know their names. He stated he didn't want to get anybody in trouble, but he just wanted his medicine like he was supposed to have it. During an interview on 08/06/2025 at 3:15 PM the ADON stated she was educated on how to document when received her education for her license. The ADON stated she expected that the nurses had been trained to document in school, and they were also trained during orientation and provided in-services by the facility on an as needed basis. The ADON stated her expectation would have been that staff document the care when given and that they administer the creams as ordered, She stated an adverse outcome for the resident would be the resident not receive the care he needed to make him better. During an interview on 08/06/2025 at 3:25 PM the DON stated her expectation was that nurses follow physician orders and document their actions in residents electronic chart in the MAR and/or the progress notes. The DON stated if an order stated, apply the medication 2 times a day, the nurse should have applied the medications 2 times a day and monitoring the resident's response to the treatment in the resident's electronic chart. The DON stated resident's response should have been documented on the MAR or in the progress notes. The DON stated the failure could have caused Resident #5 to have a negative outcome of not having the care that he needed . The DON stated the failure occurred because of the nurses' failure to follow the policy on proper documentation of medications. The DON stated herself and the ADONs were ultimately responsible to monitor to ensure residents were receiving their medications as ordered. Record review of facility policy titled, Medication Treatment Administration and Documentation dated January 2014 stated in part: Verify labels accurately reflect the physicians orders on the MAR or TAR prior to administering medication and treatments. Verify and provide medication or treatment focused assessment such as wound status, blood pressure as indicated by physician orders, Administer the medication according to the physicians orders, document and sign for medications and treatments when administered immediately following administration. Medications or treatments that were not administered should be documented as not administered on MAR/TAR.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerator and dry storage This failure could place residents that eat out of the kitchen at risk for foodborne illnesses. Findings include: During an observation of dry storage on 02/19/2025 at 09:10 AM revealed the following: *2 large plastic containers with label-powder milk with no use by date, *One bag of light brown in color, appeared to be crushed breadcrumbs sealed bag no label or date, *1 bag egg noodles in plastic zip bag with no used by date, *1 bag spaghetti noodles in plastic zip bag no used by date, *1 box lasagna noodles in plastic bag with no used by date, *1 bag vanilla wafers in zip lock with use by date 10/23, *8 packages vanilla wafers with no label or dates, *1 box powdered sugar open with no dates, *1 bag coconut flakes in a box with plastic bag not sealed or labeled. During an observation three door refrigerators on 02/18/2025 at 09:30 AM revealed the following: *1 open 1/2 box bacon slices not sealed or dated. *1 1/2 empty grape jelly jar with lid on, not dated or labeled. *1 carton approximately half full (40-ounce box) thickened sweet tea opened with no open date or use date. * 4 cartons of thickened sweet tea unopened. During an interview on 02/18/2025 at 10:00 AM the DM stated all products should have a received date and used by date. She stated some products have a used by date and that should be circled. The DM stated the potential harm to residents would be food poising, diarrhea, sickness, bacteria on food. The DM stated the failure occurred due to staff not paying attention. During an interview on 02/21/2025 at 09:10 AM the ADMIN stated his expectations was all products in the kitchen be labeled and dated correctly. The ADMIN stated he did spot checks periodically in kitchen to be sure everything was working in kitchen. The ADMIN stated if residents were served out of date food products it could result in stomach aches, diarrhea, cause them to get sick. The ADMIN stated it was the responsibility of the DM to ensure all products are labeled correctly. During a telephone interview on 02/21/2025 at 09:21 AM the Dietician with contracted dietary services, stated all products should be dated with date received and once a product was opened, it was dated with used by date. The Dietician stated potential harm to resident could be it could cause illness and contain bacteria. The Dietician stated she comes to facility once every 6 weeks to monitor kitchen staff and ensure products are labeled and dated. The Dietician stated the DM was new and was trying to educate kitchen staff on labeling and dating food products. Review of facility's policy titled: Food Storage-Dry Goods It is the center policy to insure all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code . Review of facility's policy titled Food Storage: Cold dated October 2019 revealed: It is the center policy to ensure all time/Temperature control for Safety (TCS), frozen and refrigerated foods items, will be appropriately stored in accordance with guidelines of the FDA Food Code. 5. The Dining Services Director Cook(s) insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination .

Based on interview and record review, the facility failed to ensure that the residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the residents unopened for the entire facility reviewed for resident rights. The facility failed to ensure that residents received packages unopened. This failure could affect residents by placing them at risk of not receiving packages unopened that could result in residents experiencing diminished psychosocial well-being and quality of life. The findings included: During a confidential resident group meeting 02/19/25 at 02:13 PM, 10 confidential residents stated they had received mail and packages that had been opened by staff. They stated mailed was not delivered daily and there was no set schedule. They stated sometimes the mail was just placed in their rooms and they were not aware they had received a letter or a package. Residents stated they felt that it was a violation of their rights for their mail and packages to be opened and gone through. They stated no staff had ever asked them if they could open their mail nor had they been present while staff opened their mail. During an interview on 02/20/25 at 02:50 PM, the AD stated she delivered the mail daily. She stated she never opened residents mail but if a resident received a package, she took it to the ADON who opened it to ensure that the resident had not ordered anything that they were not allowed to have, such as medications or tobacco products. During an interview on 02/20/25 at 03:11 PM, the ADON stated packages were brought to his office before delivered to the residents because there could be medication in them. He stated he did not open boxes unless he knew they contained medications. During an interview on 02/20/25 at 03:19 PM, the DON stated he was unsure as to who was responsible for passing out mail. He stated he was unaware of any residents' mail or packages being opened. He stated no residents mail should ever have been opened unless approved by the resident and the resident was present. The DON stated it was a violation of resident rights to open any mail or packages. During an interview on 02/21/25 at 09:26 AM, the ADMN stated mail should have been delivered daily by the activity director. He stated residents mail should have never been opened without the resident's permission. He stated he was not notified of packages being opened. Admin stated it was a violation of resident rights to open and look at any mail. He stated he did not know what lead to the failure. Review of facility document titled, Statement of Resident Rights, not dated, revealed in part: You, the resident, do not give up any rights when you enter a nursing facility .You have the right to .17) Receive unopened mail and to receive assistance in reading and writing correspondence .

Based on observation, interview, and record review the facility failed to ensure pharmacy procedures were followed for 1 of 4(200 Hall Medication Cart) medication carts, and 2 of 2 medication refrigerators reviewed for pharmacy services. The facility failed to remove expired medications from the 200 Hall Medication Cart. The facility failed to document monitoring of temperatures in the medication storage refrigerators in the medication room. These failures could place residents at risk of receiving ineffective therapeutic doses. The findings include: An observation on 02/19/25 at 11:45 AM of the 200 Hall Medication Cart revealed that the bottom drawer contained a bottle of a liquid oral supplement that was marked as opened on 06/01/24 and expired 07/27/2024 per date on the bottom of the bottle per manufacturer. In an interview on 02/19/25 at 11:48 AM with RN A, who was using 200 Hall Medication Cart, stated that the bottle should have been checked and discarded way before now. She further stated there are no patients on 200 Hall at this time with orders for this supplement. She stated it was the expectation of the staff to review supplies on the cart daily to verify nothing was expired. She also stated expired medications or supplements that are given to patients could result in making a resident sick or resident may not receive the therapeutic dose they need. In an interview on 02/19/25 at 03:48 PM with DON, stated the expectation of the medication cart and expired medications was to not have any. He stated he and the ADON are always going through them and have a pharmacy consultant that comes and audited the facility. He stated he was amazed there was anything expired, and an adverse outcome could be the resident would get sick or the medication could be ineffective. In an observation on 02/20/25 at 09:20 AM of the medication room revealed 2 temperature logs have not been completed since 02/12/25 for 2 refrigerators. Refrigerator #1 stored lab draws and urine specimens that must be refrigerated while waiting to be picked up, current temperature on thermometer shows 36 degrees and there was currently 1 urine specimen for pick up. Refrigerator #2 contained medications (such as inhalants for breathing treatments, suppositories, and some narcotics which have a secondary lock) that must be refrigerated and current temperature on thermometer shows 38 degrees. In an interview on 02/20/25 at 09:22 AM with RN B stated the temperature logs for the refrigerators are to be completed every day but she was not sure why it was not done since 02/12/25. She further stated the DON oversaw that they are completed. She stated an adverse outcome would be the medication would probably be ineffective or make a resident sick. In an interview on 02/20/25 at 09:30 AM with DON stated his expectations for the refrigerator temperature logs in the medication room was for the temperatures to be checked and logged every night and it was the night nurse's job. He stated an adverse outcome would be defective medications or labs ruined that were collected and waiting for pick up. Record review of the facility policy titled VIII. Storing Drugs, undated, reflected [in-part]: Procedures: 6. Drugs are to be store at proper temperatures. Drug storage conditions are defined as follows: Temperature Range Storage Condition Celsius Fahrenheit Refrigerated 2 - 8 36 - 46 7. Drugs requiring refrigeration are kept in the refrigerator in the locked medication room and kept separate from other items. 8. Drugs are not to be kept on hand after the expiration date which appears on the label. Outdated, contaminated, or deteriorated drugs, and those in containers which are cracked, soiled or without secure closure are to be immediately withdrawn from stock, re-ordered from the pharmacy if a current order exists for it, and disposed of in accordance with the procedures for drug destruction.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff (LVN-B, CNA-D, CNA-C) reviewed for infection control procedures. The facility failed to ensure the LVN-B perform proper hand hygiene before and after providing resident care. The facility failed to ensure the CNA-D perform proper hand hygiene before and after removal of gloves. The facility failed to ensure the CNA-C performed incontinent care in accordance with facility policy. These failures could place residents at risk for the transmission of communicable diseases. Findings included: During an observation and interview on 03/14/2024 at 9:33 a.m., LVN B was observed performing medication pass. LVN B went into resident's room to obtain blood pressure using wrist cuff and did not perform hand hygiene before or after leaving room. LVN B brought in a different wrist blood pressure cuff into room to attempt to obtain another blood pressure without performing hand hygiene before or after leaving room. She opened medication cart and dispensed scheduled medications into cup. LVN B brought medication and water into resident's room and watched as he swallowed medications then she left room without performing hand hygiene. She went to medication cart to open and count narcotic sheets and did not perform hand hygiene. LVN B stated that she has had training on infection control. She stated hand hygiene should have been performed upon entering and leaving resident's room. She stated she had been busy that morning and nerves also contributed to her not performing hand hygiene. She stated not performing could cause spread of infection from one resident to another. During an observation and interview on 03/14/2024 at 10:04 a.m., CNA D performed urine incontinent care for resident. She rolled resident to the right side and cleansed buttocks with wipes. She reused wipes after folding in half. She then applied cream to resident's buttocks with right gloved hand. She removed right glove on right hand and threw into trash receptacle. She then put on another glove to right hand without performing hand hygiene. She placed a new brief under resident and instructed for her to roll onto back. CNA D then wiped front or resident toward the back reusing wipe after folding in half. CNA D secured brief onto resident and removed her gloves throwing into trash receptacle. CNA D did not perform hand hygiene and started opening drawer to get pants out. CNA D stated that she was unsure if hand hygiene needed to be performed when changing gloves. CNA D stated that she should have cleansed front of resident before cleansing back when performing incontinent care. She wasn't sure why she cleansed back prior to cleansing front but felt that being nervous may have made her perform wrong. She did not know what facility policy stated on hand hygiene or incontinent care. She stated performing incontinent care incorrectly could cause resident to have infection. During an observation on 03/14/2024 at 10:13 a.m., CNA C performed bowel incontinent care. CNA C used disposable wipe to collect stool and then folded wipe in half and reused again to wipe skin. She disposed of soiled wipes into trach receptacle and did not remove gloves. She opened dresser drawer to get clean brief and placed under the resident. She removed gloves after and washed her hands with soap and water. During an interview on 03/14/2024 at 10:25 a.m., CNA C stated she should have replaced gloves and performed hand hygiene before opening drawer to obtain clean brief. She stated it was not appropriate to fold disposable wipes in half and continue to clean skin but should have gotten new wipe each time. She felt that being rushed to perform incontinent care led to failure since wound care nurse was performing care at the time incontinence occurred. CNA C stated she had been trained on infection control and that not performing incontinent care correctly could lead to resident having infections. During an interview on 03/14/2024 at 3:23 p.m., the DON stated his expectation of staff would be that hand hygiene be performed when entering and exiting a resident's room. He stated it would not be appropriate to reuse disposable wipes after folding and he expected new wipe to be used every time. The DON stated he expected staff to perform hand hygiene before and after removing gloves and failing to perform hand hygiene could cause infections to spread and residents to become sick. The DON stated he did not know why staff failed to perform hand hygiene appropriately and LVN B was an infection preventionist at the facility. He stated that both him and the ADONs were responsible to monitor that staff were knowledgeable in infection control and performed resident care appropriately to help prevent risk of infections from occurring. Record review on 03/14/2024 at 3:20 p.m. revealed LVN B, CNA C, and CNA D had infection control training upon hire and then annually. Review of facility policy titled Hand Hygiene dated 02/11/2022 revealed: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand hygiene table revealed: Either soap and water or alcohol-based hand rub should be used between resident contacts; after handling contaminated objects; before applying and after removing personal protective equipment including gloves; before preparing or handling medications; before performing resident care procedures; after handling items potentially contaminated with blood, body fluids, secretions or excretions. Review of facility policy titled Incontinence Care dated 02/14/2020 revealed: If feces present, remove with toilet paper or disposable wipe by wiping from front of perineum toward rectum. Discard soiled materials and gloves. Wash hands. Put on non-sterile, latex-free gloves. Position on back with knees flexed and feet flat on bed (care may also be provided with patient sitting on commode or shower chair or in a standing position). Cleanse peri-area and buttocks with cleansing agent wiping from front of perineum toward rectum. Turn patient side to side to cleanse entire affected area, as needed. Rinse with water, if needed or per incontinent product manufacturer's instructions. Dry peri-area and buttocks from front to back. Apply skin protectant products, if needed and, or as ordered, per manufacturer's instructions. Remove linen/ underpad and discard. Remove and discard gloves. Wash hands. Apply clean linen/underpad, brief or other incontinent products, as needed. Reposition for comfort with call light in reach and provide additional care as needed as requested by patient. Return equipment to designated area and clean/dispose as indicated.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services The facility failed to prevent the following: 1. Vinyl mesh liner was used to cover stainless steel surfaces on shelves and in drawers. 2. Floor tile grout was soiled with a dark colored build-up and dried food throughout the kitchen. 3. The interior surface of the microwave oven was soiled with dried food and grease. 4. The three-door freezer unit for storing breakfast foods and desserts had a temperature above zero and food items were not frozen solid. 5. The sink for the garbage disposal leaked and a bucket was on the floor beneath it to catch dripping water. 6. Floor tiles were missing near the dish machine. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may be contaminated. The findings included: Observations on 1/22/24 at 10:45 AM, during the initial tour of the dietary department, revealed the following: - mesh liner was on the shelves beneath the microwave counter, food processor counter, and center island food preparation counter; - mesh liner was on the bottom surface of three stainless steel drawers used for storing cooking utensils; - the interior surface of the microwave oven was soiled with dried splattered food and grease; - dark colored grease streaks and drips were on the front exterior surface of the oven door; - the manual can opener was soiled with dried food; - plastic storage container lids were soiled with dust and food crumbs in the non-perishable food storage room; - floor tile grout was soiled with a dark colored build-up and dried food throughout the kitchen. Observation and interview on 1/22/24 at 11:08 AM revealed a freezer unit with three locked doors was located against a wall outside the kitchen in the area leading to the dining room. The Dietary Supervisor unlocked the first door for the breakfast food freezer and the thermometer inside registered 11 degrees F. The middle door for desserts was unlocked and thermometer inside registered 21 degrees F; the containers with ice cream and sherbet were not frozen solid. The exterior unit dial thermometer registered 21 degrees F. The Dietary Supervisor threw the soft sherbet and ice cream in a trash can. A stainless steel rectangular pan was covered with plastic wrap on the top shelf in freezer. The plastic wrap was blowing due being close to the fan at the top and a corner of plastic fell into the pan. The it Dietary Manager stated it was jello and attempted to cover the pan with the plastic wrap, which then fell into the center of the pan. The Dietary Manager removed the pan of red colored liquid from the freezer. She instructed a nearby staff member to tell the Administrator the freezer unit was not working. The exterior stainless steel surface of the freezer unit soiled with dried and smeared food particles. A temperature log was in a plastic sheet holder on the side of the freezer unit. The temperature log had documented temperatures for morning and evening on 1/22/24, and the morning of 1/23/24 was documented as 2 degrees F. The Dietary Manager stated the weekend cook had initialed the temperature log for 1/22/24. She stated the staff had been off by one day all month. Observation on 1/22/24 at 11:15 AM revealed the Maintenance Director was standing on a step ladder by the freezer unit against the wall outside the kitchen. He checked the top of the breakfast and dessert freezer and stated a paper had been above the filter. He stated he had removed the paper and the temperature of the freezer was already coming down. He stated he would check the freezer temperature again later today. Observation on 1/22/24 at 11:20 AM revealed the beverage station counter in the dining room had a water and ice dispenser machine. The exterior stainless steel surface was spotted with dry water drop stains. Observation on 1/24/24 at 11:35 AM revealed the garbage disposal sink leaked in the bottom left-hand corner and a bucket had been placed on the floor beneath it to catch the dripping water. Floor tiles were missing and had been covered with a towel and rubber mat in front of the garbage disposal to prevent a trip hazard. Review of the facility's Food and Nutrition Services Policy and Procedure Manual - Equipment Cleaning Procedures, dated 10/2005 and revised 12/31/2017, revealed [in part]: Policy It is the policy of this facility that all dietary equipment and the environment are cleaned and sanitized in a manner that meets local (if applicable), state, and federal regulations. Fundamental Information Routine cleaning will be practiced on a regular basis to keep all dietary equipment and the environment safe, sanitary, and in compliance with state and federal regulations. Cleaning is the practice of removing soil and dirt with an approved cleaning agent . Cleaning Frequency Daily, weekly, monthly . The Food and Drug Administration Food Code 2022 specified [in part]: Chapter 4 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.

Based on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for 1 of 3 residents (Resident #44) reviewed for enactment of advance directives. The facility failed to ensure Resident #44 had the Out of Hospital Do Not Resuscitate (OOH-DNR) documentation in his electric record. This failure could put residents at risk of not having their OOH-DNR honored, resulting in receiving medical treatment they did not desire. The findings included: Record review of Resident #44's face sheet dated [DATE] revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the primary diagnosis of dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Record review of Resident #44's Care Plan, last revised on [DATE], revealed resident was a DNR. Record review of Resident #44's Physician Order Summary, dated [DATE], revealed the order DNR. Record review of Resident #44's electric record failed to have the Out of Hospital Do Not Resuscitate (OOH-DNR) documentation. In an interview on [DATE] at 10:57 AM, the MDS Coordinator looked in Resident #44's electronic records and said the advance directive was not in his documentation. In an interview on [DATE] at 2:08 PM, the Social Worker said it was her responsibility to ensure documentation of advanced directives were in the resident's electronic record. The Social Worker said she was recently hired, and she did not know why the OOH-DNR was not in Resident #44's electronic record. She said she would immediately get the required documentation completed. The Social Worker said a potential negative outcome would be Resident #44's end of life wishes might not get honored. Record review of facility policy Advanced Directives/Advanced Care Planning, dated as revised on ,d+[DATE] revealed the following [in part]: Policy: It is the policy of this facility to recognize two fundamental rights of a person, the right to live and to continue treatment and the right to refuse or terminate unwanted treatment. This facility will honor a resident's wishes and advanced directives pertaining to his/her own medical treatment, including wishes to withhold treatment. Fundamental Information: Advanced directives include written instructions about care and treatment and include such documents as Directive to Physician (Living Will), Durable Power of Attorney for Health Care, Directive to Physician, Family and Surrogates, Out of Hospital DNR, and instructions for no CPR. All of these directives are recognized by state law. Procedure: Upon admission, significate changes or condition and periodic care plan reviews, the Social Service Director reviews each resident end of life care plan and revises as indicated.

Based on interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 2 residents (Resident #27) whose records were reviewed for resident assessment, in that: Resident #27 had a PASRR evaluation dated 2/18/2020 which documented he was positive for mental illness. His annual MDS assessment dated [DATE] documented he had no Level II PASRR conditions. This failure placed the resident at risk for not receiving mental health services as needed. The findings included: Review of Resident #27's Admission Record, dated 1/24/2024, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: post-traumatic stress disorder (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations); bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs - mania or and lows - depression); anxiety disorder; and major depressive disorder, recurrent (mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident #27's annual MDS assessment, dated 9/14/2023, revealed no documentation of Level II PASRR conditions and the item for mental illness was not selected. Review of Resident #27's PASRR Level I screening, dated 2/14/2020, revealed an indication of MI. Review of Resident #27's PASRR Evaluation for MI, dated 2/18/2020, revealed he met the PASRR definition of MI and was PASRR positive for mental illness. Review of the PASRR quarterly IDT meeting notes, dated 12/18/2023, revealed Resident #27 received PASRR specialized services including community attendant services, individual skills training, medication training, and routine case management. During an interview and record review on 1/25/24 at 11:18 AM, the MDS Coordinator reviewed Resident #27's annual MDS, dated [DATE], for the sections for PASRR. She stated she had coded them wrong and Section A1500 should have been answered yes and Section A1510 should have selected A. mental illness. She stated she would do a correction for the annual MDS assessment. The MDS Coordinator stated there was not a facility policy for MDS completion and accuracy and she went by the instructions in the RAI manual.

Based on interview, and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 2 residents (Resident #76) reviewed for PASRR Level 1 screenings. The facility did not correctly identify Resident #76 as having a mental illness and did not complete a new PASRR Level One Screening. This failure could place residents at risk of not being evaluated for PASRR services . The findings include: Record review of Resident #76's face sheet, dated 01/24/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #76's had admitting diagnosis of bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). Record review of the Resident #76's Admission MDS assessment, dated 11/19/2023, revealed resident had a BIMS score of 13, which indicated moderate cognitive impairment. Resident #76 had an active diagnosis of Manic Depression (bipolar disorder) and received antipsychotic medication. Record review of Resident #76's Care Plan, last revised on 11/20/2023, revealed the care plan: Resident #76 uses psychotropic medications. Record review of Resident #76's PASRR Level One Screening Forms, dated 11/10/2023, revealed he did not have a primary diagnosis of dementia. It revealed he was negative for mental illness, intellectual disability, or developmental disability. The form had not been updated. In an interview on 01/24/2024 at 1:38 PM, the Social Worker stated she just started on 11/27/2023 and was responsible for the PASRR process. She was not here when Resident #76 was admitted but his should have been updated at admission to reflect his diagnosis of bipolar disorder. She said the resident might not receive services he was entitled to. In an interview on 01/24/24 at 1:43 PM, the MDS Coordinator said she was responsible for PASRR screenings at the time of the resident's admission due to there being no social worker. Resident #76's PASRR should have been updated at the time of admission but it was missed. Record review of the facility policy Preadmission and Screening Resident Review (PASRR) Rules Guidelines, last revised on 07/2023, revealed the following [in part]: Guideline: It is the intent of Advanced Health Care Solutions to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Review (PASRR) rules. Purpose: the purpose of the guideline is to direct the user through the PASRR procedure. Procedure: If positive .the Social Worker or designee enters the positive PL1 into the Simple LTC Portal.

Based on observation, interviews, and record review, the facility failed to ensure that residents were free of a med error rate of 5% or greater (8%) for 2 (Residents #300 and #49) of 6 residents reviewed for medication administration. 1. The facility failed to ensure RN F primed (removing air bubbles from the needle to ensure that the needle is open and working) insulin pen for Resident #300 before administering Lantus insulin. 2. The facility failed to ensure RN G primed the insulin pen for Resident #49 before administering Novolog insulin. 3. The facility had a 8% medication error rate based on 2 errors out of 25 opportunities, which involved 2 of 6 residents reviewed for pharmacy services. This failure placed residents at risk of incorrect doses of medications. Findings included: 1. Resident #300 Record review of Resident #300 Admission Record dated 01/25/24 revealed a [AGE] year-old female with admitted [DATE]. Resident had an active diagnosis list that included a Primary diagnosis of Diabetes Mellitus. She did not have a BIMS score due to being a new admission. Record review of Resident #300's Physician Orders dated 01/23/24 revealed an order for HumaLOG Injection Solution 100 UNIT/ML Inject 50 units subcutaneously before meals related to TYPE 2 DIABETES MELLITUS In an observation on 01/24/24 at 11:55 AM, RN F checked Resident #300 blood glucose and obtained a reading of 164. RN F gave Resident #30 50 units of Humalog KwikPen without priming the insulin pen prior to administering the medication. 2. Resident #49 Record review of Resident # 49's Admission Record dated 01/25/24 revealed a was a [AGE] year-old male admitted to facility on 12/22/20 with a BIMS of 11 (mild cognitive impairment) diagnosis of Insulin dependent Type 2 Diabetes Mellitus with unspecified complications. Record review of Resident #49's Physician Orders dated 01/25/24 an ordered on 11/30/23 revealed: Humalog KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Lispro) inject as per sliding scale (BLOOD SUGAR): if 200-250+= 2 UNITS, IF 251-300=4 UNITS; 301-350=6 UNITS GREATER THAN 350 GIVE 8 UNITS AND NOTIFY PROVIDER subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH OTHER UNSPECIFIED COMPLICATIONS with a start date of 11/30/24. In an observation on 01/24/24 at 3:55 PM with RN G, Resident # 49 received insulin of 6 units and received Humalog KwikPen Solution 100 UNIT/ML without the needle being primed. In an interview on 01/24/24 at 3:57 PM with RN G said, she had never been educated on priming insulin pens. G stated that failure could affect residents to receive wrong dose each time. In an interview on 01/24/24 at 3:55 PM, the RC said her expectation for nurses was to prime insulin pens per facility policy. She said the adverse outcome for residents could be not getting the correct dose of insulin and increased blood sugar. In an interview on 01/24/24 at 4:00 PM with the DON, he said any resident that received insulin via an insulin pen, the pen should always be primed. He said the failure could cause a resident to not receive the correct dose of insulin. Record review of facility's policy titled Insulin Pen Administration revised October 2020 revealed [in part]: Point the needle up. Tap the insulin cartridge to force any air bubbles to the top. Dial the 2-units used to Prime pen before each injection (This releases a small amount of insulin into the pen to help get rid of air bubbles that may be in the pen).

Based on interview and record review , the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 3 residents (Residents #14 and #66) whose record were reviewed for accurate and complete documentation. The facility failed to prevent the following: 1. The facility failed to ensure Resident #14's Out of Hospital - Do Not Resuscitate Order form was signed as by the resident and two witnesses in the box at the bottom of the form. 2. The facility failed to ensure Resident #66's Out of Hospital - Do Not Resuscitate Order form included a date for the physician's stamped signature, the physician's printed name, or the physician's license number. This failure could place residents at risk for discrepancies in the provision of necessary medical care and services and desired end-of-life decisions not being honored. The findings included: 1. Resident #14 Review of Resident #14's Admission Record, dated 1/24/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: chronic obstructive pulmonary disease (chronic lung disorder); chronic respiratory failure; hypertension (high blood pressure); heart failure; type 2 diabetes mellitus; bipolar disorder; schizoaffective disorder; anxiety disorder; major depressive disorder; and traumatic brain injury. The Admission Record documented the resident was DNR status. Review of Resident #14's Physician Order Summary dated 1/24/2024 revealed an order for DNR dated 8/29/2023. Review of Resident #14's OOH-DNR form revealed it had been signed by the resident on 5/22/22, signed by 2 witnesses on 5/26/22, and signed by the physician on 6/06/22. The resident and the 2 witnesses did not sign in the bottom box of the form to acknowledge the form being properly completed. In an interview and record review on 1/24/24 at 2:53 PM, the Social Worker stated she had a binder notebook with copies of the residents' OOH-DNR order forms. Review of the notebook revealed it contained the same copy of the OOH-DNR order that was in Resident 14's electronic health record. There was no evidence of an updated form. 2. Resident #66 Review of Resident #66's Admission Record, dated 1/24/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: hypertension (high blood pressure); anxiety; cerebral infarction (stroke); dysphagia (swallowing problem); hypothyroidism (thyroid disorder); alcohol abuse; and hypokalemia (high potassium level). The record documented the resident was DNR status. Review of Resident #66's comprehensive care plan revealed a care plan dated 4/24/23 which addressed the order for DNR status. Review of Resident #66's Physician Order Summary dated 1/24/2024 revealed an order for DNR dated 4/24/2023. Review of Resident #66's OOH-DNR form revealed it had been signed by the resident's representative and 2 witnesses on 4/21/2023. There was a stamped physician signature but it was not dated and the physician's license number and printed name were not documented on the form. In an interview on 1/24/24 at 2:53 PM, the Social Worker stated she had a binder notebook with copies of the residents' OOH-DNR order forms. She stated there was a code status binder at the nurses station desk and there were Hospice binders in the chart room which may have updated OOH-DNRs. Review of the Social Worker's binder revealed it contained the same copy of what was in Resident 66's electronic health record. Observation and interview on 1/24/24 at 03:05 PM revealed the Social Worker went to nurses station desk and asked for the code status binder. The LVN at the desk did not find it at nurses station desk. The LVN stated the medical records clerk may have taken it to update it. Observation and record on 1/24/24 at 3:08 PM revealed the chart room had residents' hospice charts on a chart rack. Review of Resident #66's hospice chart revealed no evidence of an OOH-DNR form. The name of the physician listed as the hospice doctor was the same as the physician name stamped on Resident #66's OOH-DNR Order form. Review of the facility's policy and procedure for Advance Directives and Advance Care Planning, dated as revised 4/2015 revealed it did not include instructions for the accuracy of completing the Out of Hospital - Do Not Resuscitate form.

Based on observation, interview and record review the facility failed to distribute and serve food in accordance with professional standards for food service safety as evidenced by; one of one dietary aide observed using unsanitary practices while transferring drinking glasses and filling drinking glasses with ice as well as a catch tray in dining room that was worn and pitted and had a thick, black tarry appearing substance along the back above a wire rack that was also covered in some sort of viscous looking substance. Dishwashing machine also was not reaching minimum concentration for sanitizing rinse. These failures could place residents at risk of acquiring foodborne and other illnesses. Findings include: On 11/2/2022 at 10:28 AM observed ice and water dispenser in the facility dining area that had a tarry, black, viscous looking coating along the back portion of the catch tray. The catch tray itself was dark gray plastic that is pitted and has a dirty appearance. The metal grate in the catch tray was also dirty with an unidentified accumulation covering about two-thirds of the grate. The backsplash above the catch tray which was stainless steel has a muddy brown appearance. A few minutes later at 10:35 AM observed a resident in a wheelchair pull up to the ice dispenser side, filling a cup with ice while holding the catch tray with her free hand. 11/2/2022 at 10:35 AM in an interview with DM about ice and water machine who said it is cleaned often and because of the material and age the tray always looks like it did. She could not identify what the black substance on the tray was. 11/2/2022 at 10:52 AM observed DM run chemical test strips on dishwashing machine. Three attempts were made with the DM adjusting the sanitation level between the second and third attempt. At no point did the test show at least 50PPM of sanitation occurring which is the lower range of 50-100 PPM of chemical sanitation recommended by the manufacturer. Immediately after the last attempt the DM called the company who maintains the machine and placed a service call. The kitchen switched to disposable plates for food service for the evening meal until the dishwashing machine was running properly. 11/2/2022 at 11:07 AM observed DA1 placing her fingers and thumb inside of drinking glasses to transfer them from one tray to another. After moving the glasses, she filled each with soda. 11/2/2022 at 11:24 AM observed DA1 again placing fingers and thumb into resident drinking glasses prior to filling them. 11/2/2022 at 11:30 AM observed DA1 wearing gloves and grabbing ice with gloved hands taking ice from one hand to another to put into resident drinking glasses. At no time was a scoop or other utensil used to transfer ice from the bowl into the glasses. 11/2/2022 at 11:40 AM DA1 continues using gloved hands to transfer ice into resident drinking glasses. 11/2/2022 at 11:55 in an interview with DA1, when asked if it was appropriate to put fingers and thumb inside of residents drinking glasses DA1 said no it was not the way to do it. When asked about using gloved hands to directly transfer ice into resident drinking glasses she also said it was not the correct way to do it. 11/2/2022 at 2:15 PM in an interview with DM, DM said DA1 should not have put her fingers and thumb into resident drinking glasses and should handle the glasses from the side. DM also said DA1 should not have been transferring ice with her gloved hands. 11/2/2022 at 3:35 PM record review of a policy titled Food & Nutrition Services Policy and Procedure Manual, Disposable Glove use in Dietary Service, Origination Date: 11/2006, Review Date: 11/14/2017, Revision Date: 11/14/2017 states the following. Policy Dietary staff will maintain proper food safety practices through proper hand washing and disposable glove use as appropriate. Fundamental Information Dietary Staff should wear disposable gloves when: Gloves are not worn when handling clean dishes. When washing dishes, after handling dirty dishes and prior to handling clean dishes, the employee will remove gloves and wash hands.

Based on interview and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for one (Resident #4) of 16 residents reviewed for neglect. 1. The facility failed to ensure the facility's contracted radiology technician x-rayed the correct resident, after Resident #4 fell on [DATE] and complained of pain to his leg. Resident #4's left leg was swollen "twice the size of his right leg," and he had pain. A second x-ray was obtained on 02/18/14, which indicated he had a [MEDICAL CONDITION] with displacement, and he was sent to the hospital that day, which was four days after his fall. This was determined to be Past Noncompliance (PNC) Immediate Jeopardy due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. These failures could affect the facility's 77 residents, who may need radiology services, by placing them at risk for not receiving the services ordered by their physician. Findings included: Resident #4 was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #4's MDS admission assessment dated [DATE] reflected Resident #4 was an [AGE] year-old male, who was admitted to the facility on [DATE]. The assessment reflected Resident #4 had both short-term and long-term memory problems with severe cognitive impairment. In regards to his functional status, the assessment reflected Resident #4 required extensive assistance from staff with bed mobility, transferring, dressing, toileting, and personal hygiene. The MDS assessment reflected the resident did not have a history of falls. Resident #4's Nurse's Notes for Friday, 02/14/14 reflected the following entries were documented: 02/14/14 at 12:15 PM - "Res stood up to transfer to lobby chair alarm sounded & resident fell over onto (L) side. Did not hit head & no (symbol used) injuries noted. (Physician Q) notified no (symbol used) N/O @ this time. Notified (family member). No (symbol used) concerns voiced." 02/14/14 at 1:00 PM- "C/O pain to (L) hip 'Hurts like hell' (resident) stated. Called (Physician Q) N/O X-Ray on left hip. (Family member) notified via telephone. Noted resident having trouble lifting (L) leg." Interview with LVN D on 02/26/14 at 9:40 AM revealed she saw Resident #4 fall on Friday, 02/14/14. He stood up from his wheelchair, his chair alarm was going off, and he fell to the floor. After the fall, LVN D stated she asked Resident #4 if he was hurting anywhere. She stated Resident #4 responded by repeating "hurting anywhere." LVN D stated she then assisted the resident to his wheelchair and took his vital signs. She stated the resident was then administered Tylenol for pain, and the physician and family were notified of the fall. LVN D stated an order was obtained for an x-ray of Resident #4's left hip. When LVN D was queried as to why she did not document giving Resident #4 medication on 02/14/14, she revealed she was busy and just did not document it. Resident #4's Nurse's Notes, dated 02/14/14 at 8:24 PM, reflected, "Xray results negative. No (symbol used) evidence of fx on (L) lower extremities. (Physician Q) in to see res and lab reports....Res favors (L) side when up (symbol used) in w/c. WCTM" Resident #4's February 2014 MAR indicated [REDACTED]. Interview with CNA A on 02/26/14 at 4:30 PM revealed she did not witness Resident #4 fall, but she did care for him on the evening that he fell . On the date of the fall, CNA A stated she saw Resident #4 in the dining room at dinner time, and she attempted to assist him to his room. While Resident #4 was in his wheelchair, he was unable to lift his left leg. CNA A explained she attempted to cross the resident's left leg over his right leg so it could be supported, but the resident had a "look of pain on his face." CNA A revealed she saw the radiologist that day at the front desk, but she did not see him afterwards. CNA A stated she reported Resident #4's pain to LVN E, who was his charge nurse on 02/14/14. Interview with LVN F on 02/26/14 at 9:00 AM revealed she was working on 02/14/14 (her shift was Monday through Friday 8:00 AM to 5:00 PM) when Resident #4 fell , but she did not witness the fall. She stated she did not see the x-ray technologist, and believed he entered after her shift. LVN F stated she worked Saturday, 02/15/14, night (one day after the fall) and stated no reports were given to her that reflected Resident #4 was experiencing pain. She stated she saw the resident in bed on 02/15/14, and staff was changing him without any complaints. Interview with CNA H on 02/26/14 at 4:39 PM revealed she worked the 2:00 PM to 10:00 PM shift on 02/14/14, which was the day Resident #4 fell . CNA H stated she gave Resident #4 a shower that day, and he was complaining of pain in his left leg. When she brought him to the shower room, CNA H stated she had to support the resident because he could not support himself nor turn himself. CNA H explained that was unusual for Resident #4 because he could transfer himself with minimal assistance. CNA H revealed she noticed swelling to the resident's left leg that day, and she reported it to the nurse. CNA H stated she did not work over the weekend (02/15/14 through 02/16/14), which were the two days immediately following the resident's fall. Resident #4's x-ray report dated 02/14/14 reflected x-rays of the resident's left hip and left knee were taken. The report reflected: "FINDINGS...Left hip... IMPRESSIONS: 1. Partial hip replacement with intact femoral component in anatomic alignment. 2. No radiographic evidence of acute fracture or dislocation. If symptoms persist, consider follow-up radiographs in order to evaluate for initial radiographically occult fracture.... FINDINGS...Left knee... IMPRESSIONS: Total knee replacement with intact femoral and tibial components in anatomic alignment. No radiographic evidence of acute fracture or dislocation...." Review of Resident #4's clinical records revealed there was no documented evidence reflecting the resident had a partial hip replacement or a total knee replacement. Interview with the RN Supervisor on 02/27/14 at 3:00 PM revealed she was working the weekend after Resident #4 had the fall. The RN Supervisor saw Resident #4 in his wheelchair by the front door on Saturday, and the resident was also in the dining room for dinner that evening. The RN Supervisor stated she was aware Resident #4 had a fall the day before from reviewing the 24-hour report, and she was aware the radiology report came back negative for fracture. The RN Supervisor stated none of the staff members reported to her Resident #4 was in pain over the weekend. The RN Supervisor was asked about post-fall documentation, and she stated the resident should be monitored for 72 hours following a fall, and neurological checks were done if the resident hit his or her head. Further review of Resident #4's Nurse's Notes revealed the next entry, following the 02/14/14 entries, was documented on 02/17/14 at 8:30 AM which was three days after the resident's fall. This Nurse's Note reflected, "Noted Res (L) thigh swollen twice the size of the (R). No bruising, warmth, or discoloration at this time. Called (Physician Q) no (symbol used) N/O at this time." Interview with LVN D on 02/26/14 at 9:40 AM revealed she did not work over the weekend following the fall. However, when she returned to the facility on Monday, 02/17/14,, she was concerned about Resident #4's left leg being "swollen twice the size of the right leg." She stated she did not see any documentation or nursing notes through the weekend in Resident #4's clinical record. She revealed she contacted the physician with her concerns and was told there was "no need for an additional x-ray as the results were negative for a fracture and there was no need to do anything else." LVN D stated she saw Physician Q in the facility twice since Resident #4 fell , but she was not sure if the physician saw Resident #4. Resident #4's February 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]." Further review of the February 2014 MAR indicated [REDACTED]. Resident #4's Nurse's Notes, dated 02/18/14, reflected 02/18/14 at 1:00 PM - "Resident (L) thigh swollen twice the size of the (R). (Physician Q) notified continues to refuse x-ray of femur. DON notified." Interview with LVN D on 02/26/14 at 9:40 AM revealed she reported to the Administration her concerns about Resident #4 on Tuesday 02/18/14, and she was told to keep calling the physician until he ordered another x-ray. Resident #4's Nurse's Notes dated 02/18/14 at 7:35 PM reflected: "Late entry: 2/18/14 1700 (5:00 PM) Res c/o pain to (L) LE. Swelling noted. PRN tylenol given for pain. (Physician Q) called & asked for xray D/T swelling & pain- refused. WCTM." Resident #4's Nurse's Notes dated 02/18/14 at 5:30 PM reflected: "Resident c/o pain (L) upper leg (femur area) with (symbol used) ROM, does not want to bear wt with (symbol used) transferring. (L) upper leg with (symbol used) [MEDICAL CONDITION], and pain. (Physician Q) called and xray ordered of (L) femur. (Radiology Company) called; xray (L) femur ordered. Called (family member) and notified of order." Interview with LVN D on 02/26/14 at 9:40 AM revealed she called up to the facility on [DATE] after her shift to check on the resident, and she asked LVN G to contact the physician to try to obtain an order for [REDACTED].#4's leg was clearly broken and not in alignment. Interview with LVN G on 02/26/14 at 3:00 PM revealed he was working on 02/14/14 the 2:00 PM to 10:00 PM shift. He was the charge nurse for Hall 200 and 300. Resident #4 resided on the 400 hall. He did not see the x-ray technician come into the facility that day. LVN G stated on Monday he remembered seeing Resident #4 in his wheelchair and noticed his left leg was quite swollen. He revealed the other nurses were calling the physician trying to obtain an order for [REDACTED]." LVN G described himself as "more aggressive than some of the other nurses," and he stated was able to get the physician to order another x-ray. Resident #4's February 2014 MAR indicated [REDACTED]. Resident #4's x-ray report dated 02/18/14 reflected an x-ray was taken of the resident's left femur on that date. The report reflected: "IMPRESSIONS: 1. Acute intertrochanteric femoral fracture with moderate displacement with varus angulation. 2. Moderate degree of [MEDICAL CONDITION]. 3. Moderate [MEDICAL CONDITION]." Resident #4's Nurse's Notes dated, 02/18/14 at 7:24 PM, reflected, "Xray reveals fx femoral head to (L) LE. (Physician Q) notified. Order to send to ER to eval & tx. (Family member) notified via vm x1. WCTM." Resident #4's Nurse's Notes dated, 02/18/14 at 7:27 PM reflected: "Ambulance arrives to take res to ER." Resident #4's hospital Progress Notes, dated 02/20/14, reflected, "...ASSESSMENT: 1. Acute intertrochanteric fracture, left femur...." Resident #4's hospital Progress Notes, dated 02/21/14, reflected: "...SUBJECTIVE DATA: The patient complains that he is having a great deal of pain from his left leg. His (family member) is a (sic) the bedside, states surgery was postponed due to pending echo report that is rescheduled for today. (The family member) does relate feeling torn about decision for surgical intervention versus not though (the family member) does not feel like not going through with the surgery is a [MEDICATION NAME] choice. We did discuss the option of hospice and comfort care at this time. (The family member) is not ready to make that decision and does feel that if surgical intervention is the best choice at this time...PLAN: 1. The patient's surgical repair of the left [MEDICAL CONDITION] rescheduled for today...." Interview on 02/26/14 at 2:47 PM with LVN E revealed she was working the 2:00 PM to 10:00 PM shift the day Resident #4 fell . LVN E stated it was around 3:00 PM, and she was passing medications on the resident's hallway when she saw the x-ray technician in the facility. LVN E stated she saw the x-ray technician go to the front desk and get a copy of the resident's Face Sheet and sign the order. LVN E stated she saw him walk down to Resident #4's room unassisted, and he entered the room. LVN E revealed there was usually somebody at the front desk, but she was not sure if anybody was there at the time. LVN E revealed they usually say "the one by the window or the one by the wall" when they see x-ray come in, but said she did not do that this time. LVN E stated, "I think they know what bed A is and what bed B is." LVN E revealed Resident #4's roommate had received a lot of x-rays recently and that may have been the reason for the "mix up." LVN E stated she did not work over the weekend, but returned on Monday working the 2:00 PM to 10:00 PM shift. She stated Resident #4 was favoring his left leg, and it was swollen. She revealed any movement caused pain. LVN E stated she contacted the physician, but was told he "didn't see the point to do another x-ray as it was negative." LVN E revealed on Tuesday 02/18/14 she assisted another staff member, and they undressed Resident #4 and stood him up. She stated they saw the displacement in the hip and contacted the physician and asked for another x-ray to be ordered, and he said, "No." Later that day LVN E revealed she asked another nurse to contact the physician and request an order. LVN G contacted the physician and was able to obtain an order to do a second x-ray. Interview on 02/26/14 at 2:20 PM with Physician Q, who was also the facility's Medical Director, revealed he was aware of Resident #4's fall on 02/14/14 and ordered an x-ray to rule out a fracture. Physician Q stated he saw Resident #4 on Monday 02/17/14 around noon while the resident was in his room in bed. He stated Resident #4 showed no signs or symptoms of pain at that time. The resident's left leg was swollen, but there was no bruising, and the resident did not wince or show signs of pain when the leg was moved. When asked about documentation, the physician replied he usually documented his visits, but did not this time as he was planning to see the resident the next day. Physician Q stated on Tuesday, 02/17/14, he did not notice changes to the resident's leg from the previous day. Physician Q revealed he reviewed the x-ray report on Monday, and the report was negative for a fracture. At the time, he saw no reason to repeat the x-ray. He stated he went by the x-ray results. Physician Q stated the nurses told him the resident was "hurting," but he associated it with the fall. Resident #4 was not "screaming in pain," when he was moved. Physician Q reported that he saw Resident #4 again on Tuesday 02/18/14, and the family reported to the nurses that the resident was in pain. That was when the second x-ray was ordered. Physician Q stated this was a "rare occurrence to x-ray the wrong person," and it never occurred to him there could have been a "mix-up" during the procedure. Interview with the DON on 02/26/14 at 8:10 AM revealed she witnessed the fall on 02/14/14 for Resident #4. She stated the resident was not complaining of pain until later that night. The x-ray was negative for a fracture. The DON stated Physician Q saw the resident at least two times and stated it was "not consistent of a fracture," however by Monday it was "very swollen." When queried about the lack of documentation relating to post-fall monitoring, medication administration documentation and nurse's notes, the DON stated she had begun in-servicing nursing staff on proper documentation and reporting. Interview with the Administrator on 02/25/14 at 11:10 AM revealed the facility reported the incident regarding Resident #4 to DADS on 02/19/14. The Administrator reported Resident #4 had a witnessed fall on 02/14/14 at approximately 2:30 PM. The physician was notified and an x-ray was ordered and obtained. The x-ray results per the radiologic report were negative, and the resident was monitored for a change or further issues related to the fall. The resident began having difficulty lifting his leg while wheeling or being wheeled in his chair on Saturday, 02/15/14, and Sunday, 02/16/14. The Administrator stated on Monday morning, Resident #4 had a swollen thigh. Physician Q examined the resident at lunchtime and then that evening during his rounds. He wanted to continue to monitor this problem and attributed it to the previous fall. On Tuesday 02/18/14, the resident's thigh was still swollen, and the physician checked it again noting the x-ray was negative and continued to monitor him. By later that afternoon, the swelling worsened, and the pain increased so another x-ray was ordered and obtained. The radiologic report indicated a fracture of his left femur, and the resident was sent out to the hospital for evaluation and treatment. The Administrator stated Resident #4's family was contacted, and the facility started an investigation. The Administrator explained that upon reviewing the radiology reports, a discrepancy was found, and the facility's contracted x-ray company was contacted to alert them the technician had possibly x-rayed the wrong resident. The radiology company launched their own investigation, and the technician was placed on 90-day probation. The Administrator explained the facility held a QAA meeting and began working on updating policies and procedures related to outside vendors. The facility's contracted mobile x-ray company documented the following Customer Service Inquiry, dated 02/20/14, which reflected: "Concern: Patient Fracture Specifics: Patient (Resident #4) had a Left Hip/Left Knee study ordered on [DATE] at 12:59 p.m. (Mobile x-ray company) radiologic technologist (X-ray Technician R) was sent to complete exam. The study was negative/no fracture. Patient (Resident #4) had a Left Femur study ordered 02/08/2014 (sic, 02/18/2014) at 5:32 p.m. (Mobile x-ray company) radiologic technologist (X-ray Technician S) was sent to complete the exam. The study was positive, acute intertrochanteric femoral fracture with moderate displacement. Santa Fe Director of nurses contacted (mobile x-ray company) (on) 02/19/2014 with questions regarding the patient findings, and why the fracture was not discovered on the 02/14 exam. Inquiry findings: (Mobile x-ray company) radiologic technologist (X-ray Technician R) performed the Left Hip/Left Knee study ordered for (Resident #4) on the wrong patient. The exam was done on (Resident #4's) roommate (Resident #17). (X-ray Technician R) did not utilize two patient identifiers. Miscommunication between Santa Fe staff and (X-ray Technician R) occurred when (X-ray Technician R) ask (sic) who/where the patient is. The ultimate responsibility to correctly identify a patient before completing an exam lies solely with the technologist performing the study. Action Plan: Continue quality assurance with (mobile x-ray company) staff to ensure that before an exam is performed, no less than three patient identifiers are to be utilized. In conjunction with patient identifiers, before performing exam, (X-ray Technician R) will be consulting with nursing home staff, to ensure correct patient is being done. Radiologic Technologist (X-ray Technician R) has been put on a 90 (day) probation." Interview with Resident #4's family member on 02/25/14 at 5:45 PM revealed Resident #4 had been living at the facility for approximately three to four months. The family member explained that Resident #4 had severe dementia and was still adjusting to the facility. The family member stated Resident #4 did not always recognize family and was oriented only to himself. The family member stated he/she was called on 02/14/14 and informed that Resident #4 had fallen, and "hit hard." The family member stated he/she was told Resident #4 was given Tylenol for the pain. The family member revealed he/she went to the facility that day, and Resident #4 was complaining of pain and dragging his left leg as staff was wheeling him out from the dining room. Over the weekend, the family member stated Resident #4 was sore, but he was not complaining of pain. The family member stated Resident #4 "would not necessarily complain of pain" due to him being "very hard of hearing and slow to process speech and articulate." At times he stated, "It hurts," but would be forgetful of the fall. The family member stated the facility called again a few days later on Tuesday night 02/18/14 and said another x-ray was taken, and it appeared he had a broken hip and was being transferred to the hospital. The family member revealed the hospital physicians had to wait until the resident could be seen by the cardiologist to ensure the resident could withstand surgery. The family member stated Physician Q contacted them on 02/24/14 and stated he had some "disturbing information to share." The family member stated Physician Q informed him/her that the initial x-ray ordered for Resident #4 had been done on the wrong resident. The family member revealed he/she was "shocked" and not sure how the error could have happened. The family member was told the facility was conducting an investigation into the matter. The family member was concerned about the extended amount of time Resident #4 went without treatment for [REDACTED]. The facility's current policy, "Abuse Prohibition Policy and Procedure," revised July 2012, reflected, "...Identification: The facility will be proactive in identifying events and occurrences that may contribute to abuse or neglect...residents, families and staff will be educated and encouraged to report concerns, incidents and grievances without fear or retaliation... Attachment A- Definitions...Neglect- A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident... Attachment H 'Neglect' - The failure of a caregiver to provide the goods and services that are necessary to maintain the health or safety of a resident. Additionally neglect is the failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. Neglect includes, but is not limited to, lack of care and supervision and unmet physical, social, emotional, spiritual or medical needs...'Serious Bodily Injury' - An injury involving extreme physical pain; involving substantial risk of death; involving he protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation." It was determined these failures placed Resident #4 in an Immediate Jeopardy (IJ) situation from 02/14/14 through 02/18/14, until medical intervention and hospitalization . The facility's Quality Assurance Performance Improvement Plan, dated 02/20/14 reflected the following relating to Resident #4: "1. Residents will be identified as a fall risk and proper equipment will be in place. Action steps: Nurses will give report to nursing administration at 9:00 AM and 7:00 PM. Nurses will go to room and verify resident and part to x-ray. System Correction: All incidents and accidents will be reviewed with the interdisciplinary team for appropriate action to be taken and any recommendations. Training: Staff will be educated and trained in post fall procedures. Physicians will be incorporated with the care and follow up of residents that have fallen. Monitoring: Reviewed in QAA. Resolution Date: 02/20/14 2. Post Fall Documentation and Change in condition, dated 02/26/14. Purpose: To identify changes and document on a residents condition related post-fall. In-service: Staff will be able to verbalize purpose of the post fall documentation. Staff will be able to recognize changes of resident's condition. Staff will be able to verbalize how and when to notify physician of a change in condition. Staff will be able to verbalize how to use the post fall documentation. Post fall assessments are to stay in the 24 hour report for 72 hours. 3. Pain flow sheets, dated 02/26/14. Purpose: Pain flow sheets must be used on every resident that receives pain medications. Pain assessments must be updated with admission, readmission, change of condition, increased requests for pain medications, after a fall and quarterly. (Attachments included policy and procedure, example of pain flow sheet and pain validation too.) 4. Outside vendors, dated 02/26/14. All outside vendors (lab, radiology, etc.,) will have to sign in at the front desk upon arrival to the facility. Nursing staff along with the vendor will verify the order and the outside vendor will be physically escorted to the resident to ensure correct resident receives services. 5. The DON of the facility will continue to monitor and educate the nursing staff on the pain documentation, 24 hour reporting, follow up on incidents, and change of condition. This will be an ongoing process to improve the quality of care for the residents and the best practice for the nursing staff, signed and dated by the DON 02/27/14." Review of the in-services revealed the following topics were covered: - Nursing staff was in-serviced to physically walk to a resident's room and identify the resident for any outside vendors such as x-ray or lab technicians. This in-service was completed on 02/25/14 and 02/26/14, with 53 signatures of nursing staff who received the in-service. - Change of condition and 24-hour report sheets: This in-service included handouts and lectures dated 02/20/14 and 02/26/14, with 28 signatures. The handouts covered observing, recording and reporting any change of condition to ensure proper treatment was implemented. This included Pain Flow Sheets being used on every resident that received pain medications. The in-service materials also reflected that staff were in-serviced to do pain assessments upon admission, readmission, quarterly, change of condition, increased requests for pain medications, and after a fall. Review of the facility's vendor sign-in sheet revealed that outside vendors were signing in upon arrival. Interview on 02/26/14 at 8:10 AM with the DON revealed she and the facility's only ADON had been working on in-servicing all nursing staff relating to the incident. New policies were in place to ensure the proper resident would be identified and would receive the appropriate services as ordered by the physician. Staff now escort the vendors to the resident and identify them. Staff had been in-serviced on documentation, post fall documentation, medication administration, reporting and change of condition. Interview with LVN F on 02/26/14 at 9:00 AM revealed changes which had occurred at the facility since learning of the incident involving Resident #4 included many in-services relating to communication, documentation, and vendors. It was the responsibility of the nursing staff to ensure they brought the outside vendor to the correct resident for identification in order for the resident to receive the proper treatment. Change of condition and documentation were also in-serviced on. Proper documentation and assessments post fall were to be completed for 72 hours post fall on any fall and included in the 24 hour report. Interview with LVN D on 02/26/14 at 9:40 AM revealed in-service topics included having vendors sign in at the desk, checking the order in the chart and have the vendor sign the order and make a copy, and escorting the vendor to the resident and assist as needed. When a resident had a fall, it needed to be documented and followed, nurses were to assess the resident post fall and document their findings, and report was given to next shift. Any medication given should be documented and followed up on to ensure it was effective. Nurse's notes should be complete and accurate, and any changes of condition should be reported and documented. Interview with LVN E on 02/26/14 at 2:47 PM revealed recent in-services included the following: outside vendors were to check in and sign in with the front desk, staff member was to verify the order and escort the vendor to the resident to ensure correct resident and correct procedure. In addition, staff were in-serviced regarding proper documentation post fall, pain, and change of condition were discussed. Interview with LVN G on 02/26/14 at 3:00 PM revealed recent in-services included outside vendors and the new policy and procedure, documentation relating to post falls and medication administration. When outside vendors entered the facility they were to sign in at the front desk. Staff member was to check the order with the vendor and physically escort them to the resident and assist as needed. Documentation in a resident's chart any changes of condition, pain or if medications were given for pain they should be followed up on. In-serviced on reporting and following falls for 24 hours post fall, 72 hours if resident hit their head. Report all changes to following shift and utilize 24-hour report. Interview with RN Supervisor on 02/27/14 at approximately 3:00 PM revealed she received recent in-services that included how to follow up and monitor residents post-fall. All falls were to be monitored and documented for 24-72 hours. Incident reports were completed and reviewed for accuracy. Pain was to be assessed on the resident and documented. Staff would report any change of condition to the charge nurse and it would be placed on the 24-hour report and followed. The DON was responsible for ensuring documentation and monitoring was completed and accurate. This was determined to be Past Noncompliance (PNC) Immediate Jeopardy due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility's Resident Census and Conditions of Residents Form CMS-672 completed by LVN T on 02/25/14 reflected the facility had a census of 77 residents.

Based on interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #4) of 16 residents reviewed for neglect. 1. The facility failed to ensure the facility's contracted radiology technician x-rayed the correct resident, after Resident #4 fell on [DATE] and complained of pain to his leg. Resident #4's left leg was swollen "twice the size of his right leg," and he had pain. A second x-ray was obtained on 02/18/14, which indicated he had a [MEDICAL CONDITION] with displacement, and he was sent to the hospital that day, which was four days after his fall. This was determined to be Past Noncompliance (PNC) Immediate Jeopardy due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. These failures could affect the facility's 77 residents, who may need radiology services, by placing them at risk for not receiving the services ordered by their physician. Findings included: The facility's current policy, "Abuse Prohibition Policy and Procedure," revised July 2012, reflected, "...Identification: The facility will be proactive in identifying events and occurrences that may contribute to abuse or neglect...residents, families and staff will be educated and encouraged to report concerns, incidents and grievances without fear or retaliation... Attachment A- Definitions...Neglect- A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident... Attachment H 'Neglect' - The failure of a caregiver to provide the goods and services that are necessary to maintain the health or safety of a resident. Additionally neglect is the failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. Neglect includes, but is not limited to, lack of care and supervision and unmet physical, social, emotional, spiritual or medical needs...'Serious Bodily Injury' - An injury involving extreme physical pain; involving substantial risk of death; involving he protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation." Resident #4 was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #4's MDS admission assessment dated [DATE] reflected Resident #4 was an [AGE] year-old male, who was admitted to the facility on [DATE]. The assessment reflected Resident #4 had both short-term and long-term memory problems with severe cognitive impairment. In regards to his functional status, the assessment reflected Resident #4 required extensive assistance from staff with bed mobility, transferring, dressing, toileting, and personal hygiene. The MDS assessment reflected the resident did not have a history of falls. Resident #4's Nurse's Notes for Friday, 02/14/14 reflected the following entries were documented: 02/14/14 at 12:15 PM - "Res stood up to transfer to lobby chair alarm sounded & resident fell over onto (L) side. Did not hit head & no (symbol used) injuries noted. (Physician Q) notified no (symbol used) N/O @ this time. Notified (family member). No (symbol used) concerns voiced." 02/14/14 at 1:00 PM- "C/O pain to (L) hip 'Hurts like hell' (resident) stated. Called (Physician Q) N/O X-Ray on left hip. (Family member) notified via telephone. Noted resident having trouble lifting (L) leg." Interview with LVN D on 02/26/14 at 9:40 AM revealed she saw Resident #4 fall on Friday, 02/14/14. He stood up from his wheelchair, his chair alarm was going off, and he fell to the floor. After the fall, LVN D stated she asked Resident #4 if he was hurting anywhere. She stated Resident #4 responded by repeating "hurting anywhere." LVN D stated she then assisted the resident to his wheelchair and took his vital signs. She stated the resident was then administered Tylenol for pain, and the physician and family were notified of the fall. LVN D stated an order was obtained for an x-ray of Resident #4's left hip. When LVN D was queried as to why she did not document giving Resident #4 medication on 02/14/14, she revealed she was busy and just did not document it. Resident #4's Nurse's Notes, dated 02/14/14 at 8:24 PM, reflected, "Xray results negative. No (symbol used) evidence of fx on (L) lower extremities. (Physician Q) in to see res and lab reports....Res favors (L) side when up (symbol used) in w/c. WCTM" Resident #4's February 2014 MAR indicated [REDACTED]. Interview with CNA A on 02/26/14 at 4:30 PM revealed she did not witness Resident #4 fall, but she did care for him on the evening that he fell . On the date of the fall, CNA A stated she saw Resident #4 in the dining room at dinner time, and she attempted to assist him to his room. While Resident #4 was in his wheelchair, he was unable to lift his left leg. CNA A explained she attempted to cross the resident's left leg over his right leg so it could be supported, but the resident had a "look of pain on his face." CNA A revealed she saw the radiologist that day at the front desk, but she did not see him afterwards. CNA A stated she reported Resident #4's pain to LVN E, who was his charge nurse on 02/14/14. Interview with LVN F on 02/26/14 at 9:00 AM revealed she was working on 02/14/14 (her shift was Monday through Friday 8:00 AM to 5:00 PM) when Resident #4 fell , but she did not witness the fall. She stated she did not see the x-ray technologist, and believed he entered after her shift. LVN F stated she worked Saturday, 02/15/14, night (one day after the fall) and stated no reports were given to her that reflected Resident #4 was experiencing pain. She stated she saw the resident in bed on 02/15/14, and staff was changing him without any complaints. Interview with CNA H on 02/26/14 at 4:39 PM revealed she worked the 2:00 PM to 10:00 PM shift on 02/14/14, which was the day Resident #4 fell . CNA H stated she gave Resident #4 a shower that day, and he was complaining of pain in his left leg. When she brought him to the shower room, CNA H stated she had to support the resident because he could not support himself nor turn himself. CNA H explained that was unusual for Resident #4 because he could transfer himself with minimal assistance. CNA H revealed she noticed swelling to the resident's left leg that day, and she reported it to the nurse. CNA H stated she did not work over the weekend (02/15/14 through 02/16/14), which were the two days immediately following the resident's fall. Resident #4's x-ray report dated 02/14/14 reflected x-rays of the resident's left hip and left knee were taken. The report reflected: "FINDINGS...Left hip... IMPRESSIONS: 1. Partial hip replacement with intact femoral component in anatomic alignment. 2. No radiographic evidence of acute fracture or dislocation. If symptoms persist, consider follow-up radiographs in order to evaluate for initial radiographically occult fracture.... FINDINGS...Left knee... IMPRESSIONS: Total knee replacement with intact femoral and tibial components in anatomic alignment. No radiographic evidence of acute fracture or dislocation...." Review of Resident #4's clinical records revealed there was no documented evidence reflecting the resident had a partial hip replacement or a total knee replacement. Interview with the RN Supervisor on 02/27/14 at 3:00 PM revealed she was working the weekend after Resident #4 had the fall. The RN Supervisor saw Resident #4 in his wheelchair by the front door on Saturday, and the resident was also in the dining room for dinner that evening. The RN Supervisor stated she was aware Resident #4 had a fall the day before from reviewing the 24-hour report, and she was aware the radiology report came back negative for fracture. The RN Supervisor stated none of the staff members reported to her Resident #4 was in pain over the weekend. The RN Supervisor was asked about post-fall documentation, and she stated the resident should be monitored for 72 hours following a fall, and neurological checks were done if the resident hit his or her head. Further review of Resident #4's Nurse's Notes revealed the next entry, following the 02/14/14 entries, was documented on 02/17/14 at 8:30 AM which was three days after the resident's fall. This Nurse's Note reflected, "Noted Res (L) thigh swollen twice the size of the (R). No bruising, warmth, or discoloration at this time. Called (Physician Q) no (symbol used) N/O at this time." Interview with LVN D on 02/26/14 at 9:40 AM revealed she did not work over the weekend following the fall. However, when she returned to the facility on Monday, 02/17/14,, she was concerned about Resident #4's left leg being "swollen twice the size of the right leg." She stated she did not see any documentation or nursing notes through the weekend in Resident #4's clinical record. She revealed she contacted the physician with her concerns and was told there was "no need for an additional x-ray as the results were negative for a fracture and there was no need to do anything else." LVN D stated she saw Physician Q in the facility twice since Resident #4 fell , but she was not sure if the physician saw Resident #4. Resident #4's February 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]." Further review of the February 2014 MAR indicated [REDACTED]. Resident #4's Nurse's Notes, dated 02/18/14, reflected 02/18/14 at 1:00 PM - "Resident (L) thigh swollen twice the size of the (R). (Physician Q) notified continues to refuse x-ray of femur. DON notified." Interview with LVN D on 02/26/14 at 9:40 AM revealed she reported to the Administration her concerns about Resident #4 on Tuesday 02/18/14, and she was told to keep calling the physician until he ordered another x-ray. Resident #4's Nurse's Notes dated 02/18/14 at 7:35 PM reflected: "Late entry: 2/18/14 1700 (5:00 PM) Res c/o pain to (L) LE. Swelling noted. PRN tylenol given for pain. (Physician Q) called & asked for xray D/T swelling & pain- refused. WCTM." Resident #4's Nurse's Notes dated 02/18/14 at 5:30 PM reflected: "Resident c/o pain (L) upper leg (femur area) with (symbol used) ROM, does not want to bear wt with (symbol used) transferring. (L) upper leg with (symbol used) [MEDICAL CONDITION], and pain. (Physician Q) called and xray ordered of (L) femur. (Radiology Company) called; xray (L) femur ordered. Called (family member) and notified of order." Interview with LVN D on 02/26/14 at 9:40 AM revealed she called up to the facility on [DATE] after her shift to check on the resident, and she asked LVN G to contact the physician to try to obtain an order for [REDACTED].#4's leg was clearly broken and not in alignment. Interview with LVN G on 02/26/14 at 3:00 PM revealed he was working on 02/14/14 the 2:00 PM to 10:00 PM shift. He was the charge nurse for Hall 200 and 300. Resident #4 resided on the 400 hall. He did not see the x-ray technician come into the facility that day. LVN G stated on Monday he remembered seeing Resident #4 in his wheelchair and noticed his left leg was quite swollen. He revealed the other nurses were calling the physician trying to obtain an order for [REDACTED]." LVN G described himself as "more aggressive than some of the other nurses," and he stated was able to get the physician to order another x-ray. Resident #4's February 2014 MAR indicated [REDACTED]. Resident #4's x-ray report dated 02/18/14 reflected an x-ray was taken of the resident's left femur on that date. The report reflected: "IMPRESSIONS: 1. Acute intertrochanteric femoral fracture with moderate displacement with varus angulation. 2. Moderate degree of [MEDICAL CONDITION]. 3. Moderate [MEDICAL CONDITION]." Resident #4's Nurse's Notes dated, 02/18/14 at 7:24 PM, reflected, "Xray reveals fx femoral head to (L) LE. (Physician Q) notified. Order to send to ER to eval & tx. (Family member) notified via vm x1. WCTM." Resident #4's Nurse's Notes dated, 02/18/14 at 7:27 PM reflected: "Ambulance arrives to take res to ER." Resident #4's hospital Progress Notes, dated 02/20/14, reflected, "...ASSESSMENT: 1. Acute intertrochanteric fracture, left femur...." Resident #4's hospital Progress Notes, dated 02/21/14, reflected: "...SUBJECTIVE DATA: The patient complains that he is having a great deal of pain from his left leg. His (family member) is a (sic) the bedside, states surgery was postponed due to pending echo report that is rescheduled for today. (The family member) does relate feeling torn about decision for surgical intervention versus not though (the family member) does not feel like not going through with the surgery is a [MEDICATION NAME] choice. We did discuss the option of hospice and comfort care at this time. (The family member) is not ready to make that decision and does feel that if surgical intervention is the best choice at this time...PLAN: 1. The patient's surgical repair of the left [MEDICAL CONDITION] rescheduled for today...." Interview on 02/26/14 at 2:47 PM with LVN E revealed she was working the 2:00 PM to 10:00 PM shift the day Resident #4 fell . LVN E stated it was around 3:00 PM, and she was passing medications on the resident's hallway when she saw the x-ray technician in the facility. LVN E stated she saw the x-ray technician go to the front desk and get a copy of the resident's Face Sheet and sign the order. LVN E stated she saw him walk down to Resident #4's room unassisted, and he entered the room. LVN E revealed there was usually somebody at the front desk, but she was not sure if anybody was there at the time. LVN E revealed they usually say "the one by the window or the one by the wall" when they see x-ray come in, but said she did not do that this time. LVN E stated, "I think they know what bed A is and what bed B is." LVN E revealed Resident #4's roommate had received a lot of x-rays recently and that may have been the reason for the "mix up." LVN E stated she did not work over the weekend, but returned on Monday working the 2:00 PM to 10:00 PM shift. She stated Resident #4 was favoring his left leg, and it was swollen. She revealed any movement caused pain. LVN E stated she contacted the physician, but was told he "didn't see the point to do another x-ray as it was negative." LVN E revealed on Tuesday 02/18/14 she assisted another staff member, and they undressed Resident #4 and stood him up. She stated they saw the displacement in the hip and contacted the physician and asked for another x-ray to be ordered, and he said, "No." Later that day LVN E revealed she asked another nurse to contact the physician and request an order. LVN G contacted the physician and was able to obtain an order to do a second x-ray. Interview on 02/26/14 at 2:20 PM with Physician Q, who was also the facility's Medical Director, revealed he was aware of Resident #4's fall on 02/14/14 and ordered an x-ray to rule out a fracture. Physician Q stated he saw Resident #4 on Monday 02/17/14 around noon while the resident was in his room in bed. He stated Resident #4 showed no signs or symptoms of pain at that time. The resident's left leg was swollen, but there was no bruising, and the resident did not wince or show signs of pain when the leg was moved. When asked about documentation, the physician replied he usually documented his visits, but did not this time as he was planning to see the resident the next day. Physician Q stated on Tuesday, 02/17/14, he did not notice changes to the resident's leg from the previous day. Physician Q revealed he reviewed the x-ray report on Monday, and the report was negative for a fracture. At the time, he saw no reason to repeat the x-ray. He stated he went by the x-ray results. Physician Q stated the nurses told him the resident was "hurting," but he associated it with the fall. Resident #4 was not "screaming in pain," when he was moved. Physician Q reported that he saw Resident #4 again on Tuesday 02/18/14, and the family reported to the nurses that the resident was in pain. That was when the second x-ray was ordered. Physician Q stated this was a "rare occurrence to x-ray the wrong person," and it never occurred to him there could have been a "mix-up" during the procedure. Interview with the DON on 02/26/14 at 8:10 AM revealed she witnessed the fall on 02/14/14 for Resident #4. She stated the resident was not complaining of pain until later that night. The x-ray was negative for a fracture. The DON stated Physician Q saw the resident at least two times and stated it was "not consistent of a fracture," however by Monday it was "very swollen." When queried about the lack of documentation relating to post-fall monitoring, medication administration documentation and nurse's notes, the DON stated she had begun in-servicing nursing staff on proper documentation and reporting. Interview with the Administrator on 02/25/14 at 11:10 AM revealed the facility reported the incident regarding Resident #4 to DADS on 02/19/14. The Administrator reported Resident #4 had a witnessed fall on 02/14/14 at approximately 2:30 PM. The physician was notified and an x-ray was ordered and obtained. The x-ray results per the radiologic report were negative, and the resident was monitored for a change or further issues related to the fall. The resident began having difficulty lifting his leg while wheeling or being wheeled in his chair on Saturday, 02/15/14, and Sunday, 02/16/14. The Administrator stated on Monday morning, Resident #4 had a swollen thigh. Physician Q examined the resident at lunchtime and then that evening during his rounds. He wanted to continue to monitor this problem and attributed it to the previous fall. On Tuesday 02/18/14, the resident's thigh was still swollen, and the physician checked it again noting the x-ray was negative and continued to monitor him. By later that afternoon, the swelling worsened, and the pain increased so another x-ray was ordered and obtained. The radiologic report indicated a fracture of his left femur, and the resident was sent out to the hospital for evaluation and treatment. The Administrator stated Resident #4's family was contacted, and the facility started an investigation. The Administrator explained that upon reviewing the radiology reports, a discrepancy was found, and the facility's contracted x-ray company was contacted to alert them the technician had possibly x-rayed the wrong resident. The radiology company launched their own investigation, and the technician was placed on 90-day probation. The Administrator explained the facility held a QAA meeting and began working on updating policies and procedures related to outside vendors. The facility's contracted mobile x-ray company documented the following Customer Service Inquiry, dated 02/20/14, which reflected: "Concern: Patient Fracture Specifics: Patient (Resident #4) had a Left Hip/Left Knee study ordered on [DATE] at 12:59 p.m. (Mobile x-ray company) radiologic technologist (X-ray Technician R) was sent to complete exam. The study was negative/no fracture. Patient (Resident #4) had a Left Femur study ordered 02/08/2014 (sic, 02/18/2014) at 5:32 p.m. (Mobile x-ray company) radiologic technologist (X-ray Technician S) was sent to complete the exam. The study was positive, acute intertrochanteric femoral fracture with moderate displacement. Santa Fe Director of nurses contacted (mobile x-ray company) (on) 02/19/2014 with questions regarding the patient findings, and why the fracture was not discovered on the 02/14 exam. Inquiry findings: (Mobile x-ray company) radiologic technologist (X-ray Technician R) performed the Left Hip/Left Knee study ordered for (Resident #4) on the wrong patient. The exam was done on (Resident #4's) roommate (Resident #17). (X-ray Technician R) did not utilize two patient identifiers. Miscommunication between Santa Fe staff and (X-ray Technician R) occurred when (X-ray Technician R) ask (sic) who/where the patient is. The ultimate responsibility to correctly identify a patient before completing an exam lies solely with the technologist performing the study. Action Plan: Continue quality assurance with (mobile x-ray company) staff to ensure that before an exam is performed, no less than three patient identifiers are to be utilized. In conjunction with patient identifiers, before performing exam, (X-ray Technician R) will be consulting with nursing home staff, to ensure correct patient is being done. Radiologic Technologist (X-ray Technician R) has been put on a 90 (day) probation." Interview with Resident #4's family member on 02/25/14 at 5:45 PM revealed Resident #4 had been living at the facility for approximately three to four months. The family member explained that Resident #4 had severe dementia and was still adjusting to the facility. The family member stated Resident #4 did not always recognize family and was oriented only to himself. The family member stated he/she was called on 02/14/14 and informed that Resident #4 had fallen, and "hit hard." The family member stated he/she was told Resident #4 was given Tylenol for the pain. The family member revealed he/she went to the facility that day, and Resident #4 was complaining of pain and dragging his left leg as staff was wheeling him out from the dining room. Over the weekend, the family member stated Resident #4 was sore, but he was not complaining of pain. The family member stated Resident #4 "would not necessarily complain of pain" due to him being "very hard of hearing and slow to process speech and articulate." At times he stated, "It hurts," but would be forgetful of the fall. The family member stated the facility called again a few days later on Tuesday night 02/18/14 and said another x-ray was taken, and it appeared he had a broken hip and was being transferred to the hospital. The family member revealed the hospital physicians had to wait until the resident could be seen by the cardiologist to ensure the resident could withstand surgery. The family member stated Physician Q contacted them on 02/24/14 and stated he had some "disturbing information to share." The family member stated Physician Q informed him/her that the initial x-ray ordered for Resident #4 had been done on the wrong resident. The family member revealed he/she was "shocked" and not sure how the error could have happened. The family member was told the facility was conducting an investigation into the matter. The family member was concerned about the extended amount of time Resident #4 went without treatment for [REDACTED]. It was determined these failures placed Resident #4 in an Immediate Jeopardy (IJ) situation from 02/14/14 through 02/18/14, until medical intervention and hospitalization . The facility's Quality Assurance Performance Improvement Plan, dated 02/20/14 reflected the following relating to Resident #4: "1. Residents will be identified as a fall risk and proper equipment will be in place. Action steps: Nurses will give report to nursing administration at 9:00 AM and 7:00 PM. Nurses will go to room and verify resident and part to x-ray. System Correction: All incidents and accidents will be reviewed with the interdisciplinary team for appropriate action to be taken and any recommendations. Training: Staff will be educated and trained in post fall procedures. Physicians will be incorporated with the care and follow up of residents that have fallen. Monitoring: Reviewed in QAA. Resolution Date: 02/20/14 2. Post Fall Documentation and Change in condition, dated 02/26/14. Purpose: To identify changes and document on a residents condition related post-fall. In-service: Staff will be able to verbalize purpose of the post fall documentation. Staff will be able to recognize changes of resident's condition. Staff will be able to verbalize how and when to notify physician of a change in condition. Staff will be able to verbalize how to use the post fall documentation. Post fall assessments are to stay in the 24 hour report for 72 hours. 3. Pain flow sheets, dated 02/26/14. Purpose: Pain flow sheets must be used on every resident that receives pain medications. Pain assessments must be updated with admission, readmission, change of condition, increased requests for pain medications, after a fall and quarterly. (Attachments included policy and procedure, example of pain flow sheet and pain validation too.) 4. Outside vendors, dated 02/26/14. All outside vendors (lab, radiology, etc.,) will have to sign in at the front desk upon arrival to the facility. Nursing staff along with the vendor will verify the order and the outside vendor will be physically escorted to the resident to ensure correct resident receives services. 5. The DON of the facility will continue to monitor and educate the nursing staff on the pain documentation, 24 hour reporting, follow up on incidents, and change of condition. This will be an ongoing process to improve the quality of care for the residents and the best practice for the nursing staff, signed and dated by the DON 02/27/14." Review of the in-services revealed the following topics were covered: - Nursing staff was in-serviced to physically walk to a resident's room and identify the resident for any outside vendors such as x-ray or lab technicians. This in-service was completed on 02/25/14 and 02/26/14, with 53 signatures of nursing staff who received the in-service. - Change of condition and 24-hour report sheets: This in-service included handouts and lectures dated 02/20/14 and 02/26/14, with 28 signatures. The handouts covered observing, recording and reporting any change of condition to ensure proper treatment was implemented. This included Pain Flow Sheets being used on every resident that received pain medications. The in-service materials also reflected that staff were in-serviced to do pain assessments upon admission, readmission, quarterly, change of condition, increased requests for pain medications, and after a fall. Review of the facility's vendor sign-in sheet revealed that outside vendors were signing in upon arrival. Interview on 02/26/14 at 8:10 AM with the DON revealed she and the facility's only ADON had been working on in-servicing all nursing staff relating to the incident. New policies were in place to ensure the proper resident would be identified and would receive the appropriate services as ordered by the physician. Staff now escort the vendors to the resident and identify them. Staff had been in-serviced on documentation, post fall documentation, medication administration, reporting and change of condition. Interview with LVN F on 02/26/14 at 9:00 AM revealed changes which had occurred at the facility since learning of the incident involving Resident #4 included many in-services relating to communication, documentation, and vendors. It was the responsibility of the nursing staff to ensure they brought the outside vendor to the correct resident for identification in order for the resident to receive the proper treatment. Change of condition and documentation were also in-serviced on. Proper documentation and assessments post fall were to be completed for 72 hours post fall on any fall and included in the 24 hour report. Interview with LVN D on 02/26/14 at 9:40 AM revealed in-service topics included having vendors sign in at the desk, checking the order in the chart and have the vendor sign the order and make a copy, and escorting the vendor to the resident and assist as needed. When a resident had a fall, it needed to be documented and followed, nurses were to assess the resident post fall and document their findings, and report was given to next shift. Any medication given should be documented and followed up on to ensure it was effective. Nurse's notes should be complete and accurate, and any changes of condition should be reported and documented. Interview with LVN E on 02/26/14 at 2:47 PM revealed recent in-services included the following: outside vendors were to check in and sign in with the front desk, staff member was to verify the order and escort the vendor to the resident to ensure correct resident and correct procedure. In addition, staff were in-serviced regarding proper documentation post fall, pain, and change of condition were discussed. Interview with LVN G on 02/26/14 at 3:00 PM revealed recent in-services included outside vendors and the new policy and procedure, documentation relating to post falls and medication administration. When outside vendors entered the facility they were to sign in at the front desk. Staff member was to check the order with the vendor and physically escort them to the resident and assist as needed. Documentation in a resident's chart any changes of condition, pain or if medications were given for pain they should be followed up on. In-serviced on reporting and following falls for 24 hours post fall, 72 hours if resident hit their head. Report all changes to following shift and utilize 24-hour report. Interview with RN Supervisor on 02/27/14 at approximately 3:00 PM revealed she received recent in-services that included how to follow up and monitor residents post-fall. All falls were to be monitored and documented for 24-72 hours. Incident reports were completed and reviewed for accuracy. Pain was to be assessed on the resident and documented. Staff would report any change of condition to the charge nurse and it would be placed on the 24-hour report and followed. The DON was responsible for ensuring documentation and monitoring was completed and accurate. This was determined to be Past Noncompliance (PNC) Immediate Jeopardy due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility's Resident Census and Conditions of Residents Form CMS-672 completed by LVN T on 02/25/14 reflected the facility had a census of 77 residents.

Based on interview and record review, it was determined the facility failed to obtain radiology services to meet the needs of one (Resident #4) of 16 residents reviewed for physician ordered x-rays. 1. The facility failed to ensure the facility's contracted radiology technician x-rayed the correct resident, after Resident #4 fell on [DATE] and complained of pain to his leg. Resident #4's left leg was swollen "twice the size of his right leg," and he had pain. A second x-ray was obtained on 02/18/14, which indicated he had a [MEDICAL CONDITION] with displacement, and he was sent to the hospital that day, which was four days after his fall. This was determined to be Past Noncompliance (PNC) Immediate Jeopardy due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. These failures could affect the facility's 77 residents, who may need radiology services, by placing them at risk for not receiving the services ordered by their physician. Findings included: Resident #4 was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #4's MDS admission assessment dated [DATE] reflected Resident #4 was an [AGE] year-old male, who was admitted to the facility on [DATE]. The assessment reflected Resident #4 had both short-term and long-term memory problems with severe cognitive impairment. In regards to his functional status, the assessment reflected Resident #4 required extensive assistance from staff with bed mobility, transferring, dressing, toileting, and personal hygiene. The MDS assessment reflected the resident did not have a history of falls. Resident #4's Nurse's Notes for Friday, 02/14/14 reflected the following entries were documented: 02/14/14 at 12:15 PM - "Res stood up to transfer to lobby chair alarm sounded & resident fell over onto (L) side. Did not hit head & no (symbol used) injuries noted. (Physician Q) notified no (symbol used) N/O @ this time. Notified (family member). No (symbol used) concerns voiced." 02/14/14 at 1:00 PM- "C/O pain to (L) hip 'Hurts like hell' (resident) stated. Called (Physician Q) N/O X-Ray on left hip. (Family member) notified via telephone. Noted resident having trouble lifting (L) leg." Interview with LVN D on 02/26/14 at 9:40 AM revealed she saw Resident #4 fall on Friday, 02/14/14. He stood up from his wheelchair, his chair alarm was going off, and he fell to the floor. After the fall, LVN D stated she asked Resident #4 if he was hurting anywhere. She stated Resident #4 responded by repeating "hurting anywhere." LVN D stated she then assisted the resident to his wheelchair and took his vital signs. She stated the resident was then administered Tylenol for pain, and the physician and family were notified of the fall. LVN D stated an order was obtained for an x-ray of Resident #4's left hip. When LVN D was queried as to why she did not document giving Resident #4 medication on 02/14/14, she revealed she was busy and just did not document it. Resident #4's Nurse's Notes, dated 02/14/14 at 8:24 PM, reflected, "Xray results negative. No (symbol used) evidence of fx on (L) lower extremities. (Physician Q) in to see res and lab reports....Res favors (L) side when up (symbol used) in w/c. WCTM" Resident #4's February 2014 MAR indicated [REDACTED]. Interview with CNA A on 02/26/14 at 4:30 PM revealed she did not witness Resident #4 fall, but she did care for him on the evening that he fell . On the date of the fall, CNA A stated she saw Resident #4 in the dining room at dinner time, and she attempted to assist him to his room. While Resident #4 was in his wheelchair, he was unable to lift his left leg. CNA A explained she attempted to cross the resident's left leg over his right leg so it could be supported, but the resident had a "look of pain on his face." CNA A revealed she saw the radiologist that day at the front desk, but she did not see him afterwards. CNA A stated she reported Resident #4's pain to LVN E, who was his charge nurse on 02/14/14. Interview with LVN F on 02/26/14 at 9:00 AM revealed she was working on 02/14/14 (her shift was Monday through Friday 8:00 AM to 5:00 PM) when Resident #4 fell , but she did not witness the fall. She stated she did not see the x-ray technologist, and believed he entered after her shift. LVN F stated she worked Saturday, 02/15/14, night (one day after the fall) and stated no reports were given to her that reflected Resident #4 was experiencing pain. She stated she saw the resident in bed on 02/15/14, and staff was changing him without any complaints. Interview with CNA H on 02/26/14 at 4:39 PM revealed she worked the 2:00 PM to 10:00 PM shift on 02/14/14, which was the day Resident #4 fell . CNA H stated she gave Resident #4 a shower that day, and he was complaining of pain in his left leg. When she brought him to the shower room, CNA H stated she had to support the resident because he could not support himself nor turn himself. CNA H explained that was unusual for Resident #4 because he could transfer himself with minimal assistance. CNA H revealed she noticed swelling to the resident's left leg that day, and she reported it to the nurse. CNA H stated she did not work over the weekend (02/15/14 through 02/16/14), which were the two days immediately following the resident's fall. Resident #4's x-ray report dated 02/14/14 reflected x-rays of the resident's left hip and left knee were taken. The report reflected: "FINDINGS...Left hip... IMPRESSIONS: 1. Partial hip replacement with intact femoral component in anatomic alignment. 2. No radiographic evidence of acute fracture or dislocation. If symptoms persist, consider follow-up radiographs in order to evaluate for initial radiographically occult fracture.... FINDINGS...Left knee... IMPRESSIONS: Total knee replacement with intact femoral and tibial components in anatomic alignment. No radiographic evidence of acute fracture or dislocation...." Review of Resident #4's clinical records revealed there was no documented evidence reflecting the resident had a partial hip replacement or a total knee replacement. Interview with the RN Supervisor on 02/27/14 at 3:00 PM revealed she was working the weekend after Resident #4 had the fall. The RN Supervisor saw Resident #4 in his wheelchair by the front door on Saturday, and the resident was also in the dining room for dinner that evening. The RN Supervisor stated she was aware Resident #4 had a fall the day before from reviewing the 24-hour report, and she was aware the radiology report came back negative for fracture. The RN Supervisor stated none of the staff members reported to her Resident #4 was in pain over the weekend. The RN Supervisor was asked about post-fall documentation, and she stated the resident should be monitored for 72 hours following a fall, and neurological checks were done if the resident hit his or her head. Further review of Resident #4's Nurse's Notes revealed the next entry, following the 02/14/14 entries, was documented on 02/17/14 at 8:30 AM which was three days after the resident's fall. This Nurse's Note reflected, "Noted Res (L) thigh swollen twice the size of the (R). No bruising, warmth, or discoloration at this time. Called (Physician Q) no (symbol used) N/O at this time." Interview with LVN D on 02/26/14 at 9:40 AM revealed she did not work over the weekend following the fall. However, when she returned to the facility on Monday, 02/17/14,, she was concerned about Resident #4's left leg being "swollen twice the size of the right leg." She stated she did not see any documentation or nursing notes through the weekend in Resident #4's clinical record. She revealed she contacted the physician with her concerns and was told there was "no need for an additional x-ray as the results were negative for a fracture and there was no need to do anything else." LVN D stated she saw Physician Q in the facility twice since Resident #4 fell , but she was not sure if the physician saw Resident #4. Resident #4's February 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]." Further review of the February 2014 MAR indicated [REDACTED]. Resident #4's Nurse's Notes, dated 02/18/14, reflected 02/18/14 at 1:00 PM - "Resident (L) thigh swollen twice the size of the (R). (Physician Q) notified continues to refuse x-ray of femur. DON notified." Interview with LVN D on 02/26/14 at 9:40 AM revealed she reported to the Administration her concerns about Resident #4 on Tuesday 02/18/14, and she was told to keep calling the physician until he ordered another x-ray. Resident #4's Nurse's Notes dated 02/18/14 at 7:35 PM reflected: "Late entry: 2/18/14 1700 (5:00 PM) Res c/o pain to (L) LE. Swelling noted. PRN tylenol given for pain. (Physician Q) called & asked for xray D/T swelling & pain- refused. WCTM." Resident #4's Nurse's Notes dated 02/18/14 at 5:30 PM reflected: "Resident c/o pain (L) upper leg (femur area) with (symbol used) ROM, does not want to bear wt with (symbol used) transferring. (L) upper leg with (symbol used) [MEDICAL CONDITION], and pain. (Physician Q) called and xray ordered of (L) femur. (Radiology Company) called; xray (L) femur ordered. Called (family member) and notified of order." Interview with LVN D on 02/26/14 at 9:40 AM revealed she called up to the facility on [DATE] after her shift to check on the resident, and she asked LVN G to contact the physician to try to obtain an order for [REDACTED].#4's leg was clearly broken and not in alignment. Interview with LVN G on 02/26/14 at 3:00 PM revealed he was working on 02/14/14 the 2:00 PM to 10:00 PM shift. He was the charge nurse for Hall 200 and 300. Resident #4 resided on the 400 hall. He did not see the x-ray technician come into the facility that day. LVN G stated on Monday he remembered seeing Resident #4 in his wheelchair and noticed his left leg was quite swollen. He revealed the other nurses were calling the physician trying to obtain an order for [REDACTED]." LVN G described himself as "more aggressive than some of the other nurses," and he stated was able to get the physician to order another x-ray. Resident #4's February 2014 MAR indicated [REDACTED]. Resident #4's x-ray report dated 02/18/14 reflected an x-ray was taken of the resident's left femur on that date. The report reflected: "IMPRESSIONS: 1. Acute intertrochanteric femoral fracture with moderate displacement with varus angulation. 2. Moderate degree of [MEDICAL CONDITION]. 3. Moderate [MEDICAL CONDITION]." Resident #4's Nurse's Notes dated, 02/18/14 at 7:24 PM, reflected, "Xray reveals fx femoral head to (L) LE. (Physician Q) notified. Order to send to ER to eval & tx. (Family member) notified via vm x1. WCTM." Resident #4's Nurse's Notes dated, 02/18/14 at 7:27 PM reflected: "Ambulance arrives to take res to ER." Resident #4's hospital Progress Notes, dated 02/20/14, reflected, "...ASSESSMENT: 1. Acute intertrochanteric fracture, left femur...." Resident #4's hospital Progress Notes, dated 02/21/14, reflected: "...SUBJECTIVE DATA: The patient complains that he is having a great deal of pain from his left leg. His (family member) is a (sic) the bedside, states surgery was postponed due to pending echo report that is rescheduled for today. (The family member) does relate feeling torn about decision for surgical intervention versus not though (the family member) does not feel like not going through with the surgery is a [MEDICATION NAME] choice. We did discuss the option of hospice and comfort care at this time. (The family member) is not ready to make that decision and does feel that if surgical intervention is the best choice at this time...PLAN: 1. The patient's surgical repair of the left [MEDICAL CONDITION] rescheduled for today...." Interview on 02/26/14 at 2:47 PM with LVN E revealed she was working the 2:00 PM to 10:00 PM shift the day Resident #4 fell . LVN E stated it was around 3:00 PM, and she was passing medications on the resident's hallway when she saw the x-ray technician in the facility. LVN E stated she saw the x-ray technician go to the front desk and get a copy of the resident's Face Sheet and sign the order. LVN E stated she saw him walk down to Resident #4's room unassisted, and he entered the room. LVN E revealed there was usually somebody at the front desk, but she was not sure if anybody was there at the time. LVN E revealed they usually say "the one by the window or the one by the wall" when they see x-ray come in, but said she did not do that this time. LVN E stated, "I think they know what bed A is and what bed B is." LVN E revealed Resident #4's roommate had received a lot of x-rays recently and that may have been the reason for the "mix up." LVN E stated she did not work over the weekend, but returned on Monday working the 2:00 PM to 10:00 PM shift. She stated Resident #4 was favoring his left leg, and it was swollen. She revealed any movement caused pain. LVN E stated she contacted the physician, but was told he "didn't see the point to do another x-ray as it was negative." LVN E revealed on Tuesday 02/18/14 she assisted another staff member, and they undressed Resident #4 and stood him up. She stated they saw the displacement in the hip and contacted the physician and asked for another x-ray to be ordered, and he said, "No." Later that day LVN E revealed she asked another nurse to contact the physician and request an order. LVN G contacted the physician and was able to obtain an order to do a second x-ray. Interview on 02/26/14 at 2:20 PM with Physician Q, who was also the facility's Medical Director, revealed he was aware of Resident #4's fall on 02/14/14 and ordered an x-ray to rule out a fracture. Physician Q stated he saw Resident #4 on Monday 02/17/14 around noon while the resident was in his room in bed. He stated Resident #4 showed no signs or symptoms of pain at that time. The resident's left leg was swollen, but there was no bruising, and the resident did not wince or show signs of pain when the leg was moved. When asked about documentation, the physician replied he usually documented his visits, but did not this time as he was planning to see the resident the next day. Physician Q stated on Tuesday, 02/17/14, he did not notice changes to the resident's leg from the previous day. Physician Q revealed he reviewed the x-ray report on Monday, and the report was negative for a fracture. At the time, he saw no reason to repeat the x-ray. He stated he went by the x-ray results. Physician Q stated the nurses told him the resident was "hurting," but he associated it with the fall. Resident #4 was not "screaming in pain," when he was moved. Physician Q reported that he saw Resident #4 again on Tuesday 02/18/14, and the family reported to the nurses that the resident was in pain. That was when the second x-ray was ordered. Physician Q stated this was a "rare occurrence to x-ray the wrong person," and it never occurred to him there could have been a "mix-up" during the procedure. Interview with the DON on 02/26/14 at 8:10 AM revealed she witnessed the fall on 02/14/14 for Resident #4. She stated the resident was not complaining of pain until later that night. The x-ray was negative for a fracture. The DON stated Physician Q saw the resident at least two times and stated it was "not consistent of a fracture," however by Monday it was "very swollen." When queried about the lack of documentation relating to post-fall monitoring, medication administration documentation and nurse's notes, the DON stated she had begun in-servicing nursing staff on proper documentation and reporting. Interview with the Administrator on 02/25/14 at 11:10 AM revealed the facility reported the incident regarding Resident #4 to DADS on 02/19/14. The Administrator reported Resident #4 had a witnessed fall on 02/14/14 at approximately 2:30 PM. The physician was notified and an x-ray was ordered and obtained. The x-ray results per the radiologic report were negative, and the resident was monitored for a change or further issues related to the fall. The resident began having difficulty lifting his leg while wheeling or being wheeled in his chair on Saturday, 02/15/14, and Sunday, 02/16/14. The Administrator stated on Monday morning, Resident #4 had a swollen thigh. Physician Q examined the resident at lunchtime and then that evening during his rounds. He wanted to continue to monitor this problem and attributed it to the previous fall. On Tuesday 02/18/14, the resident's thigh was still swollen, and the physician checked it again noting the x-ray was negative and continued to monitor him. By later that afternoon, the swelling worsened, and the pain increased so another x-ray was ordered and obtained. The radiologic report indicated a fracture of his left femur, and the resident was sent out to the hospital for evaluation and treatment. The Administrator stated Resident #4's family was contacted, and the facility started an investigation. The Administrator explained that upon reviewing the radiology reports, a discrepancy was found, and the facility's contracted x-ray company was contacted to alert them the technician had possibly x-rayed the wrong resident. The radiology company launched their own investigation, and the technician was placed on 90-day probation. The Administrator explained the facility held a QAA meeting and began working on updating policies and procedures related to outside vendors. The facility's contracted mobile x-ray company documented the following Customer Service Inquiry, dated 02/20/14, which reflected: "Concern: Patient Fracture Specifics: Patient (Resident #4) had a Left Hip/Left Knee study ordered on [DATE] at 12:59 p.m. (Mobile x-ray company) radiologic technologist (X-ray Technician R) was sent to complete exam. The study was negative/no fracture. Patient (Resident #4) had a Left Femur study ordered 02/08/2014 (sic, 02/18/2014) at 5:32 p.m. (Mobile x-ray company) radiologic technologist (X-ray Technician S) was sent to complete the exam. The study was positive, acute intertrochanteric femoral fracture with moderate displacement. Santa Fe Director of nurses contacted (mobile x-ray company) (on) 02/19/2014 with questions regarding the patient findings, and why the fracture was not discovered on the 02/14 exam. Inquiry findings: (Mobile x-ray company) radiologic technologist (X-ray Technician R) performed the Left Hip/Left Knee study ordered for (Resident #4) on the wrong patient. The exam was done on (Resident #4's) roommate (Resident #17). (X-ray Technician R) did not utilize two patient identifiers. Miscommunication between Santa Fe staff and (X-ray Technician R) occurred when (X-ray Technician R) ask (sic) who/where the patient is. The ultimate responsibility to correctly identify a patient before completing an exam lies solely with the technologist performing the study. Action Plan: Continue quality assurance with (mobile x-ray company) staff to ensure that before an exam is performed, no less than three patient identifiers are to be utilized. In conjunction with patient identifiers, before performing exam, (X-ray Technician R) will be consulting with nursing home staff, to ensure correct patient is being done. Radiologic Technologist (X-ray Technician R) has been put on a 90 (day) probation." Interview with Resident #4's family member on 02/25/14 at 5:45 PM revealed Resident #4 had been living at the facility for approximately three to four months. The family member explained that Resident #4 had severe dementia and was still adjusting to the facility. The family member stated Resident #4 did not always recognize family and was oriented only to himself. The family member stated he/she was called on 02/14/14 and informed that Resident #4 had fallen, and "hit hard." The family member stated he/she was told Resident #4 was given Tylenol for the pain. The family member revealed he/she went to the facility that day, and Resident #4 was complaining of pain and dragging his left leg as staff was wheeling him out from the dining room. Over the weekend, the family member stated Resident #4 was sore, but he was not complaining of pain. The family member stated Resident #4 "would not necessarily complain of pain" due to him being "very hard of hearing and slow to process speech and articulate." At times he stated, "It hurts," but would be forgetful of the fall. The family member stated the facility called again a few days later on Tuesday night 02/18/14 and said another x-ray was taken, and it appeared he had a broken hip and was being transferred to the hospital. The family member revealed the hospital physicians had to wait until the resident could be seen by the cardiologist to ensure the resident could withstand surgery. The family member stated Physician Q contacted them on 02/24/14 and stated he had some "disturbing information to share." The family member stated Physician Q informed him/her that the initial x-ray ordered for Resident #4 had been done on the wrong resident. The family member revealed he/she was "shocked" and not sure how the error could have happened. The family member was told the facility was conducting an investigation into the matter. The family member was concerned about the extended amount of time Resident #4 went without treatment for [REDACTED]. It was determined these failures placed Resident #4 in an Immediate Jeopardy (IJ) situation from 02/14/14 through 02/18/14, until medical intervention and hospitalization . The facility's Quality Assurance Performance Improvement Plan, dated 02/20/14 reflected the following relating to Resident #4: "1. Residents will be identified as a fall risk and proper equipment will be in place. Action steps: Nurses will give report to nursing administration at 9:00 AM and 7:00 PM. Nurses will go to room and verify resident and part to x-ray. System Correction: All incidents and accidents will be reviewed with the interdisciplinary team for appropriate action to be taken and any recommendations. Training: Staff will be educated and trained in post fall procedures. Physicians will be incorporated with the care and follow up of residents that have fallen. Monitoring: Reviewed in QAA. Resolution Date: 02/20/14 2. Post Fall Documentation and Change in condition, dated 02/26/14. Purpose: To identify changes and document on a residents condition related post-fall. In-service: Staff will be able to verbalize purpose of the post fall documentation. Staff will be able to recognize changes of resident's condition. Staff will be able to verbalize how and when to notify physician of a change in condition. Staff will be able to verbalize how to use the post fall documentation. Post fall assessments are to stay in the 24 hour report for 72 hours. 3. Pain flow sheets, dated 02/26/14. Purpose: Pain flow sheets must be used on every resident that receives pain medications. Pain assessments must be updated with admission, readmission, change of condition, increased requests for pain medications, after a fall and quarterly. (Attachments included policy and procedure, example of pain flow sheet and pain validation too.) 4. Outside vendors, dated 02/26/14. All outside vendors (lab, radiology, etc.,) will have to sign in at the front desk upon arrival to the facility. Nursing staff along with the vendor will verify the order and the outside vendor will be physically escorted to the resident to ensure correct resident receives services. 5. The DON of the facility will continue to monitor and educate the nursing staff on the pain documentation, 24 hour reporting, follow up on incidents, and change of condition. This will be an ongoing process to improve the quality of care for the residents and the best practice for the nursing staff, signed and dated by the DON 02/27/14." Review of the in-services revealed the following topics were covered: - Nursing staff was in-serviced to physically walk to a resident's room and identify the resident for any outside vendors such as x-ray or lab technicians. This in-service was completed on 02/25/14 and 02/26/14, with 53 signatures of nursing staff who received the in-service. - Change of condition and 24-hour report sheets: This in-service included handouts and lectures dated 02/20/14 and 02/26/14, with 28 signatures. The handouts covered observing, recording and reporting any change of condition to ensure proper treatment was implemented. This included Pain Flow Sheets being used on every resident that received pain medications. The in-service materials also reflected that staff were in-serviced to do pain assessments upon admission, readmission, quarterly, change of condition, increased requests for pain medications, and after a fall. Review of the facility's vendor sign-in sheet revealed that outside vendors were signing in upon arrival. Interview on 02/26/14 at 8:10 AM with the DON revealed she and the facility's only ADON had been working on in-servicing all nursing staff relating to the incident. New policies were in place to ensure the proper resident would be identified and would receive the appropriate services as ordered by the physician. Staff now escort the vendors to the resident and identify them. Staff had been in-serviced on documentation, post fall documentation, medication administration, reporting and change of condition. Interview with LVN F on 02/26/14 at 9:00 AM revealed changes which had occurred at the facility since learning of the incident involving Resident #4 included many in-services relating to communication, documentation, and vendors. It was the responsibility of the nursing staff to ensure they brought the outside vendor to the correct resident for identification in order for the resident to receive the proper treatment. Change of condition and documentation were also in-serviced on. Proper documentation and assessments post fall were to be completed for 72 hours post fall on any fall and included in the 24 hour report. Interview with LVN D on 02/26/14 at 9:40 AM revealed in-service topics included having vendors sign in at the desk, checking the order in the chart and have the vendor sign the order and make a copy, and escorting the vendor to the resident and assist as needed. When a resident had a fall, it needed to be documented and followed, nurses were to assess the resident post fall and document their findings, and report was given to next shift. Any medication given should be documented and followed up on to ensure it was effective. Nurse's notes should be complete and accurate, and any changes of condition should be reported and documented. Interview with LVN E on 02/26/14 at 2:47 PM revealed recent in-services included the following: outside vendors were to check in and sign in with the front desk, staff member was to verify the order and escort the vendor to the resident to ensure correct resident and correct procedure. In addition, staff were in-serviced regarding proper documentation post fall, pain, and change of condition were discussed. Interview with LVN G on 02/26/14 at 3:00 PM revealed recent in-services included outside vendors and the new policy and procedure, documentation relating to post falls and medication administration. When outside vendors entered the facility they were to sign in at the front desk. Staff member was to check the order with the vendor and physically escort them to the resident and assist as needed. Documentation in a resident's chart any changes of condition, pain or if medications were given for pain they should be followed up on. In-serviced on reporting and following falls for 24 hours post fall, 72 hours if resident hit their head. Report all changes to following shift and utilize 24-hour report. Interview with RN Supervisor on 02/27/14 at approximately 3:00 PM revealed she received recent in-services that included how to follow up and monitor residents post-fall. All falls were to be monitored and documented for 24-72 hours. Incident reports were completed and reviewed for accuracy. Pain was to be assessed on the resident and documented. Staff would report any change of condition to the charge nurse and it would be placed on the 24-hour report and followed. The DON was responsible for ensuring documentation and monitoring was completed and accurate. This was determined to be Past Noncompliance (PNC) Immediate Jeopardy due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility's Resident Census and Conditions of Residents Form CMS-672 completed by LVN T on 02/25/14 reflected the facility had a census of 77 residents.