Every finding on record at Skytop View Rehabilitation Center

Based on interview and record review, the facility failed to ensure physician ordered medication parameters were followed for adequate indications for use, resulting in the administration of unnecessary medications for 1 of 3 residents, Resident #1, reviewed for unnecessary pain medications. Findings include: Review of Resident #1's admission record documented diagnosis of atherosclerotic heart disease of native coronary artery(heart disease) without angina pectoris (chest pain), fibromyalgia (a disorder of pain processing causing chronic widespread pain), essential (primary) hypertension (high blood pressure), major depressive disorder, recurrent, unspecified, anxiety disorder unspecified, personal history of pulmonary embolism (a blood clot in the lung), personal history of malignant neoplasm breast (breast cancer), muscle weakness generalized, and difficulty in walking not elsewhere classified. Review of Resident #1's physician order dated 10/22/2025 read, Oxycodone-Acetaminophen tablet 10-325 mg (milligram) give one tablet by mouth every six hours as needed for severe pain 7-10, hold for lethargy. Review of Resident #1's Medication Administration Record (MAR) for October 2025 documented Oxycodone-Acetaminophen tablet 10-325 mg was administered on 10/23/2025 at 0821 (8:21 am) for a pain level of 6, on 10/28/2025 at 0818 (8:18 am) for a pain level of 6, on 10/29/2025 at 11:30 am for a pain level of 6, on 10/30/2025 at 0859 (8:59 am) for a pain level of 6, on 10/31/2025 at 1557 (3:57 pm) for a pain level of 5, and on 10/31/2025 at 2242 (10:42 pm) for a pain level of 3. During an interview on 12/16/2025 at 10:30 AM the Director of Nursing (DON) stated, All staff should follow the physician ordered parameters for pain medications, I see she was administered the medication outside the parameters. During an interview on 12/16/2025 at 12:20 PM Staff A, Registered Nurse (RN) stated, I did give her pain medicine outside the parameters. I should have let the doctor know and gotten another order or the parameters changed. I should have followed the doctors order. Review of the policy and procedure titled Medication Administration review date of 10/3/2024 read, I. Purpose: This Department process explains how medications are administered in a skilled nursing facility. Medications are administered by licensed nurses, who are legally authorized to do so in this state, as ordered by the provider and following professional standards of practice in a manner to prevent contamination or infection. III. Department process: I. Obtain And record vital signs when applicable or per physician orders. Hold the medication for those vital signs if they are outside the providers prescribed parameters. P. Controlled substances are administered per provider orders. Q. Administer medications as ordered following manufacturer specifications.

Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided for oxygen administration for 1 of 3 Residents, Resident #5, reviewed for respiratory services. Findings include: Record review of Resident #5's clinical record documented the resident was admitted with diagnosis that included: anemia, atherosclerosis heart disease, pulmonary hypertension, and chronic obstructive pulmonary disease. Review of Resident #5's physician orders dated 3/3/2025 read, Oxygen at 4LPM [liters per minute] via NC [nasal cannula] every shift. Review of Resident #5's care plan dated 2/6/2025 read, Focus: The resident has oxygen therapy r/t [related to] COPD [chronic obstructive pulmonary disease]. Interventions/Tasks: Give medications as ordered by physician. During an observation on 3/3/2025 at 10:08 AM of Resident #5, the resident was sitting at bedside. Oxygen was being administered at 3 liters per minute via nasal cannula. (Photograph evidence obtained). During an interview on 3/3/2025 at 1:16 PM Resident #5 stated, I do not change the settings [oxygen]., Normally I am on 4 liters when I am up walking around and 3 liters when I'm resting. During an observation on 3/3/2025 at 1:16 PM with Staff A, Registered Nurse (RN) Resident #5 was observed sitting at bedside with oxygen administered at 3 liters per minute via nasal cannula. During an interview on 3/3/2025 at 1:16 PM Staff A, RN verified the physician orders were for oxygen to be administered at 4 liters per minute via nasal cannula. During an interview on 3/3/2025 at 1:30 PM the Director of Nursing (DON) stated, The physician orders have to be followed, and the rate should be 4 liters a minute. Review of the policy and procedure titled Oxygen Therapy dated 1/22/2025 read, Policy: III. A. 1. Specific delivery device, liter flow or concentration .Procedure: IV. A. Set up oxygen utilizing appropriate delivery device according to physician's order, or according to protocol.

Based on record review and interview, the facility failed to ensure a rationale was in the medical record for psychotropic PRN (pro re nata/as needed) medications being prescribed for greater than 14 days for 1 of 5 residents, Resident #84, reviewed for unnecessary medications. Findings include: Review of the pharmacist's consultation report, dated 2/17/2025, read [Resident #84's Name] has a PRN order for a sedative/hypnotic, without a stop date: Zolpidem 10mg [milligrams] q [every] HS [hour of sleep] PRN for insomnia. Recommendation: Please discontinue PRN Zolpidem, or a stop date that is less than 14 days from initiation. If the medication cannot be discontinued at this time, document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Review of Resident #84's physician's orders dated 2/17/25 read Zolpidem Tartrate Oral Tablet 10MG [milligrams] (Zolpidem Tartrate) *Controlled Drug* Give 1 tablet by mouth every 24 hours as needed for Difficulty Sleeping for 30 days. The physician's order did not contain documented rationale for prescribing the medication for more than 14 days. Review of a physician's visit encounter note, dated 2/17/2025, read Zolpidem Tartrate 10mg 1 tab [tablet] q24 [every 24] hours PRN x 30 days (end 3/19/25). During an interview on 3/4/2025 beginning at 12:04 PM, the Director of Nursing stated she was unable to answer whether or not the physician had documented in Resident #84's clinical record the rationale for prescribing hypnotic medication for more than 14 days. Review of the policy titled Drug Regimen Review, last reviewed 1/22/2025, read, I. PURPOSE: This department process explains how this facility follows State and Federal Regulations, by having the Consultant Pharmacist review each resident's clinical chart monthly. Apparent irregularities will be reported in writing to the Director of Nursing, Medical Director, Attending Physician, Provider and Administrator. The facility will review and follow through on the Consultant Pharmacist's recommendations to ensure all residents maintain the highest practicable level of functioning .D. Follow up on Consultant Pharmacist Recommendations: .b. Clinical justification will be documented in the chart if a recommendation is declined by the physician/provider.

Based on observation, interview, and record review, the facility failed to secure medications for 1 of 3 wings, the south. Findings included: During an observation on 3/3/2025 at 10:08 AM of Resident #5's room there was one bottle of Saline Nasal Mist and one bottle of normal saline eye solution on the bedside table unsecured. (Photograph evidence obtained). During an observation on 3/3/2025 at 12:18 PM of Resident #5's room there was one bottle of Saline Nasal Mist and one bottle of normal saline eye solution on the bedside table unsecured. During an interview on 3/3/2025 at 12:22 PM Resident #5 stated, My wife brought them to me and I use them as needed at least daily. During an interview on 3/3/2025 at 12:30 PM Staff A, Registered Nurse (RN) verified the Saline Nasal Mist and bottle of normal saline eye solution medications unsecured at Resident #5's bedside. Staff A, RN stated, Medication cannot be kept at the bedside, all medications have to be secured. During an interview on 3/3/2025 at 1:16 PM the Director of Nursing stated, Medications cannot be at the bedside unsecured. Review of the policy and procedure titled Medication Storage dated 1/22/2025 read, This department process explains how medications and biologicals are stored safely, securely, and properly . B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended to by persons with authorized access.

Based on record review and interview, the facility failed to ensure transmission-based precautions were implemented for 1 of 3 residents reviewed, Resident #5, to prevent the possible spread of infections and communicable diseases. Findings include: Review of Resident #5's progress note, dated 7/12/24 at 8:51 PM, revealed the resident was noted with congested cough. The progress note documented Resident #5's physician ordered COVID-19 PCR [polymerase chain reaction] test. Review of Resident #5's COVID-19 test result, received by the facility on 7/15/2024 at 2:20 PM, revealed the resident had been tested for COVID-19 on 7/13/2024 at 8:27 AM and had been positive for COVID-19 on 7/13/2024 at 10:08 AM. Review of Resident #5's physician orders revealed no order for transmission-based precautions on 7/12/2024 after the resident was symptomatic with congested cough. Review of Resident #5's physician orders revealed orders for Zinc Sulfate oral capsule 50 milligrams one capsule by mouth one time a day for COVID-19 prophylaxis for 10 days (start date 7/15/2024 at 2:24 PM); Zyrtec Allergy Tablet 10 milligrams 1 tablet by mouth one time a day for allergy (start date 7/15/2024 at 2:24 PM); and Vitamin C 500 milligrams by mouth one time a day for immune health (start date 7/15/2024 at 2:24 PM). Review of Resident #5's physician orders failed to reveal an order for transmission-based precautions on 7/15/2024 after the facility was notified that Resident #5 had tested positive for COVID-19. Review of Resident #5's physician order showed the resident was placed on transmission-based precautions on 7/16/2024 at 9:41 AM. During an interview on 8/20/2024 at 11:36 AM, the Director of Nursing stated that an agency nurse was working with Resident #5 when Resident #5 was noted with a congested cough. She stated Resident #5 should have been placed on transmission-based precautions when she became symptomatic. She confirmed Resident #5 had tested positive for COVID-19 on 7/13/2024, the facility had not received the positive test results until 7/15/2024 and the physician had not ordered Resident #5 to be placed on transmission-based precautions until 7/16/2024. She acknowledged the facility's infection prevention policy requires residents to be placed on transmission-based precaution if there is reasonable suspicion of an infectious disease. Review of the facility policy and procedure titled Isolation- Initiating Transmission-Based Precautions with the last review date of 3/13/2024, showed the policy read, Policy Statement: Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions . Policy Interpretation and Implementation: 1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Nurse or Nursing Supervisor shall notify the Infection Preventionist (or (designee) and the resident's Attending Physician for appropriate Transmission-Based Precautions. 2. If the Attending Physician or his/her alternate fails to respond appropriately to notification of a suspected or confirmed communicable infectious disease, the staff will inform the Medical Director and Administrator. 3. In the event the Attending Physician fails to take appropriate action, the Infection Preventionist or Medical Director shall have the authority to implement appropriate Transmission-Based Precautions.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice by not dating the oxygen tubing for 1 of 3 residents reviewed for oxygen administration, Resident #184 (photographic evidence obtained). Findings include: During an observation on 11/19/2023 at 10:50 AM, Resident #184 was sitting in her bedside chair with oxygen being administered at 2 liters per minute from the oxygen concentrator. There was no date labeled on the tubing. During an observation on 11/19/2023 at 1:18 PM, Resident #184 was sitting in her bedside chair with oxygen being administered at 2 liters per minute from the oxygen concentrator. There was no date labeled on the tubing. Review of Resident #184's admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of, but not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation. Review for Resident #184's physician order dated 11/16/2023 reads, Change oxygen and or nebulizer tubing, every week every night shift every Sun [Sunday] for preventative. During an interview on 11/20/2023 at 11:15 AM, the Director of Nursing stated, When a patient enters the facility, a date should be placed on the oxygen tubing, and then changed every Sunday night. Review of the facility policy and procedure titled Oxygen Administration reads, Policy: The purpose of this procedure is to provide guidelines for safe oxygen administration. Reporting 2. Report other information in accordance with facility policy and professional standards of practice.

Based on record review and interview, the facility failed to ensure the clinical records was accurate for 1 of 3 sampled residents, Resident #82. Findings include: Review of Resident #82's admission record showed the resident was most recently admitted to the facility on [DATE]. Review of Resident #82's progress note dated 11/18/2023 showed the progress note reads, 97 y/o [year old] female arrived on 9/18/2023 . During an interview on 11/20/2023 beginning at 11:49 AM, the Director of Nursing confirmed Resident #82 was admitted on [DATE]. She confirmed the progress note entry related to Resident #82's admitted was inaccurate. Review of Resident #82's wandering risk assessment dated [DATE] showed the assessment reads Medications 1. Taking antipsychotics. Review of Resident #82's current, discontinued and completed physician orders with the Director of Nursing did not show any documentation indicating Resident #82 was or had been prescribed with an antipsychotic medication. During an interview on 11/20/2023 beginning at 11:49 AM, the Director of Nursing confirmed Resident #82's wandering risk assessment documented Resident #82 was taking an antipsychotic medication. She confirmed Resident #82 was not or had not been prescribed with an antipsychotic medication and stated that Resident #82's wandering risk assessment was inaccurate.

Based on observation, interview and record review the facility failed to label and store all medications available for use in accordance with professional standards in 2 out of 2 medications carts reviewed. Findings: During an observation conducted on 6/14/22 at 8:22 AM with Staff A, Licensed Practical Nurse (LPN) medication cart #1 contained one opened [MEDICATION(S)] insulin pen with no date opened or expiration date, and two [MEDICATION(S)] insulin pens unopened with a label from the pharmacy to refrigerate until opened. During an interview conducted on 6/14/2022 at 8:28 AM Staff A, LPN stated, I haven't gotten to check these yet and all insulin if it is on the cart should have the date opened on them or be kept in the refrigerator until they are opened During an observation conducted on 6/14/22 at 8:36 AM with Staff B, Registered Nurse (RN) medication cart #2 contained one opened [MEDICATION(S)] insulin pen with no date opened or expiration date, and two unopened [MEDICATION(S)] insulin pens with a label from the pharmacy to refrigerate until opened During an interview conducted on 6/14/2022 at 8:40 AM Staff B, Registered Nurse stated, These should not be on the cart if they haven't been opened yet and once they are opened we need the dates on them. During an interview conducted on 6/15/22 at 2:34 PM, The Director of Nursing (DON) stated, All insulin should be labeled when they are taken from the refrigerator otherwise, they should stay in the refrigerator until we need them. Review of the policy and procedure titled, Storage and Expiration of Medications, Biologicals, syringes and needles with an approval date of 7/5/2021 reads, Procedure: 4. Facility should ensure that medications and biologicals: 4.1 Have an expiration date on the label. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. 11. Facility should ensure that all medications and biologicals for each resident are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges.

Based on observation, interview, and record review the facility failed to provide respiratory care services in accordance with professional standards of practice for 4 of 7 residents, Residents #12, #68, #118, and #119, reviewed for oxygen administration and respiratory equipment. Findings: 1. During an observation on 6/14/2022 at 9:44 AM Resident #119 was observed sitting at the bedside with oxygen being administered at 2 liters per minute by nasal cannula. Review of the medical record for Resident #119 documented the resident was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] }, history of falling, fracture of third thoracic vertebra, pulmonary embolism (a blood clot) without acute cor pulmonale (a form of sudden right sided heart failure), traumatic subarachnoid hemorrhage (bleeding in the brain). Review of the physician's orders dated 6/3/2022 reads Oxygen at 3 L [liters] via NC [nasal cannula]. During an observation on 6/15/2022 at 8:32 AM Resident #119 was sitting in a wheelchair at the bedside with no oxygen being administered. During an observation on 6/15/2022 at 11:37 AM Resident #119 was observed sitting at the bedside in a wheelchair with no oxygen being administered. During an interview on 6/15/2022 at 11:37 AM Staff B, Registered Nurse (RN) verified Resident #119 was not being administered oxygen and the physician's order was for continuous oxygen administration. Staff B, RN stated, I thought that her order was PRN [as needed]. I should get an order to have the oxygen prn. It should be administered as a doctor ordered it to be administered or we should get the order changed. 2. On 6/14/2022 at 9:39 AM Resident #118 was observed with oxygen being administered at 4 liters per minute by nasal cannula. Review of the medical record for Resident #118 documented the resident was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's order dated 6/3/2022 reads Oxygen 2 L/M [liters per minute] via n/c [nasal cannula] every shift for shortness of breath. During an observation on 6/15/2022 at 9:09 AM Resident #118 was resting in bed, with no oxygen being administered and signs of mild shortness of breath; the Resident was unable to say more than two to three words before needing to take a breath. During an interview conducted on 6/15/2022 at 9:09 AM Resident #118 stated, I feel a little short of breath, but I'm always a little short of breath. During an observation on 6/15/2022 at 11:42 AM Resident #118 was observed sitting at the bedside in a wheelchair with no oxygen being administered. The Resident continued to say two to three words before needing a deep breath. On 6/15/2022 at 11:42 AM Staff B, Registered Nurse (RN) verified Resident #118 was not being administered oxygen and the physician order was for continuous oxygen administration. Staff B, RN stated, No oxygen was running per orders and there should be oxygen running if there is an order otherwise, they need a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the policy and procedure titled, Oxygen Administration with an approval date of 07/07/21 reads, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order or facility protocol for oxygen administration. Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs and symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes). 2. Signs and symptoms of [CONDITION(S)] (i.e., rapid breathing, rapid pulse rate, restlessness, confusion. 4. Vital signs. 5. Lung sounds. 6. Arterial blood gas and oxygen saturation, if applicable. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 6. All assessment data obtained before, during, and after the procedure. 3. Review of the Admission Record documented Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/14/22 at 12:45 PM, Resident #12 was observed sitting at the bedside wearing a nasal cannula. The oxygen tubing was observed along the floor from the resident to the bathroom. The oxygen concentrator was located inside the bathroom door. The oxygen concentrator was off. During an interview on 06/14/22 at 12:45 PM, Resident #12 stated therapy was trying to wean her off oxygen, but she was usually on 1-2 liters. On 06/15/22 at 04:09 PM, Resident #12 was observed with oxygen being administered at 4 L (liters) via an oxygen concentrator. During an interview on 6/14/22 at 4:10 PM Staff A, Licensed Practical Nurse (LPN) confirmed the oxygen was being administered at 4 L and stated, She is not supposed to be on 4 liters, I think it's supposed to be at 2 liters. You know she is a retired nurse and I think she adjusts it herself. During an interview on 06/16/22 at 10:49 AM, Resident #12 when asked if she ever changes her oxygen for her own comfort she stated, There is no way I can do that. I can't bend over, plus just trying to get to it [the concentrator inside the bathroom]. Besides I want to get off oxygen. I was not on it prior to being here at the facility. Review of the physician orders dated 6/1/22 documented, Oxygen @ [at] 2 L [liters] via NC [nasal cannula] every shift. 4. Review of the Admission Record documented Resident #68 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/22 at 12:05 PM Resident #68 was observed sitting at bedside in a chair eating lunch. On the resident's nightstand was a [CONDITION(S)] (continuous positive airway pressure) machine. During an interview on 6/15/22 at 12:05 PM Resident #68 stated that he uses the [CONDITION(S)] at night. Review of the physician orders for Resident #68 dated 06/08/22 read, Oxygen @ 2 L via nasal cannula at HS [hour of sleep] ([CONDITION(S)] machine not available) as needed for OSA [obstructive sleep apnea]. During an interview on 06/15/22 at 2:45 PM Staff B, RN stated that it was a standard of practice to obtain physician orders for [CONDITION(S)] therapy. She confirmed Resident #68 has a [CONDITION(S)] and there was no physician's order. During an interview on 06/15/22 at 2:52 PM the Direction of Nursing (DON) confirmed Resident #68 does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed that it was a standard of practice to obtain a physician's order for [CONDITION(S)] therapy. Review of the policy titled [CONDITION(S)]/[CONDITION(S)] [bilevel positive airway pressure] Support revised October 2010, last reviewed on July 7, 2021, reads: Purpose. 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. Preparation. 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP (Positive end-expiratory pressure) pressure ([CONDITION(S)], IPAP [inspiration] and EPAP [expiration]) for the machines.

Based on interview and record review the facility failed to provide care in accordance with professional standards of practice for 2 of 6 residents, Residents #14 and #114, reviewed for unnecessary medications. Findings: Review of the medical record for Resident #14 documented the resident was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record documented vital signs dated 4/21/2022 at 10:53 PM oxygen saturation of 94% on room air. Review of the nursing progress note dated 4/22/22 at 12:20 AM authored by the Director of Nursing (DON) reads: O2 [oxygen] at 2 liters applied secondary to patient requested [CONDITION(S)] [continuous positive airway pressure] to be turned off. Review of the medical record vital signs dated 4/22/2022 at 12:02 AM documented an oxygen saturation of 87% on room air. Review of the physician orders document no orders for oxygen administration. During an interview conducted on 6/15/2022 at 12:00 PM the DON stated, I was the nurse that worked the 11-7 shift the night that [Resident #14's name] refused to wear his [CONDITION(S)] and I started him on oxygen. I was not informed immediately that his oxygen saturation was low, and he was refusing his [CONDITION(S)]. I did administer the oxygen at two liters and attempted to get him to wear his oxygen and [CONDITION(S)]. There is no assessment of his lung sounds when I put him on the oxygen and his saturation dropped to 87%, there should have been. There are no other vital signs or oxygen saturation and there should have been. I should have called the doctor and gotten an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I should have called the doctor. During an interview conducted on 06/16/22 at 3:38 PM Medical Doctor (MD) stated, I want to be notified if any patient has an oxygen saturation less than 90% so that I can determine if I need to add any further treatments. I would expect that the nurses would call with any other assessment such as lung sounds. I want to be notified immediately to determine the need to possibly return the patient to the hospital. Review of the policy and procedure titled Oxygen Administration approval date of 7/8/2021 reads, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order or facility protocol for oxygen administration. Assessment. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs and symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes). 2. Signs and symptoms of [CONDITION(S)] (i.e., rapid breathing, rapid pulse rate, restlessness, confusion). 4. Vital signs. 5. Lung sounds. 6. Arterial blood gas and oxygen saturation, if applicable. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 6. All assessment data obtained before, during, and after the procedure. 2. Review of the medical record for Resident #114 documented the resident was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders dated 6/10/2022 reads, [MEDICATION(S)] Solution Prefilled syringe ([MEDICATION(S)]) inject 0.9 ml [milliliters]/hr [hour] subcutaneously two times a day for DVT [a blood clot]. Review of the physician order dated 6/10/2022 reads, [MEDICATION(S)] solution prefilled syringe 80 mg (milligrams)/0.8 ml [[MEDICATION(S)]] inject 0.8 ml subcutaneously two times a day for PE [pulmonary emboli] d/c [discontinue] once INR [international ratio] is therapeutic above 2.0. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the administration note dated 6/11/2022 at 8:24 AM authored by Staff A, Licensed Practical Nurse (LPN) reads, pending pharmacy delivery. Review of the administration note dated 6/11/2022 at 8:28 PM authored by Staff C, LPN reads awaiting delivery. During an interview conducted on 6/15/2022 at 1:50 PM Staff A, LPN stated, If there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I did not call the doctor about the [MEDICATION(S)] and that I could not administer it. I should have called with the missed dose. During an interview conducted on 6/15/2022 at 4:10 PM Staff C, LPN stated, I was not able to administer [MEDICATION(S)] when the doctor ordered it. I should have notified him that it couldn't be given because we didn't have it. It is a routine practice to notify a doctor when we can't give a medication like a blood thinner. During an interview conducted on 6/16/2022 at 10:45 AM the Director of Nursing (DON) stated, I was not aware that the staff did not administer the [MEDICATION(S)] when it was ordered. We should have notified the doctor when they were not able to administer the [MEDICATION(S)]. During an interview conducted on 6/16/22 3:35 PM the Medical Doctor (MD) stated, When I am bridging anticoagulant therapy of [MEDICATION(S)] with [MEDICATION(S)] it is because the INR is subtherapeutic and the patient has a need for the additional therapy and I absolutely want to be notified that they cannot get the additional coverage needed. Review of the Policy and procedure titled, Adverse Consequences and Medication Errors with an approval date of 7/5/2021 reads, Policy interpretation and Implementation 5. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medication errors include: a. Omission-a drug is ordered but not administered. B. Unauthorized drug-a drug is administered without a physician's order.

Based on interview and record review the facility failed to ensure a qualified director of food and nutritional services was provided for oversight of the daily operations of the facility dietary services. Findings: During an interview on 06/15/22 at 10:00 AM the Dietary Manager stated he is not certified or licensed as a Dietary Manager. During an interview on 06/15/22 at 10:00 AM the dietitian stated she works for the hospital and does not work at the facility full time as a dietitian; she stated she works part time. During an interview on 06/15/22 at 02:12 PM the Administrator stated that the Dietary Manager does not have his Certified Dietary Manager certification. He does not have an associate degree in food service management or hospitality. The dietitian works at the hospital full time and comes to the Skilled Nursing Unit part time. Review of the Dietary Manager's application documented a high school diploma; there was no associates degree contained in the file. Review of the Learner Records for [Dietary Manager's name] did not document training in Certified Dietary Manager certification courses. Review of the Completed Training for [Dietary Manager's name] did not document training in Certified Dietary Manager certificate courses.

Based on interview and record review the facility failed to have a designated Infection Preventionist who completed specialized training in infection prevention and control. Findings: During an interview conducted on 6/16/2022 at 11:30 AM the Director of Nursing stated, I am the designated infection control nurse I complete all the tracking and trending of infections throughout the facility. I have not taken any special course on infection control. I am not certified in Infection control, and I did not know that I needed anything special to be the infection control nurse. During a review of the education and training for the Director of Nursing there was no specialized certifications for infection control. During an interview conducted on 6/16/2022 at 12:00 PM the Facility Administrator stated, I should have known that she needed to have the Infection control training, she is new, and our previous Director of Nursing had the training.

Based on interview and record review, the facility failed to provide a discharge summary that included a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, pertinent lab, radiology, and consultation results for 1 of 3 residents, Resident #1 sampled for closed record review. Findings: Review of the progress note for Resident #1 dated 6/7/22 documented Patient was discharged home with her friend. All discharge instructions were reviewed with the patient. [MEDICATION(S)] 7.5/325 mg (milligrams) #21 [count of 21] was sent home with the patient. Patient was educated on medication use and precautions. She expressed an understanding. Skin intact, no new areas observed at discharge. All personal items were sent home with the patient. All other questions and concerns were addressed. The patient expressed gratitude toward the staff for her care during her stay here at the facility. Review of the discharged Resident Medication Transfer Record documented all medications sent home with Resident #1. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . The section titled Wound Care or other Treatments' was blank. The Post Discharge Plan of Care was not signed by a representative of the facility. Review of the clinical record discharge documentation showed no evidence of a recapitulation of the resident's stay that included diagnoses, course of treatment, therapy, or any pertinent lab, radiology, and consultation results. During an interview on 6/16/22 at 12:19 PM the Administrator and Social Services Director stated the facility used the Post Discharge Plan of Care form for the resident at discharge. They confirmed that Resident #1 was not provided a recapitulation of their stay that included diagnosis, course of treatment, therapy or any pertinent lab, radiology, and consultation results at discharge.

Based on observation, interview, and policy and procedure review the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with current professional standards for 3 of 3 medication carts and 1 of 1 medication storage rooms. Findings: During an observation of Medication Cart #1 on 1/5/2021 at 9:05 AM with Staff A, LPN (Licensed Practical Nurse) it showed one bottle of Regular Insulin for Resident #8 that is unopened and unrefrigerated, one [MEDICATION NAME] IM (intramuscular) injection without the original pharmacy packaging and unlabeled with a resident identifier. During an interview conducted on 1/5/2021 at 9:15 AM with Staff A, LPN she stated, This insulin should be refrigerated until we open it. I'm not sure why it isn't. The [MEDICATION NAME] should be in its pharmacy package and be labeled for a resident. During an observation of Medication Cart #2 on 1/5/2020 at 9:20 AM with Staff B, RN (Registered Nurse) it showed there were two [MEDICATION NAME] 40 mg/0.4 ml (milligrams/milliliter) syringes without a resident identifier and not in the original pharmacy packaging. During an observation of Medication Cart #3 on 1/5/2021 at 9:40 AM with Staff B, RN it showed there was one bottle of eye drops with an opened date of 10/20/2020 with no resident identifier. During an observation of the medication storage room on 1/5/2021 at 9:58 AM with Staff B, RN it showed there were four expired [MEDICATION NAME] ([MEDICAL CONDITION] skin test) syringes for Residents #4, #5, #11 and #77. During an interview conducted on 1/5/2021 at 10:10 AM with Staff B, RN she stated, No medication cart should have unlabeled medications on them. I'm not sure who the [MEDICATION NAME] was for, it is not labeled. It should be returned to the pharmacy or destroyed. Eye drops expire after 30 or 60 days and should have who they belong to on the package. During an interview conducted on 1/5/2021 at 1:15 PM with the Director of Nursing (DON) she stated, All medication carts should have no medication that is expired and unlabeled. I'm shocked that so many TB ([MEDICAL CONDITION]) syringes that have not been removed from the refrigerator and destroyed. It is my expectation that the nurses check their medication carts every day for any expired medications and destroy them or return them to the pharmacy. Review of the policy and procedure titled, Storage of Medications (Medipass 2001, revised April 2007) reads; Policy statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. 3. Drug containers that have missing, incomplete, improper or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses station or other secured location.

Based on record review, interview, and policy and procedure review the facility failed to implement a comprehensive care plan for 1 of 2 residents reviewed for pressure ulcers, Resident #9, in a total sample of 16 residents. Findings: A review of the facility medical record for Resident #9 revealed the resident is [AGE] years of age with [DIAGNOSES REDACTED]. Review of the Agency for Health Care Administration (ACHA) form 3008 from the receiving hospital dated 12/7/2020 under Section T: Skin Care stage and assessment reads: Coccyx is intact. Review of the nursing admission screening/history dated 12/7/2020 under Section L: Skin reads: Site: Coccyx, type: other reddened. Review of the facility nursing progress notes dated 12/29/2020 reads; SDTI (suspected deep tissue injury) wounds to sacrum and bilateral heels show no improvement at this time despite nutritional and nursing interventions. Wound to sacrum measures 9 cm (centimeters) by 6 cm (centimeters) with 1 mm (millimeter) depth. Left heel has a SDTI of 3 cm by 2 cm with purple discoloration to center. Right heel has discoloration of 3 cm by 2 cm with purple discoloration to center. Review of the Weekly Skin Observation tools completed on 12/14/2020, 12/21/2020, 12/28/2020 and 01/04/2021 under notes reads: no new skin issues observed. Review of the physician orders dated 12/21/2020 reads apply skin prep to bilateral heels topically every day and evening shift for SDTI. Review of physician order dated 12/31/2020 reads clean coccyx with normal saline apply ample amount of Santyl ointment and cover with a Meplix dressing every day and as needed. Review of Resident #9's care plan updated on 12/19/2020 reads: The resident has SDTI of coccyx and right/left heels related to immobility. Assess, record, monitor wound healing: measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (Medical Doctor). During an interview conducted on 1/5/2021 at 2:15 PM with the Director of Nursing (DON) she stated, We complete a weekly skin observation tool that addresses the wounds or any new skin concerns. The nurses complete this weekly. There is no documentation of this wound. I can't tell you when it was identified or what its condition was but I see there was an order put in on 12/19/2020 for wound care to her heels and coccyx but there are no notes on what her wound looked like; there should be. The nurses should complete the weekly wound documentation. There are no clear nursing notes to show when this wound occurred, there are only doctor orders. During an interview conducted on 1/6/ at 4:15 PM with Staff C, Registered Nurse she stated, We complete assessments of patients and will note any new skin concerns on either the weekly skin assessments or on the weekly wound care form. We complete our dressings as ordered and would document the wound stage, and any drainage. We document in the notes any worsening of the wound, any new wounds and would let the doctor know and get orders for wound care. A review of the facility policy and procedure titled, Wound Management Program, dated 6/25/2020 reads; The purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment and management of pressure as well as non-pressure related wounds. 4. The nurse identifying the area initiates the weekly wound documentation in the EMR (Electronic Medical Record) and will inform the Nurse manager or designee of the area who will then inform the DON or designee. 6. Each week the nurse responsible for the weekly skin check will complete the documentation on the residents weekly wound documentation, noting size, depth, drainage etc. When there has been noted worsening or deterioration of a wound, the identifying nurse will contact the resident's physician and consult for the need for change in treatment orders.

Based on observation, record review and interview the facility failed to implement the safety alarm objectives of the care plan for 1 of 3 residents reviewed for fall preventions out of 18 total sampled residents. (#271) Findings: An observation was conducted with the Nursing Manager and the survey team's Registered Nurse, of Resident # 271 on 7/8/19 at approximately 3:10 PM. The observation revealed the resident was in his wheelchair in his room. The clip and black cord for the alarm system affixed to the back of his wheelchair were not functioning. The black cord was wrapped and knotted around the clip, so the clip could not be opened and attached to the resident. It was found laying between the resident and the back of the chair. The cord was not attached to the alarm in any manner. The Nursing Manager untangled the cord from around the clip so it could be opened and attached to the resident. After it was untangled, the cord was able to reach the alarm on the back of the chair. During an interview with the Nursing Manager on 7/8/19 at approximately 3:10 PM she confirmed the cord was tangled and knotted around the clip so it could not be opened and attached to the resident nor would it reach the alarm box. She stated the alarm was not functioning. She stated the clip should have been attached to his collar and the alarm box. She stated the alarms were attached to residents upon admission if there was a history of falls. She confirmed Resident #271 had a recent history of falls. No further information was provided including the post 72 hour evaluation. During an interview with the Licensed Practical Nurse /Staff A on 7/8/19 at approximately 3:20 PM she confirmed the Certified Nursing Assistants ensure the alarms are properly attached after care. She stated she checks the alarms every shift also. She had no further information. During an interview with the Licensed Practical Nurse /Staff B on 7/9/19 at 9:40 AM she stated she checks each alarm when she give the resident their medications each shift. During an interview with the Certified Nursing Assistant / Staff C on 7/8/19 at approximately 3:20 PM she confirmed she checks the alarms each shift and after care. During an interview with the Certified Nursing Assistant /Staff D on 7/9/19 at 9:45 AM she stated she checks the electronic alarms after she provided care to the resident. Review of Resident # 271's record revealed he was admitted on [DATE] for orthopedic aftercare, back surgery. Review of the Fall Risk Evaluation completed on admission on 7/5/19 revealed a high risk score begins at 45 with this resident receiving a score of 75. The evaluation notes a history of falls, use of crutches can or walker and impaired gait. His Pressure Sore evaluation notes under # 6 he has a potential problem because he occasionally slides down while in his bed or the chair. His Nursing Assessment upon admission revealed he had poor balance and a history of a recent fall with injury. He had a Physician's Order dated 7/5/19 directing alarm to bed and chair for fall precautions. Check every shift for placement and function. every shift for 3 days alarm to bed and chair fall precautions and every shift for safety for 3 days for placement and function, one time only for safety precaution for 1 day after 72 hours reevaluate patient and document Y for yes alarm can be discontinued. N for alarm cannot be discontinued Write order to continue. Further the Care Plan for Falls dated 7/6/19 described the resident as Moderate risk for falls due to Gait/Balance problems. The Goal stated resident will not sustain a serious injury through the review date was added on 7/8/19. The Care Plan was updated on 7/8/19 to add resident uses chair/bed electronic alarm. Ensure the alarm is in place as needed. The His Brief Interview for Mental Status completed on 7/8/19 at 7:18 PM revealed a score of 15. The Treatment Administration Record dated 07/08/2019 had a set of initials for the 7 AM-3 PM shift noting the alarms were checked. Review of the facility policy of electronic alarms to prevent falls revealed under #3 Nursing staff will implement safety alarms for 72 hours. After 72 hours post admission, nursing staff will assess and determine continued need for alarms.

Based on record review, observation and interview facility failed to reassess a personal alarm for 1 of 3 Residents (Resident 223) that were reviewed for fall precautions out of 18 total sampled residents. Findings: On 07/08/19 at 11:57 AM Resident 223 was observed to have personal alarm clipped to back of shirt and attached to recliner. Record review of Physicians orders revealed an order dated 6/26/19 for alarm to bed and chair for fall precautions. Order reads: Check every shift for placement and function. Every shift for safety for 3 days alarm to bed and chair for fall precautions. And every shift for safety for 3 days check every shift for placement and function. Document Y for Yes its functioning and in place and N for No it is not (and then correct issue) and one time only for safety precaution for 1 Day after 72 hours re-evaluate patient and document Y (Yes) for Yes alarm can be discontinued. N (No) for alarm cannot be discontinued. Write order to continue. Record review of Residents 223 chart revealed no re-evaluation or reassessment was conducted for the continued or discontinued use of alarm. Policy and Procedure for Fall Prevention. A. Admission of New Patients 3. Upon admission nursing staff will implement safety alarms for 72 hours. 4. After 72 hours post admission nursing staff will assess and determine continued need for alarms. An interview conducted on 7/9/19 at 11:25 AM with Director of Nursing (DON) confirmed that no re-evaluation was conducted by a nurse after 72 hours for the personal alarm for Resident 223 .

Based on observation, interview, and record review, the facility failed to implement the written plan of care for 2 of 13 resident care plans related to monitoring and documenting anticoagulant side effects and effectiveness of medications (Resident #167) and related to fluid restrictions for a resident on [MEDICAL TREATMENT] (Resident #2) Findings: 1. ) A record review of the written plan of care for Resident #167 revealed the resident has an alteration in hematological status related to anticoagulant ([MEDICATION NAME]) side effects with a goal to remain free of complications related to altered hematological status. The staff interventions include monitor side effects and effectiveness of medications. A record review of the Medication Administration Record (MAR) showed no documentation of the monitoring for side effects and effectiveness of the medication related to anticoagulant use. An interview was conducted with Staff F, an LPN, on 6/19/18 at 2:57 PM. She stated that the resident is supposed to be monitored and recorded on the MAR each shift for side effects for anticoagulant use. She stated it is not on the MAR for Resident #167. An interview was conducted with the Acting Director of Nursing, Staff E, on 6/19/18 at 2:57 PM. She stated there is supposed to be a place to document monitoring of the anticoagulant on the Medication Administration Record to show the nurse has done a head to toe assessment before giving the medications. She stated this one slipped through the cracks. She confirmed there was no documentation in the clinical record for monitoring the anticoagulant use. 2.) A review of the care plan initiated 06/11/2018 revealed, the resident was to be on 1000 CC fluid restriction. An observation on 06/19/2018 at 1:09 PM revealed the resident was sitting in her chair at her bedside. The resident was observed to have one eight ounce bottle of ensure [MEDICATION NAME], one eight ounce Styrofoam cup of water with ice, one eight ounce Styrofoam cup of another liquid (Juven per the nurse). There was also one four ounce hard plastic empty cup sitting on the over bed table. An interview was conducted on 06/19/2018 at 1:20 PM. with Staff B Registered Nurse. She stated the resident was given the eight ounce cup of water to take her medications on the day shift. The resident was also given the eight ounce ensure [MEDICATION NAME], and the eight ounce cup of Juven. The nurse stated she did not think the nutritional supplements were included in the fluid restrictions. During an interview on 06/19/2018 at 2:00 PM, with Staff C Dietician she stated, the nutritional supplements are counted in the 1000 Milliliter (ML) fluid restriction. The way the 1000 ML fluid restriction should work is the resident is given 120 ML for breakfast which should be her juice. The resident is receive the Juven in eight ounces (240 ML) of juice at lunch. The resident is to get 120 ML of fluid at dinner. The resident should receive 2 eight ounce 240 ML bottles of ensure [MEDICATION NAME] one bottle at 10:30 AM and one at 7:30 PM. The resident is to receive 40 ML of fluids on the night shift. The resident should not be receiving 240 ML of water because this makes the resident exceed her 1000 ML of fluid restriction. A review of the physicians order dated 06/09/2018 revealed the resident was on fluid restrictions of 1000 ML a day.

Based on observation, interview, and record review, the facility failed to ensure the appropriate storage of drugs and biologicals related to expired and unsecured controlled substances. Findings: During an observation on [DATE] beginning at 12:31 PM with staff A of the medication storage room revealed the following: One bottle of [MEDICATION NAME] containing (6) pills belonging to a discharged resident, was in an unlocked cabinet to the left of the sink. [MEDICATION NAME] is a controlled substance. One pro air inhaler and one [MEDICATION NAME] inhaler with no patient identifiers was sitting on the bottom shelf in the same cabinet. In the refrigerator in the medication room two protein purified derivatives (PPD) prefilled syringes expired on [DATE]. Continued observation of the medication storage room on [DATE] at 8:30 AM with Staff E revealed the controlled substance was still unsecured. The inhalers were still sitting on the shelf with no patient identifiers. During an interview on [DATE] at 12:43 PM with Staff A LPN he stated, he does not know why the controlled substance ([MEDICATION NAME]) was not locked in a secure location. The LPN nurse stated he has never counted the controlled substance. The nurse did not know who the inhalers belonged to. The LPN confirmed the two PPDs in the refrigerator was expired. The LPN stated any medication nurse has a key to the medication storage room. During an interview on [DATE] at 8:30 AM, with Staff E she stated, it is not the practice of the facility to store controlled substance in an unsecured cabinet. When a resident or the residents family brings in a controlled substance or any medications from home the nursing staff should encourage the resident or the resident's family to take the medication home. If the family has already left, and there is a controlled substance, the nursing staff should remove, count the controlled substance together, and place the controlled substance either in the medication drawer of the medication cart or the locked cabinet that houses the controlled substance in the medication storage room. A review of the policy and procedure titled storage of medication, last revised [DATE], revealed the facility shall not use discontinued, outdated,or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, it was confirmed the facility failed to ensure a resident specific Care Plan was developed which included measurable goals and objectives related to the specifics of [MEDICAL TREATMENT] care and services for 1 of 2 [MEDICAL TREATMENT] residents, Resident #162 out of a total 17 sampled residents. Findings: An observation and interview with Resident #162 was conducted on 7/05/2017 at 1:45 PM. She confirmed she receives [MEDICAL TREATMENT] therapy three (3) times weekly on Tuesday, Thursday and Saturday, leaving the building around 6:00 AM. There was a sign posted above the resident's bed indicating Left Arm, No blood pressure (BP), no blood draws or venipuncture, no injections. While being interviewed, the resident confirmed she had a fistula site for her [MEDICAL TREATMENT] treatments on the upper right arm. The resident was in good spirits and displayed no signs of distress at that time. The resident's Care Plan was reviewed specifically for [MEDICAL TREATMENT] Care and Services. It was found that there was no Care Plan developed which directly addressed the specifics of the care and services which the resident would be receiving since she was receiving the [MEDICAL TREATMENT] services/treatments out of the facility three (3) times weekly on Tuesday, Thursday and Saturday. The additional Care Plans were reviewed and confirmed the information was not contained in the other plans. There is no indication of: a.) Location of the resident's shunt site, care and services. b.) Monitoring of bruit and thrill and frequency. c.) Medication variances to times of administration due to the dialyzing of medications from the system. d.) Sending a snack or lunch with the resident and what time to have ready for her. How to package. f) Specifics to blood draws, blood pressures, etc. on the resident's affected shunt site arm. f.) Diet: The restrictions to the resident's renal and Cardiac diet g.) Phosphorus level is high per laboratory results with no phosphorus binder or recommendation by Dietitian. h.) The physician wanting daily weights however no consistency documented regarding the time the resident is to be weighed due to her [MEDICAL TREATMENT] departure time (6:00 AM) and indicating night shift taking the weights. On the four (4) non-[MEDICAL TREATMENT] days, would the resident still be woken during the night shift in order to obtain the weight. A telephone interview was conducted with the facility Consultant Dietitian, Nurse Manager and Administrator on 7/06/2017 at 11:00 AM. The areas of concern were addressed to include the lack of a resident Care Plan specifically addressing the needs of the [MEDICAL TREATMENT] resident. It was confirmed there was no resident specific Care Plan for the [MEDICAL TREATMENT] services.

Based on staff interviews and record review the facility failed for 1 of 3 residents (resident #1) to ensure supervision to prevent a fall resulting in injury. Findings: 1. Review of the medical record for patient #1 revealed that the resident was admitted to the facility on [DATE]. The resident was transferred from South Lake Hospital, the parent owner of the facility. The resident was admitted with the following diagnosis/ conditions, generalized muscle weakness, anemia, type 2 diabetes, anxiety disorder, [DIAGNOSES REDACTED], glaucoma, hypertension, atherosclerotic heart disease, Takotsubo ([DIAGNOSES REDACTED]) syndrome, cerebrovascular disease with history of CVA and left hemiparesis and chronic back pain. The resident was admitted to the hospital following several falls at home, back pain and weakness. The resident was admitted to the facility for strengthening and conditioning with the plan to return home. Review of the resident ' s vital signs between [DATE] and [DATE] revealed the blood pressure to be stable and within normal limits, the resident weight to be stable at 135 pounds, pulse to be regular and within normal limits, and her temperature to be consistently normal. Review of the hospital transfer form AHCA ,[DATE] dated [DATE], the day of the transfer, revealed under section G Patient Risk Alerts that the resident was at risk for falls and under section S, Physical Function, that transfers were 2 person assist. Review of the medical record revealed a Tinetti Balance Assessment tool completed on [DATE] that had a balance score of ,[DATE]. Review of the score tool revealed that any score less than 18 indicated a High risk of falls. Review of the MDS (minimum data set) assessment completed on [DATE] revealed in Section G, Activities of Daily Living, that the resident requires extensive 2-person assistance with transfers. Review of the section G0300 revealed that under E,. Surface-to Surface Transfer, that the resident was Not steady, only able to stabilize with staff assistance. Review of the Care Area Assessment Summary revealed that both Activities of Daily Living and Falls were triggered care areas and a decision to develop care plans for the 2 areas made. Review of the care plans dated [DATE] revealed a care plan focus titled The resident has an ADL self-care performance deficit r/t (related to) impaired balance, weakness with an Intervention/Task for Transfer The resident requires extensive assist of ,[DATE] staff to move between surfaces and as necessary . Review of the care plans dated [DATE] revealed a care plan focus titled The resident is (high) risk for fall r/t Gait/balance problems . Review of the related care plan for falls revealed under Intervention/Tasks to Follow facility Fall protocol . Review of the Fall Reduction Policy and procedure did not reveal guidance on resident supervision or transferring residents with a sit to stand lift. Interview on [DATE] at 11:15 A with the Registered Nurse on duty revealed that she was not aware of a written protocol. When asked what follow the protocol written in the care plan referred to was, she stated that she would use Lippincott to guide her. When the CNA (certified nursing assistant) on duty was asked, on [DATE] at 11:30 AM, what fall protocol was, she stated she would ask the nurse. She stated that at the beginning of the shift the nurse would tell the CNA's of any special needs the residents may have. Review of the Occupational Therapy notes # dated [DATE] revealed Pt (patient) participated in transfer training for Edge of Bed, (EOB), and from chairs, requiring moderate assist and 10% verbal clues for hand placement . Review of a nursing progress note dated [DATE] at 10:36 AM revealed CNA notified LPN (licensed practical nurse) of fall. CNA states that she left patient sitting on the side of the bed and when she returned found the patient on the floor. Patient is alert and oriented x 4, denies any pain, numbness, blurred vision. Patient has a tennis ball size hematoma on her forehead between her eye, above her nose and had some bleeding form her nose. Patient was left in the position she was found on the floor and EMS was notified for transport to be evaluated by ER (emergency room ). Vitals ,[DATE], HR 89, RR 20. EMS arrived and transported patient to the ER with no further incident. Physician A. was notified, RN manager notified, and attempted to contact family member with no answer . Review of a hand written note by CNA dated [DATE] the day after the fall revealed I was assisting patient get dressed to transfer to chair. The patient moved her feet to side of the bed and pulling on the bed rail. I placed my hand on her shoulder, for her not to lean back while she was moving to side of bed. I made sure the patient was secure in sitting position. I grabbed her pants and while I was going to grab sit and stand lift by her door, I stopped because I heard patient slide down off bed. Patient stated she slid down and hit her head. I notified nurse on duty immediately. Review of a second hand written not by CNA#1 dated [DATE] revealed I was providing care to patient on [DATE] in RM 21 A, other CNA's were assisting other patients. I planned on doing as much as I could on my own, then was going to use call light for assistance with lift transfer. Review of the final physician progress notes [REDACTED]. She had marked weakness of left side upper and lower limbs. She was on a restricted diet per speech therapy recommendations with Thick Nectar and mechanical soft diet. She was never happy with diet restriction and always refused foods other that few thing were tolerated by her. She had very poor appetite. She rarely reported any complaints except refusing food and therapy. The physician noted: During initial course of stay, I saw the patient last on [DATE]. Unfortunately, on [DATE], she had an episode of fall and hit her head w/development of hematoma so I was contacted by phone while I was not at Skytop Rehab site but I advised to take patient to ER ASAP. She was transferred to ER by EMS and later take to a (regional) hospital. As per information from (the regional) hospital chart, it was non surgical right medial temporal hematoma, so she was treated w/conservative management and discharged back to Skytop Rehab. Pt was readmitted to Skytop Rehab on [DATE] with ongoing Generalized weakness for further strengthening and PT/OT physical/occupational therapy. The final paragraph of the progress note revealed: As per my Knowledge,this patient was already very deconditioned on first admission to Skytop Rehab with poor strength, poor motivation and Left sided [DIAGNOSES REDACTED] due to old Stroke and multiple other comorbidities with failure to thrive with poor oral intake. Unfortunately, her overall health was anyway declining steadily on chronic basis, but her fall and consequent Hematoma might have caused the further decline in motivation overall. Review of the re-admission documentation, (Admission Report Sheet), dated [DATE] revealed that was being transferred from Orlando Regional Medical Center located in Orlando. The admitting [DIAGNOSES REDACTED]. The record revealed MRI shows bleed stable. Physical signs revealed right pupil fixed and left pupil sluggish. The cognition was alert and lethargic. The medical record revealed that the resident remained in the facility until [DATE] and was discharged to a Hospice facility, where she expired on [DATE]. Review of the re-admission documentation, (Admission Report Sheet), dated [DATE] revealed that was being transferred from the Regional Medical Center located in Orlando. The admitting [DIAGNOSES REDACTED]. The record revealed MRI shows bleed stable. Physical signs revealed right pupil fixed and left pupil sluggish. The cognition was alert and lethargic. The medical record revealed that the resident remained in the facility until [DATE] and was discharged to a Hospice facility, where she expired on [DATE].