Every finding on record at Soddy-Daisy Health Care Center

Based on review of facility policy, observation, and interview, the facility failed to maintain privacy curtains in a clean and sanitary condition, failed to maintain resident rooms in good repair, and in a homelike condition for12 rooms (Rooms #209, #210, #212, #119, #121, #120, #123, #124, #127, #125, #126, and #128) of 71 rooms observed for homelike condition. The findings include: Review of the facility policy titled, Maintenance Service, 12/2009, revealed .Maintenance service shall be provided to all areas of the building, grounds, and equipment.Functions of maintenance personnel include.Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.Maintaining the building in good repair.Establishing priorities in providing repair service.Providing routinely scheduled maintenance services to all areas.The Maintenance Director is responsible for maintaining the following records/reports.Inspection of building. Review of the facility policy titled, Safe and Homelike Environment, dated 6/1/2025, revealed .In accordance with residents' rights, the facility will provide a safe, clean, comfortable and home environment.Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.Report any unresolved environmental concerns to the Administrator. Review of the facility policy titled, Routine Cleaning and Disinfection, dated 6/1/2025, revealed .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products.Consistent surface cleaning and disinfection will be conducted with a detailed focus on high touch areas.Cleaning of walls.window curtain will be conducted when visibly soiled.Privacy curtains in resident rooms will be changed when visibly dirty by laundering or cleaning with and EPA [Environmental Protection Agency] registered disinfectant. Review of an undated facility policy titled, CLEANING PRIVACY CURTAINS, revealed, .Privacy Curtains.should be changed with every Detailed Cleaning or as needed. During an observation on 9/29/2025 at 12:00 PM, revealed resident room [ROOM NUMBER] with scuff marks, torn sheet rock, and missing paint on the walls. Continued observation revealed loose baseboard peeling from the wall. During an observation on 9/29/2025 at 12:05 PM, revealed resident room [ROOM NUMBER] with torn sheet rock and missing paint on the walls. During an observation on 9/29/2025 at 12:10 PM, revealed resident room [ROOM NUMBER] with torn sheet rock and missing paint on the walls. During an interview on 9/29/2025 at 12:50 PM, the Maintenance Director stated, the facility attempted to make needed repairs to 2-3 resident rooms per month but could vary depending on .what was going on in the facility. and the number could be more or less. Continued interview revealed there was no written plan for needed room repairs and repairs were made as needed. During an interview on 9/29/2025 at 1:09 PM, the Administrator stated the facility was not currently working on any performance improvement plans (PIPS). During an observation of a shared resident room [ROOM NUMBER]-A on 9/29/2025 at 2:35 PM, revealed dark scuff marks on the wall beside and at the foot of the bed. During an observation of a shared resident room [ROOM NUMBER]-B on 9/29/2025 at 2:36 PM, revealed chipped dry wall and paint on the wall at the foot of the bed. During an observation of a shared empty resident room [ROOM NUMBER]-A on 9/29/2025 at 2:38 PM, revealed chipped plaster and missing paint behind the bedside table near the head of the bed. During an observation of a shared resident room [ROOM NUMBER]-B on 9/29/2025 at 2:40 PM, revealed missing trim on the bathroom sink and several scuffed areas on the door of the room. Continued observation revealed chipped dry wall and missing paint on the wall at the foot of the bed. During an observation of a shared resident room [ROOM NUMBER]-A on 9/29/2025 at 2:42 PM, revealed the privacy curtain was scattered with an unknown brown substance. Continued observation revealed the wall at the head of the bed had scuffed walls with missing paint. The wall at the foot of the bed contained black markings, chips in the drywall, and missing paint. During an observation of a shared resident room [ROOM NUMBER]-B on 9/29/2025 at 2:43 PM, revealed the privacy curtain was scattered with an unknown brown substance. Continued observation revealed the wall at the head of the bed with missing paint, the closet trim was noted with chipped wood, the wall at the foot of the bed with chipped dry wall and missing paint. Further review revealed the shared bathroom of 120 was noted with black scuffs on the wall, chipped and missing paint, and trim missing from the bathroom counter. During an interview on 9/29/2025 at 2:45 PM, a family visitor of room [ROOM NUMBER]-B stated the condition of the room and bathroom had been in a bad condition since the resident's admission over a year ago. The family visitor stated, .it bothered me at first, but now I've just gotten used to it. During an observation of a shared empty resident room [ROOM NUMBER]-A on 9/29/2025 at 2:50 PM, revealed a soiled privacy curtain scattered with a brown unknown substance. During an observation of a shared resident room [ROOM NUMBER]-B on 9/29/2025 at 2:51 PM, revealed the privacy curtain with a scattered unknown brown substance. Continued observation revealed the wall at the head of the bed with scuff marks, and missing and peeling paint. The wall corners at the foot of the bed with large, chipped areas of dry wall and missing paint, and the baseboards peeling from the wall. The shared bathroom for room [ROOM NUMBER] had a large, patched area of dry wall which was left unpainted. During an observation of shared resident room [ROOM NUMBER]-A on 9/29/2025 at 2:53 PM, revealed chipped paint on the wall at the beside bed. During an observation of a shared resident room [ROOM NUMBER]-B on 9/29/2025 at 2:54 PM, revealed chipped areas of dry wall and missing paint on the wall at the foot of the bed. Continued observation revealed a piece of the lighting fixture propped against a wall, and several pieces of wood slats to the closet door missing. During an observation of an empty shared resident room [ROOM NUMBER]-A on 9/29/2025 at 2:56 PM, revealed a soiled privacy curtain scattered with a brown unknown substance. Continued observation revealed chipped dry wall to the left of the heating and air unit and on the wall behind the head of the bed. During an observation of shared resident room [ROOM NUMBER]-B on 9/29/202 at 2:57 PM, revealed a scattered unknown brown substance on the privacy curtain. Continued observation revealed chipped dry wall on the wall behind the head of the bed. During an observation of a shared resident room125-A and interview on 9/29/2025 at 2:59 PM, revealed the wall at the head of the bed and the wall at the foot of the bed had chipped dry wall, scuffed walls, and missing paint. The closet was observed with missing pain and chipped wood. Resident #99 stated she had resided at the facility since 7/2024 and the walls in her room had been in disrepair since that time. Resident #99 stated she would like the walls repaired because .it looks trashy. During an observation of a shared empty resident room [ROOM NUMBER]-B on 9/29/2025 at 3:00 PM, revealed the wall at the foot of the bed with scuffed walls and missing paint. During an observation of a shared empty resident room [ROOM NUMBER]-A on 9/29/2025 at 3:06 PM, revealed the wall at the head of the bed with chipped dry wall, part of the metal on the bed frame sticking in a hole where the dry wall was chipped. During an observation of a shared empty resident room [ROOM NUMBER]-B on 9/29/2025 at 3:05 PM, revealed the wall at the head of the bed with chipped dry wall and scuffed paint, chipped paint and scuff marks to the left and right of the heat and air unit. During an observation of an empty resident room [ROOM NUMBER]-A on 9/29/2025 at 3:06 PM, revealed the wall at the head of the bed with chipped dry wall and missing paint. During an interview on 9/29/2025 at 3:08 PM, the Environmental Services (EVS) staff stated the resident rooms were cleaned daily. Continued interview revealed the resident's privacy curtains were cleaned weekly and as needed .I'm pretty sure. The EVS Staff stated she did not remember the last time she had removed or had observed the privacy curtains removed to be laundered. During an observation on 9/29/2025 at 3:26 PM, revealed the wall to the right of the entrance door to the kitchen was observed with a splattered unknown brown substance on a large area of the wall. The corner of the wall baseboards were peeling away from the wall and was soiled with dirt and debris. During an interview on 9/30/2025 at 2:54pm with the Maintenance Director, revealed he was made aware if resident rooms needed repair through the facility's TELS (electronic communication) system and was not aware of a specific concern or condition of room that had been recently reported. The Maintenance Director confirmed resident rooms #119, #120, #121, #123, #124, #125, #126, #127, #128, #209, #210, #212 were in disrepair and not maintained in a homelike environment. During an interview on 9/30/2025 at 3:10 PM, the Regional Director of Operations of Environmental Services, revealed resident rooms were cleaned daily, and terminal cleaning (top to bottom) was completed after a resident was discharged . Further interview revealed privacy curtains were cleaned monthly unless soiled. Continued interview confirmed the privacy curtains in rooms 120-A, 120-B, 123-A, 123-B, 127-A, and 127-B were soiled and in need of laundering or replaced, and the resident's homelike environment was not maintained.

Based on facility policy review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment after a fall for 1 resident (Resident #8) of 3 residents reviewed for falls. The findings include:Review of the facility policy titled, RAI [Resident Assessment Instrument] - MDS [Minimum Data Set] 3.0 Completion, dated 3/2025, revealed .Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan.According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State.Review of medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Alzheimer's Disease, Dementia with Behaviors, Diabetes, Osteoarthritis, Chronic pain, Dysphagia, and Muscle weakness.Review of the event note for Resident #8 dated 9/4/2025 revealed .unwitnessed fall and obtained head injury .Review of the quarterly MDS assessment for Resident #8 dated 9/12/2025, revealed the fall which had occurred on 9/4/2025 had not been identified and documented on the 9/12/2025 MDS assessment. Continued review revealed the resident had not had any falls.During an interview on 10/1/2025 at 10:55 AM, MDS Coordinator E confirmed Resident #8 had a fall on 9/4/2025 and the MDS assessment for a fall had not been documented on the 9/12/2025 MDS assessment .I must have overlooked it.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to implement the care plan related to fall interventions for 1 resident (Resident #8) of 19 residents reviewed for care plans.The findings include:Review of the facility policy titled, Comprehensive Care Plans, dated 3/3/2025, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, physical, mental, and psychosocial needs.The care planning process will include an assessment of the resident's strengths and needs.The comprehensive care plan will describe, at a minimum, the following.The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident specific interventions that reflect the resident's needs.as indicated. Review of the facility policy titled, Falls, dated 6/2025, revealed .[Facility] strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measure.Care plan interventions should be implemented that address the resident's risk factors.Should the Resident experience a fall the attending nurse shall complete a post fall assessment.interventions to reduce risk of repeat episode and a review by the IDT [Interdisciplinary Team] to evaluate thoroughness of the investigation and appropriateness of the interventions.The resident care plan should be updated to reflect, any new or change in interventions. Review of medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Alzheimer's Disease, Dementia with Behaviors, Diabetes, Osteoarthritis, Chronic pain, Dysphagia, Muscle weakness. Review of the comprehensive care plan for Resident #8 dated 9/19/2025, revealed the resident was at risk for falls due to weakness and unstable mobility. Continued review revealed on 9/26/2023 the fall intervention included low bed as the resident will allow and on 8/12/2024 the fall intervention included bilateral fall mats to bedside related to resident having multiple attempts of getting out of bed without assistance. During an observation in Resident #8's room on 9/29/2025 at 12:19 PM revealed Resident #8 lying in bed with no fall mats in the floor at the bedside. Continued observation revealed the resident's bed was not positioned in the lowest position. During an observation in Resident #8's room on 9/30/2025 at 8:21 AM revealed Resident #8 lying in bed with no fall mats in the floor at the bedside. Continued observation revealed the resident's bed was not positioned in the lowest position. During an observation in Resident #8's room on 10/1/2025 at 7:44 AM revealed Resident #8 lying in bed with no fall mats in the floor at the bedside. Continued observation revealed the resident's bed was not positioned in the lowest position. During an interview on 10/1/2025 at 7:49 AM, the Wound Care Nurse) stated she was not aware of Resident #8's fall interventions and could not recall the last time fall mats were observed in the resident's room. During an observation and interview on 10/1/2025 at 10:29 AM, the Director of Nursing (DON) confirmed Resident #8 did not have bilateral fall mats at the bedside and the facility failed to implement the care plan related to fall interventions for Resident #8.

Based on review of facility policy, review of the medical record, observation, and interview, the facility failed to revise a comprehensive care plan for fall interventions for 1 resident (Resident #8) of 19 residents reviewed for care plans.The findings include:Review of the facility policy titled, Comprehensive Care Plans, dated 3/3/2025, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, physical, mental, and psychosocial needs.The care planning process will include an assessment of the resident's strengths and needs.The comprehensive care plan will describe, at a minimum, the following.The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident specific interventions that reflect the resident's needs.as indicated. Review of the facility policy titled, Falls, dated 6/2025, revealed .[Facility] strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measure.Care plan interventions should be implemented that address the resident's risk factors.Should the Resident experience a fall the attending nurse shall complete a post fall assessment.interventions to reduce risk of repeat episode and a review by the IDT [Interdisciplinary Team] to evaluate thoroughness of the investigation and appropriateness of the interventions.The resident care plan should be updated to reflect, any new or change in interventions. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Alzheimer's Disease, Dementia with Behaviors, Diabetes, Osteoarthritis, Chronic pain, Dysphagia, and Muscle weakness. Review of the physician encounter note dated 9/5/2025, revealed .Continue to keep wheelchair seat in lowest position with anti-rollback lock in place . Review of an Occupational Therapy Treatment Encounter Note dated 9/8/2025, revealed .looked at wheelchair needs to be dumped to 30 degrees for safety and prevent falls. Review of the physician encounter note dated 9/11/2025, revealed .Continue to keep wheelchair seat in lowest position with anti-rollback lock in place . Review of the comprehensive care plan for Resident #8 dated 9/19/2025, revealed the resident was at risk for falls due to weakness and unstable mobility. Continued review revealed the fall intervention of anti-rollbacks for the wheelchair, bolster mattress, and reclined seat of wheelchair was not revised on the care plan. During an observation on 9/29/2025 at 12:19 PM, revealed the resident way lying in a bolster bed. The resident's wheelchair was observed with anti-roll back devices and the wheelchair was noted to have a seat which was slightly tilted back. During an observation on 9/30/2025 at 8:21 AM revealed the resident way lying in a bolster bed. The resident's wheelchair was observed with anti-roll back devices and the wheelchair was noted to have a seat which was slightly tilted back. During an observation on 10/1/2025 at 7:44 AM; 10:04 AM, and 10:29 AM, revealed the resident way lying in a bolster bed. The resident's wheelchair was observed with anti-roll back devices and the wheelchair was noted to have a seat which was slightly tilted back. During an observation and interview on 10/1/2025 at 10:29 AM, the Director of Nursing (DON) confirmed the Resident #8 had anti-rollbacks to the wheelchair, the wheelchair seat was lowered, and the resident had a bolster matrress. The DON further confirmed the facility failed to revise the comprehensive care plan for the anti-roll back devices on the wheelchair, the tilted wheelchair seat, and the bolster bed for Resident #8.

Based on review of facility policy, medical record review, and interview, the facility failed to accurately complete a Medication Administration Record (MAR) for 1 resident (Resident #8) of 6 residents review for MAR documentation.The findings include: Review of the facility policy titled, Documentation in Medical Record, dated 7/1/2025, revealed .Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Principles of documentation include, but are not limited to.Documentation shall be factual, objective, and resident centered.False information shall not be documented.Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided.Documentation shall be accurate, relevant, and complete. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Alzheimer's Disease, Dementia with Behaviors, Diabetes, Osteoarthritis, Chronic pain, Dysphagia, and Muscle weakness. Review of the Physician's Orders for Resident #8 dated 8/12/2024 , revealed .Check placement of fall mats to Bilateral bedside every shift. Review of the comprehensive care plan for Resident #8 dated 9/19/2025, revealed the resident was at risk for falls due to weakness and unstable mobility. Continued review revealed a fall intervention which included bilateral fall mats. Review of the MAR for Resident #8 dated 7/1/2025-7/31/2025, revealed .Check placement of fall mats to Bilateral bedside every shift. the MARS had been signed off by a nurse the fall mats were in place for all day shifts and all night shifts. Review of the MAR for Resident #8 dated 8/1/2025-8/30/2025, revealed .Check placement of fall mats to Bilateral bedside every shift. the MARS had been signed off by a nurse the fall mats were in place for all day shifts and all night shifts. Review of the MAR for Resident #8 dated 9/1/2025-9/30/2025, revealed .Check placement of fall mats to Bilateral bedside every shift. the MARS had been signed off by a nurse the fall mats were in place for all day shifts and all night shifts. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During an observation on 9/29/2025 at 12:19 PM, revealed Resident #8 lying in bed with no fall mats present. During an observation on 9/30/2025 at 8:21 AM, revealed Resident #8 lying in bed with no fall mats present. During an observation on 10/1/2025 at 7:44 AM, revealed Resident #8 lying in bed with no fall mats present. During an interview on 9/30/2025 at 3:08 PM, Environmental Services Staff stated she had been employed at the facility for approximately 2 months. EVS Staff F stated she had cleaned Resident #8's room several times (daily when she worked) and had not observed floor mats in place. During an interview on 10/1/2025 at 7:45 AM, Certified Nursing Assistant (CNA) B stated she had been employed with the facility for several months .maybe a year. and had not observed floor mats at Resident #8's bedside. During an interview on 10/1/2025 at 10:23 AM, Licensed Practical Nurse (LPN) A stated Resident #8 had bilateral fall mats listed as a fall intervention on the resident's care plan and .looks like they have been in place for a while. LPN A stated she had signed the MARs for the past several months the bilateral fall mats had been in place. LPN A further stated she could not recall observing the fall mats this morning (10/1/2025). During an interview on 10/1/2025 at 10:29 AM, the Director of Nursing (DON) confirmed Resident #8 did not have bilateral fall mats in place in Resident #8s room and the facility had failed to accurately document on the resident's medical record.

Based on medical record review and interview, and Centers for Disease Control (CDC) COVID 19 Vaccination Guidelines the facility failed to timely notify the responsible party of a change in medical condition (positive COVID 19 test), for one resident, (Resident #1) of 3 sampled residents. The facility failure resulted in a 24 -hour delay in notification of the responsible party of Resident #1's positive COVID 19 test results on 12/4/2022. The findings included: Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident, Right Hemiparesis, Chronic Obstructive Pulmonary Disease, Generalized Anxiety Disorder, Depression, Chronic Kidney Disease and Hypertension. Resident #1 was alert and oriented, with a Brief Interview of Mental status score (BIMS) of 15 indicating the resident was cognitively intact and was independent in decision making. On admission, Resident #1 designated her daughter as her responsible party and an authorized healthcare decision maker. Resident #1 was bedfast and required assistance of one person for activities of daily living (ADLs). Resident #1 had received the primary COVID 19 vaccination series (2 injections) prior to admission to long term care in January and February of 2021. Medical record review showed Resident #1 tested positive for COVID 19 on 12/4/2022. Medical record review of Medication Administration Records (MARs), Treatment Administration Records (TARs) and vital signs monitoring flow sheets for December 2022 showed Resident #1 was treated for COVID 19 with over the counter (OTC) vitamin supplementation and supportive therapies and did not require antiviral treatment or acute care. Resident #1 remained asymptomatic. Interview with Resident #1 on 5/8/2023 at 1:45 PM in her room, revealed the resident to be alert and oriented. Resident #1 reported her medical history in detail. The resident stated she used her I-phone and I Pad devices to communicate via face time with her relatives and engaged in social media interactions with family and friends regularly. Resident #1 reported in December 2022 she posted on social media about her positive COVID test which was seen by her family and friends the same day. Interview with Licensed Practical Nurse (LPN) #1 on 5/8/2023 at 3:00 PM in the conference room, revealed LPN #1 reported when Resident #1 tested positive for COVID 19 in December 2022, the nurse had inadvertently forgotten to notify Resident #1's responsible party and confirmed Resident #1's daughter had learned of her mother's positive COVID status via social media and had not been informed by the facility. LPN #1 reported at the time Resident #1 tested positive for COVID 19, several other residents on the unit were under investigation for COVID 19 symptoms, others had converted positive for COVID 19 that same day, and the unit was engaged in multiple calls for room changes, doctor orders etc. and the call to Resident #1's family was missed as an oversight. Interview with Social Work assistant (SWA) on 5/8/2023 at 4:30 PM in the conference room, confirmed she spoke with Resident #1's responsible party on or around 12/6/2022, about concerns related to the facility failure to call the family the same day Resident #1 tested positive for COVID 19. Interview with the Director of Nursing (DON) on 5/8/2023 at 5:02 PM in the conference room confirmed LPN #1 failed to notify the family of Resident #1's positive COVID test timely on 12/4/2022.

Based on medical record review, review of Centers for Disease Control (CDC) COVID 19 Vaccination Guidelines, and interview the facility failed to provide 1 resident (Resident #1) a COVID 19 booster vaccination of 3 sampled residents. The findings included: Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident, Right Hemiparesis, Chronic Obstructive Pulmonary Disease, Generalized Anxiety Disorder, Depression, Chronic Kidney Disease and Hypertension. Resident #1 was alert and oriented, with a Brief Interview of Mental status score (BIMS) of 15 indicating the resident was cognitively intact and was independent in decision making. On admission, Resident #1 designated her daughter as her responsible party and an authorized healthcare decision maker. Resident #1 was bedfast and required assistance of one person for activities of daily living (ADLs). Resident #1 had received the primary COVID 19 vaccination series (2 injections) prior to admission to long term care in January and February of 2021. Review of Centers for Disease Control (CDC) and Food and Drug Administration (FDA) Emergency Use Authorizations posted online at www.CDC.gov and www.FDA.gov showed booster vaccinations for the prevention of COVID 19 and concurrent emergency use authorizations issued by the FDA to vaccine manufacturers, were made public in August 2022. Review of the facility vaccination logs, nursing notes, and medical progress notes showed no evidence Resident #1 was timely offered or had declined a COVID 19 booster injection as recommended by the CDC in 2022. Resident #1 tested positive for COVID 19 on 12/4/2022. Resident #1 received a bivalent booster for COVID 19 in January 2023. Medical record review of Medication Administration Records, Treatment Records and vital sign flow sheets for December 2022 showed Resident #1 remained asymptomatic of COVID 19 during her infection. Interview with Resident #1 on 5/8/2023 at 1:45 PM in her room, revealed the resident to be alert and oriented. Resident #1 reported her medical history in detail. Resident #1 reported in December 2022 she posted on social media about her positive COVID test and lack of booster shot at the facility, which she felt contributed to her infection. Resident #1 reported she had received her yearly flu shot at the facility in October 2022 and was perplexed as to why her COVID 19 booster had not been offered around the same time and reported she had discussed that with her responsible party in December 2022 as well. Interview with Licensed Practical Nurse (LPN) #1 on 5/8/2023 at 3:00 PM in the conference room, confirmed LPN #1 did advise the responsible party, Resident #1 had not received a COVID 19 booster injection. Interview with the Director of Nursing (DON) on 5/8/2023 at 5:02 PM in the conference room confirmed per her review of the medical records, the facility did not offer a COVID 19 booster to Resident #1 in 2022. The DON reported the missed dose was an oversight by a former Infection Preventionist who had left the facility before December 2022. The DON reported there was no evidence in the facility records Resident #1 had been offered or declined the booster between August and December 2022, and when she was made aware of the situation in December 2022, she assured Resident #1 received a bivalent booster in January 2023 as soon as the resident was eligible for it.

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary environment in the kitchen, with the potential to affect 88 of 89 residents dining in the facility. The findings include: Review of the facility policy titled, Food Safety-Food Service Manager's Responsibility, dated 2013, showed .The food service manager is responsible for providing safe foods to all individuals .The food service manager assures the following .Sanitary conditions are maintained in the storage, preparation and serving areas .All personnel follow proper cleaning and sanitizing instructions for all kitchen equipment. Cleaning schedules are posted and followed . Review of the facility policy titled, Employee Sanitary Practices, dated 2013, showed .All kitchen employees will practice standard sanitary procedures .All employees shall .Clean and sanitize equipment and work units after use . Review of the facility policy titled, General Sanitization of Kitchen, dated 2013 showed .The staff shall maintain the sanitization of the kitchen through compliance with a written, comprehensive cleaning schedule. A cleaning schedule will be posted. Employees will initial and date tasks when completed . Review of facility documentation titled, Daily Cleaning Schedule, dated 4/24/2022 - 5/2/2022, showed no documentation the fryer had been cleaned. Review of facility documentation titled, Weekly Cleaning Schedule, dated 4/2022 and 5/2022, showed no documentation the deep fryer had been cleaned. During the initial kitchen observation and interview on 5/2/2022 at 10:55 AM, with the Dietary Manager (DM), the can opener was found to be unsanitary, with brown food debris build up behind the blade of the can opener. Continued observation revealed, the deep fryer was found in an unsanitary condition, with brown food debris present on the top of the oil reservoir, and a copious amount of food debris along the right side of the deep fryer. The DM confirmed the deep fryer had not been used in a while and should have been cleaned. Continued observation revealed a copious amount of food debris present on the top of the stove/range, the burners, and the removable crumb tray. The stove/range was observed to have brown and white food debris splashed down the left side, on the front door of the oven, and beneath the burners. Further observation revealed the mobile steam tray/hot cart used to serve resident meals on the Dogwood hall was in an unsanitary condition, with brown food debris observed in the bottom of all 3 serving bins. During an interview on 5/2/2022 at 11:10 AM, the DM confirmed she had made a cleaning schedule which staff were to follow. The DM confirmed she was responsible to over-see the kitchen and to ensure staff performed sanitization of the equipment. The DM further confirmed the can opener, deep fryer, stove and mobile steam table had been used the day before and each piece of equipment had not been cleaned after each use.

Based on medical record review and interview the facility failed to refer 1 resident (#63), after the resident was identified with possible serious mental disorders, to the state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASARR) of 4 residents reviewed for PASARR. The findings include: Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a PASARR Level II Change in Status Request dated 4/28/2016, revealed Resident #63 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set assessment dated [DATE], revealed Resident #63 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/3/2022 at 12:40 PM, the Social Services Director confirmed there was no documentation a new PASARR had been submitted after the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #63. During an interview on 5/3/2022 at 3:35 PM, the Director of Nursing confirmed a new PASARR had not been submitted to the state-designated authority for Resident #63 after the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on medical record review, observations and interviews, the facility failed to maintain privacy of resident clinical needs by posting clinical care directives related to them in areas visible to others, on the walls of rooms or doorframes visible from the hallway for 2 of 7 sampled residents, (Residents #4 and #2) on 1 of 3 units observed for privacy. The findings included: Medical record review showed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations and interview of Resident #4 on 1/26/22 at 1:21 PM in the resident's room revealed a sign posted on the wall beside her bed which read .Wash under breasts and abdominal folds at 8 AM and 8 PM .be sure areas completely dry .apply [MEDICATION(S)] (an antifungal powder) generously .very important .is to be in bed between meals due to sacral wound Resident #4 appeared unaware the sign was posted at eye level just behind her head during interview. Review of the Electronic Care Plan and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Medical record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations of Resident #2's door frame outside his room visible from the hallway on 1/26/22 at 3:10 PM showed a square sign estimated to be around 4 inches by 4 inches in size, affixed at eye level which read .2000 Fluid Restriction Daily Fluids . Interview with the Director of Nursing (DON) on 1/26/22 at 6:00 PM in the conference room, confirmed the facility expectation per clinical policy was that no private information or care instructions were to be posted on doors or walls of resident rooms at any time, for any reason, with the exception of signs in use that specified infection control measures in place for residents on isolation in accordance with Infection Control and the COVID 19 Prevention Policies. The DON confirmed the facility had failed to maintain privacy for Residents #4 and #2.

Based on review of maintenance records, interview and observation the facility failed to maintain functional equipment and comfortable water temperatures in 1 of 4 shower stalls on 1 of 3 units observed. The facility failure resulted in low water temperatures that caused 3 of 7 residents reviewed (Resident #2 and #3) to defer showers due to cold water temperatures on 1/24/22 and 1/26/22. The findings included: Review of maintenance records (maintenance requests and water temperature records) showed the facility made adjustments to the water temperature setting in the Dogwood Unit common shower room A Stall (nearest to the doorway) on 1/25/22 at 8:40 AM. Interview with the Maintenance Director on 1/26/22 at 1:50 PM in the conference room, revealed he reported on 1/25/22 he adjusted the water temperature setting in the Dogwood Wing shower room in the A stall per requests of staff who reported low water temperatures occurring as they showered residents. The Maintenance Director reported no requests for additional adjustments had been relayed to him afterwards and to his knowledge and per the facility logs, water temperatures checked daily by his staff were maintained in safe and comfortable ranges and no other concerns had been voiced to him. The Maintenance Director reported he and his staff had made multiple adjustments to the mixing valve in the A Stall shower on the Dogwood unit in recent weeks, cleaning a mixing valve several days beforehand which seemed to resolve issues with water turning cold in the stall after a few minutes use. Interview with Certified Nurse Aides (CNA) #2 and #3 on 1/26/22 at 2:06 PM on the Dogwood Unit revealed they informed the surveyor issues with cool water temperatures in the common shower there were ongoing for months. CNA #2 reported 1 of 2 shower stalls in the shower room was currently inoperable as it would not turn off and the water ran cool continuously and the A shower stall water supply would turn cool to cold without warning mid shower at times after a few minutes use. CNA #3 reported the issue was most prominent after the dietary department washed dishes after meals, and both CNAs confirmed for several days staff on the unit allowed residents to test the water before a shower to see if they could tolerate cooler temperatures before showering, which had caused several of them to skip scheduled showers and had led many family members to complain to them. Both CNAs confirmed they had made multiple reports of the situation to their nurse supervisors, who in turn had relayed those concerns to facility management but the situation had not improved. Observations of the Dogwood Unit common shower on 1/26/22 at 2:10 PM in the presence of the Maintenance Director revealed the B stall (farthest from the door) ran continuously, would not shut off, and the water was cool to the touch. Attempts to turn up the water temperature with the handle were unsucessful. The Maintenance Director reported the stall was under repair that day and not available for resident use. Continued observations of the A shower stall (nearest the door) showed it was available for use. Temperature measurements taken with a digital thermometer calibrated in the presence of the surveyor a few minutes beforehand, showed the water temperature in the shower was 93.5 degrees Fahrenheit (F) (low). Interview with Licensed Practical Nurse (LPN) #3 on 1/26/22 at 2:12 PM on the Dogwood unit corroborated the information obtained from CNAs #2 and #3 in prior interview. LPN #3 confirmed she had reported the issue with low water temperatures in the A shower stall at her CNAs requests multiple times to maintenance staff in the prior weeks and staff on the unit considered the issue to still be unresolved. Interviews with Residents #2 and #3, both occupants of the Dogwood Wing who were alert and oriented, on 1/26/22 at 3:00 PM in their room, revealed both had elected to skip their scheduled showers that day due to cold water in the shower room that morning. Both agreed the issue with water turning cold without warning mid shower had been ongoing for quite some time and despite attempts by the maintenance workers to address it, it still occurred on a regular basis. A second observation of the Dogwood Shower A stall on 1/26/22 at 3:15 PM with the Maintenance Director, revealed attempts to increase the water temperature in the A shower stall via adjustment of the mixing valve screw on the control faceplate were unsuccessful. The water remained cool to the touch, and measurements taken showed it was 90.5 degrees F after over 2 minutes of continuous run time at maximum hot setting on the control lever. Interview with the Maintenance Director on 1/26/22 at 3:18 PM in the Dogwood Unit A shower stall, confirmed the facility had failed to maintain comfortable water temperatures in the shower. The Maintenance Director reported the valve behind the shower was faulty, was likely the original unit installed sometime around 1994, and the tiles on the shower wall would have to be demolished to access the plumbing system behind the shower wall for replacement, which had delayed an effective repair of it to date.

Based on medical record review and interview, the facility failed to maintain a resident's right to be accompanied by next of kin to a doctor's appointment for 1 resident (#1) of 3 residents reviewed. The findings include: Medical record review showed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the rehabilitation hospital discharge instructions, showed at the facility Resident #1 had a doctor's appointment on 10/20/2020 with the urologist to address the resident's ongoing need for an indwelling catheter. Interview by telephone with the Ombudsman on 10/26/2020 at 11:25 AM, revealed there was a conference call conducted on 10/9/2020 with the Administrator, Director of Nurses (DON) and Resident #1's daughter who had been asked by the doctor's office to attend the urology appointment. Interview confirmed there was a conflict between the parties due to the facility wanting to prevent the daughter from being present at the doctor's appointment. Interview with the Administrator on 10/27/2020, at 1:00 PM, revealed when possible, they were using telemedicine for all residents' appointments with consulting doctors. The facility expanded their transporter's role to accompany residents into doctor's appointments and use Facetime, as needed, to include a family member in the appointment. He stated all residents were subject to these protective measures. The Administrator stated they had developed this practice in March 2020. The Administrator confirmed the facility's practice of not allowing the next of kin to be present at doctor's appointments was being advocated for during the conference call with the Ombudsman and daughter on 10/9/2020. The interview confirmed the facility did not have a written policy for the current practice of restricting visitation during doctor's appointments. He stated the practice would continue as a containment effort to reduce exposure to Covid-19.

Based on medical record review and interview, the facility failed to allow [MEDICATION NAME] Care Visits for 1 resident (#1) of 3 residents reviewed. The findings include: Medical record review showed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Activity Admission Assessment revealed Resident #1 had been widowed on 9/18/2020, 15 days prior to admission to the facility. Review of the Occupational Therapy (OT) notes revealed the resident was treated from 10/3/2020 through 10/9/2020. Review of the OT notes showed on 10/5/2020, .increased confusion today with increased anxiety. On 10/7/2020, the OT noted increased confusion with mild hallucinations. Review of the Speech Therapist note, dated 10/7/2020, showed .pt (patient) .at the nurses' station with agitation d/t (due to) wanting to put pants on. Pt however, had on pants. Pt was unable to elaborate on what he wanted specifically. Pt was noted with impaired general cognitive processes .impaired judgement and reasoning; impaired recall of short and long term information, impaired problem solving of simple problems .impaired safety awareness. Pt was noted with no insight into his deficits. Pt was also noted as attempting to roll away from SLP (therapist) during entirety of session to look for his daughter . Interview with the Administrator and the Director of Nurses (DON) on 10/26/2020 at 3:00 PM, stated the Covid-19 positivity rate for their county prevented visitation. They stated [MEDICATION NAME] Care Visits had been allowed for dying residents. Interview confirmed [MEDICATION NAME] Care Visits were not allowed for Resident #1's daughter, even though he was recently widowed, having adjustment problems and asking for his daughter. This interview revealed the facility's current practice did not coincide with the guidelines for [MEDICATION NAME] Care Visits put into effect by Centers for Medicare/Medicaid Services on 9/16/2020, to begin on 10/1/2020.

Based on facility policy review, medical record review, observation and interview, the facility failed to ensure practices to prevent the spread of infection were maintained for 1 resident (#302) of 1 resident reviewed with [MEDICAL CONDITIONS] (C. Difficile-bacteria that causes severe diarrhea and intestinal infection) of 19 residents sampled. The findings include: Review of the facility's policy Isolation-Categories of Transmission-Based Precautions revised 10/2018, revealed, .Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives with symptoms of an infection .and is at risk of transmitting the infection to other residents .Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment . Review of the facility's policy Infection Control Guidelines for All Nursing Procedures, revised 8/2012, revealed .Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions .Before and after direct contact with residents: .When there is likely exposure to spores (i.e., [DIAGNOSES REDACTED]icile .) . Medical record review revealed Resident #302 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED].gastroenteritis and [MEDICAL CONDITION] .CONTACT ISOLATION THRU 6.6.19 (6/6/19)-C. DIFF. (C. difficile) Discontinue Date: 6/06/19 . Medical record review of Resident # 302's Baseline Care Plan dated 5/29/19 revealed, . infection [DIAGNOSES REDACTED] contact isolation through 6/6 (6/6/19) . Observation on 6/3/19 at 12:15 PM revealed, the isolation cart positioned outside Resident #302's room and contact isolation signage posted on the resident's door . Observation of the meal tray delivery on 6/3/19 at 1:00 PM, revealed Certified Nursing Assistant (CNA) #1 entered Resident #302's room placed a meal tray on the over bed table, and exited the resident's room. Further observation revealed CNA #1 failed to don gown and gloves prior to entering the room, and failed to wash the hands prior to exiting the room. Interview with CNA #1 on 6/3/19 at 1:02 PM, in the hallway revealed, .I should have put on gloves and a gown before entering the room and washed my hands before I walked out . Further interview confirmed CNA #1 failed to follow the facility's infection control policy for the resident on contact isolation. Observation on 6/4/19 at 1:05 PM, revealed the Speech Therapist entered Resident #302's room, obtained an item from the resident's over bed table, placed the item in resident's top dresser drawer, and exited the room. Continued observation revealed the Speech Therapist failed to don the gown and wash the hands. Further observation revealed the Speech Therapist entered the storage room, obtained a towel, and re-entered Resident #302's room. Further observation revealed the Speech Therapist failed to don gown and gloves prior to entering the room, handed a towel to the resident, exited the resident's room, and failed to wash the hands prior to exiting the room. Interview with the Speech Therapist on 6/4/19 at 1:10 PM, in the hallway, revealed .I was only going in his room for a few minutes .I should have worn a gown . Further interview confirmed the Speech Therapist failed to follow the facility's infection control policy for the resident on contact isolation. Interview with the Director of Nursing (DON) on 6/5/19 at 9:10 AM, in the DON's office, revealed the nurse failed to initiate appropriate isolation precautions for a resident with [DIAGNOSES REDACTED]icile. Further interview confirmed the facility failed to follow their infection control policy for a resident on contact isolation.

Based on review of the facility Surety Bond, review of resident trust fund accounts, and interview, the facility failed to ensure the Surety Bond covered the amount in the Resident Trust for 34 of 34 residents of 98 census residents. The findings include: Review of the facility's Continuation Certificate (Surety Bond) revealed .in the amount of Thirty Thousand Dollars .in favor of .the Residents of the Facility Participating in the Fund .for the period BEGINNING 01/01/2018 and ENDING 01/01/2019 . Review of the resident's Resident Fund Management Service Statements dated 3/31/2018, revealed the current balance was $31,150.40. Interview with the Administrator on 6/13/18 at 5:15 PM, in the Administrator's Office, confirmed the facility failed to ensure the Surety Bond was in sufficient ammount to cover the total of the residents' trust accounts.

Based on observation and interview, the facility failed to ensure all expired medication related supplies were discarded in 1 of 2 medication storage rooms. The findings include: Observation with the Assistant Director of Nursing on [DATE] at 9:26 AM, in the East Wing Medication Room, revealed the following expired supplies: * 25 red top laboratory tubes 6ml (milliliter) with an expiration date of [DATE] * 11 universal medium transport systems (laboratory swab) with expiration date of [DATE] * 10 purple top laboratory tubes 4ml with an expiration date of [DATE] * 5 blue top laboratory tubes 3ml with an expiration date of ,[DATE] * 2 absorbent clear dressings 3 ½ in (inch) x 3.75 in clear acrylic dressing with an expiration date of ,[DATE] * 1 infusion set 90 degree Needle (connecter for intrvenous infusions) and wing with an expiration date of ,[DATE] * 1 wing blood collection and infusion set with an expiration date of ,[DATE] * 1 red top 6ml laboratory tube with expiration date of [DATE] * 1 grey top 4ml laboratory tube with an expiration date of [DATE] * 1 transparent film dressings 4 ,[DATE] in x 4 ¾ in with an expiration date of ,[DATE] * 1 transparent film dressings 4 ,[DATE] in x 4 ¾ in with an expiration date of ,[DATE] * 1 transparent dressing 4 in x 4 ¾ in with an expiration date of ,[DATE] * 1 non adherent film dressing pad 3 ½ in x 4 ½ in with an expiration of ,[DATE] * 1 connector with needles adaptor port (connecter for intrvenous infusions) with an expiration date of ,[DATE] * 1 cap less positive pressure valve (connecter for intrvenous infusions) with expiration date of ,[DATE] Interview with the ADON on [DATE] at 9:26 AM, in the East Wing Medication Room, confirmed .These items are expired . Continued interview confirmed the supplies were stored with non-expired medical supplies in two baskets in cabinets and all the items in the baskets were available for patient use. Interview with the East Wing Unit Coordinator on [DATE] at 10:06 AM, in the conference room, confirmed .I do check stock in med rooms. The nurses are responsible to rotate stock in med rooms .That stuff was not supposed to be in there, we can't have that . .

Based on review of facility policy, medical record review, and interview the facility failed to develop a comprehensive care plan to address anticoagulant use and Diabetes Mellitus Type 2 (DM II) for 1 resident (#88), of 37 residents reviewed. The findings include: Review of the facility policy Care Plans - Comprehensive undated revealed .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and physiological needs is developed for each resident .Each resident's comprehensive care plan has been designed to: a. incorporate identified problem areas; b. incorporate risk factors associated with identified problems .Care plan goals and objectives are defined as the desired outcome for a specific resident problem .Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . Medical record review revealed Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Continued review revealed the resident was diabetic and received an insulin injection 1 day during the assessment. Further review revealed Resident #88 received an anticoagulant daily. Medical record review of the Physician's Recap Orders dated 5/2018 revealed .Acute embolism and [MEDICAL CONDITION] (blood clot) .Xarelto (medication used to treat and prevent blood clots) .give one tablet by mouth daily .Type 2 Diabetes .[MEDICATION NAME] (medication used to treat high blood sugar levels associated with DM II) .give one tablet by mouth daily .Insulin [MEDICATION NAME] (fast acting form of insulin to treat high blood sugar levels associated with DM II) . Medical record review of Resident #88's Care Plan dated 5/24/18 revealed a plan of care was not developed with individualized goals and interventions for the treatment and management of DM II and anticoagulant use. Interview with MDS Coordinator #1 confirmed the facility failed to develop an individualized plan of care to address DM II and anticoagulant use. Interview with the Director of Nursing on 6/12/18 at 4:12 PM, in the conference room confirmed the facility failed to develop a comprehensive care plan to address DM II and anticoagulant use for Resident #88.

Based on review of the facility policy, medical record review, observation and interview, the facility failed to revise a comprehensive care plan for 1 Resident (#46) of 37 residents reviewed for care plans. The findings include: Review of the facility policy Care Plan - Comprehensive, undated, revealed .Care Plans are revised as changes in the resident's condition dictate .Goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition . Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #46's weight history revealed a 20 pound weight loss from 4/9/18-5/5/18. Medical record review of Resident #46's current care plan dated 4/24/18 revealed .Care plan goal .adequalte fluid/nutritional intake .Intervention .assess resident food preferences .labs as ordered .weights as ordered . Further review revealed the care plan was not revised to include interventions to address the resident's severe weight loss. Interview with the Regional Director of Clinical Services Support on 6/13/18 at 12:30 PM, in the conference room, confirmed the comprehensive care plan dated 4/24/18 had not been revised to include the severe weight loss with new interventions put in place. Interview with the Minimum Data Set (MDS) Coordinator on 6/13/18 at 2:00 PM, in the MDS office, confirmed the care plan was not revised/updated after the severe weight loss.

Based on review of facility policy, medical record review, and interview the facility failed to develop a baseline care plan to address Diabetes Mellitus Type 2 (DM II) for 1 Resident (#300) of 37 residents reviewed. The findings include: Review of the Facility Policy Care Planning Process- Baseline (Interim) Care Plan Revised 11/17/17, revealed .The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care . Medical record review revealed Resident #300 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #300's Nursing Risk assessment dated [DATE] revealed .Predisposing Diseases: Diabetes Mellitus .Predisposing conditions for nutritional concerns .Diabetes (check marked) . Medical record review of Resident #300's Baseline Care Plan dated 6/8/18 revealed no approach to address DM II. Interview with Admission Registered Nurse #1 on 6/13/18 at 4:02 PM, in the conference room confirmed she failed to include DM II to Resident #300's Baseline Care Plan .it should have been there .I honestly don't know why it isn't in there .

Based on medical record review and interview, the facility failed to complete discharge Minimum Data Set (MDS) assessments for 2 (#2 and #3) of 37 residents reviewed. The findings include: Medical record review revealed Resident #2 expired at the facility on [DATE]. Further review of completed MDS's revealed the last MDS completed for Resident #2 was a quarterly assessment dated [DATE]. Continued review revealed no discharge assessment was found. Medical record review revealed Resident #3 expired at the facility on [DATE]. Further review of completed MDS's revealed the last MDS completed for Resident #3 was a quarterly assessment dated [DATE]. Continued review revealed no discharge assessment was found. Interview with the MDS Registered Nurse #1 on [DATE] at 5:12 PM, in the conference room confirmed Resident #2 expired at the facility on [DATE], and Resident #3 expired at the facility on [DATE]. Continued interview confirmed the facility failed to complete the Death in Facility Tracking Record MDS.

Based on medical record review, review of a facility investigation and interview, the facility failed to ensure the care plan was followed to provide a two person transfer for one resident (#3) of four residents reviewed for transfers. The facility's failure resulted in fractures of the eighth and ninth ribs for Resident #3 (Actual Harm). The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set, dated dated dated [DATE], revealed the resident with a Brief Interview of Mental Status (BIMS) score of 3/15 (severely cognitively impaired), and required maximum assistance of two persons for transfers. Medical record review of the care plan dated December 9, 2014, revealed the resident was to be transferred by two persons at all times. Review of a facility investigation dated December 14-15, 2014, revealed the resident sustained [REDACTED].#1) from chair to bed. Interview with CNA #1 on January 27, 2015, at 12:15 p.m., in the conference room revealed CNA #1 performed a single person transfer of the resident on December 14, 2014, prior to the onset of the symptoms of injury. Continued interview revealed CNA #1 was unaware at the time of the transfer the resident was to be transferred at all times by two persons. CNA #1 stated had not checked the resident's care plan prior to the transfer. Further interview confirmed CNA #1 failed to follow the care plan to provide a two person transfer for Resident #3. Interview with the Director of Nursing (DON), on January 26, 2014, at 4:15 p.m., in the conference room confirmed CNA #1 failed to follow the care plan to provide a two person transfer for Resident #3. Continued interview with the DON confirmed the facility's failure resulted in fractures to the eighth and ninth ribs for Resident #3 (Actual Harm). C/O #

Based on medical record review, review of a facility investigation and interview, the facility failed to ensure two staff members provided a safe transfer in accordance with the the resident's assessed needs for one resident (#3) of four residents reviewed for transfers. The facility's failure resulted in fractures of the eighth and ninth ribs for Resident #3 (Actual Harm). The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set, dated dated dated [DATE], revealed the resident with a Brief Interview of Mental Status (BIMS) score of 3/15 (severely cognitively impaired), and required maximum assistance of two persons for transfers. Continued medical record review of the Nursing Notes, Physician Notes, Medication Administration Records, Treatment Administration Records, Nutritional and Therapy Notes revealed the resident weighed eighty pounds and was high risk for falls or fractures. Continued review of the Pharmacy Notes and physician progress notes [REDACTED]. Medical record review of the care plan dated December 9, 2014, revealed the resident was to be transferred by two persons at all times. Review of a facility investigation dated December 14-15, 2014, revealed the resident sustained [REDACTED].#1) who utilized a single person stand pivot transfer technique to move the resident from chair to bed. Interview with CNA #1 on January 27, 2015, at 12:15 p.m., in the conference room revealed CNA #1 performed a single person transfer of the resident on December 14, 2014, prior to the onset of the symptoms of injury. Continued interview revealed CNA #1 lifted the resident from a chair by placing the right arm beneath the resident's left arm pit, reaching around the resident, and grasping the resident's waist band, while using the other arm to reach around the resident's waist and lifted the resident from the chair, pivoted, and placed the resident on the bed. Further interview revealed CNA #1 was unaware at the time of the transfer the resident was to be transferred at all times by two persons. CNA #1 stated had not checked the resident's care plan prior to the transfer. Further interview confirmed CNA #1 failed to follow the care plan to provide a two person transfer of Resident #3. Interview with the Director of Nursing (DON), on January 26, 2014, at 4:15 p.m., in the conference room confirmed CNA #1 failed to provide a two person transfer for Resident #3 per the care plan. Continued interview with the DON confirmed the facility failed to ensure a two person transfer was provided resulting in fractures to the eighth and ninth ribs for Resident #3 (Actual Harm). C/O #

Based on medical record review, review of facility investigation, review of facility nursing shift reports, review of facility policy, observation, and interview, the facility failed to follow facility policies in a timely manner, resulting in a delay of treatment from a fall with a [MEDICAL CONDITION] distal femur (broken left thigh bone near the knee) and failed to provide pain management for one (#1) of eleven residents reviewed. The facility's failure to follow policies and failure to provide pain management for resident #1 resulted in a delay of treatment and complaints of pain without treatment (Actual Harm). The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Progress Note dated June 23, 2012, (no time), revealed a physician evaluation for a routine visit and a complaint of dizziness." Continued review revealed, "...appears somewhat confused...(resident) reports fall...no record of any fall in nursing notes...pain in both legs...pt (patient) with NIDDM (Non-Insulin Dependent Diabetes Mellitus), History of OA ([MEDICAL CONDITION]), Psychoses, ? (questionable) PMR (Polymyalgia Rheumatica-muscle pain and stiffness)...c/o numbness in feet..." Continued review revealed [DIAGNOSES REDACTED]. Medical record review of a Physician's Telephone Order dated June 23, 2012, revealed an order for [REDACTED]. Medical record review of a Nurse's Note dated June 23, 2012, at 2:41 p.m., revealed the Physician evaluated the resident due to complaints of dizziness. Medical record review of a Nurse's Note dated June 25, 2012, at 7:04 p.m., revealed, "In bed all day. C/O (complaining of) pain in the left knee..." Medical record review of a Nurse's Note dated June 26, 2012, at 2:34 a.m., revealed, "Charting for 12:45 a.m. This nurse (Registered Nurse (RN) #1) called to eval (evaluate) resident d/t (due to) increased pain and Lt. (left) upper leg swelling. Resident cries out in severe pain when leg is touched or with any movement. This nurse in to check resident Lt. leg swelling and old yellowish green bruises noted to left knee. Resident is unable to move (resident's) leg and cries when staff attempts to move (resident's) leg. This nurse asked resident what happened and (resident) stated "I fell in the bathroom and they had to get me up." Resident has not been getting up...as per (resident's) normal. Called...(Physician) at 1:00 a.m., and new order to send to the ER (emergency room ) for eval of Lt. leg. Also order noted to give [MEDICATION NAME] (for moderate to severe pain) 5 mg (milligrams) SQ (subcutaneous-under the skin)...2:30 a.m., Ambulance service here to transport resident to (hospital) ER..." Continued review of the Nurse's Notes dated June 26, 2012, at 2:42 a.m., revealed, LPN #2 assessed resident's left leg, "Nurse on day shift reported to this nurse of increased pain...Old bruising and swelling of the left leg and knee noted. Resident c/o pain to left leg. Supervisor (RN #1) notified." Medical record review of a (hospital) radiology report of the left hip, dated June 26, 2012, revealed the resident had a comminuted (splintered or crushed) displaced left distal one-third femoral fracture (a traumatic break in the bone above the knee in which the two ends of the fractured bone are separated and out of their normal positions). Medical record review of a Nurse's Note dated June 27, 2012, revealed the resident returned to the facility from the hospital on June 27, 2012, at 1:25 p.m. with [DIAGNOSES REDACTED]. Review of a facility investigation dated June 26, 2012, at 8:30 a.m., completed by the Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) revealed, "...RN Supervisor (RN #1) assessed resident d/t increased pain, left leg swelling and bruising noted to left knee. MD (Medical Doctor) notified and resident sent to ER for evaluation and tx (treatment). Upon investigation it was found that on 6:00 p.m. to 6:00 a.m., shift on Friday June 22, 2012, a CNA (Certified Nursing Assistant) reported to charge nurse (LPN #1) that resident was found in the bathroom floor..." Continued review of the investigation revealed the resident's Physician was not notified of the resident's fall on June 22, 2012, until June 26, 2012, at 1:00 a.m.; the resident's family was not notified until June 26, 2012, at 1:25 a.m. Review of a written statement dated June 25-26, 2012, by RN #1 revealed RN #1 was notified by LPN #2 of resident's increased pain and swelling of the left upper leg. RN #1's statement revealed the resident's left leg was swollen, with old yellow bruising. "Resident stated (resident) fell in...bathroom [ROOM NUMBER]-3 (two to three) days ago...but no report of a fall...(Physician) was here and checked resident on June 23, 2012...(Physician's) note states that resident also reported to (Physician) that (resident) fell but there was no nurses' notes to support resident's c/o...(Physician) was called at 1:00 a.m., and wanted (resident) to go to the ER and that (resident's) leg may be broken..." (Resident) started crying and stated "yes, it's broken...I fell in my bathroom between the wall and the commode..." RN #1 asked the resident if someone helped (resident) up, and resident stated "it was two women." RN #1 informed the resident of pain medication to be administered, and the resident "started crying" and stated "thank you." Review of a written statement dated June 25, 2012, (beginning of June 25-26, 2012, night shift from 6:00 p.m.-6:00 a.m.) by LPN #2 revealed the resident's left leg was painful and swollen above and around the knee. Review of a written statement (no date) by CNA #1, revealed on June 22, 2012, CNA #1 walked into the resident's room and heard a banging noise. CNA #1 opened the resident's bathroom door, found the resident sitting on the bathroom floor, banging the garbage can on the floor. "I ran and got the nurse (LPN #1), we picked (resident) up and then put (resident) in the bed." Review of a written statement (no date) by LPN #1, revealed, "About 6:20 p.m., (no date) assisted (resident) to BR (bathroom)...call light on. When assisting (resident) back to w/c (wheelchair) (resident's) left leg went outward when wt. (weight) put on it. I was on (R) (right) side of pt. During the transfer pt. stated "my leg popped" 6:25 p.m., after assisting pt back to bed removed pants to check leg saw a knot with [MEDICAL CONDITION] (L) (left) leg above knee at back. Ask pt about knot stated "that has been there" No discoloration noted ROM (range of motion) intact...Assisted pt with personal care due to stress incontinet (incontinence). 7:30 p.m. Pt. up to BR per self in w/c transferred self to and from bed with no assistance. Cont (continued) taking self to BR with no assistance till (until) 6:00 a.m..." Medical record review revealed no documentation the resident fell on [DATE]. Continued review revealed no documentation of the resident being assessed for injury or change in condition (no vital signs, no pain assessment, no neurological assessment, and no body systems assessment) on June 22, 2012; continued review revealed no documentation the Physician was notified of the resident falling on June 22, 2012, until June 26, 2012. Review of the nursing shift-to-shift reports dated June 22, 23, 24, and 25, 2012, revealed no documentation of the resident having a fall on June 22, 2012, or Physician notification of the resident falling on June 22, 2012. Review of the facility "Procedure: Post Fall" (no date), revealed, "...4. Do neurochecks for all unwitnessed falls...7. Nursing to complete...Fall Tracking Form; Incident Report, to include vital signs, with lying and standing blood pressure...Incident Report and Accident/Event Management Protocol to be completed per nurse...; Pain Assessment..." Review of the facility policy "Accidents and Incidents-Investigating and Reporting" dated October 01, 2011, revealed, "Policy: All accidents or incidents involving residents...occurring at our facilities must be investigated and reported...as soon as the accident/incident is discovered...b. An Incident Report Form must be completed for all reported accidents or incidents. 3. Medical Attention:...e. If the incident involves a resident, immediately contact the physician and responsible party of the incident..." Review of the facility policy "Pain Management" (no date), revealed, "Policy:...Any resident who experiences pain will be reviewed and a plan will be established to treat his or her pain...Purpose(s): 1. To ensure the physical and psychological well being of the resident. Guiding Principles:...Members of the interdisciplinary care team have a responsibility to advocate for resident comfort...Procedure(s):...B. Process 1. Pain will be reviewed/scored using a numeric 0-10 (zero to ten) scale...Alternate scales may be used...The type of scale used, if different than policy, must be documented...3. Every resident will be regularly and systematically reviewed for pain...b. With any change in resident condition...new onset complaints of pain...To maintain a complete account of the resident's care...Purpose: To ensure that all services provided to the resident or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. General Guidelines:...3. All incidents, accidents, or changes in the resident's condition must be recorded..." Observation of the resident in the presence of the SDC, in the resident's room, on June 27, 2012, at 9:20 p.m., confirmed the resident was lying on the bed, very confused and verbalized a nonsensical conversation with the surveyor. The SDC confirmed the resident was not typically confused to this degree. Continued observation confirmed an immobilizer was on the resident's left lower extremity, extending from the mid-thigh to the upper ankle. Yellow bruising extended laterally, above the immobilizer. The resident expressed complaints of pain "Oh, oh, oh...that hurts..." with the slightest touch and/or movement during care per nursing staff. Continued observation of the resident, in the resident's room, on July 10, 2012, confirmed the immobilizer was present on the resident's left lower extremity; with continued observation confirming the resident had one large yellow bruise on the lateral left thigh, measuring 12.5 inches by 11.0 inches. Within the yellow bruising were three separate purple bruises; (1) the upper lateral measured 4.5 inches by 4.5 inches, (2) the mid-lateral measured 5.0 inches by 3.0 inches, and (3) the lower lateral measured 3.0 inches by 1.5 inches. Interview with the SDC on June 27, 2012, at 4:30 p.m., in the conference room, confirmed upon arriving to work at the facility on June 26, 2012, at approximately 5:45 a.m., RN #1 gave report to the SDC. RN #1 reported on June 26, 2012, sometime around midnight (couldn't recall the exact time), the resident had increased complaints of pain with swelling in the left thigh; the resident alleged to have fallen and was assisted up by two females. The physician was notified (sometime around midnight) and ordered the resident to be sent to the ER for an evaluation. An x-ray of the left hip was completed on June 26, 2012, at the hospital, and confirmed the resident had a left femoral fracture. The SDC confirmed, on June 26, 2012, at approximately 8:45 a.m., to report RN #1's findings regarding the resident in the facility's morning clinical meeting. An investigation was initiated immediately, to determine the cause of the fracture. The resident's chart was retrieved and reviewed; the physician's note dated June 23, 2012, was reviewed, which included complaints of dizziness and allegations of a fall. No Incident Report had been completed; and the resident's chart revealed no documentation of a fall. Nursing assignment schedules from June 21-25, 2012, were reviewed and interviews began. The SDC's interview with CNA #1 revealed CNA #1 found the resident on the floor banging on a garbage can on June 22, 2012, after supper; CNA #1 left the resident's room and immediately notified LPN #1 for assistance; together, CNA #1 and LPN #1 went back to the resident's room, got the resident out of the floor, and put the resident in the bed. The SDC called LPN #1 after completing the interview with CNA #1. The SDC asked LPN #1 "Do you know anything that may have happened to (resident)?" LPN #1 denied knowing anything. The SDC continued questioning "Are you sure you don't know anything that happened to the resident on Friday or Saturday night (June 22 or 23, 2012)?" LPN #1 revealed to remember providing assistance to (resident), who "began to go down and LPN #1 caught (resident) and put (resident) in the wheelchair." The SDC confirmed this was the only information provided or revealed by LPN #1. Interview with LPN #1, in the presence of the Administrator, on June 27, 2012, at 5:45 p.m., in the conference room, confirmed LPN #1 intentionally gave false and misleading information during the facility's investigation of the resident's left femoral fracture. LPN #1 confirmed the resident did have an unwitnessed fall on June 22, 2012, and at approximately 6:20 p.m., CNA #1 notified LPN #1 the resident was on the floor in the bathroom. LPN #1 and CNA #1 went to the resident's room to assist the resident up from the floor. LPN #1 confirmed the resident was sitting on the buttocks, with the knees bent upward. As the resident was assisted up, the resident complained of pain in the right foot, and LPN #1 heard the resident's left leg pop. When the surveyor asked if pain medication had been administered or if the Physician was notified, LPN #1 confirmed, "No...I didn't give any pain medication...No, I didn't call the Doctor...I know better...I knew better then...I knew what to do, I just didn't do it..." Continued interview confirmed the Physician was not notified of the resident's fall, complaint of pain, or of the left leg popping. LPN #1 confirmed when the SDC called (LPN #1) on June 26, 2012, and asked about the resident's left femoral fracture, "I intentionally deceived (SDC); I lied to (SDC) and (Administrator)...The written statement I gave to (Administrator) was false...I knew it was untruthful...I did not call the Physician and did not follow the facility's policies and procedures...I knew what to do...the resident was in the floor and I didn't do what I was supposed to do...I failed to follow the protocol and it's the patient that suffered." Interview with CNA #1, on June 27, 2012, at 8:30 p.m., via telephone, confirmed the resident fell on [DATE], after supper (unsure of exact time). CNA #1 went into the resident's room and heard a noise coming from the bathroom. Upon entering the bathroom, CNA #1 confirmed the resident was sitting on the bathroom floor, with the right leg extended outward and the left leg bent up under (resident's) bottom (buttocks). CNA #1 went and got LPN #1 and they went back into the resident's bathroom, got the resident up and into a wheelchair, then put the resident to bed. CNA #1 confirmed the resident verbalized complaints of knee pain, but the resident did not identify which knee was hurting. Continued interview with CNA #1 confirmed LPN #1 did not assess the resident, "Once the resident was in bed, we (CNA #1 and LPN #1) left (resident's) room together." Interview with the resident's attending Physician (Medical Director) on June 27, 2012, at 7:35 p.m., in the conference room, confirmed on June 23, 2012, the resident told the Physician, (resident) had fallen (did not state when). The Physician evaluated the resident, saw no [MEDICAL CONDITION] or discoloration; the resident complained of back and bilateral (both) leg pain. The Physician confirmed the resident had chronic pain secondary to generalized Arthritis. Upon the resident reporting the fall, the Physician confirmed to review the resident's chart and there was no documentation of a fall. Continued interview confirmed the Physician was not notified of any fall occurring recently, or on June 22, 2012. The Physician confirmed, "Based upon the fracture...it is most likely she fell on to her knee..." The Physician confirmed, "I expect to be notified of all falls...If I had gotten this information on the fall, I would have focused my examination on the (resident's) leg." The Physician confirmed the nurse's failure to follow facility policies and failure to provide pain management for resident #1 resulted in a delay of treatment and complaints of pain without treatment. C/O #

Based on medical record review, review of facility investigation, review of facility nursing shift reports, review of facility policy, observation, and interview, the facility failed to notify the attending Physician and/or Resident's Responsible Party of a fall, and a [MEDICAL CONDITION] distal femur (broken left thigh bone near the knee) for one (#1) of eleven residents reviewed. The facility's failure to notify the attending physician of resident #1's fall resulted in a delay of identifying and treating the [MEDICAL CONDITION] distal femur (Actual Harm). The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Progress Note dated June 23, 2012, (no time), revealed a physician evaluation due to "pain management" and "c/o (complaint of) of dizziness." Continued review revealed, "...appears somewhat confused...(resident) reports fall...no record of any fall in nursing notes...pain in both legs...pt (patient) with NIDDM (Non-Insulin Dependent Diabetes Mellitus), History of OA ([MEDICAL CONDITION]), Psychoses, ? (questionable) PMR (Polymyalgia Rheumatica-muscle pain and stiffness)...c/o numbness in feet..." Continued review revealed [DIAGNOSES REDACTED]. Medical record review of a Physician's Telephone Order dated June 23, 2012, revealed an order for [REDACTED]. Medical record review of a Nurse's Note dated June 23, 2012, at 2:41 p.m., revealed the Physician evaluated the resident due to complaints of dizziness. Medical record review of a Nurse's Note dated June 26, 2012, at 2:34 a.m., revealed, "Charting for 12:45 a.m. This nurse (Registered Nurse (RN) #1) called to eval (evaluate) resident d/t (due to) increased pain and Lt. (left) upper leg swelling. Resident cries out in severe pain when leg is touched or with any movement. This nurse in to check resident Lt. leg swelling and old yellowish green bruises noted to left knee. Resident is unable to move (resident's) leg and cries when staff attempts to move (resident's) leg. This nurse asked resident what happened and (resident) stated "I fell in the bathroom and they had to get me up." Resident has not been getting up...as per (resident's) normal. Called...(Physician) at 1:00 a.m., and new order to send to the ER (emergency room ) for eval of Lt. leg. Also order noted to give [MEDICATION NAME] (for moderate to severe pain) 5 mg (milligrams) SQ (subcutaneous-under the skin)...2:30 a.m., Ambulance service here to transport resident to (hospital) ER..." Continued review of the Nurse's Notes dated June 26, 2012, at 2:42 a.m., revealed, LPN #2 assessed resident's left leg, "...Old bruising and swelling of the left leg and knee noted. Resident c/o pain to left leg. Supervisor (RN #1) notified." Medical record review of a (hospital) radiology report of the left hip, dated June 26, 2012, revealed the resident had a comminuted (splintered or crushed) displaced left distal one-third femoral fracture (a traumatic break in the bone above the knee in which the two ends of the fractured bone are separated and out of their normal positions). Medical record review of a Nurse's Note dated June 27, 2012, revealed the resident returned to the facility from the hospital on June 27, 2012, at 1:25 p.m. with [DIAGNOSES REDACTED]. Review of a facility investigation dated June 26, 2012, at 8:30 a.m., completed by the Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) revealed, "...RN Supervisor (RN #1) assessed resident d/t increased pain, left leg swelling and bruising noted to left knee. MD (Medical Doctor) notified and resident sent to ER for evaluation and tx (treatment). Upon investigation it was found that on 6:00 p.m. to 6:00 a.m., shift on Friday June 22, 2012, a CNA (Certified Nursing Assistant-#1) reported to charge nurse (LPN #1) that resident was found in the bathroom floor..." Continued review of the investigation revealed the resident's Physician was not notified of the resident's fall on June 22, 2012, until June 26, 2012, at 1:00 a.m.; the resident's Responsible Party was not notified until June 26, 2012, at 1:25 a.m. Review of a written statement dated June 25-26, 2012, by RN #1 revealed RN #1 was notified by LPN #2 of resident's increased pain and swelling of the left upper leg. RN #1's statement revealed the resident's left leg was swollen, with old yellow bruising. "Resident stated (resident) fell in...bathroom [ROOM NUMBER]-3 (two to three) days ago...but no report of a fall...(Physician) was here and checked resident on June 23, 2012...(Physician's) note states that resident also reported to (Physician) that (resident) fell but there was no nurses' notes to support resident's c/o...(Physician) was called at 1:00 a.m., and wanted (resident) to go to the ER and that (resident's) leg may be broken..." (Resident) started crying and stated "yes, it's broken...I fell in my bathroom between the wall and the commode..." RN #1 asked the resident if someone helped (resident) up, and resident stated "it was two women." RN #1 informed the resident of pain medication to be administered, and the resident "started crying" and stated "thank you." Review of a written statement dated June 25, 2012, (beginning of June 25-26, 2012, night shift from 6:00 p.m.-6:00 a.m.) by LPN #2 revealed the resident's left leg was painful and swollen above and around the knee. Review of a written statement (no date) by CNA #1, revealed on June 22, 2012, CNA #1 walked into the resident's room and heard a banging noise. CNA #1 opened the resident's bathroom door, found the resident sitting on the bathroom floor, banging the garbage can on the floor. "I ran and got the nurse (LPN #1), we picked (resident) up and then put (resident) in the bed." Review of a written statement (no date) by LPN #1, revealed, "About 6:20 p.m., (no date) assisted (resident) to BR (bathroom)...call light on. When assisting (resident) back to w/c (wheelchair) (resident's) left leg went outward when wt. (weight) put on it. I was on (R) (right) side of pt. During the transfer pt. stated "my leg popped" 6:25 p.m., after assisting pt back to bed removed pants to check leg saw a knot with [MEDICAL CONDITION] (L) (left) leg above knee at back. Ask pt about knot stated "that has been there" No discoloration noted ROM (range of motion) intact...Assisted pt with personal care due to stress incontinet (incontinence). 7:30 p.m. Pt. up to BR per self in w/c transferred self to and from bed with no assistance. Cont (continued) taking self to BR with no assistance till (until) 6:00 a.m..." Medical record review revealed no documentation the resident fell on [DATE]. Continued review revealed no documentation the Physician and/or the Responsible Party was notified of the resident falling on June 22, 2012, until June 26, 2012. Review of the nursing shift-to-shift reports dated June 22, 23, 24, and 25, 2012, revealed no documentation of the resident having a fall on June 22, 2012, or Physician and/or the Responsible Party notification of the resident falling on June 22, 2012. Review of the facility "Protocol: Post Fall" (no date), revealed, "1. Assess the resident and implement appropriate measure to provide immediate care. Neurological checks to be done for all unwitnessed falls...2. Nursing to complete...a. Fall Tracking Form. b. Incident Report, to include vital signs, with lying and standing blood pressure. Incident Report and accident/event management protocol to be completed per nurse...c. FSI- Fall Scene Investigation Report (used to identify the root cause analysis). d. Change of status review. e. Resident Event Documentation...f. Pain Assessment...6. Discuss findings...with the resident and the Responsible Party..." Review of the facility policy "Accidents and Incidents-Investigating and Reporting" dated October 01, 2011, revealed, "Policy: All accidents or incidents involving residents...occurring at our facilities must be investigated and reported to the Administrator. Purpose: To ensure the safety of all residents...General Guidelines: 1. Reporting of Accidents/Incidents: a...must be reported to the department supervisor as soon as the accident/incident is discovered...b. An Incident Report Form must be completed for all reported accidents or incidents. d. The nurse supervisor/charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided...3. Medical Attention:...e. If the incident involves a resident, immediately contact the physician and responsible party of the incident... " Observation of the resident in the presence of the SDC, in the resident's room, on June 27, 2012, at 9:20 p.m., confirmed the resident was lying on the bed, with an immobilizer on the resident's left lower extremity, extending from the mid-thigh to the upper ankle. Yellow bruising extended laterally, above the immobilizer. Continued observation of the resident, in the resident's room, on July 10, 2012, confirmed the immobilizer was present on the resident's left lower extremity; with continued observation confirming the resident had one large yellow bruise on the lateral left thigh, measuring 12.5 inches by 11.0 inches. Within the yellow bruising were three separate purple bruises; (1) the upper lateral measured 4.5 inches by 4.5 inches, (2) the mid-lateral measured 5.0 inches by 3.0 inches, and (3) the lower lateral measured 3.0 inches by 1.5 inches. Interview with the SDC on June 27, 2012, at 4:30 p.m., in the conference room, confirmed upon arriving to work at the facility on June 26, 2012, at approximately 5:45 a.m., RN #1 gave report to the SDC. RN #1 reported on June 26, 2012, sometime around midnight (couldn't recall the exact time), the resident had increased complaints of pain with swelling in the left thigh; the resident alleged to have fallen and was assisted up by two females. The Physician was notified (sometime around midnight on June 26, 2012) and ordered the resident to be sent to the ER for an evaluation. An x-ray of the left hip was completed on June 26, 2012, at the hospital, and confirmed the resident had a left femoral fracture. The resident's chart was retrieved and reviewed; the Physician's Progress Note dated June 23, 2012, was reviewed, which included complaints of dizziness and allegations of a fall. No Incident Report had been completed; and the resident's chart revealed no documentation of a fall. Interview with LPN #1, in the presence of the Administrator, on June 27, 2012, at 5:45 p.m., in the conference room, confirmed LPN #1 intentionally gave false and misleading information during the facility's investigation of the resident's left femoral fracture. LPN #1 confirmed the resident did have an unwitnessed fall on June 22, 2012, and at approximately 6:20 p.m., CNA #1 notified LPN #1 the resident was on the floor in the bathroom. LPN #1 and CNA #1 went to the resident's room to assist the resident up from the floor. LPN #1 confirmed the resident was sitting on the buttocks, with the knees bent upward. As the resident was assisted up, the resident complained of pain in the right foot, and LPN #1 heard the resident's left leg pop. When the surveyor asked if pain medication had been administered or if the Physician was notified, LPN #1 confirmed, "No...I didn't give any pain medication...No, I didn't call the Doctor or the resident's Responsible Party (family)...I know better...I knew better then...I knew what to do, I just didn't do it..." Continued interview confirmed the Physician was not notified of the resident's fall, complaint of pain, or of the left leg popping. LPN #1 confirmed when the SDC called (LPN #1) on June 26, 2012, and asked about the resident's left femoral fracture, "I intentionally deceived (SDC); I lied to (SDC) and (Administrator)...The written statement I gave to (Administrator) was false...I knew it was untruthful...I did not call the Physician and did not follow the facility's policies and procedures...I knew what to do...the resident was in the floor and I didn't do what I was supposed to do...I failed to follow the protocol and it's the patient that suffered." Interview with CNA #1, on June 27, 2012, at 8:30 p.m., via telephone, confirmed the resident fell on [DATE], after supper (unsure of exact time). CNA #1 went into the resident's room and heard a noise coming from the bathroom. Upon entering the bathroom, CNA #1 confirmed the resident was sitting on the bathroom floor, with the right leg extended outward and the left leg bent up under (resident's) bottom (buttocks). CNA #1 went and got LPN #1 and they went back into the resident's bathroom, got the resident up and into a wheelchair, then put the resident to bed. CNA #1 confirmed the resident verbalized complaints of knee pain, but the resident did not identify which knee was hurting. Continued interview with CNA #1 confirmed LPN #1 did not assess the resident, "Once the resident was in bed, we (CNA #1 and LPN #1) left (resident's) room together." Interview with the resident's attending Physician (Medical Director) on June 27, 2012, at 7:35 p.m., in the conference room, confirmed on June 23, 2012, the resident told the Physician, (resident) had fallen (did not state when). The Physician evaluated the resident, saw no [MEDICAL CONDITION] or discoloration; the resident complained of back and bilateral (both) leg pain. The Physician confirmed the resident had chronic pain secondary to generalized Arthritis. Upon the resident reporting the fall, the Physician confirmed to review the resident's chart and there was no documentation of a fall. Continued interview confirmed the Physician was not notified of any fall occurring recently, or on June 22, 2012. The Physician confirmed, "I expect to be notified of all falls...If I had gotten this information on the fall, I would have focused my examination on the (resident's) leg." Continued interview confirmed the facility's failure to notify the Physician of resident #1's fall resulted in a delay of identifying and treating the [MEDICAL CONDITION] distal femur. C/O # .

Based on medical record review, review of facility investigation, review of facility nursing shift reports, review of facility policy, observation, and interview, the facility failed to follow facility policies to provide the necessary services, and prevent neglect for one (#1) resident with a left femur fracture after a fall, of eleven residents reviewed. The facility's failure to follow policies and prevent neglect resulted in a three-day delay of treatment from an unreported fall with a [MEDICAL CONDITION] distal femur (broken left thigh bone near the knee) and failed to provide pain management for one (#1) of eleven residents reviewed (Actual Harm). The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Physician's Progress Note dated June 23, 2012, (no time), revealed a physician evaluation due to "pain management" and "c/o (complaint of) of dizziness." Continued review revealed, "...appears somewhat confused...(resident) reports fall...no record of any fall in nursing notes...pain in both legs...pt (patient) with NIDDM (Non-Insulin Dependent Diabetes Mellitus), History of OA ([MEDICAL CONDITION]), Psychoses, ? (questionable) PMR (Polymyalgia Rheumatica-muscle pain and stiffness)...c/o numbness in feet..." Continued review revealed [DIAGNOSES REDACTED]. Medical record review of a Physician's Telephone Order dated June 23, 2012, revealed an order for [REDACTED]. Medical record review of a Nurse's Note dated June 23, 2012, at 2:41 p.m., revealed the Physician evaluated the resident due to complaints of dizziness. Medical record review of a Nurse's Note dated June 26, 2012, at 2:34 a.m., revealed, "Charting for 12:45 a.m. This nurse (Registered Nurse (RN) #1) called to eval (evaluate) resident d/t (due to) increased pain and Lt. (left) upper leg swelling. Resident cries out in severe pain when leg is touched or with any movement. This nurse in to check resident Lt. leg swelling and old yellowish green bruises noted to left knee. Resident is unable to move (resident's) leg and cries when staff attempts to move (resident's) leg. This nurse asked resident what happened and (resident) stated "I fell in the bathroom and they had to get me up." Resident has not been getting up...as per (resident's) normal. Called...(Physician) at 1:00 a.m., and new order to send to the ER (emergency room ) for eval of Lt. leg. Also order noted to give [MEDICATION NAME] (for moderate to severe pain) 5 mg (milligrams) SQ (subcutaneous-under the skin)...2:30 a.m., Ambulance service here to transport resident to (hospital) ER..." Continued review of the Nurse's Notes dated June 26, 2012, at 2:42 a.m., revealed, LPN #2 assessed resident's left leg, "...Old bruising and swelling of the left leg and knee noted. Resident c/o pain to left leg. Supervisor (RN #1) notified." Medical record review of a (hospital) radiology report of the left hip, dated June 26, 2012, revealed the resident had a comminuted (splintered or crushed) displaced left distal one-third femoral fracture (a traumatic break in the bone above the knee in which the two ends of the fractured bone are separated and out of their normal positions). Medical record review of a Nurse's Note dated June 27, 2012, revealed the resident returned to the facility from the hospital on June 27, 2012, at 1:25 p.m. with [DIAGNOSES REDACTED]. Review of a facility investigation dated June 26, 2012, at 8:30 a.m., completed by the Staff Development Coordinator (SDC) and Assistant Director of Nursing (ADON) revealed, "...RN Supervisor (RN #1) assessed resident d/t increased pain, left leg swelling and bruising noted to left knee. MD (Medical Doctor) notified and resident sent to ER for evaluation and tx (treatment). Upon investigation it was found that on 6:00 p.m. to 6:00 a.m., shift on Friday June 22, 2012, a CNA (Certified Nursing Assistant) reported to charge nurse (LPN #1) that resident was found in the bathroom floor..." Continued review of the investigation revealed the resident's Physician was not notified of the resident's fall on June 22, 2012, until June 26, 2012, at 1:00 a.m. Review of a written statement dated June 25-26, 2012, by RN #1 revealed RN #1 was notified by LPN #2 of resident's increased pain and swelling of the left upper leg. RN #1's statement revealed the resident's left leg was swollen, with old yellow bruising. "Resident stated (resident) fell in...bathroom [ROOM NUMBER]-3 (two to three) days ago...but no report of a fall...(Physician) was here and checked resident on June 23, 2012...(Physician's) note states that resident also reported to (Physician) that (resident) fell but there was no nurses' notes to support resident's c/o...(Physician) was called at 1:00 a.m., and wanted (resident) to go to the ER and that (resident's) leg may be broken..." (Resident) started crying and stated "yes, it's broken...I fell in my bathroom between the wall and the commode..." RN #1 asked the resident if someone helped (resident) up, and resident stated "it was two women." RN #1 informed the resident of pain medication to be administered, and the resident "started crying" and stated "thank you." Review of a written statement dated June 25, 2012, (beginning of June 25-26, 2012, night shift from 6:00 p.m.-6:00 a.m.) by LPN #2 revealed the resident's left leg was painful and swollen above and around the knee. Review of a written statement (no date) by CNA #1, revealed on June 22, 2012, CNA #1 walked into the resident's room and heard a banging noise. CNA #1 opened the resident's bathroom door, found the resident sitting on the bathroom floor, banging the garbage can on the floor. "I ran and got the nurse (LPN #1), we picked (resident) up and then put (resident) in the bed." Review of a written statement (no date) by LPN #1, revealed, "About 6:20 p.m., (no date) assisted (resident) to BR (bathroom)...call light on. When assisting (resident) back to w/c (wheelchair) (resident's) left leg went outward when wt. (weight) put on it. I was on (R) (right) side of pt. During the transfer pt. stated "my leg popped" 6:25 p.m., after assisting pt back to bed removed pants to check leg saw a knot with [MEDICAL CONDITION] (L) (left) leg above knee at back. Ask pt about knot stated "that has been there" No discoloration noted ROM (range of motion) intact...Assisted pt with personal care due to stress incontinet (incontinence). 7:30 p.m. Pt. up to BR per self in w/c transferred self to and from bed with no assistance. Cont (continued) taking self to BR with no assistance till (until) 6:00 a.m..." Medical record review revealed no documentation the resident fell on [DATE]. Continued review revealed no documentation of the resident being assessed for injury or change in condition (no vital signs, no pain assessment, no neurological assessment, and no body systems assessment) on June 22, 2012; continued review revealed no documentation the Physician was notified of the resident falling on June 22, 2012, until June 26, 2012. Review of the nursing shift-to-shift reports dated June 22, 23, 24, and 25, 2012, revealed no documentation of the resident having a fall on June 22, 2012, or Physician notification of the resident falling on June 22, 2012. Review of the facility "Protocol: Post Fall" (no date), revealed, "1. Assess the resident and implement appropriate measure to provide immediate care. Neurological checks to be done for all unwitnessed falls...2. Nursing to complete... a. Fall Tracking Form. b. Incident Report, to include vital signs, with lying and standing blood pressure. Incident Report and accident/event management protocol to be completed per nurse...c. FSI- Fall Scene Investigation Report (used to identify the root cause analysis). d. Change of status review. e. Resident Event Documentation...f. Pain Assessment...6. Discuss findings...with the resident and family..." Review of the facility "Procedure: Post Fall" (no date), revealed, "...3...Obtain blood pressure and pulse while resident is on the ground. Leave blood pressure cuff on resident. If resident is able to stand, do so and obtain blood pressure immediately. Do not wait for blood pressure to stabilize. If not, place in chair and obtain blood pressure. 4. Do neurochecks for all unwitnessed falls...7. Nursing to complete...Fall Tracking Form; Incident Report, to include vital signs, with lying and standing blood pressure...Incident Report and Accident/Event Management Protocol to be completed per nurse...; FSI-Fall Scene Investigation Report...; Pain Assessment..." Review of the facility policy "Accidents and Incidents-Investigating and Reporting" dated October 01, 2011, revealed, "Policy: All accidents or incidents involving residents...occurring at our facilities must be investigated and reported to the Administrator. Purpose: To ensure the safety of all residents...General Guidelines: 1. Reporting of Accidents/Incidents: a...must be reported to the department supervisor as soon as the accident/incident is discovered...b. An Incident Report Form must be completed for all reported accidents or incidents. d. The nurse supervisor/charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided...3. Medical Attention:...e. If the incident involves a resident, immediately contact the physician and responsible party of the incident...Steps in the Procedure: 1. The Incident Report...a. The nurse supervisor/charge nurse and/or the department director or supervisor shall:...3. Use information obtained during the investigation to complete the Incident Report Form; and 4. Complete the assessment of the resident...complete the information required and give a full description of the occurrence. Record time of incident, and describe exactly what occurred or was observed..." Review of the facility policy "Charting and Documentation: Nurse's Notes" pages one through three, revealed, "Policy: To maintain a complete account of the resident's care...Purpose: To ensure that all services provided to the resident or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. General Guidelines:...3. All incidents, accidents, or changes in the resident's condition must be recorded..." Review of the facility policy "Pain Management" (no date), revealed, "Policy:...Any resident who experiences pain will be reviewed and a plan will be established to treat his or her pain...Purpose(s): 1. To ensure the physical and psychological well being of the resident. 2. To maintain optimum functional ability. Guiding Principles: In the long-term care setting, the comfort and well-being of the individual resident should always be paramount (of chief concern or importance). This principle is the foundation for effective management of pain. Adequate pain management should be sought in each case. Individualized care...ensures that pain management is tailored to each resident's needs, circumstances, conditions, and risk factors. Members of the interdisciplinary care team have a responsibility to advocate for resident comfort...Procedure(s):...B. Process 1. Pain will be reviewed/scored using a numeric 0-10 (zero to ten) scale...Alternate scales may be used...The type of scale used, if different than policy, must be documented...3. Every resident will be regularly and systematically reviewed for pain...b. With any change in resident condition...new onset complaints of pain...To maintain a complete account of the resident's care...Purpose: To ensure that all services provided to the resident or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. General Guidelines:...3. All incidents, accidents, or changes in the resident's condition must be recorded..." Observation of the resident in the presence of the SDC, in the resident's room, on June 27, 2012, at 9:20 p.m., confirmed the resident was lying on the bed, very confused and verbalized a nonsensical conversation with the surveyor. The SDC confirmed the resident was not typically confused to this degree. Continued observation confirmed an immobilizer was on the resident's left lower extremity, extending from the mid-thigh to the upper ankle. Yellow bruising extended laterally, above the immobilizer. The resident expressed complaints of pain "Oh, oh, oh...that hurts..." with the slightest touch and/or movement during care per nursing staff. Continued observation of the resident, in the resident's room, on July 10, 2012, confirmed the immobilizer was present on the resident's left lower extremity; with continued observation confirming the resident had one large yellow bruise on the lateral left thigh, measuring 12.5 inches by 11.0 inches. Within the yellow bruising were three separate purple bruises; (1) the upper lateral measured 4.5 inches by 4.5 inches, (2) the mid-lateral measured 5.0 inches by 3.0 inches, and (3) the lower lateral measured 3.0 inches by 1.5 inches. Interview with the SDC on June 27, 2012, at 4:30 p.m., in the conference room, confirmed upon arriving to work at the facility on June 26, 2012, at approximately 5:45 a.m., RN #1 gave report to the SDC. RN #1 reported on June 26, 2012, sometime around midnight (couldn't recall the exact time), the resident had increased complaints of pain with swelling in the left thigh; the resident alleged to have fallen and was assisted up by two females. The physician was notified (sometime around midnight) and ordered the resident to be sent to the ER for an evaluation. An x-ray of the left hip was completed on June 26, 2012, at the hospital, and confirmed the resident had a left femoral fracture. The SDC confirmed, on June 26, 2012, at approximately 8:45 a.m., to report RN #1's findings regarding the resident in the facility's morning clinical meeting. An investigation was initiated immediately, to determine the cause of the fracture. The resident's chart was retrieved and reviewed; the physician's note dated June 23, 2012, was reviewed, which included complaints of dizziness and allegations of a fall. No Incident Report had been completed; and the resident's chart revealed no documentation of a fall. Nursing assignment schedules from June 21-25, 2012, were reviewed and interviews began. The SDC's interview with CNA #1 revealed CNA #1 found the resident on the floor banging on a garbage can on June 22, 2012, after supper; CNA #1 left the resident's room and immediately notified LPN #1 for assistance; together, CNA #1 and LPN #1 went back to the resident's room, got the resident out of the floor, and put the resident in the bed. The SDC called LPN #1 after completing the interview with CNA #1. The SDC asked LPN #1 "Do you know anything that may have happened to (resident)?" LPN #1 denied knowing anything. The SDC continued questioning "Are you sure you don't know anything that happened to the resident on Friday or Saturday night (June 22 or 23, 2012)?" LPN #1 revealed to remember providing assistance to (resident), who "began to go down and LPN #1 caught (resident) and put (resident) in the wheelchair." The SDC confirmed this was the only information provided or revealed by LPN #1. Interview with LPN #1, in the presence of the Administrator, on June 27, 2012, at 5:45 p.m., in the conference room, confirmed LPN #1 intentionally gave false and misleading information during the facility's investigation of the resident's left femoral fracture. LPN #1 confirmed the resident did have an unwitnessed fall on June 22, 2012, and at approximately 6:20 p.m., CNA #1 notified LPN #1 the resident was on the floor in the bathroom. LPN #1 and CNA #1 went to the resident's room to assist the resident up from the floor. LPN #1 confirmed the resident was sitting on the buttocks, with the knees bent upward. As the resident was assisted up, the resident complained of pain in the right foot, and LPN #1 heard the resident's left leg pop. When the surveyor asked if pain medication had been administered or if the Physician was notified, LPN #1 confirmed, "No...I didn't give any pain medication...No, I didn't call the Doctor...I know better...I knew better then...I knew what to do, I just didn't do it..." Continued interview confirmed the Physician was not notified of the resident's fall, complaint of pain, or of the left leg popping. LPN #1 confirmed when the SDC called (LPN #1) on June 26, 2012, and asked about the resident's left femoral fracture, "I intentionally deceived (SDC); I lied to (SDC) and (Administrator)...The written statement I gave to (Administrator) was false...I knew it was untruthful...I did not call the Physician and did not follow the facility's policies and procedures...I knew what to do...the resident was in the floor and I didn't do what I was supposed to do...I failed to follow the protocol and it's the patient that suffered." Interview with CNA #1, on June 27, 2012, at 8:30 p.m., via telephone, confirmed the resident fell on [DATE], after supper (unsure of exact time). CNA #1 went into the resident's room and heard a noise coming from the bathroom. Upon entering the bathroom, CNA #1 confirmed the resident was sitting on the bathroom floor, with the right leg extended outward and the left leg bent up under (resident's) bottom (buttocks). CNA #1 went and got LPN #1 and they went back into the resident's bathroom, got the resident up and into a wheelchair, then put the resident to bed. CNA #1 confirmed the resident verbalized complaints of knee pain, but the resident did not identify which knee was hurting. Continued interview with CNA #1 confirmed LPN #1 did not assess the resident, "Once the resident was in bed, we (CNA #1 and LPN #1) left (resident's) room together." Interview with the resident's attending Physician (Medical Director) on June 27, 2012, at 7:35 p.m., in the conference room confirmed, on June 23, 2012, the resident told the Physician, (resident) had fallen (did not state when). The Physician evaluated the resident, saw no [MEDICAL CONDITION] or discoloration; the resident complained of back and bilateral (both) leg pain. The Physician confirmed the resident had chronic pain secondary to generalized Arthritis. Upon the resident reporting the fall, the Physician confirmed to review the resident's chart and there was no documentation of a fall. Continued interview confirmed the Physician was not notified of any fall occurring recently, or on June 22, 2012. The Physician confirmed, "I expect to be notified of all falls...If I had gotten this information on the fall, I would have focused my examination on the (resident's) leg." The Physician confirmed the nurse's failure to follow facility policies and failure to provide pain management for resident #1 resulted in a delay of treatment and complaints of pain without treatment. Interview with the Administrator on June 27, 2012, at 9:00 p.m., and July 10, 2012, at 6:00 p.m., in the conference room, confirmed LPN #1 failed to follow facility policies, failed to report the resident's fall on June 22, 2012, failed to provide accurate information (both verbally and written) during a facility investigation to determine the cause of a resident with a fractured left femur, failed to provide the necessary services to prevent a three-day delay in treatment for [REDACTED]. Continued interview confirmed LPN #1 was suspended on June 27, 2012, and remained on suspension until terminated on July 3, 2012. Continued interview confirmed the facility's failure resulted in neglect of resident #1. C/O # .