Every finding on record at Springs at Monarch Landing, The

Based on observation, interview, and record review, the facility failed to supervise a high-risk fall resident (R1) and provide a safe environment to a dependent resident (R2) when rendering care.These failures resulted in R1 having an unwitnessed fall and sustaining a laceration to her right posterior scalp requiring sutures, and in R2 having a witnessed fall and sustaining a fracture to her left ninth rib. This applies to 2 out of 3 (R1 and R2) reviewed for falls.The findings include:1. The EMR (Electronic Medical Record) said R1 had multiple diagnoses, including a history of falls, dementia with anxiety disorder, muscle weakness, osteoporosis, and osteoarthritis. R1's MDS (Minimum Data Set) dated 4/21/2026, said she had moderate cognitive impairment and had limited memory recall. The MDS also said R1 required supervision and touch assistance from staff when transferring and ambulating with her rolling walker. R1's EMR also said she was at risk for falls and required staff supervision.On 6/09/2026 at 9:40 AM, R1 was sitting in her personal transport wheelchair in the dining room, eating breakfast. R1 said she was unable to recall the details regarding her fall on 5/26/2026 but believes she stood up and fell in the dining room. R1 said she was transferred to the hospital and required four sutures to the back of her scalp. R1's right posterior scalp laceration was dry and scabbed over. R1 continued to say that she was able to ambulate with her rolling walker, and staff assisted her with her mobility. R1 then displayed anxiety when she overheard the phone in her room ringing, and V8 (Certified Nurse Assistant/CNA) proceeded to approach her to provide her with reassurance. Then V4 (Registered Nurse/RN) also approached R1 and wheeled her to her room. On 6/09/2026 at 9:50 AM, V8 (CNA) said R1 had a history of falls and her fall interventions included having her meals in the dining for supervision, participating in activities, and being monitored in the common areas. V8 said R1's memory was impaired and she would frequently try to stand without assistance, requiring frequent monitoring and redirection to ensure her safety. On 6/09/2026 at 10 AM, V4 (RN) said R1 tended to try to stand and ambulate with and without her rolling walker. V4 said R1 was considered a high-fall risk and staff were to monitor her when in the common areas, including when in the dining room for meals. V4 said R1 was able to ambulate with a rolling walker but required contact guard assistance with the use of a gait belt to ensure her safety. R1's unwitnessed fall incident report dated 5/26/2026 said that at 5:40 PM, R1 was observed on the floor in the dining room on her left lateral side. R1 was unable to provide details regarding her fall and sustained a laceration to the right posterior area of her head. R1 had to be transferred to the hospital for emergency treatment for her injury.R1's progress note dated 5/27/2026 said R1 returned from the hospital's ER (emergency room) after receiving medical treatment for her laceration. The note said the Laceration noted to the right posterior parietal side measured 4 cm x 2 cm. 4 sutures noted.On 6/09/2026 at 1:15 PM, V9 (CNA) said she was assigned to R1 on 5/26/2026 and was familiar with her safety interventions, including requiring supervision during meals. V9 said that she left the dining room to assist another resident with care in their room. V9 said she did not notify V10 (CNA), who remained in the dining room assisting and supervising the other residents. V9 said she then heard a loud noise from the dining room, and when she returned, R1 was on the floor next to her walker. V9 continued to say R1's fall could have been prevented if she had been supervised. V9 said she failed to communicate with V10, to inform her to continue to monitor R1 and the other residents in the dining room.On 6/09/2026 at 1:20 PM, V10 (CNA) said she was also aware of R1's high-risk for falls and the need to be supervised. V10 said that on 5/26/2026, during the meal service, she was unaware that V9 (CNA) had left the area. V10 said she had also left the dining room to assist another resident in their room. V10 said when she returned, R1 was on the floor. V10 continued to say that if she had been informed by V9 that she was leaving, she would have stayed in the dining room to ensure the residents were being monitored appropriately. On 6/09/2026 at 12:30 PM, V7 (RN) said she was R1's assigned nurse on 5/26/2026, and when V9 and V10 called her in the dining room, they informed R1 had an unwitnessed fall. V7 said R1 was identified and known to V9 and V10 as a high fall risk due to her cognitive impairment and poor safety awareness. V7 said she immediately educated both V9 and V10 regarding providing proper continuous supervision during the meal service to ensure the safety of all residents. R1's care plan said she was at risk for falls and included multiple interventions, including Identify resident-specific interventions to aid in the prevention of falls and communicate interventions.On 6/09/2026 at 1:35 PM, V3 (Nursing Supervisor) said she responded to R1's unwitnessed fall incident on 5/26/2026 and initiated an investigation to identify the root cause of the incident. V3 said she interviewed the staff and R1, and concluded that R1 stood up and lost her balance after both V9 and V10 (CNAs) left the dining area unsupervised. V3 said staff were expected to remain in the dining room until the last resident was assisted to ensure the safety of all residents. V9's (CNA) communication action documents dated 5/27/2026 said that On 5/26/2026, the employee failed to properly communicate to the other staff that she was going to leave the Dining room to take another resident from the dining room to her room. The documents also noted that if a resident requires supervision during meals in the dining room, staff must inform another staff member before stepping away to assist or toilet another resident, ensuring continued supervision in the dining area.On 6/09/2026 at 2:40 PM, V12 (Medical Physician) said she was R1's medical provider and aware of her high-fall risk due to her multiple risk factors. V12 said she expects the facility staff to follow their fall policy and R1's plan of care to ensure she is being monitored safely. 2. The EMR showed R2 had multiple diagnoses, including a history of stroke with left side hemiplegia, kyphosis, osteoarthritis, general muscle weakness, abnormal gait, impaired mobility, and left upper extremity contracture. R2's MDS dated [DATE], said she was cognitively intact. The MDS also said R2 required partial to moderate assistance with transfers and was dependent on staff for her showering needs. R2's EMR also said she was at risk for falls due to her comorbidities.On 6/09/2026 at 10:15 AM, R2 was in her room, sitting in her wheelchair. R2's left arm and hand were severely contracted both were in a fixed position. R2 had yellowish bruising to her left lateral forearm. R2 said the bruising was from her fall on 5/23/2026 when V11 (Certified Nurse Assistant/CNA) was assisting her to bed after her shower. R2 said she was transferred to the hospital and had sustained a fracture on her left ninth rib. R2 proceeded to raise the left side of her shirt and had scattered purple bruising and a white dermal-pain patch over her lateral rib area. R2 said she required staff assistance with her stand-pivot transfers due to her left side weakness. R2 continued to say that on the evening of 5/23/2026, after her shower, V11 dried her in the bathroom located in her room and applied a hospital gown, then proceeded to wheel her next to her bed to transfer her into bed. R2 said she did not believe V11 was attempting to further dry her back but rather placing her hands around her trunk area to transfer her, and when she stood up barefoot, her left foot slid, and she fell. R2 said V11 was unable to brace her fall because she did not use a gait belt. R2's witnessed fall incident report dated 5/23/2026 said that at 7:10 PM, R2 was observed on the floor next to her bed with V11 (CNA) beside her. R2 reported, My foot got stuck on the carpet. R2's progress note dated 5/24/2026 at 1:40 AM said R2 was being monitored after her fall incident and now reporting increased pain 9/10 to left forearm and left rib cage. R2's physician was updated and ordered R2 to be transferred to the hospital for further evaluation.R2's progress note dated 5/24/2026 at 8:36 AM said R2 returned from the hospital and was diagnosed with a closed fracture of the left rib. The note also said R2 was further assessed and had approximately 2.3 cm x 8.5 cm bruise/discoloration noted under her left breast, and approximately 3.1 cm x 13.3 cm discoloration noted to the left rib cage area.On 6/09/2026 at 12:40 PM, V11 (CNA) said she had showered R2 on 5/23/2026, and afterwards had wheeled and positioned her next to her bed. V11 said she intended to continue to dry R2's back prior to proceeding with her transfer to bed. V11 confirmed R2 was barefoot, and a gait belt was not applied during the task. V11 said she was not ready to transfer R2, and when R2 leaned forward, she started to slide off the shower chair and fell on her left side. V11 said she believed her cueing was off when rendering care to R2, and the fall could have been prevented if she had communicated clearly with R2 regarding the task. R2's care plan said she was at risk for falls and included multiple interventions, including evaluate Resident's environment to identify factors known to increase risk for falls and assist with ambulation and transfers, utilizing therapy recommendations.On 6/09/2026 at 1:35 PM, V3 (Nursing Supervisor) said she responded to R2's fall incident. V3 said when she arrived at R2's room, she was on the floor next to her bed, barefoot and wearing a gown. V3 said R2 did not have a gait belt in place. V3 said R2 reported she fell from the shower chair, and V11 originally also reported that R2 fell during the transfer. V3 said she initiated an investigation to identify the root cause of the incident and reinterviewed V11 because it was unclear if R2 slid off the shower chair when leaning forward as later reported by V11. V3 continued to say that V11 was expected to prioritize the safety of R2 when rendering her care, including during bath care and transfers. V3 said she further educated V11 after the incident about ensuring non-skid socks and a gait belt were applied prior to transferring a resident, and to clearly communicate with the resident when rendering care. V11's (CNA) communication action documents dated 5/26/2026 said that On 5/23/2026, the staff had performed transfer without a gait belt and failed to clearly communicate the task with the resident to avoid miscommunication. The documents also noted that staff were to use a gait belt at all times when transferring residents who required one or two person assistance.On 6/09/2026 at 2:40 PM, V12 (Medical Physician) said R2 was at risk for falls due to her medical conditions and required staff assistance with her care. V12 said she expected the facility staff to provide a safe environment when rendering care and transferring residents as per the facility's policy to ensure the safety of residents.The facility's Falls and Fall Risk Managing undated policy said that based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent a resident from falling and try to minimize complications from falling. Fall risk factors would be evaluated, which included cognitive impairment, gait and balance disorders, lower extremity weakness, and unsafe or absent footwear. The facility would systematically evaluate and implement Resident-Centered interventions for the management of fall risks and falls. The facility expects staff to identify, implement, and prioritize relevant interventions to try to minimize the serious consequences of falling.

Based on observation, interview and record review, the facility failed to sanitize pots and pans per facility policy. This applies to all 81 residents receiving oral diets in the facility. The findings include: Long term Care Facility Application for Medicare and Medicaid, dated July 28, 2024, shows the facility census was 82. Diet Type Report dated July 28,2024, shows one resident did not receive an oral diet at the facility. On July 28, 2024, at 10:18 AM with V6 (Food Service Manager), the dish machine sanitizer temperature was measured using a 180 degree F (Fahrenheit) test strip. The test strip instructions showed the black indicator line on the test strip was to turn completely orange when 180 degrees F was reached during the sanitizing cycle of the dish machine. After running through a full cycle of the dish machine, the test strip indicator line remained gray. During the sanitizing cycle, the dish machine water temperature (as indicated by the dish machine thermometer) did not elevate above 174 degrees F. Instructions posted on the dish machine showed the minimum water temperature for the final rinse sanitizing water was 180 degrees F. V6 stated the local health department recommended the 180 degree F strips were utilized to check the sanitizing temperature of the dish machine. July Dish Washer Temperature Log, dated July 2024, shows none of the Dishwasher Temperature strips turned completely orange to indicate the dish machine reached the desired temperature of 180 degrees F. On July 29, 2024, at 11:15 AM, the facility's July dish machine sanitizing water temperature test strip results showed none of the test strips turned completely orange indicating the sanitizing water temperature reached 180 degrees F. V6 stated on July 28, 2024, facility maintenance identified that the switch on the booster heater was turned off. V6 stated the booster heater switch was turned on which provided sanitizing water at 180 degrees F to the final rinse of the dish machine. Facility Dishwashing Machine Use Policy/Procedure, reviewed July 30, 2024, shows, 2. Dishwashing machines may use hot water to sanitize must maintain the following: .b. 180 degrees F for a final rinse cycle (160 degrees F at the rack level/dish level surface reflects a 180 degree F temperature at the manifold, which is the area just before the final rinse nozzle where the temperature of the dish machine is measured 4. A supervisor or designee will check the machine for proper temperature and report inadequate temperatures for immediate correction. a. A secondary thermometer or temperature gauge will be run through machine to compare temperature to gauge on machine daily. b. If hot water temperatures do not meet requirements, cease use of dishwashing machine immediately until temperatures are adjusted. Dish machine test strips instructions showed, 1. Attach the test strip to a utensil or rack by wrapping around and slipping the color bar through the slit . Wash the item. 2. If the color bar has turned bright orange, the dishwasher is maintaining the proper temperature. 3. When finished with the test, sign, date and place the strip in dishwasher temperature log.

Based on observation, interview and record review, the facility failed to label medications with the date when opened and failed to remove discontinued eye medication from the medication cart. This applies to 4 of 4 residents (R5, R10, R21, R63) reviewed for medication storage in the sample of 18. The findings include: On July 29, 2024, between 2:32 PM to 4:30 PM, the medication cart inspections were conducted with V3 (Registered Nurse/RN) and V4 (License Practical Nurse/LPN). The following was observed: 1. R63's Insulin Lispro Kwik Pen was opened and not dated. The Pharmacy's undated Insulin Storage Recommendation Beyond Use Date procedure showed to discard the insulin pen 28 days after opened. 2. R10's Humulin Lantus Solostar Injectable 100 ml (milliliters). was opened and not dated. The Pharmacy's undated Insulin Storage Recommendation Beyond Use Date procedure, showed to discard the insulin pen 28 days after opened. 3. R5's Netarsudil and Latanoprost 0.2%/0.005% eye drops were opened and not dated, with instructions to keep refrigerated. The Pharmacy's undated Recommendation for Eye Drop Storage procedure, showed that the eye drops can be stored up to 6 weeks after opened. 4. R21 Moxifloxacin 0.5% eye drops were opened and not dated. R21's Medication Administration Record (MAR) showed that this medication had been discontinued on July 9, 2024. On July 30, 2024 at 1:14 PM, V2 (Director of Nursing/DON) stated that staff must date the insulin, and the eye drops, when opened, to identify the expiration date of the medications. The facility's undated Medication Labeling and Storage Policy and Procedure showed Medication Storage: 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview and record review, the facility failed to ensure a residents urinary catheter tubing was kept off the floor for one resident (R26) reviewed for infection control with urinary catheter in the sample of 18. Findings include: On July 30, 2024, at 10:15 AM, R26 was in her bedroom, sitting in her wheelchair. R26's urinary catheter tube and bag were underneath her wheelchair. While R26 was talking to the surveyor, R26 kept moving her wheelchair back and forth while her indwelling urinary catheter tube was dragging on the floor. On July 30, 2024, at 1:26 PM, V2 (Director of Nursing/DON) stated the catheter tube shouldn't touch the floor to prevent potential infection. The facility's Urinary Catheter Care Policy and Procedure showed: Infection Control: 2. Maintain a clean technique when handling or manipulating the catheter tubing, or drainage bag. b. Be sure the catheter tubing and drainage bag are kept off the floor. 8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of care. This applies to 1 of 4 residents (R28) reviewed for infection control in the sample of 18. Findings include: 1. On July 29, 2024, at 4:55 PM, V5 (Certified Nursing Assistant/CNA) provided incontinence care to R28, who was wet with urine. V5 wiped/cleaned R28's perineum from front to back, placed a new incontinence brief, pulled his pants back in place, repositioned R28, placed the motorized wheelchair at bedside and assisted R28 to transfer from bed to wheelchair, while wearing the same soiled gloves all throughout the different tasks. On July 30, 2024, at 1:26 PM, V2 (Director of Director/DON) stated during provisions of incontinence care, staff must perform hand hygiene and change gloves before and after, and in between tasks to prevent cross contamination and spread of infection. The facility's undated Handwashing/Hand Hygiene policy and Procedure, showed: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: f. Before moving from a contaminated body site to a clean body site during resident care. g. After contact with a resident's intact skin. h. After contact with blood and body fluids. 1. After handling used dressings, contaminated equipment, etc. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment.

Based on observation, interview and record review, the facility failed to ensure residents were assessed for the ability to self administer medications. This failure affects two of residents (R54, R333) reviewed for medication use on the sample list of 30. Findings include: 1. R54's Admission Record shows R54 was admitted on [DATE] with diagnoses including gout, right shoulder and left knee pain, and obsessive-compulsive disorder. R54's 12/03/2022 cognitive function care plan showed she has impaired cognitive function related to a diagnosis of dementia, and her [Minimum Data Set] (MDS) scoring does not reflect cognitive fluctuations and forgetfulness that is observed by staff. On 08/22/2023 at 10:29 AM, R54 had an unlabeled tube of topical menthol pain reliever gel and an antifungal powder container on her nightstand on the right side of her bed. On 8/22/2023 at 10:30 AM, R54 said she regularly bought the menthol gel from an online retailer. R54 said she ordered the medication so she can always have and use it when she wanted to. R54 said she uses the gel on any part of her body that is hurting and she cannot remember how many times a day she uses it. R54 said she uses the antifungal powder on her groin after going to the bathroom. On 08/24/2023 at 09:55 AM, V2 (DON-Director of Nursing) said it is the facility's policy that nurses will administer medications. V2 stated there are concerns if medications are kept at the bedside without an assessment and physician orders, including a risk for the patient to self-administer medications outside of parameters of the orders, causing over- or under-dosing. On 8/24/2023 at 10:30 AM, R54's August 2023 POS (Physician Order Sheet) showed an order for the menthol gel to be applied to the right shoulder, left knee and scapula, three times a day as needed, for pain. R54's August 2023 POS also showed R54's order for the antifungal powder was discontinued on 08/20/2023. R54's POS showed no orders to keep either medication at the bedside. 2. R333's Face Sheet showed his diagnoses include chronic obstructive pulmonary disease and muscle weakness. R333's 8/13/23 Minimum Data Set (MDS) showed he is cognitively intact. On 08/22/23 at 12:24 PM, an albuterol metered-dose inhaler was on R333's desk. The inhaler was visible from the doorway. R333 stated the inhaler was left by the nursing staff and was for his use. The next day at 9:15 AM, R333's inhaler was again seen on his desk. On 08/23/23 at 09:18 AM, V4 RN (Registered Nurse) stated as far as he knew, R333 was not assessed for keeping medications at the bedside, he did not have orders to keep medications there, and R333 did not have orders to self-administer his own medications. On 08/24/23 at 09:57 AM, V2 DON (Director of Nursing) stated if residents do not have a physicians order to keep medication at the bedside, then medication should be stored in the medication cart and the nurse should be the only person to administer medication.

Based on observation, interview and record review, the facility failed to ensure residents' medications were secured and labeled. This applies to 2 residents of 20 residents (R54, R333) reviewed for medication storage on the sample list of 30. Findings include: 46380 1. R54's Admission Record shows R54 was admitted on [DATE] and her diagnoses include gout, right shoulder and left knee pain, and obsessive-compulsive disorder. R54's 12/03/2022 cognitive function care plan showed she has impaired cognitive function related to a diagnosis of dementia, and her [Minimum Data Set] (MDS) scoring does not reflect cognitive fluctuations and forgetfulness that is observed by staff. On 08/22/2023 at 10:29 AM, R54 had an unlabeled tube of topical menthol pain reliever gel and an antifungal powder container on her nightstand on the right side of her bed. On 8/22/2023 at 10:30 AM, R54 said she regularly bought the menthol gel from an online retailer. R54 said she ordered the medication so she can always have and use it when she wanted to. R54 said she uses the gel on any part of her body that is hurting and she cannot remember how many times a day she uses it. R54 said she uses the antifungal powder on her groin after going to the bathroom. On 08/24/2023 at 09:55 AM, V2 (DON-Director of Nursing) said all medications are kept in the medication carts or the medication room. V2 said all medications should be labeled and the facility does not allow medication from outside sources. V2 said if unlabeled medications were found, they are returned to the family and the facility will obtain physician orders and obtain the medication from facility's pharmacy. On 8/24/2023 at 10:30 AM, R54's August 2023 POS (Physician Order Sheet) showed an order for the menthol gel to be applied to the right shoulder, left knee and scapula, three times a day as needed, for pain. R54's August 2023 POS also showed R54's order for the antifungal powder was discontinued on 08/20/2023. R54's POS showed no orders to keep either medication at the bedside. Facility's November 2020 policy on Storage of Medications showed Policy heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . Facility's 1/29/2020 Policy on Labeling of Medication Containers showed .2. Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. For inadequately or improperly labeled medications from home or outside pharmacy, medication will be returned to patient representative or back to patient at time of discharge . 4. Labels for over-the-counter drugs include all necessary information, such as: a. The original label indicating the name, strength, and quantity of the medication; b. The expiration date when aplicable; c. Directions for use and appropriate accessory/cautionary statements 2. 1. R333's Face Sheet showed his diagnoses include chronic obstructive pulmonary disease and muscle weakness. R333's 8/13/23 Minimum Data Set (MDS) showed he is cognitively intact. On 08/22/23 at 12:24 PM, an albuterol metered-dose inhaler was on R333's desk. The inhaler was visible from the doorway. R333 stated the inhaler was left by the nursing staff and was for his use. The next day (8/23/23) at 9:15 AM, R333's inhaler was again seen on his desk. On 08/23/23 at 09:18 AM, V4 RN (Registered Nurse) stated as far as he knew, R333 was not assessed for keeping medications at the bedside, he did not have orders to keep medications there. On 08/24/23 at 09:57 AM, V2 DON (Director of Nursing) stated if residents do not have a physicians order to keep medication at the bedside, then medication should be stored in the medication cart.

Based on interview and record review, the facility failed to ensure a resident receiving a transdermal medication patch, only had one medication patch in place during transdermal medication administration. This failure affects one of three residents (R1) reviewed for transdermal medication use on the sample list of six. Findings include: R1's face sheet (8/1/23) documents R1's diagnoses including Parkinson's Disease, Dementia, Anxiety Disorder, and Adult Failure to Thrive. R1's current Physician Order Sheet (POS) documents R1's orders including Exelon (Rivastigmine) (reversible cholinesterase inhibitor) transdermal patch 24-hour 4.6 milligram (mg), apply one patch transdermal at a time related to Dementia. On 8/1/23 at 10:58 AM, V5 (R1's husband) was wheeling R1 back to her room. V5 stated he had concerns with R1's Exelon transdermal patch. V5 stated on 7/2/23 and 7/26/23, R1 had two of the Exelon transdermal patches on her. V5 stated R1 is supposed to have only one patch on her at a time. On 8/1/23 at 3:36 PM, V11 (LPN- Licensed Practical Nurse) stated on 7/2/23, V11 took an Exelon transdermal patch off R1's back before applying a new patch on the other side of R1's back. V11 stated later that day, V5, R1's husband showed V11 that R1 had another patch on R1's arm and R1 had two patches on R1's body. V11 stated she did not see the second patch prior to V5 showing her the patch on R1's arm. V11 stated it did not occur to her to check if R1 had more patches on R1. On 8/1/23 at 4:02 PM, V12 (Agency LPN) stated on 7/26/23, V12 took an Exelon transdermal patch off R1 prior to applying a new patch. V12 stated V12 placed the new patch on R1's right chest. V12 stated V4, R1's daughter showed V12 that R1 had another patch to R1's right back, later after V12 had already removed a patch prior to placing a new patch. R1 had two Exelon transdermal patches on at the same time. On 8/2/23 at 9:37 AM, V2 (DON-Director of Nursing) stated R1 had two Exelon transdermal patches on her on two separate days: on 7/2/23 and 7/26/23. V2 stated R1's family informed V11 and V12 of the multiple patches. V2 also stated there should only be one Exelon patch on R1 per physician order because it can lead to adverse effects of the medication. On 8/2/23 at 9:13 AM, V13 (Pharmacist) stated R1 should have one patch on at a time. V13 stated the downside to having two patches on is that there could be augmentation of the adverse effects of the medication; some of the adverse effects includes increased tremors, increased sedation, upset stomach, diarrhea, feeling dizzy, sleepy and headache. The facility's Transdermal drug delivery system (patch) application (undated) states to remove old patch from body and apply new patch firmly against the skin.

Based on interview and record review the facility failed to administer an opioid medication to the correct resident. This applies to 1 of 1 resident (R1) reviewed for medications in a sample of 8. Finding include: On 2/22/23 at 3:42 pm V1 (Director of Nursing/DON) stated R1 was given a controlled medication in error by V8 (Registered Nurse/RN) back in June of 2022. On 2/22/23 at 3:20 pm, V8 (RN) stated she gave R1 the wrong pain medication. V8 stated R1 became nauseated and anxious after she was notified of the error. V8 stated the Nurse Practitioner ordered Narcan as a precaution. On 6/20/22 at 4:46 pm, Nurse practitioner progress note documents notification by staff that resident received Hydromorphone 2mg in error at 2 pm. Narcan 4 MG given to reverse the effects of narcotic. R1 to have increased vital sign monitoring for 24 hours. On 6/20/22, an order was entered into R1's EMR (Electronic Medical Record) for Narcan 4MG/0.1ML for narcotic administration was completed. Facility Administration Procedure for All Medications policy, dated July 2018, states to administer medications in a safe and effective manner review the 5 rights (right patient, right medication, right dose, right route, right time) 3 times. Check the Medication Administration Record/Treatment Administration Record for order. Identify resident using two identification methods before administering medication.

Based on observation, interview, and record review the facility failed to ensure residents were served menu items from the dietitian approved spreadsheet to meet the resident's nutritional needs. This applies to all 74 residents residing in the facility. The findings include: The Resident Census and Condition Report (Federal Form 672) shows that on 9/6/22, the facility housed 74 residents. The Spreadsheet for Tuesday's lunch includes tilapia, bowtie pasta, kale salad and pear halves for the resident's on a general diet. The Spreadsheet shows pureed tilapia, bowtie pasta, green beans and pears for the resident's on a pureed diet. On 9/6/22 at 10:31 AM, V6 (Cook) pureed the noon meal. V6 pureed fish and green beans. On 9/6/22 at 12:20 PM, V8 (Cook) did not have bowtie pasta on the steam table to be served. V8 served R4, R7, R15, R25 and R62 the prepared pureed meal. V8 stated, They are getting fish, mashed potatoes and peas. R4, R7, R15, R25 and R62 did not receive pureed pears or any dessert substitute. On 9/07/22 at 2:15 PM, V6 said that the spreadsheet showed that the residents were supposed to get bowtie pasta with the noon meal on 9/6/22 but the menu that was printed for the residents didn't include it. V6 said that she just went off of the menu and not the spreadsheet when she prepared the meal so no bowtie pasta was prepared. V6 said that the pureed desserts are usually done by the cooks on the unit. V6 said that she does not know why it was not done yesterday but the resident's on a pureed diet should have received a dessert. On 9/7/22 at 2:27 PM, V1 (Administrator) said that Diet Spreadsheets are reviewed by the dietician. V1 said that the spreadsheets should be followed to ensure that the residents receive the appropriate amount of nutrition daily. V1 said that the noodles were not transcribed over to the menu but the staff should have followed the spreadsheet. V1 said that dessert should have been pureed by the kitchen and served to the residents on a pureed diet. The facility's Menus Policy dated 4/3/19 shows, Menus will be planned that meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board Menus will provide a variety of foods from the basic daily food groups.

Based on observation, interview, and record review the facility failed to ensure food was stored and served in a sanitary manner, dishes were cleaned under sanitary conditions, and food temperatures were taken to prevent foodborne illnesses for all 74 residents residing in the facility. The findings include: The Resident Census and Condition Report (Federal Form 672) shows that on 9/6/22, the facility housed 74 residents. 1. On 9/6/22 at 10:15 AM, there were multiple opened food items in the dry storage area that were not dated with the date opened. These food items include: baking powder, lime gelatin, marshmallows, noodles, strawberry gelatin, brown sugar, 2 bags of pecans and sunflower kernels. A bag of pecans and a box of sunflower kernels were not sealed closed. There was a bag of white chocolate chips that were dated, Use by 2/22. On 9/6/22 at 10:15 AM, V1 (Administrator) said that all food should be labeled with the open date once it is opened. V2 said that it is important to know since different types of foods are only good for a certain amount of time after opening. The facility's undated Dining and Nutrition packet shows, When a product comes in, it needs to be labeled with the following: item name, day it was made or opened, shelf life of the product ., use by date, and employees name (Person that made the item or opened it). 2. On 9/6/22 at 10:44 AM, V9 (Dietary Aide) was hand washing pots and pans before putting them into the dishwasher. With the same gloves on, V9 went to the clean side of the dishwasher, wiped her gloves off with a hand towel and proceeded to put away clean pots and pans. On 9/6/22 at 1:30 PM, V1 (Administrator) said that staff should perform hand hygiene before touching clean dishes when they are using the dishwasher. The facility's Dishwashing Machine Use Policy dated 4/3/19 shows, Wash hands before and after running the dishwashing machine and during the process. The facility's Dining and Nutrition booklet shows, When putting away clean dishes, wash hands, put on gloves, then put them away. 3. On 9/6/22 at 12:07 PM, V7 (Cook) was serving the noon meal on the 2nd floor. V7 had a beard with no beard restraint on. At 12:20 PM, V8 (Cook) was serving the noon meal on the 3rd floor. V8 had a beard with no beard restraint on. On 9/7/22 at 2:15 PM, V6 (Cook) said that hairnets should be worn at all times. V6 said that if a staff member has a beard, they should wear a beard net at all times to ensure that hair does not get into the food. The facility's Preventing Foodborne Illness-Employee Hygiene and Sanitary Practice Policy dated 4/3/19 shows, Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. 4. The facility's 2nd floor Steam Table Temperature Logbook shows that food temperatures were not taken on 9/2/22 for the lunch and dinner meal, 9/3 for the lunch meal and 9/5 for lunch and dinner meal. The log book did not have a sheet for 9/4/22. The facility's Dining and Nutrition Booklet shows, Temperature control of food is important to prevent foodborne illnesses. All hot food in the warming pantries must be above 140 degrees Fahrenheit Food Temperature Logs will be kept in every warming pantry and country kitchen in a binder. You will record what food you are testing, the time and the temperature.

Based on observation, interview, and record review the facility failed to socially distance residents who are on droplet isolation while in the dining room. This applies to two residents (R19, R21) outside the sample reviewed for infection control. This has the potential to affect all 74 residents in the facility. The findings include: The facility face sheet for R19 shows diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility face sheet for R21 shows diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessment dated [DATE] shows her to be cognitively intact. On 9/6/2022 at the noon meal, R19 was observed sitting next to another resident at a table in the dining room. The two residents were not sitting six feet away from each other. On 9/7/2022 during breakfast, R21 was observed sitting at the same dining room table across from another resident. The residents were not sitting six feet from each other. On 9/7/2022 at the noon meal, R19 and R21 were observed sitting at a dining room table with one other resident. The residents were not sitting six feet away from each other. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/06/22 at 11:40 AM, V3 Infection Preventionist said, currently due to an outbreak, all residents not up to date are on isolation for 10 days starting on 9/3. For the resident who can not maintain isolation due to safety reasons, they should be 6 ft apart from anyone at all times and mask as much as possible/tolerable. If seen next to a resident, staff should re-direct from other residents. Try and have them eat in room but if they can not for safety reasons, I would prefer them to eat in the living room socially distanced from others and not in the dining room. The facility list of residents currently on isolation include R19 and R21 for not being up to date on COVID-19 vaccinations. The facility care plan for R19 shows risk for exposure to COVID-19 and to maintain social distancing, including dining and recreation services. The intervention for not complying with droplet precautions shows she may come out of her room during meals while observing social isolation. The facility care plan for R21 shows risk for exposure to COVID-19 and to maintain social distancing, including dining and recreation services. The intervention for inability to comply with precautions due to safety reasons the resident may come out of her room for meals while observing social distancing. The facility policy with a revision date of 5/31/22 shows residents who are not up to date with COVID-19 vaccinations are restricted to their rooms, even if testing is negative .they do not participate in group activities.

Based on observation, interview, and record review, the facility failed to treat a resident in a dignified manner by ensuring a resident's urinary drainage bag was covered while in common areas for one of three residents (R15) reviewed for catheters in the sample of 18. The findings include: On 09/06/22 at 10:29 AM, R15 was in her high back wheelchair in a common area during an exercise activity. R15's urinary drainage bag was visible and hanging to right of resident on the chair. The catheter tubing came down through R15's right pant leg. At 12:30 PM, R15 was in the high back chair seated at a dining room table. The dining room was full of residents. R15's urinary drainage bag remained visible and attached to her chair. On 09/08/22 at 08:37 AM, V10 MDS (Minimum Data Set) Coordinator said the purpose of a privacy bag is for dignity. It's meant to preserve the patient's privacy. Everyone doesn't need to know that R15 has an indwelling urinary catheter. Resident's with catheters should have a privacy bag even if they are in their room. R15's 9/7/22 face sheet showed a [AGE] year old female with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's undated indwelling catheter care plan showed to use a privacy bag at all times. R15's 6/30/22 facility assessment showed total dependence of two plus persons for transfers, toilet use, and bathing. This assessment showed R15 required extensive assistance of two plus persons for bed mobility, and extensive assistance of one plus person for dressing and personal hygiene. The Illinois Department on Aging's Resident Rights for people in long term care facilities showed your medical and personal care are private. The facility's 9/29/19 Dignity Policy showed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to administer the complete amount of intravenous antibiotic, and omitted a physician-ordered medication. There were 30 opportunities with 2 errors, resulting in a 6.67% medication error rate. This applies to R36 and R53, who were reviewed for medication errors. The findings include: 1. R36's Face Sheet showed she has a [DIAGNOSES REDACTED]. The printed pharmacy label on R36's bag of IV antibiotics showed there were 50 milliliters (ml) in the bag and to infuse it over thirty minutes. On April 7, 2021 at 1:20 PM, V4 RN (Registered Nurse) prepared R36's IV antibiotic for administration. V4 hung the bag of antibiotics on R36's IV pole and spiked the bag with IV tubing to prime it. V4 quickly ran the medication through the tubing to the point that some of R36's medication ran into the trash can. As V4 began to attach the tubing to R36's IV port, R36 commented that there was air in the tubing. V4 ran more of R36's IV antibiotic into the trash and connected the tubing to R36's port. V4 set the antibiotic volume to be infused on R36's IV pump as 52 ml, and set it to infuse over thirty minutes. At 2:06 PM, a staff member alerted V4 to R36's IV pump's alarm. R36's bag of IV antibiotic was empty, and the pump display showed that 13 ml remained to be infused of the original 52 ml (meaning R36 received 39 ml of her dose, or 78% of it). On April 8, 2021 at 10:08 AM, V2 (RN, Director of Nursing) stated she expects the full dose of IV medications to be administered. 2. On April 7, 2021 at 9:51 AM, V7 LPN (Licensed Practical Nurse) prepared R53's medications for administration. V7 prepared six pills and a topical patch to administer to R53, then administered them. V7 returned to her medication cart and signed off R53's medications as administered. Review of R53's April 2021 Physician order [REDACTED]. The timestamp in R53's Electronic Medical Record (EMR) showed V7 signed off R53's powdered bowel medication as administered at 9:58 AM, at the same time R53's other medications were given. On April 8, 2021 at 11:11 AM, V2 (Director of Nursing) stated she expects medications to be administered as ordered. The facility's Administering Medications policy (revised January 10, 2020) showed Medications shall be administered in a safe and timely manner, and as prescribed .

Based on observation, interview, and record review, the facility failed to follow its emergency response pandemic policy and isolation-categories of transmission-based precaution policy by staff not changing disposable gown in between resident visits in COVID floor and has the potential to affect one (R4) of four residents reviewed for infection control practices in a sample of four residents. Findings include: On 10/27/20 at 12:15 PM, observed V7 (Nurse Practitioner) entering R3's room (room [ROOM NUMBER] in COVID unit) wearing personal protective equipment. At 12:21 PM, observed V7 entering R4's room (room [ROOM NUMBER] in COVID unit) without changing gown from room [ROOM NUMBER]. On 10/27/20 at 12:40 PM, V7 stated, I am covering for V6. The last time when I was here, I wore the same gown to see all patients. The facility didn't tell me they changed their policy to change gowns for each patient. That's my mistake; I apologize. On 10/27/20 at 1:10 PM, V2 (Director of Nursing) stated, Our first floor COVID unit has ten residents tested positive for COVID-19. V7 should have changed her gown in between the COVID patient visit. I will in-service her on her mistake. Facility presented policy on emergency response pandemic COVID-19 (updated on 6/10/20) document: All staff members must be familiar with Monarch Landing's Pandemic COVID-19 plan and related policies and procedures. Facility presented isolation-categories of transmission-based precaution policy reviewed on 10/2020 document: 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces.

Based on observation, interview, and record review, the facility failed to follow the facility transfer policy during a resident transfer requiring the use of a mechanical lift and two staff for assistance. This failure resulted in the resident experiencing an acute displaced femoral shaft fracture. This applies to 1 of 3 residents (R1) reviewed for injuries in a sample of 5. The findings include: Face sheet, dated 12/4/19, shows R1's [DIAGNOSES REDACTED]., major [MEDICAL CONDITIONS], coronary [MEDICAL CONDITION], panic disorder, urinary tract infection, and pain. MDS (Minimum Data Set), dated 10/14/19, shows R1's cognitive status was severely impaired, and R1 required the extensive assistance of two staff for transfers, bed mobility, toileting, and personal hygiene. ADL (Activity of Daily Living) care plan, dated 5/19/16, shows R1 had impaired mobility due to weakness and had an intervention, dated 7/23/19, that R1 was to have the extensive assistance of two staff for bed mobility/toileting and the use of a mechanical lift for transfers. Hospital physician history and physical, dated 12/1/19, show R1 was admitted to the hospital emergency room with a [DIAGNOSES REDACTED]. The record shows the facility staff noticed R1's right leg was swollen and were unsure if R1 injured herself or fell . Physician Assessment / Plan shows, Right femur fracture, unclear etiology, likely due to unwitnessed fall, injury. Initial facility report, dated 12/1/19, shows R1 sustained an injury of unknown origin. Final facility report, dated 12/4/19, shows the facility investigated R1's injury of unknown origin and, It was determined that the injury was sustained when the resident was lowered to the floor during a transfer. The resident's care summary states that the resident's transfer status is a two person assist with the use of a mechanical lift lift. The CNA (Certified Nursing Assistant) assigned to the resident's care performed the transfer individually without mechanical assistance. The facility concludes that the CNA's failure to follow the resident's care summary is the root cause of the injury. Witness statement, dated 12/4/19, shows V6 (CNA) stated she was assigned to R1 on 12/1/19 during the AM shift. V6 dressed R1 and attempted to transfer R1 from the bed to the wheelchair independently. R1 began to lose her balance and slid down V6's leg. V6 lowered R1 to the floor, and V6 placed a pillow underneath the resident's head. V6 called V7 (CNA) for assistance with R1 and together they transferred R1 from the floor to her chair. V6 and V7 brought R1 out of the room at approximately 8:00 AM in her wheelchair. V6 stated she informed the nurse she lowered R1 to the ground at that time and asked if she should fill out anything regarding R1 being lowered to the ground. V8 (LPN- Licensed Practical Nurse) stated no paperwork was required because the incident was not considered a fall. The statement shows R1 first showed signs of discomfort prior to lunch when R1's foot was placed on her footrest and R1 began to scream more than usual. R1 then ate lunch and V8 applied pain relieving cream to R1's knee after lunch. At approximately 2:00 PM, V6 and V7 transferred R1 back to bed. Witness statement, undated, shows V9 (CNA) cared for R1 on 12/1/19 during the PM shift and received R1 in bed sleeping. At 4:10 PM. V9 attempted to get R1 up from bed from dinner and when V9 lifted the blanket the resident screamed and she noted that the resident's right leg near the knee was noticeably larger than the left leg. Witness statement, undated, shows V8 (LPN) was assigned to R1 on 12/1/19 and V6 informed V8 that she lowered R1 to the foot rests of R1's wheelchair. V8 stated he applied pain relieving gel to R1's knee after lunch but did not observe swelling at that time. V8 stated he did not consider the change in R1's pain due to a fall because R1 did not land on the ground. Witness statement, undated, shows V7 stated she assisted V6 on 12/1/19 in transferring R1 at approximately 8:00 AM from the ground to the chair and after lunch from R1's chair to the bed. On 12/4/19 at 12:50 PM with V11 (ADON-Assistant Director of Nursing), V2 (Director of Nursing) stated R1's fall occurred during a transfer on 12/1/19 at approximately 7:30 AM during the AM shift when V6 began to transfer R1 by attempting to stand R1, with no assistance from another staff and no use of a mechanical device, and R1 was unable to bear weight on her legs and began sliding down to the floor. V2 stated V6 was trained and knew that R1 required two staff and a mechanical lift device for a safe transfer. V2 stated there was no gait belt on the resident at the time of the fall, per her investigation. V2 stated V6 told V2 during the initial transfer, R1 started to slide down, R1's feet crisscrossed under V6's forward leg and V6 lowered her to the floor. V6 then called V7 (CNA) into the room and, without calling the nurse to assess R1 while on the floor, they performed a two person transfer on R1 without a mechanical device and placed her into the wheelchair. V6 later asked V8 (LPN) if V6 needed to fill any paperwork out because R1 slid to the floor. V8 asked if R1 fell , and V6 told V8 no, that R1 was lowered to the floor. V8 did not consider that a fall and did not instruct V6 to do a witness statement. V2 stated V8 did not clinically assess R1 at the time of the fall and did not complete an incident report. V2 stated R1 was again transferred without the use of a mechanical device after lunch when put to bed. V2 stated her expectations of the staff were that the V6, V7 and V8 should have recognized R1 fell , V6 should have reported R1's fall immediately to V8 who should have assessed R1 for injuries, V6 and V7 should not have moved R1 when she fell , and V6 and V7 should never have transferred R1 without the use of a mechanical device and two staff assisting. V2 stated Resident Summaries are located in resident closets and staff are trained on orientation to look at the resident summaries for transfer status. On 12/16/19 at 2:45 PM, V10 (RN-Registered Nure) stated no staff endorsed R1's fall to him at change of shift on 12/1/19 when he began his PM shift. Nursing note 12/1/19 16:37, V10 (RN) wrote, 1615 CNA informed RN of right thigh swelling and RN went to room, resident in bed and noted swelling on right thigh, no bruising, no redness noted. RN noted pain 4/10 pain to right femur when touched and moved, (pain relieving) gel applied to area of pain. RN instructed CNA not to move resident due to pain while moving. 1625 RN contacted (V13 (Physician)) STAT (Urgent) X-ray of right femur ordered, processed and noted. RN informed nursing supervisor. 1630 RN informed POA (Power of Attorney) via voicemail of patient status and MD (Physician) order, requested for a callback. 1635 RN contact (X-Ray) 1645 (X-ray) technician did X-ray of right thigh 1815 (X-ray) faxed to unit right femur X-ray results and informed (V13) of right femur fracture, telephone ordered to send resident to ER On 12/16/19 at 1:50 PM V13 (Physician) stated R1 being improperly transferred and subsequently lowered to the ground could have quite possibly caused the femur fracture. Resident Summary, dated 12/5/19, shows R1 required a mechanical lift with the assistance of two staff for bed to chair and chair to bed transfers. Resident Summary and Fall inservice document, 12/2/17, shows Resident Summary - this is the sheet that is posted behind the door of every resident's closet and also in the kiosk that has the information on how to take care of a patient or resident, which includes diet, transfer any special care. The resident Summary must be read each shift. The Resident Summary must be followed and when in doubt, clarify with the nurse. Fall - Unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. If these occur, need to be reported to the nurse before assisting the resident back to the bed or chair. The nurse then will assess the patient, document and inform POA (Power of Attorney) and family Facility document Assessing Falls and Their Causes, revised (MONTH) (YEAR), shows, Steps in the Procedure After a Fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying or standing position, and then document relevant details. 5. Notify the resident's attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. B. When a fall does not result in significant injury or condition change, notify the practitioner routinely (e.g., by fax or by phone the next office day). 6. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 8. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nurse on duty at the time. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred.

Based on observation, interview, and record review, the facility failed to evaluate a resident for injuries, pain, and delayed complications following a fall. This applies to 1 of 3 residents (R1) reviewed for injuries in a sample of 5. The findings include: Face sheet, dated 12/4/19, shows R1's [DIAGNOSES REDACTED]., major [MEDICAL CONDITIONS], coronary [MEDICAL CONDITION], panic disorder, urinary tract infection, and pain. MDS (Minimum Data Set), dated 10/14/19, shows R1's cognitive status was severely impaired, and R1 required the extensive assistance of two staff for transfers, bed mobility, toileting, and personal hygiene. ADL (Activity of Daily Living) care plan, dated 5/19/16, shows R1 had impaired mobility due to weakness and had an intervention, dated 7/23/19, that R1 was to have the extensive assistance of two staff for bed mobility/toileting and the use of a mechanical lift for transfers. Witness statement, dated 12/4/19, shows V6 (CNA) stated she was assigned to R1 on 12/1/19 during the AM shift. V6 dressed R1 and attempted to transfer R1 from the bed to the wheelchair independently. R1 began to lose her balance and slide down V6's leg. V6 lowered R1 to the floor, V6 called V7 (CNA) for assistance with R1 and together they transferred R1 from the floor to her chair. V6 and V7 brought R1 out of the room at approximately 8:00 AM in her wheelchair. V6 stated she informed the nurse she lowered R1 to the ground at that time and asked if she should fill out anything regarding R1 being lowered to the ground. V8 (LPN- Licensed Practical Nurse) stated no paperwork was required because the incident was not considered a fall. The statement shows R1 first showed signs of discomfort prior to lunch when R1's foot was placed on her footrest and R1 began to scream more than usual. R1 then ate lunch and V8 applied pain relieving cream to R1's knee after lunch. At approximately 2:00 PM, V6 and V7 transferred R1 back to bed. Witness statement, undated, shows V8 (LPN) was assigned to R1 on 12/1/19 and V6 informed V8 that she lowered R1 to the foot rests of R1's wheelchair. V8 stated he assessed R1's vital signs. V8 stated he did not believe R1 fell because he did not think R1 hit the ground. V8 stated he applied pain relieving gel to R1's knee after lunch but did not observe swelling at that time. R1's clinical documentation shows blood pressure, pulse, pulse oximeter and respirations were recorded on 12/1/19 at 10:49 AM. On 12/17/19 at 11:01 AM, V2 (DON) stated she is unable to determine what time R1's vitals were taken, or by whom, on 12/1/19 as entered at 10:49 AM in the clinical record. V2 stated a CNA or a nurse may have taken the vitals for the shift, and the vitals may have been taken prior to R1's fall. Witness statement, undated, shows V9 (CNA) cared for R1 on 12/1/19 during the PM shift and received R1 in bed sleeping. At 4:10 PM. V9 attempted to get R1 up from bed from dinner and when V9 lifted the blanket the resident screamed and she noted that the resident's right leg near the knee was noticeably larger than the left leg. On 12/16/19 at 2:45 PM, V10 (RN-Registered Nurse) stated no staff endorsed R1's fall to him at change of shift on 12/1/19 when he began his PM shift. Nursing note 12/1/19 16:37, V10 (RN) wrote, 1615 CNA informed RN of right thigh swelling and RN went to room, resident in bed and noted swelling on right thigh, no bruising, no redness noted. RN noted pain 4/10 pain to right femur when touched and moved, (pain relieving) gel applied to area of pain. RN instructed CNA not to move resident due to pain while moving. 1625 RN contacted (V13 (Physician)) STAT (Urgent) X-ray of right femur ordered, processed and noted. RN informed nursing supervisor. 1630 RN informed POA (Power of Attorney) via voicemail of patient status and MD (Physician) order, requested for a callback. 1635 RN contact (X-Ray) 1645 (X-ray) technician did X-ray of right thigh 1815 (X-ray) faxed to unit right femur X-ray results and informed (V13) of right femur fracture, telephone ordered to send resident to ER On 12/4/19 at 12:50 PM with V11 (ADON-Assistant Director of Nursing), V2 (Director of Nursing) stated R1's fall occurred during a transfer on 12/1/19 at approximately 7:30 AM during the AM shift when V6 began to transfer R1 by attempting to stand R1, with no assistance from another staff and no use of a mechanical device, and R1 was unable to bear weight on her legs and began sliding down to the floor. V2 stated V6 told V2 during the initial transfer, R1 started to lower down, R1's feet crisscrossed under V6's forward leg and V6 lowered her to the floor. V6 then called V7 (CNA) into the room and, without calling the nurse to assess R1 while on the floor, they performed a two person transfer on R1 without a mechanical device and placed her into the wheelchair. V6 later asked V8 (LPN) if V6 needed to fill any paperwork out because R1 slid to the floor. V8 asked if R1 fell , and V6 told V8 no, that R1 was lowered to the floor. V8 did not consider that a fall and did not instruct V6 to do a witness statement. V2 stated V8 did not clinically assess R1 at the time of the fall and did not complete an fall incident report. V2 stated her expectations of the staff were that the V6, V7 and V8 should have recognized R1 fell , V6 and V7 should not have moved R1 when she fell , V6 should have reported R1's fall immediately to V8, and V8 should have immediately assessed R1 for injuries. On 12/16/19 at 1:50 PM V13 (Physician) stated it was his expectation that the staff would notify the nurse at the time R1 was lowered to the ground for the nurse to assess R1 prior to staff moving R1. Hospital physician history and physical, dated 12/1/19, show R1 was admitted to the hospital emergency room with a [DIAGNOSES REDACTED]. The record shows the facility staff noticed R1's right leg was swollen and were unsure if R1 injured herself or fell . Physician Assessment / Plan shows, Right femur fracture, unclear etiology, likely due to unwitnessed fall, injury. Initial facility report, dated 12/1/19, shows R1 sustained an injury of unknown origin. Final facility report, dated 12/4/19, shows the facility investigated R1's injury of unknown origin and, It was determined that the injury was sustained when the resident was lowered to the floor during a transfer. Resident Summary and Fall inservice document, 12/2/17, shows Fall - Unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. If these occur, need to be reported to the nurse before assisting the resident back to the bed or chair. The nurse then will assess the patient, document and inform POA (Power of Attorney) and family Facility document Assessing Falls and Their Causes, revised (MONTH) (YEAR), shows, Steps in the Procedure After a Fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying or standing position, and then document relevant details. 5. Notify the resident's attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. B. When a fall does not result in significant injury or condition change, notify the practitioner routinely (e.g., by fax or by phone the next office day). 6. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 8. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nurse on duty at the time. After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. Facility document Change in a Resident's Condition or Status, undated, shows Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): a. accident or incident involving the resident 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source 7. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview and record review, the facility failed to provide meal orientation to a resident with impaired vision. This applies to one of one resident (R10) reviewed for accommodation of needs in the sample of 18. The findings include: Review of R10's face sheet showed R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R10's Physician order [REDACTED]. R10's care plan on diet showed, assist at meal for set up and to explain plate related to low vision/legally blind. R10's Minimum data set (MDS) with observation date 2/20/19 showed BIMS (Brief interview for Mental Status) of 13 which meant that resident was cognitively intact. R10's functional ability for eating showed R10 requires supervision that is (oversight, encouragement or cueing), and setup (help only). On 5/20/19 at 12:24pm, R10's lunch was placed in front of her by V7 Certified Nursing Assistant (CNA) without any cuing or explanation. R10 was sitting at a table with three other residents. R10 picked up her flatware to locate the food on her plate. R10 took a couple of bites and pushed the plate away from her. R10 was later served a small plate of jello by V7. V7 placed the small plate of jello in front of R10 without informing R10 what was in the plate. R10 used her flatware to taste the jello and started eating. On 5/20/19 at 12:29 pm, when asked, R10 stated she does not know what she was served and would like to know. On 5/20/19 at 12:36 pm, V7 stated she did not explain to R10 what she was been served because she thought R10 knew the lunch menu. V7 further stated she assisted R10 to fill out the the lunch menu that morning so she assumed R10 would have known what was served for lunch. On 5/20/19 at 12:38pm, V7 asked R10 what she was having for lunch and R10 told V7 she could not remember what she was to have for lunch. V7 stated she should have explained R10's lunch to R10.

Based on observation interview and record record the facility failed to provide pain medication to resident prior to therapy session. This applies to one of one resident (R79) reviewed for pain in the sample of 18. The findings include: Review of R79's face sheet showed R79 was admitted to the facility [DATE] with hypertension, anxiety, spinal stenosis, depression. R79's Physician order [REDACTED]. R79's Medication Administration Review (MAR) for (MONTH) 2019 showed [MEDICATION NAME] 5mg/[MEDICATION NAME] 325 mg one tablet was administered to R79 on [DATE] at 7:24 pm. Review of R79's care plan on pain showed R79 will express satisfaction with pain control and pain will remain at the desired level. On [DATE] at 8:30 am, R79 was observed in the hallway with the V14 (Physical Therapist Assistant). R79 turned back and saw V8 (Nurse) by the medication cart and asked, should I wait for my medication now? V8 informed R79 she will bring R79's medications to her in the room. So V14 was waiting for V8 in the hallway while R79 went back to her room to wait for her medications. On [DATE] at 8:40 am, V8 administered R79's morning medications to her. Then R79 stated where is my pain medication? I prefer to take my pain medication before therapy. V8 replied, I don't have your pain medication yet. I still have to call the doctor. V8 stated R79's pain medication prescription expired last night and needed to be renewed. When asked, R79 rated her pain level to be 4 ,[DATE] to 5 over 10. R79 further stated last time she received her pain medication was evening after dinner. On [DATE] at 12:55 pm, V9 (Nurse) stated R79's pain medication prescription was renewed at 9:30am. V9 stated R79 received her pain medication after the therapy session at 9:46am. V9 stated nursing should have obtained a new prescription for R79 at an earlier time.

Based on observation, interview and record review, the facility failed to document the [DIAGNOSES REDACTED]. This applies to one of four residents (R52) reviewed for [MEDICAL CONDITION] medications in the sample of 18. The findings include: During 3 days of the survey on 5/20/19 through 5/22/19, R52 was observed participating during activities and socializing with other residents during meal times. R52 was pleasant, conversant and well dressed. The face sheet showed that R52 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet did not include a [DIAGNOSES REDACTED]. The (MONTH) 2019 POS (physician order [REDACTED]. The (MONTH) through (MONTH) 2019 TAR (treatment administration record) which contained the behavior monitoring sheets did not show R52's targeted behavior for the continued use of the antidepressant. Review of R52's EHR (electronic health record) did not show that there was a (MONTH) 2019 behavior monitoring record for the resident. On 5/21/19 at 9:30 AM, V5 (Licensed Practical Nurse) said that the behavior monitoring record is in the MAR (medication administration) or TAR. V5 did not find (MONTH) 2019 behavior monitoring sheet started for R52. On 5/21/19 at 2:00 PM, V2 (Director of Nursing) said that when R52 was readmitted , the staff did not start the behavior monitoring record. The facility policy with revised date of (MONTH) (YEAR) titled, Lifestyle Support/Behavior Management Policy and Procedure, required, Procedure: 2. If the resident is on a [MEDICAL CONDITION] medication, the community will obtain consent for the medication. a. The resident /resident representative will be made aware of the following: The [DIAGNOSES REDACTED].