Every finding on record at St Francis Manor

Based on staff certification review, policy review, and staff interviews, the facility failed to ensure 1 of 6 staff members reviewed for Dependent Adult Abuse(DAA) Mandatory Reporter's Training had current training(Staff A). The facility reported a census of 59 residents.Findings included:The facility Abuse Prevention, Identification, Investigation, and Reporting Policy, revised 12/16/22, stated each employee would complete 1-hour reporting of dependent adult abuse training every three years.An undated facility document entitled Hire Date, documented Staff A Maintenance Staff's hire date as 4/21/08.A DAA Mandatory Reporter Training Course certificate, dated 12/31/25, stated Staff A successfully completed the course.On 2/11/26 at 12:15 p.m., via phone, Staff A stated he had trouble passing the test and took it 5 times. He stated Staff C, Administrative Assistant (AA) told him she would let it go. Staff A stated he never did take the test with a passing score. He stated it was possible that Staff C had his login for the test. He stated he did not know what happened with his test after Staff C okayed it.On 2/11/26 at 12:22 p.m., via phone, Staff B Maintenance Staff stated that Staff A struggled taking the DAA Mandatory Reporter Training Course. He stated he talked to Staff C and she stated she would take it from there. Staff B stated he was not sure what that meant. On 2/11/26 at 2:04 p.m. via phone, Staff C, AA stated at first that she had never taken a test for another employee. After further questioning, Staff C stated that she did take the test for Staff A as he was really struggling and had taken it many times. She stated no one at the facility was aware that she took this test for him and stated this was her error. On 2/11/26 at 3:04 p.m., the Executive Administrator stated employees should take tests themselves and he just became aware of the situation with Staff A and Staff C today.

Based on clinical record review, facility policy review, observations and staff interviews, the facility failed to implement Care Plan interventions based on a root cause analysis of a resident's specific fall risks in order to prevent a fall with a major injury for 1 of 3 residents reviewed for falls(Resident #103). The facility reported a census of 54 residents. Findings: The Entry Minimum Data Set (MDS) Assessment Tool, dated 5/31/23, stated the resident admitted to the facility on [DATE]. The 1/19/17 facility policy Resident Falls, directed staff regarding the procedure following a fall. The policy did not address the implementation of interventions to prevent falls for residents who had not fallen but had risks. A 5/31/23 11:59 a.m., a Nurse's Note stated the resident admitted for respite cares(temporary care of a person when their primary caregiver required a break). A 5/31/23 Fall Risk Evaluation stated the resident was at risk for falls due to intermittent confusion, 1-2 falls in the past 3 months, poor vision, and balance problems. The Baseline Care Plan, dated 5/31/23, stated the resident had a history of falls. The following section Interventions was blank. The Care Plan had a crossed out entry which stated the resident was an assist of 1 with a gait belt. This entry stated d/c(discontinue) and there was another undated entry which stated the resident required a mechanical lift. The Baseline Care Plan lacked further interventions related to the resident's risk of falls. A 6/1/23 Admission Note stated the resident took herself to the bathroom using her walker. A 6/1/23, 1:09 a.m. Admission Note documented the resident awake in bed and wondering why she was here. A 6/1/23 3:30 p.m. Nurse's Note stated a Certified Nursing Assistant (CNA) noticed the resident sitting on the floor between her bed and the recliner. Her right leg had external rotation and the resident transferred to the hospital. A 6/2/23 Hospital History and Physical stated the resident fell and had a right femoral(referring to the femur leg bone) neck fracture. A 6/12/23 9:23 a.m. Admission Note stated the resident readmitted to the facility following a hospital stay for a diagnosis of hip fracture and surgery. A 6/13/23 Physical Therapy (PT) Evaluation and Plan of Treatment stated the resident fell and sustained a right femoral neck fracture which required surgical repair. On 7/11/23 at 12:25 p.m., Staff A, CNA and Staff B, CNA transferred the resident from her wheelchair to her bed using a mechanical lift. On 7/12/23 at 10:01 a.m., Staff C, Registered Nurse (RN) stated on the morning of the resident's fall, the resident went to the bathroom by herself and Staff C educated her to utilize the call light. Staff C stated at the time of the fall, she heard a noise and walked in and observed the resident sitting on the floor with her back up against the wall. She stated she noticed some rotation of her leg and transferred her to the hospital. On 7/12/23 at 11:32 a.m. Staff E, Certified Medication Aide (CMA) stated she and Staff F, CNA discovered the resident on the floor in her room with her back against the bed. She stated the resident had a hold of her call light but it was not on. Staff E stated it seemed the resident thought the call light was a phone and someone was calling her. She stated they informed the nurse and she assessed her. On 7/12/23 at 11:47 a.m., Staff F stated on the morning of the resident's fall, she observed the resident walking down the hallway after breakfast alone with her walker and the resident asked what she was suppose to do. Staff F stated she redirected her back to her chair. On 7/12/23 at 12:29 p.m., Staff D, Licensed Practical Nurse (LPN) stated he worked the night the resident arrived and stated he sat at the Nursing Station and the resident suddenly appeared. He stated he did not know why the resident was up but thought maybe she was just confused or bored. On 7/12/23 at 1:43 p.m., Staff G, Care Plan Coordinator, stated upon admission, staff carried out a Fall Assessment and if they were a high risk, they would come up with something extra. She stated if residents started getting up on their own, they would implement another intervention. On 7/12/23 at 2:17 p.m., the Director of Nursing (DON) stated PT evaluated the resident upon admission and deemed her an assist of 1. She stated she was not aware that the resident got up on her own prior to the fall but would want to know so they could have looked into it differently.

Based on clinical record review, observation, facility policy review, and staff interview, the facility failed to implement interventions to prevent a facility acquired pressure ulcer for 1 of 3 residents reviewed.(Resident #32). The facility reported a census of 40 residents. Findings: The MDS (Minimum Data St) assessment defines pressure ulcers as follows: Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II - A partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. The wound may also present as an intact or open/ruptured blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. The wound may include undermining and tunneling. Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and it often includes undermining and tunneling. The MDS assessment, dated 9/30/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS recorded Resident #32 required extensive assistance of 1 staff for personal hygiene and dressing, extensive assistance of 2 staff for bed mobility, and depended completely on 2 staff for transfers, toilet use, and bathing. The assessment documented the resident had 1 unstageable (not stageable due to coverage of wound bed by slough and/or eschar) unhealed pressure ulcer and listed the resident's BIMS (Brief Interview for Mental Status) score as 5 out of 15, indicating severely impaired cognition. A 4/1/21 Braden Scale for Predicting Pressure Ulcer Risk documented Resident #32 at moderate risk for the development of pressure ulcers. During an observation on 10/27/21 at 9:34 a.m., Resident #32 sat in a recliner and Staff A RN (Registered Nurse) measured a dry, scabbed area whitish in color on the resident's right heel as 1.3 cm (centimeters) x 0.8 cm. Staff A then cleansed the area with [MEDICATION(S)] and stated she would leave the sock off for a few minutes so as not to stain the sock. During a subsequent observation on 10/27/21 at 10:02 a.m., Resident #32 sat in the recliner with her feet up and had heel protector boots on and her heels were not in contact with the footrest of the recliner. A Progress Note entry on 4/12/21 at 12:35 p.m. stated the resident was in her recliner with her legs up. Progress note entries at the following times stated the resident was in her recliner: 4/17/21 at 10:09 a.m., 4/19/21 at 9:58 a.m., 4/21/21 at 9:26 a.m., 4/29/21 at 12:59 p.m., 5/1/21 at 9:01 a.m., and 5/2/21 at 10:12 a.m. A 5/4/21 Progress Note recorded that during the skin assessment, staff noted a new pressure area on the right heel which measured 1.5 cm x 2.7 cm. and stated it had the appearance of a popped blister with skin intact. The resident currently wore heel protectors in bed but (the writer) would instruct staff to float heel when in bed and the recliner and to have heel protectors on at all times. A 5/4/21 Wound/Skin Healing Record entry recorded the resident had an unstageable pressure ulcer on the right heel measuring 1.5 cm x 2.7 cm. Care Plan entries, dated 3/8/21, stated the resident was at risk for pressure ulcers and directed staff to help with changing positions, provide a pressure relieving mattress, encourage the resident to elevate legs, and put heel protectors on or float heels when in bed to protect heels. The care plan lacked interventions to prevent the development of a pressure area on the heel when the resident was in the recliner. During an interview on 10/28/21 at 9:02 a.m., Staff B stated when they first discovered the skin area it looked like a deep tissue injury and was dark purple with necrotic (dead) tissue. Staff A stated the area hit right on the edge of the recliner and after the discovery of the area the facility implemented protective boots. She stated it could have been that the resident's heels were in contact with the recliner. Staff A stated the resident did not wear the boots until after the discovery of the area. During an interview on 10/28/21 at 9:09 a.m., the DON (Director of Nursing) stated if a was resident at risk for pressure ulcers sat in the recliner, staff should use protective boots or float her heels with a pillow. She stated with regard to Resident #32, if she was already wearing them in bed and her heels were in contact with the recliner, it would be best practice for her to wear boots in the recliner. At 12:58 p.m., the DON stated the facility did not have a policy on skin management but stated she typed up some of their practices. She provided the team with an undated document Skin Protocol which stated they followed the standard of practice and completed weekly skin assessments. It stated the ADON (Assistant Director of Nursing) reviewed skin books twice a week and the dietician assessed residents with pressure sores and assigned nutritional changes.

Based on clinical record review, policy review, and staff interview, the facility failed to provide a bed hold notice upon hospital transfer for 1 of 2 residents who transferred to the hospital (Resident #8). The facility reported a census of 40 residents. Findings: 1. The MDS (Minimum Data Set) assessment, dated 8/19/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 9 out of 15, indicating moderately impaired memory and cognition. Nursing Notes dated 8/5/21 recorded Resident #8 transferred to the hospital for shortness of breath. Nursing Notes dated 8/10/21 documented Resident #8 returned to the facility. The resident's clinical record lacked documentation of a bed hold notification provided to the resident or the resident representative prior to the transfer to the hospital. The facility policy titled Bed Hold, dated 7/12/17, instructed the facility would not charge the resident upon hospitalization for a maximum of 10 days. The policy stated beyond the 10 days, residents must use their own income to pay for the bed hold. The policy stated the facility provided residents bed hold information upon admission and also at the time of a temporary absence from the facility . During an interview on 10/27/21 at 2:00 p.m., the Administrator stated the facility did not charge for bed holds and this was the reason they did not provide bed hold notifications upon transfer. During an interview on 10/28/21 at 8:22 a.m., the DON (Director of Nursing) stated the Administrator informed her if the resident was on Medicaid, they held the bed for 10 days free of charge and that was the reason they did not provide bed hold notifications upon hospital transfer.

Based on interviews and record review the facility failed to complete pre and post [MEDICAL TREATMENT] assessments for 1 out of 1 resident reviewed (Resident # 17). The facility reported a census of 51 residents. Findings included: The Minimum Data Set (MDS) assessment for Resident # 17 dated 5/16/19, listed the [DIAGNOSES REDACTED]. The MDS further listed the resident with a Brief Interview for Mental Status (BIMS) of 11 indicating mild cognitive impairment. The MDS reflected the resident requires limited assist of 1 staff for transfers and extensive assist of 1 staff for toileting. The Care Plan dated 5/13/19, documented Resident # 17 currently has a port in her left chest that is used for [MEDICAL TREATMENT]. The Care Plan directed staff to monitor, document, and report to the Physician as needed (PRN) with any signs or symptom (s/s) of infection to the access site: redness, swelling, warmth, fever or drainage. The Care Plan further directed staff to obtain vital signs (VS) weekly and PRN. Report significant changes in pulse, respirations and blood pressure (BP) immediately to the Physician. The Care Plan identifies a possible side effect is high or low BP. Review of the Medication Administration Record [REDACTED]. Review of the Progress Notes dated 5/1-22/19 for resident #17, lacked documentation of pre and post [MEDICAL TREATMENT] assessment. Review of the Vitals record dated 5/19, lacked documentation of vitals before and after [MEDICAL TREATMENT]. During an interview on 05/22/19 at 8:58 a.m., Staff C, Registered Nurse (RN), reported no specific assessments or vitals are required for Resident # 17. Staff C revealed documented checking the [MEDICAL TREATMENT] port dressing 1 time a week. During an interview on 05/22/19 at 9:01 a.m., Staff J, Licensed Practical Nurse (LPN) stated assessments are not required for the resident receiving [MEDICAL TREATMENT]. During an interview 05/22/19 at 09:15 a.m., Staff I (LPN) reported no assessments are due for Resident # 17 related to [MEDICAL TREATMENT]. Staff I continued she would call [MEDICAL TREATMENT] if the dressing to the port site was wet, and stated the nurses document the dressing to the port site is dry and intact every week. During an interview on 05/22/19 at 09:51 a.m., the Director of Nursing (DON) revealed assessments are done as needed for Resident # 17. The DON stated the facility does not have a communication sheet go back and forth with the [MEDICAL TREATMENT] center, if the facility has concerns we call the [MEDICAL TREATMENT] center. During an interview on 05/22/19 at 10:09 a.m., the Administrator/Registered Nurse (RN) reported expecting staff to monitor the [MEDICAL TREATMENT] port site and document on skin sheet every week. The Administrator stated the facility documents by exception. During an interview on 05/22/19 at 1:21 p.m., the Administrator stated the facility does not have a form for assessments of a resident on [MEDICAL TREATMENT].

Based on observation and staff interview, the facility failed to properly administer medicated eye drops for one of one residents reviewed who had medicated eye drops administered (Resident #17), and failed to administer medication at the appropriate time for one of five residents reviewed (Resident #37). The facility reported a census of 51 residents. 1. During an observation on 5/21/19 at 7:58 a.m., Staff C, Registered Nurse (RN), administered a drop of [MEDICATION NAME] 0.4 % to Resident # 17's left eye. At 8:01 a.m., observed Staff C administer a drop of [MEDICATION NAME] 1% to Resident #17's left eye. During an interview 5/21/19 at 5:03 p.m., Staff G, Pharmacist, reported most liquid medicated eye medication solutions are administered first, then the suspension/ointment medication administered. Staff G stated ketoralac eye medication is considered a solution and [MEDICATION NAME] considered a suspension and steroid medication. Staff G reported staff needed to wait 5-15 minutes before administering the second medicated eye medication in order to allow for absorption of the medication. During an interview 5/22/19 at 8:42 a.m., the Administrator reported there was not a facility policy for eye medication administration. The Administrator reported when staff gave eye medications, she expected they followed the standard of practice. During an interview 5/22/19 at 8:45 a.m., the Director of Nursing (DON) reported she had spoken to the pharmacist on 5/21/19 and the pharmacist told her they needed to administer the [MEDICATION NAME] eye medication first, then the [MEDICATION NAME] eye medication. The DON reported staff needed to wait at least 5-15 minutes between administration of the first and second medicated eye drop. The DON reported she entered an order in the electronic health system which directed staff to administer the [MEDICATION NAME] eye drop first, wait 5-15 minutes, and then administer the [MEDICATION NAME] eye drop. 2. The MDS(Minimum Data Set) assessment tool, dated 4/29/19, listed [DIAGNOSES REDACTED]. During an observation on 5/21/19 at 7:31 a.m., the resident noted in her room eating breakfast. The resident stated she received her [MEDICAL CONDITION] medication at around 7:00 a.m. The resident's current physician's orders [REDACTED]. Review of Medication Administration Times for the period of 4/24/19-5/22/19 revealed the resident received her [MEDICAL CONDITION] medication on the following dates less than 30 minutes prior to her normal breakfast time of 7:15 a.m.-7:25 a.m.: 4/24/19 7:00 a.m. 4/25/19 7:37 a.m. 4/26/19 7:47 a.m. 5/9/19 7:27 a.m. 5/10/19 7:27 a.m. 5/11/19 7:34 a.m. 5/12/19 6:58 a.m. 5/13/19 7:22 a.m. 5/14/19 7:07 a.m. 5/15/19 7:34 a.m. 5/16/19 8:13 a.m. 5/17/19 7:51 a.m. 5/18/19 7:24 a.m. 5/20/19 7:38 a.m. 5/21/19 7:03 a.m. The Nursing (YEAR) Drug Handbook, used as a facility reference, directed staff to administer [MEDICATION NAME] at the same time each day on an empty stomach, preferably 30 minutes to 1 hour before breakfast. During an interview on 5/20/19 at 12:37 p.m., the resident stated she was supposed to receive her [MEDICAL CONDITION] medication early on an empty stomach but she received it at times with breakfast. She stated she ate breakfast at 7:15 a.m. so should receive her medication no later than 6:15 a.m. During an interview on 5/21/19 at 12:33 p.m., Staff E, Dietary Aide stated she passed breakfast trays at about 7:10 a.m During an interview on 5/21/19 at 5:03 p.m., Staff G, Pharmacist stated staff should administer [MEDICATION NAME] at least 30 minutes before meals and stated if staff administered the medication with food or right before a meal, it could affect the absorption of the medication. During an interview on 5/22/19 at 8:00 a.m., Staff D Cook stated staff usually distributed breakfast trays at 7:15 a.m. and the latest they would distribute them would be at 7:25 a.m During an interview on 5/22/19 at 10:02 a.m., the Director of Nursing (DON) stated staff should administer [MEDICAL CONDITION] medications 30 minutes before breakfast. She stated the facility would conduct education with the nurses regarding this. During an interview on 5/22/19 at 1:20 p.m., the Administrator stated the facility did not have a policy regarding medication administration and stated they followed the standard of practice.

Based on observation, record review, and staff interview, the facility failed to carry out sanitary food handling practices for 1 of 7 residents receiving feeding assistance during a meal (Resident #3). The facility reported a census of 51 residents. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 5/2/19, listed [DIAGNOSES REDACTED]., and depression. The MDS stated the resident completely dependent on 1 staff for eating, dressing, and personal hygiene, and completely dependent on 2 staff for bed mobility, transfers, toilet use, and bathing. The MDS listed the resident's cognition as severely impaired. During an observation on 5/20/19 at 11:44 a.m., Staff F, Paid Feeding Assistant (PFA) fed the resident a cookie while touching it with her bare hands. During an observation on 5/21/19 at 11:28 a.m., Staff F fed the resident a piece of bread while touching it with her bare hands. Prior to picking up the piece of bread, Staff F touched the handles of a fork and spoon. During an interview on 5/22/19 at 10:01 a.m., the Director of Nursing (DON) stated she would not want staff using their bare hands on food when assisting residents and stated this would be inappropriate. During an interview on 5/22/19 at 1:20 p.m., the Administrator stated the facility did not have a policy regarding food handling during feeding assistance and stated they followed the standard of practice.

Based on observation, record review, and staff interview the facility failed to utilize proper infection control techniques during resident care for 1 out of 5 residents reviewed (#22). The facility reported a census of 51 residents. The Minimum Data Set ((MDS) dated [DATE] for Resident #22 listed [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance of two staff for bed mobility, is totally dependent on two staff for transfers and toileting and is non-ambulatory. The MDS identified the resident as having an indwelling urinary catheter and was frequently incontinent of bowels. A Brief Interview for Mental Status score of 11 documented the resident as having moderate cognitive impairment for decision making. During an observation of morning cares from 8:30-9:40 a.m. on 5/21/19, Staff A and Staff B, both Certified Nurse's Aides, (CNA), entered the resident's room and washed their hands. Together they transferred the resident from the wheelchair to the bed using a mechanical lift. The resident had a large, loose bowel movement when up in the wheelchair. Feces was noted to have leaked out of the resident's brief onto the lift sling and wheelchair seat back. The CNA's donned gloves. Staff B, removed the soiled lift sling, slacks and brief from the resident once laid down in bed. Using a washcloth, she wiped across the abdomen and down both leg creases, turning the cloth to a clean area with each wipe and cleansing in a front to back motion. Staff B removed her gloves and donned clean gloves but did not perform hand hygiene. Staff B then cleansed down both inner thighs, noting her gloves to have visible feces on them. The resident was turned to their right hip. With the same visibly soiled gloves on, Staff B cleaned the buttocks, left hip and the buttocks crease/anal area-front to back. Staff B touched the left hip after cleansing it, still wearing the gloves with visible feces on the fingertips. The resident then rolled to the left hip. Still wearing the same soiled gloves, Staff B cleansed up the back of the right thigh and anal area. The CNA cleansed the resident's catheter tubing with a washcloth while securing the tubing near the urethral opening with a soiled gloved hand. Staff B removed her gloves, did not perform hand hygiene and donned new gloves. She then wiped down the catheter tubing from the urethral opening to the connection port of the urine collection bag with alcohol wipes. The resident had 3 loose BM's during cares. The process for cleaning the resident up after an incontinence episode repeated in the same manner three times. Both CNA's removed their gloves, washed their hands, and donned new gloves. Staff B applied a new catheter tubing leg strap to secure the tubing to the residents left thigh, placed a clean bed protector pad under the resident, applied a new brief and new slacks. The resident was transferred back into the wheelchair with the lift. The seat and back of the wheelchair had not been sanitized where fecal matter had soaked through the resident's clothes and the first lift sling. Both CNA's removed their gloves and washed their hands. The resident was given hand sanitizer to clean her own hands. During an interview on 5/22/19 at 8:40 a.m., the Administrator and Director of Nursing, (DON) stated staff follow the standards of practice for catheter care and the facility has no policy regarding that. The Administrator stated the standard of care would be to cleanse the catheter tubing with perineal wash and not alcohol wipes. The DON stated she would expect the staff to remove visibly soiled gloves, wash their hands, and don clean gloves during incontinence cares. She stated the facility did not have a policy regarding hand washing and glove changing either but follow the standards of practice.

Based on observation, record review, and interview, the facility failed to utilize the correct number of staff for 1 of 8 residents observed during a transfer. (Resident #1). The facility reported a census of 66 residents. Findings included: 1. The Minimum Data Set (MDS) assessment dated [DATE] listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene and dressing, limited assistance of 2 staff for walking, and extensive assistance of 2 staff for bed mobility, transfers, toilet use, and bathing. The MDS listed the resident as not steady and only able to stabilize with staff assistance while moving from seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet, and during surface to surface transfers. The MDS stated the resident utilized a walker and wheelchair and sustained 2 falls with an injury (except major) since the last MDS. The MDS listed the resident's Brief Interview for Mental Status score as 15 out of 15, indicating intact cognition. During an observation on 12/6/16 at 8:54 a.m., Staff C Certified Nurse Aide (CNA) and Staff D, CNA, assisted the resident with perineal cares while the resident stood in front of the toilet with a walker. During perineal cares, the resident struggled to stay standing and needed to sit down on the toilet 3 times for a break. After the staff completed perineal cares, the resident stood once again and Staff D pulled up the resident's pants. After the staff pulled up the resident's pants, the resident needed to sit down on the toilet again. After the resident sat on the toilet, Staff D went to the sink in the resident's room and began to wash her hands. At the same time, the resident stood up with Staff C and began to walk toward the recliner while wearing a gait belt and utilizing a walker. Staff D stated from the sink,wait for me. Staff C did not ask the resident to wait for Staff D's assistance and walked with the resident to the recliner where both Staff C and Staff D assisted the resident to sit. The staff did not follow the resident with a wheelchair from the toilet to the recliner. An 3/26/16 incident report stated the resident was with a CNA and became weak and the CNA lowered the resident to the floor. After the incident the resident stated, I got weak and couldn't stand any longer. The resident sustained [REDACTED]. A 7/4/16 incident report stated staff found the resident kneeling with the upper part of the body laid on the bed. The resident stated he/she was reaching for a urinal and went down on the knees. The resident sustained [REDACTED]. A 7/14/16 incident report stated staff found the resident sitting on the floor on the buttocks. The resident stated he/she was on the way from the bathroom and fell backwards. The resident sustained [REDACTED]. A 8/28/16 incident report stated a nurse heard a CNA calling for help and observed the CNA lower the resident down onto the floor. The resident had been walking to lunch with a gait belt and walker with the wheelchair following and the resident started to go down to the floor without warning. The CNA lowered the resident to the floor and the CNA stated the resident gave out on the left side. The resident stated, I got real tired. The resident sustained [REDACTED]. A 8/30/16 Progress Note stated the author educated the CNA involved in resident's fall on 8/28/16. The note stated the resident should have been assisted by 2 staff and the CNA voiced understanding of this. A care plan entry, revised 9/12/16, stated the resident was at risk for falls/injury related to weakness, balance deficits, and a new [DIAGNOSES REDACTED]. An informational sheet, located on the wall in the resident's room, stated the resident was an assist of 2 and directed staff to follow behind with a wheelchair. The undated facility Transfer Policy directed staff to follow the care plan regarding how to transfer residents. During the initial facility tour on 12/5/16 at 9:30 a.m., the Quality Coordinator nurse stated the resident was a 2 person assist with transfers. During an interview on 12/7/16 at 10:20 a.m., Staff A, Registered Nurse, stated she would utilize 2 staff rather than 1 staff while transferring the resident due to the resident's weakness and [DIAGNOSES REDACTED]. During an interview on 12/7/16 at 10:30 a.m., Staff B, CNA, stated she would always utilize 2 staff when assisting the resident. She stated the resident could only stand for so long and he/she started to squat and he/she didn't always inform the staff of when he/she felt weak. During an interview on 12/7/16 at 3:00 p.m., the Quality Coordinator stated staff should preferably attempt to encourage the resident to wait for assistance but the resident wasn't always receptive to this.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure staff provided proper peri care for two of five residents reviewed during personal cares. (Resident #1 & #4). The facility census was 60 residents. Findings include: The facility's policy and procedure titled Perineal Care dated 9/4/14, at point number 6 directed staff to push back the foreskin on men. Near the bottom of the second page information directed staff to always wash from front to back and always use a clean portion of the cloth with each swipe. 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident was dependent on staff for toileting. During observation on 11/18/14 at 9:10 a.m., Staff D certified nurse aide, CNA reported the resident was incontinent. Staff C, CNA cleansed from the base of the residents penis up the shaft on the left side only. Staff C did not pull back the residents foreskin and wash the penis completely. During interview on 11/20/14 at 8:55 a.m., Director of Nursing, DON reported the expectation was to pull back the penis foreskin and cleanse after incontinent episodes. 2. The MDS assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident as dependent on staff for toileting and personal hygiene needs. During observation on 11/18/14 at 9:26 a.m., the resident reported a need to go to the bathroom. Staff A, CNA reported the resident was incontinent of stool. Staff A assisted the resident to turn and cleansed the resident's left back/hip down to the vaginal area 2 times. Observation revealed brown loose bowel movement visible around the residents rectum and buttocks. Staff A cleansed the residents rectal area up the back and then went down to the vaginal area. Staff A cleansed the residents right buttock up and back down. During interview on 11/20/14 at 9:00 a.m., the DON stated the expectation was to wash from front to back and not wash from the top of the buttocks down to the vaginal area.

The following deficiency relates to incident -I: Based on record review and staff interviews the facility failed to plan for and direct nursing services to ensure one (1) of four (4) residents at risk for falls received adequate supervision to prevent accidents (Residents #1). The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) with an assessment reference date of [DATE] indicated Resident #1 with a Brief Interview for Mental Status (BIMS) score of 10 indicating short and/or long-term memory deficits and mildly impaired cognitive skills for daily decision. The assessment determined Resident #1 as independent with personal hygiene, required supervision with transfers and walking in his/her room and required limited assistance of one staff to assist with bed mobility. The resident required assistance of one staff with dressing, toilet use and bathing. Resident #1's [DIAGNOSES REDACTED]. Nurse's Notes dated [DATE] at 10:45 a.m. indicated Resident #1 had been admitted to the nursing facility from a hospital following a fall at home resulting in a fractured cervical 1 and thoracic 2 vertebrae. The vertebrae were surgically stabilized. Fall Risk Assessment completed [DATE] identified a score of 16 which revealed the resident at a high risk for falls. A second assessment completed [DATE] noted a score of 13 which also represented a high fall risk. Resident #1's plan of care dated [DATE] indicated Resident #1 was at risk for falls/injury related to history of falls at home. Interventions included: 1) Ensure resident is wearing appropriate footwear. 2) Ensure environment remains free of clutter/obstructing objects. 3) Keep room door open to maintain a better line of sight to supervise. 4) Answer call light as soon as possible. 5) Activated bed alarm when in bed. ([DATE]) Discontinued ([DATE]) 6) Activated chair alarm when in recliner. ([DATE]) 7) Activate floor mat alarm at night. ([DATE]) Discontinued ([DATE]) 8) Resident #1 able to be up independent in room with contact guard assistance of one staff while walking in halls. ([DATE]) Discontinued ([DATE]) 9) Activate chair alarm during tube feedings, otherwise up an independent in room. ([DATE]) Discontinued ([DATE]), ([DATE]) 10) Needs one assist in room now. ([DATE]) Discontinued ([DATE]) 11) Activate chair alarm when in recliner at all times. ([DATE]) Discontinued ([DATE]) 12) Due to Resident #1 continually getting up with no regard to alarm, will discontinue device and monitor the resident. ([DATE]) 13) Resident assist of one staff for toileting and personal cares, and independent in room. May ambulate independently from room to nurse ' s station. Resident independent with transfers ([DATE]). Facility Tracking Form dated [DATE] indicated Resident #1 had reported to his/her daughter that he/she had fallen yesterday or maybe Monday. Resident #1 indicated she had gotten him/herself up. There was no injury. Fall Scene Investigation Report dated [DATE] at 9:30 a.m. indicated Resident #1 had been found on his/her bedroom floor. No alarms sounding. Chair alarm only used at night or when resident was receiving tube feedings. When in room, Resident #1 was considered independent. Intervention to utilize chair alarm at all times when in recliner. The nurse ' s notes dated [DATE] at 12:30 a.m., revealed the resident continues to get up on his/her own and does not call for assistance. The alarms going off frequently. The nurse ' s notes dated [DATE], documented the resident had been up with the alarms sounding numerous of times. At [DATE], at 10 p.m. alarms in place and functioning. The nurse ' s notes dated [DATE] at 3:50 a.m., documented Resident #1 had been anxious, compulsive, danger to self. Staff documented the resident had been noisy, restless and uncooperative wandering, and continuously placed one foot out on the fall mat so it alarmed continuously getting staff to come in to his/her room. When staff arrived to turn off the sounding alarm, the resident would say everything was ok. The resident ' s behavior occurred for 1 hour constant and 2 hours since 10 p.m., Fall Scene Investigation Report dated [DATE] at 12:00 p.m. indicated a resident alerted staff that Resident #1 had been on the floor. Resident #1 had been found on his/her bedroom floor with feeding tube pole tipped over. No alarms sounding. Resident #1 indicated he/she wanted to walk. Resident #1 characterized as forgetful and confused, requires frequent redirection. The chair alarm was not being used as care planned. Fall Scene Investigation Report dated [DATE] at 4:15 a.m. indicated Resident #1 had been found on his/her bedroom floor. No alarms sounding. Resident #1 had last been toileted at 3:15 a.m. Resident #1 had been up and down as per his/her usual behavior, out in the hallway on three occasions in which staff redirected him/her back into his/her room. The resident had been sent to the emergency room (ER) for evaluation. Resident #1 passed away at the hospital at 4:13 p.m. Hospital History and Physical dated [DATE] indicated Resident #1 admitted following a fall resulting in aspiration pneumonia and a subarachnoid and subdural hemorrhage. The report noted the resident had a (previous) cervical fracture wearing a C-Collar. The resident had an emesis and an apparent aspiration. The resident had gurgling respirations with apparent vomitus in the throat and mouth area. Resident #1 expired on the afternoon of [DATE] and the cause of death would be pneumonia due to aspiration and due to subarachnoid hemorrhage. In an interview on [DATE] at 4:25 p.m. the Director of Nursing (DON) indicated Resident #1 had been admitted from home following a fall which resulted in a C1 and T1 (7th cervical vertebrae and 1st thoracic vertebrae) fracture which had been surgically repaired. Since the injury and fall at home, Resident #1 had difficulty swallowing and had been placed on a [DEVICE] for feedings. Resident #1 had been admitted on [DATE] with fall interventions which included a bed alarm, chair alarm and floor mat alarm at night. Resident #1 had received physical therapy and had been discharged from physical therapy on [DATE]. At that time Resident #1 had been considered independent while in his/her room with contact guard assistance when ambulating in the hallway. On [DATE] Resident #1 reported he/she had fallen, and did not have any injuries, and no change had been made to his/her interventions. On [DATE], Resident #1 fell when he/she got up from his/her recliner. There was no chair alarm being used as the chair alarm was only being used at night or during tube feedings. The intervention had been changed to using the chair alarm whenever he/she was in his/her recliner. On [DATE] the DON stated that several staff had reported to her that Resident #1 had been getting up unassisted and frequently setting off the alarms. The DON and staff thought the alarms were creating more anxiety for Resident #1. The DON decided to discontinue the alarms and monitor the resident. The DON stated she did not implement any alternative safety interventions for Resident #1. The DON reported there was no re-evaluation or assessment of the resident and the decision to change Resident #1's status back to independent in his/her room was solely hers. A follow up interview with the DON on [DATE] at 2:20 p.m. she reported on [DATE], she had consulted with nursing staff and decided to discontinue the bed and floor mat alarms, but retain the chair alarm when in the recliner during feedings. The DON also changed Resident #1's status back to being independent when in his/her room. The DON did not re-assess, re-evaluate or consult with physical therapy staff or the physician prior to making that decision. On [DATE] the DON stated Resident #1's roommate change rooms as Resident #1 had been up often attempting to help his/her (the roommate). In an interview on [DATE] at 10:30 p.m. Staff A, Licensed Practical Nurse, indicated it was common for Resident #1 to get up unassisted during the night. Sometimes ,[DATE] times a night. Staff A described Resident #1 as pleasantly confused and had been considered independent when in his/her room. Staff A noted the only alarm being used had been a chair alarm when the resident had received tube feedings. Staff A indicated Resident #1 had been independent when using a bathroom and occasionally incontinent. Resident #1 had a steady gait, but sometimes his/her pajama bottoms would drag and create a tripping hazard. Staff A stated Resident #1 was checked on a minimally of every two hours and Staff A was in the room for feedings and flushes every four hours. Staff A indicated she had not noticed any decline in Resident #1's condition during the last few months and didn't believe the alarms made Resident #1 any more or less anxious. Staff A indicated she had worked the overnight shift on [DATE]. At around 4:15 a.m. Staff A discovered Resident #1 on the floor bleeding from his/her head. Resident #1 had assessed and sent to the hospital for further evaluation. During a follow up interview on [DATE], at 4:21 p.m., Staff A stated Resident #1 had been up unassisted three times earlier in the shift. Staff A had passed by his/her room at about 4:00 a.m. and did not see the resident up or on the floor. Resident #1 had been last assisted to the bathroom at 3:15 a.m. Staff A indicated there were no alarms being used that evening as Resident #1 had been considered independent in his/her room and only used a chair alarm when in his/her recliner during feedings. In an interview on [DATE] at 8:23 a.m. Staff B, Registered Nurse, indicated she had worked on the day of [DATE]. At 12:00 p.m. Resident #1's roommate summoned her to the bedroom where she discovered Resident #1 lying on the floor. Staff B stated Resident #1 had been receiving a tube feeding and the feeding tube stand had been pulled over. Staff B stated there had been no alarm sounding because she had forgotten to turn the alarm on. Staff B stated it was common for Resident #1 to get up unassisted. Staff B stated she had not noticed any decline in Resident #1's condition. In an interview on [DATE] at 9:19 a.m. Staff C, Physical Therapy Assistant, indicated he was familiar with Resident #1 and had provided physical therapy services for him/her in [DATE]. Staff C indicated at the time in which Resident #1 was discharged , he/she had been considered safe/ independent in his/her room. Staff C added Resident #1 got fatigued easily and thus required stand by assistance when ambulating over 100 feet. Staff C indicated he had not been informed Resident #1 had any falls and that was unusual as the nursing staff was usually good about letting physical therapy know about falls

Based on observation and staff interview, the facility failed to follow manufacturers recommendations for use of a disinfectant product in the shower room in order to prevent transmission of infection to residents. The facility census was 65 residents. Findings include: 1. Observation on 8/20/13 at 11:15 a.m., revealed Staff K, housekeeper orienting Staff L, housekeeper to the cleaning and disinfecting procedures for the shower/whirlpool tub room in the D hallway of the facility. Staff K identified the product used to spray the shower chair, walls, and the whirlpool tub as CDC - 10. (Clinging Disinfectant Cleaner) Staff K sprayed CDC - 10 onto the resident shower chair, walls of the shower room stall and on the whirlpool tub. Staff K took the shower sprayer and immediately sprayed the shower chair with water and took the hose from the whirlpool tub and put a layer of what appeared to be water on the bottom of the whirlpool tub from the automatic disinfectant dispenser. Staff K immediately took the water sprayer for the whirlpool tub and sprayed the tub with water after spraying the inside of the whirlpool with the CDC - 10 product. Observation revealed no timing of the product to ensure disinfection of the hard nonporous surfaces of the shower chair or whirlpool tub. During interview at the time, Staff K revealed he/she kept the CDC - 10 disinfectant cleaner on for a couple of seconds and was not quite sure how long the product was left on. Staff K stated it was part of the daily sanitation process and staff brush the tub after sprayed with the disinfectant when finished with each resident. During interview on 8/22/13 at 8:30 a.m., Staff M, registered nurse, RN revealed the certified nurse aides try to shower residents with infections last and housekeeping is called to the shower room to clean before any other residents go into the shower or use the whirlpool. Staff M revealed the facility had three residents with MRSA ( Methicillin - resistant Staphylococcus Aureus), an infection resistant to many antibiotics in the past year. Review of the CDC - 10 Disinfectant Cleaner bottle in use by the facility as a disinfectant documented: GENERAL CLEANING, DISINFECTING AND DEODORIZING Spray area until surface is covered with foam. Allow surface to remain wet for 5 minutes. Wipe off with a clean damp cloth or sponge. On chrome, stainless steel or glass, rinse with water. Preliminary cleaning is required for heavily soiled areas. Based on observation, record review, and staff interviews, the facility failed to ensure adequate disinfection of the whirlpool tubs through infection control practices in place, and failed to ensure that staff that used the whirl pool tubs had received instruction on whirl pool tub disinfection. The facility reported a census of 65 residents. Findings Include: Observations on the environmental tour on 8/20/13 with Staff J, a maintenance employee, and the facility administrator revealed: At 10:35 a.m., Staff J opened the lock of the disinfectant compartment of the whirl pool tub in the A Hall shower room and revealed the Penner disinfectant container was completely empty, dry and with dust on top of the container. At 10:41 a.m., Staff D, certified nursing assistant (CNA), stated he/she used the whirl pool tub in the A Hall shower room and when asked how to disinfect the tub between resident use, Staff D stated: 1. Use a spray-bottle with blue liquid (CDC 10), spray all surfaces of the tub and leave on for 10 minutes, then rinse off. 2. Staff D stated there is a disinfection button on the side of the tub and demonstrated the feature, depressed the button and clear water started to collect in the bottom of the tub. 3. When asked how he/she would know whether or not there was disinfectant in the tub, Staff D stated the tub would make a noise. Staff D stated that he/she would rinse the tub with water after the tub disinfectant applied. At 10:55 a.m., Staff J unlocked the disinfectant compartment of the whirlpool tub in the B hall shower room that revealed the Penner disinfectant container completely empty and dry, with dust on the top. At 10:57 a.m., Staff E, CNA, described the following procedure to disinfect the whirlpool tub located on the B Hall: 1. Use CDC 10 solution, spray tub surfaces and scrub with a brush. 2. Leave the solution set for 7 to 10 minutes, then rinse with water. 3. Allow to air dry. 4. When asked how the following staff member would know whether or not the tub was disinfected, Staff E stated that the staff member would tell them. 5. When asked about the buttons on the side of the tub for disinfection, Staff E stated he/she did not know about that. During an interview on 8/20/13 at 10:35 a.m., Staff J stated that CDC 10 is reconstituted by the facility as directed by the manufacturer and placed in the spray bottles. The instruction label on the CDC 10 bottle did not direct staff the length of contact time required for disinfection. A facility document that described use of the CDC 10 product stated that when reconstituted at a 13 ounce per gallon of water concentration, the product disinfected Staphylococus aureus, Pseudomonas aeruginosa and Salmonella [MEDICATION NAME] when 5 minutes of wet contact time was maintained. When reconstituted, as practiced by the faciility, the CDC 10 product does not disinfect other pathogens common to health care settings that includes Hepatitis B, [MEDICATION NAME] resistant [MEDICATION NAME] faecalis (VRE), Methicillin resistant Staphylococcus aureus (MRSA), Herpes simplex Type 2, HIV or AIDS and Influenza A2/Hong Kong viruses; the organisms would be disinfected by 5 minutes of wet contact time with the undiluted product. During an interview on 8/20/13 at 3:05 p.m., the facility administrator stated that the disinfectant containers in all the facility's whirlpool tubs were empty, the facility did not have any Penner disinfectant for the whirlpool tubs and would not state when the facility had last ordered the product, but agreed that it was "some time ago", and that the facility had placed an order for [REDACTED]. The facility administrator also stated that effective on that date the housekeeping department would be responsible for monitoring the whirlpool tub disinfectant containers. When asked for the whirlpool tub disinfection policy/procedure, the administrator stated that the facility did not have such a policy or procedure.

Based on clinical record review and staff interview, the facility failed to ensure safety devices planned for resident fall interventions were in place and functioning for one of five residents reviewed. (Resident # 8) The facility census was 65 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #8 had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance of two staff for bed mobility, transfers, walking and toilet use. The MDS documented the resident scored seven of 15 for the brief interview for mental status, indicating cognitive impairment and had a history of [REDACTED]. The residents Care Plan identified a focus area with initiated date of 6/21/12 as the resident at risk for falls or injury related to a history of falls, poor vision, weakness, poor endurance, oxygen dependency, frequent bladder incontinence, very compromised health and administration of medications that increase fall risk. The Care Plan directed staff to assist the resident with one or two staff members for transfers and walking with the use of a gait belt and a walker initiated 3/6/13. The Care Plan directed staff to apply a bed alarm on 3/13/13 and discontinued 5/15/13, a chair alarm when up in wheelchair or in recliner initiated 3/11/13, activate personal pull alarm whenever the resident was up in wheelchair initiated 3/15/13 and discontinued 5/15/13 A floor mat alarm was initiated 5/15/13 with placement approximately a foot away from the recliner and at bedside when the resident is in bed. The Care Plan directed staff to check all alarms for proper functioning every afternoon at approximately 2:00 p.m. starting 3/18/13. The Care Plan directed staff to toilet the resident every afternoon at about 4:00 p.m., initiated 3/18/13. The Care Plan directed staff to make sure all alarms are on and functioning at the start of the shift and every one and one-half to two hours thereafter initiated 4/08/13. The Care Plan directed staff to toilet the resident nightly at 2:00 a.m., rounds and to check the alarms every two hours to make sure the alarms are on and functioning. A Tracking Report dated 3/10/13 at 6:50 p.m., documented the resident fell in the bathroom and sustained a bruise to the left buttock. A Tracking Report dated 3/13/13 at 6:50 a.m., documented the resident fell in the room near the rooms doorway and sustained a skin tear to the right arm. A Tracking Report dated 3/14/13 at 4:00 p.m., documented the resident was found sitting in front of a recliner in the bedroom. The chair alarm was in the recliner but not on and not sounding. The Tracking Report documented the resident had similar incident occurrences on 2/9/13, 3/10/13, and 3/13/13. The Tracking Report recommended staff check alarms for functioning at 2:00 p.m. and toilet the resident at 4:00 p.m. Nurse notes dated 3/14/13 at 4:00 p.m., documented the resident did not complain of pain with range of motion but had limited left upper extremity movement related to an old injury. A Tracking Reported dated 3/15/13 at 3:20 p.m., documented the resident fell in the bathroom with no apparent injury. The Tracking Report documented the alarm was not on and was not sounding. The Tracking Report documented the resident had two similar incident occurrences in the last five days. A Tracking Report dated 4/6/13 at 4:50 p.m., documented the resident fell in the bathroom and sustained a 5 centimeter by 4 centimeter bruise to the right lower back. The Tracking Report documented the alarm was on but not sounding. The Tracking Report documented the resident was toileted at 4:00 p.m. and put in the recliner. The Tracking reported recommended staff make sure all alarms are on and functioning at the start of each shift and every one and a half to two hours after that. A Tracking Report dated 4/13/13 at 2:30 a.m., documented the resident fell in the room and sustained a skin tear to the right hand and the alarm was not on. Record review revealed the resident had 8 falls from 3/10/13 to 4/23/13 with injuries that included a left buttock bruise, right arm skin tear, skin tear to right elbow, skin tear to right upper arm, bruise on back, skin tear to right hand and large bruise to right hip. During interview on 8/22/13 at 9:46 a.m., Staff N, Certified Nurse Aide, CNA reported the resident could not unhook the alarm, as it would be too difficult for the resident. Staff N reported the residents alarms are to be checked several times throughout the shift. During interview on 8/22/13 at 9:58 a.m., Staff Q, Registered Nurse reported the resident could not unhook the alarms and would sometimes use the call light. During interview on 8/22/13 at 10:15 a.m., Staff D, CNA reported the resident could not unhook the alarms. During interview on 8/22/13 at 10:30 a.m., the Director of Nursing reported the staff are to check the alarms throughout the shift to ensure it is in place and working.

Based on observation, clinical record review and interviews, the facility failed supervise care plan directives to ensure residents received adequate supervision against hazards or during transfers for 3 residents (Resident #12, Resident #8 and Resident #3). The facility reported a census of 66 residents with 15 residents reviewed. Findings include: 1. The quarterly MDS (Minimum Data Set) with an assessment reference date of 05/18/12 documented Resident #12 as severely impaired cognition with long and short term memory loss. The MDS indicated the resident required extensive to total assistance of one or more staff for activities of daily living including toileting, mobility, transfers, grooming and personal hygiene. The MDS indicated the resident had difficulty with balance unless stabilized by staff. The MDS indicated resident required a wheelchair for mobility propelled by self or staff. The MDS indicated the resident had occasional urinary incontinency and bowel incontinence. [DIAGNOSES REDACTED]. The fall risk assessment dated [DATE] scored the resident at 18 with 10 being a high risk for falls. The resident's individual care plan with an initiation date of 02/23/12 instructed staff that resident required 2 or more assistance for bed mobility, transfers and toileting, to reposition the resident every two hours, to check for incontinence and provide pericare followed by moisture barrier as needed. The MDS instructed staff to transfer the resident with a gait belt and two staff assistance, to utilize a high/low bed with a parameter (scoop) mattress in the low position, place fall mat at bedside whenever in bed. The staff were instructed to answer the call light as soon as possible, activate bed alarm while in bed, keep door to the bedroom at least slightly open for observation while in room. The care plan instructed staff to toilet resident at 8:00 p.m. and at midnight with rounds. The staff were instructed not to leave the resident alone on the toilet, to activate a chair alarm when the recliner, to utilize a lap buddy on the wheelchair when restless and place a personal alarm on the resident at all times. Review of clinical records on 07/26/12 revealed that Resident #12 had several falls, these the following: a.According to nurse ' s notes on 02/11/12 at 6:50 p.m. Staff Y, RN documented the resident had been trying to get out of bed and leaning forward, and had been transferred into the wheelchair by unnamed staff. The staff went across the room to assist the resident's roommate when they heard a thud sound and discovered the resident on the floor with an injury to the forehead. The physician had been notified and staff were instructed to monitor and if the resident had not improved to send to the emergency room . At 7:20 p.m. Staff Y noted the resident would not speak to staff, would not open the eyes and would not grip. At 7:35 p.m. Staff Y noted the resident slow pupil response but denied discomfort when asked if he/she had pain. At 9:15 p.m. Staff Y received an order from the physician to send the resident to the emergency room for assessment. At 9:35 p.m. the resident had been transferred to the emergency room per ambulance. On 02/12/12 at 00:45 a.m. the facility received a notification that the resident had been admitted to the hospital due to and elevate white blood count. A fall assessment form dated 02/11/12 documented prior to the fall, the resident was restless and trying to get out of bed so staff put him/her into the wheelchair. Staff when to the other side of the room to assist the resident ' s roommate when she heard a loud thud. The interventions included placing a fall mat at bedside, pericare provides and resident assisted to the bed. Changes made to care plan included a high/low bed in low position when in bed with the bed mat beside the bed. A Preliminary Radiology report dated 02/11/12 noted the resident had fallen at the nursing facility and had complaints of mental status, contusion/laceration to right forehead/top of head and neck pain. The report noted no acute intracranial trauma but notation of right anterior scalp swelling. A second report noted chronic odontoid fracture with significant anterolisthesis, increasing. b. According to nurse ' s notes, on 02/18/12 at 11:50 p.m. a staff certified nursing assistance (CNA) had found the resident on lying on the fall mat in front of the bed in a fetal position. The bed alarm had not sounded. As the CNA removed a body pillow from the bed the bed alarm sounded. The resident had been incontinent in the bed. Assessment by Staff Y, RN revealed no apparent injury. The staff assisted the resident off the floor and onto a commode. Staff Y documented that has the resident had been sitting on the commode, started to slide off, Staff Y noted that staff holding the gait belt kept the resident from sliding to the floor. A tracking form dated 02/18/12 noted interventions included assessment, assisted the resident from the floor with gait belt and two staff. Staff documented would continue to use high/low bed with bed in low position, fall mat, bed alarm and monitoring for need to take resident to the bathroom between 11:00 and 12:00 p.m. c. According to nurse ' s notes, on 03/0412 at 6:55 a.m. the resident had been found in the bathroom sitting on the wheelchair pedals on buttocks, facing the wall and right side facing the toilet. The assessment revealed no injury or redness noted to buttocks. the staff documented the resident had not activated the call light for assistance. There was no documentation regarding the alarms sounding. A tracking form dated 03/04/12 indicated the staff would add a chair alarm for wheelchair or recliner and a do not leave alone in the bathroom to the ADL sheet. The nurse ' s notes dated 03/17/12 at 00:30 a.m. documented the resident had been found on the floor mat. The resident had been trying to get to the bathroom. The resident's alarm had been sounding. The tracking form dated 03/17/12 noted the resident should be taken to the toilet with midnight rounds. According to nurse ' s notes, on 03/18/12 at 2:30 a.m. staff documented the resident fearful, grasping hands and saying don't leave me. The staff documented a grey/blue bruise had been noted on the resident's right inner thigh. On 03/20/12 at 9:00 p.m. staff documented the resident to be randomly crying out when staff members came near. The resident denied pain or discomfort but cried when staff attempted to assist him/her. The staff documented the staff resounded to alarms on 05/03/12 at 1:45 a.m., on 05/08/12 at 9:45 p.m. on 05/13/12 at 1:30 a.m., and on 05/17/12 at 8:10 p.m. with the resident found on the floor sitting on the fall mat after attempting to get out of bed without assistance. The staff documented no apparent injuries after these falls. Tracking forms for 05/03/12 indicated a perimeter mattress to bed along with previous interventions; on 05/08/12 interventions included taking the resident to the toilet at 10:00 p.m. and continue all other instated interventions. On 05/13/12 interventions included nurses monitoring for loose stools and take to the bathroom with midnight rounds. On 05/17/12 interventions added had been to place the resident in a wheelchair, offer snack and place at nurse ' s station when restless. d. On 06/03/12 at 7:40 p.m. the staff documented the resident had been found lying on the floor on his/her right side. The resident had removed the lap buddy and personal alarm. The chair alarm had not been sounding. The resident could not tell staff what he/she had been trying to do. The resident had range of motion three times but complained of discomfort to right wrist telling staff do not touch it. The staff documented no bruising or swelling noted but resident refused to move fingers or squeeze hands. The staff documented notification to hospice and family but no documentation regarding notification to the resident's physician. At 11:30 p.m. staff documented the resident continued to complain of tenderness to right wrist, but refused ice for the area. The tracking form for 06/03/12 included intervention of giving pain and antidepressant medication rectally as needed, continue to monitor, and possibly one to one monitoring. A Radiology report dated 06/04/12 of the residents ' right wrist and forearm noted an oblique fracture of the distal ulna shaft is demonstrated without significant angulation or displacement approximately 4 centimeters proximal to the wrist joint. On 06/04/12 at 10:45 a.m. the staff documented the hospice nurse notified of resident continuing to guard/favor the right hand and arm. The resident had been given OxyContin with minimal relief. At 11:20 hospice staff gave the facility and order to call for an x-ray to the area. At 12:45 p.m. the x-rays were completed. At 3:00 p.m. the facility received an order for [REDACTED]. On 6/15/12 at 11:30 p.m. the bed alarm sounded and the resident had been found on the fall mat on the floor. The personal alarm had been attached to the resident and not sounding. The bed alarm sounded. Tracking form for 06/15/12 included interventions for increasing antianxiety/ antidepressant medication and continue with pain medication as needed. A Radiology report dated 06/18/12 indicated a comparison study showed a transverse fracture of the distal third of the ulna with slight overriding of the fracture ends on the AP view. e. On 07/02/12 at 9:30 p.m. Staff B documented a CNA had called her into the resident's room to examine the residents left wrist that had a 13 by 16 centimeter raised blue, purple bruise that wrapped almost completely around the wrist. Staff B documented the resident denied discomfort. The hospice nurse, in the building, had been made aware of the bruising. At 8:00 p.m. the wrist remained bruised with the bruising wrapping around the wrist. On 07/02/12 interventions included discussing with hospice on possible causes of the injury and possibly getting a splint for the left arm for added protection. On 07/03/12 at 1:00 p.m. staff documented the left wrist remained bruised but no change in size and resident denied discomfort. f. According to the nurse ' s notes, on 07/21/12 at 2:00 p.m. staff documented the resident had been complaining of pain to the left wrist, guarding the arm and refusing to let staff move or touch the area. The staff noted a 3 by 2.5 centimeter raise area with a green/yellow bruise. Pain mediation had been given and the resident had been resting. At 8:00 p.m. the resident continued to complain of discomfort and guarding of the area. According to the nurse ' s notes, on 07/22/12 at 00:30 a.m. Staff Y documented resident complained of discomfort with assessment to the left wrist that noted a small gray/green bruise near the wrist area. At 1:45 p.m. the staff documented the resident refused use of the left wrist and arm on that shift. At 9:30 p.m. Staff Z documented the resident continued to guard the left wrist and arm and complain of pain when touched. Staff Z documented a faint green/yellow bruise but noted the resident could move fingers freely and continued to propel self in the wheelchair using both hands. On 07/23/12 at 12:45 p.m. the facility received an order from Hospice for x-ray of left arm and to repeat x-ray of right arm. A radiology report dated 07/23/12 noted exam of the left forearm revealed a nondisplaced fracture distal third of the left ulna, with the bones osteopenic. The wrist view showed no fracture to the wrist. The right arm follow up showed oblique fracture distal third of right ulna with incomplete healing. On 07/24/12 Staff S documented the facility received results of x-ray which noted the resident to have a fractured left ulna from the hospice nurse. Staff S documented the facility would begin an investigation into the circumstances of the fractured ulna. On 07/30/12 at 8:45 a.m. the examining physician from the resident fall on 07/23/12 stated that he felt the fracture of the ulna bones could not have happed from a fall. The physician stated this injury coupled with the one to the right ulna a month ago just did not look right and felt it needed to be looked at. The physician stated he felt this type of fracture usually resulted from a defensive move or the resident striking the arm on something hard enough to fracture a long bone. The facility investigation conducted by the DON (not dated) stated that she had received a report from the resident's hospice nurse that the resident had an injury to the left arm which the X-ray had revealed as a fracture to the third distal of the ulna. At 10:20 a.m. the facility Administration spoke with the examining physician who stated he felt the mechanism for the fracture resulted from the resident hitting something or a defensive injury such as blocking a blow. The physician stated he could not say which one is the cause but does not feel it had occurred from a fall or catching arm in a wheelchair. The Administration made the decision to move the resident closer to the nursing station. The DON and the Administrator conducted interviews with staff regarding the injury. On 07/27/12 at 10:30 a.m. Resident #12 could not respond to questions regarding the fractures that he/she had received to the right and left ulna bones. On 07/26/12 at 11:05 a.m. Staff D stated that she and a hospice nurse had transferred Resident #12 from the bed to wheelchair because of the resident had been restless. She stated they were attending to the resident's roommate when they heard Resident #12 fall. She did not say that they had placed an alarm or lap buddy on the resident. On 07/30/12 at 11:35 a.m. on a follow up interview Staff D stated that she did not remember the name of the hospice nurse that she had been assisting. She stated she did not remember if Resident #12 had a lap buddy at the time of the fall. During an interview on 07/30/12 at 11:00 a.m. Staff Y stated that regarding Resident #12's fall on 02/11/12, she had just started her shift when Staff D came and told her that Resident #12 had fallen and was on the floor. Staff Y stated she entered the resident's room and found the resident lying on the floor. Staff Y stated as she began to assess the resident, the resident became gaggy, would not verbalize and would not cooperate with the exam. Staff Y stated Staff D told her "they" had transferred the resident into the wheelchair because of restlessness. Staff Y stated she did not know who Staff D had been referring to. Staff Y stated she had done the charting on the fall because Staff D had been trying to finish her shift end tasks. On 07/30/12 at 8:30 a.m. Resident #12's Hospice nurse stated that Staff D had approached her on 07/23/12 and stated the resident had been complaining of discomfort since Friday. The Hospice Nurse stated Staff D asked her to assess the residents left arm because the facility staff had been watching it. The Hospice Nurse stated even though the bruising had faded, they ordered an x-ray because the resident had been favoring the arm and complaining of discomfort. When the X-ray resulted with finding the fracture, the Hospice nurse spoke with Staff S because of the location of the fracture and the physicians concern of the unusual circumstances of the possible mechanisms for the fractures. During an interview on 07/26/12 at 12:00 noon, Staff N stated that the staff are expected to use a gait belt on any resident who requires physical assistance for transfers. Staff N stated Resident #12 is active, likes to toll around in the wheelchair, leaning forward and likes to move stuff around in the closet. Staff N stated last week that the resident would tell the staff not to touch his/her wrist during cares and started to favorite it. During an interview on 07/26/12 at 1:15 p.m. Staff B stated she had noticed a bruise on Resident #12's left wrist at the beginning of the month and reported to the resident's Hospice nurse, who told the staff to monitor the bruise. During an interview on 07/26/12 at 11:40 a.m Staff E stated that when she had started to get Resident #12 up on 07/23/12, the resident complained of discomfort and had been guarding the left wrist. Staff E stated they told me the resident had been guarding the wrist since the past week and hospice had been notified. Staff E stated she had no idea how the resident injured the wrist. During an interview on 07/30/12 at 12:30 p.m. Staff X stated on 06/30/12 she had been in a room with another resident when she heard Staff Z call for assistance in the C wing hallway. Staff X stated when she responded she noted Resident #12 on the floor. Staff X stated after Staff Z checked the resident out, the staff applied a gait belt and assisted the resident back in to the wheelchair. Staff X stated the resident's lap buddy had been lying on the floor and she did not recall the alarm sounding. Staff X stated the resident did guard his/her right arm. Staff X stated they reported the resident guarding her right arm to Staff Z. During an interview on 07/30/12 at 12:40 p.m. Staff Z stated on 06/03/12 she found Resident #12 on the floor in the C-wing hallway. She stated the resident had removed the lap buddy and the had unclipped the personal alarm from the back of his/her shirt. Staff Z stated the alarm had not been sounding. Staff Z stated the resident had been restless all of the shift and had been self-propelling the wheelchair in the hallway. Staff Z stated as they were assessing the resident, he/she would not move the fingers or squeeze his/her hands. Staff Z stated she did not see any bruising at that time. Staff Z stated she had been concerned about the wrist so called hospice nurse to report the fall and complaints of discomfort. Staff Z stated she had been given and order to give pain and anti-anxiety medications rectally since the resident would not take anything by mouth. Staff Z stated since the resident had remained restless most of the shift they just placed him/her at the nurse ' s station with staff. Staff Z stated she did not recall any bruising to the resident ' s left arm on 07/02/12 but had worked on 07/22/12 when the resident had been complaining of pain in the left arm. Staff Z stated there had been just a faint bruise on the arm and the resident had continued to self-propel the wheelchair using both hands. Staff Z stated had not heard of the resident falling or anything so had no idea how the new fracture could have happened. 2. The Minimum Data Set (MDS) assessment with reference date of 11/4/11, identified Resident #8 with a brief interview for mental status (BIMS) score of 8 indicating some short and long term memory deficits and impaired cognitive skills for daily decision making (the BIMS scale for cognitive impairment states a score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, and 13-15 indicates the resident is not cognitively impaired). The MDS revealed Resident #8 required extensive assistance with physical assist of one staff with transfers, bed mobility, dressing, toilet use, personal hygiene and bathing. The resident was assessed as needing limited assist of one staff member for walking in his/her room. Resident #8's primary [DIAGNOSES REDACTED]. During an interview with the MDS nurse, Staff H, at 10:30 a.m. on 7/26/12, she stated she assesses residents ADL ability by reviewing the Activities of Daily Living (ADL) Questionnaire filled out by CNA staff and by interviewing nursing staff. When a MDS is due for review the ADL Questionnaire will be filled out by staff for seven days. (Review of Resident #8's ADL Questionnaire, dated 10/29/11-11/4/11, revealed staff provided physical assistance during transfers for seven of seven days on day and evening shifts. During this time the resident did not transfer independently.) Fall Risk assessment dated [DATE] indicated Resident #8 as high risk for falling with a score of 16 (10 or greater indicates high risk for falling). The resident's gait/balance assessment on the Fall Risk Assessment stated the resident had a balance problem while standing and walking. A Rehabilitation Services Screening Form was completed by a Physical Therapy Aide (PTA) on 8/5/11. The resident had difficulty with standing, walking, transferring, and rising. The PTA identified the resident demonstrated key indicators for physical therapy intervention. A quarterly Social Progress note dated 11/8/11 stated the resident needed assist to get into and out of bed but was independent with the rest of the activities of daily living. Review of the resident's Treatment Schedule flowsheet dated November 2011 and December 2011 revealed transfer of Resident #8 from bed to wheelchair or commode was to be done with the assist of one staff. This was noted as an FYI (for your information) to staff. Staff stated the Treatment schedule was kept on the medication cart with the resident's Medication Administration Record (MAR) for staff reference. The resident's plan of care with goal dates of 11/19/11 and 2/11/12 indicated Resident #8 was at risk for falls related to a history of falls, problem with balance, weakness, fall risk assessment, bladder incontinence, compromised health, periferal neuropathy, degenerative joint disease of the knees, and early Parkinson's disease. The goal for the resident, revised on 11/19/11, was to transfer from bed to wheelchair and commode with staff assist of one to minimize fall risk throughout the next quarter. The care plan identified the resident at risk for falls and directed staff to provide: 1. Extensive assistant from of one staff for bed mobility and toileting. 2. Extensive assistant from of one staff and use of gait belt and ensure wheelchair brakes are locked with all shower transfers. 3. Assistance of one PRN (as needed), use of gait belt PRN 4. Complete fall assessment on me quarterly and PRN. 5. Non-skid footwear with transfers and ambulation. 6. Safe environment clear of obstructions. 7. Non-skid strips added to the floor in front of my recliner (added 10-28-11). 8. Wheelchair brakes were tightened and the seat replaced (added 10-28-11) Review of Facility Tracking Reports for Resident #8 indicated falls occurring: 1. On 10-27-11 at 6:20 p.m. the resident was found on floor in room on buttocks. The resident stated his/her "knees gave out". No injuries to the resident were noted. New interventions added to the plan of care were non-skid strips on floor and wheelchair brakes tightened. 2. On 12/27/11 at 6:40 a.m. resident was being transferred from commode to wheelchair by Staff G, Certified Nurse's Aide (CNA) without the aid of a gait belt. Staff G assisted the resident to stand and grip the wheeled walker. The CNA removed the commode from behind the resident and went to bring the wheelchair to the resident. The resident lost balance and was lowered to the floor. Staff F, Registered Nurse (RN) was called to assess the resident and no injuries to the resident were noted. Intervention noted on the Tracking Report was " nursing staff to use gait belt for all transfers". This intervention was not added to the plan of care. During a telephone interview on 7/26/12 at 8:00 a.m., Staff G reported she did not use a gait belt to assist with Resident #8's transfer on 12/27/11 and could not recall why she did not. Staff G stated she assisted Resident #8 up (out of bed) and as the resident held onto his/her wheel walker, she removed the commode and Resident #8 started to fall. Staff G stated usually there were two (2) CNAs in the room to help but on this day it was just herself. Staff G reported when there were two (2) CNAs she would go get a gait belt but her CNA coworker sometimes told her they did not need to use one. Staff G stated this was confusing to her and she did not use one on 12/27/11. Staff G stated she usually used a gait belt to help the resident up (and when transferring other residents too). During an interview with Staff F (RN), on 7/25/12 at 7:00 a.m., she stated she was surprised that Staff G attempted to transfer Resident #8 without a gait belt. Staff F stated all residents who required minimal assist of one help or more (excluding mechanical transfers) should have a gait belt used when being transferred. She recalled the resident required assist first thing in the morning and as the day progressed was independent in his/her room. Review of Nurses Notes for 12/27/11 at 6:40 a.m. revealed Staff F documented she instructed Staff F never to transfer this resident without a gait belt and to "always use a gait belt even if you are not making much contact with resident". During an interview at 12:30 p.m. on 7/26/12 Staff M, Restorative Aide (RA) revealed staff policy is to use a gait belt for any resident that requires any kind of physical assist. Staff M defined "physical assist" as assist that requires staff to touch the resident. Four CNAs, Staff I. J, E, and L were interviewed separately on 7/25/12 throughout the day and all stated they were to use gait belts when transferring or ambulating any resident who required any physical assistance. All four staff agreed Resident #8 required assistance first thing in the morning to get out of bed and to use the commode. Later in the morning the resident was independent in his/her room. Investigation revealed information on transfer and ambulation status was kept in the CNA ADL book at the nurse ' s station and noted on the resident's care plan sign posted on the inside door of each room. During an interview with the Director of Nurses on 7-25-12 at 8:00 a.m., she stated the resident needed assistance in the morning for getting out of bed. She stated after the resident was "up and going" in the morning she was independent in his/her room. The resident used a wheelchair for locomotion outside of his/her room. She would expect her staff to use a gait belt for residents who were care planned for assist with transfers. 3. The annual MDS (Minimum Data Set) with an assessment reference date of 07/06/12 documented Resident #3 with a BIMS (brief interview for mental status) score of three (3) which indicated severely impaired cognition. The MDS indicated the resident required total assistance for all activities of daily living including toileting, mobility, transfers, grooming and personal hygiene. The MDS indicated the resident had difficulty with balance unless stabilized by staff. The MDS indicated the resident showed functional limitations in one side of the upper extremities and both sides of the lower extremities. The resident required a wheelchair for mobility propelled by self or staff. The MDS indicated the resident had frequent urinary incontinency and bowel incontinence. [DIAGNOSES REDACTED]. The resident's individual care plan with an initiation date of 08/31/10 instructed staff assist to the toilet with two or more staff before and after meals and two times during the night and as needed. The MDS instructed staff to transfer the resident with a gait belt and two staff assistance, to utilize a high/low bed in the low position, place fall mat at bedside whenever in bed. The care plan indicated the resident utilized a body pillow on outside of bed and to make sure the resident was scooted back in bed. The fall risk assessment dated [DATE] scored the resident at 14 with 10 being a high risk for falls. Observations on 07/23/12 at 7:45 a.m. revealed Staff O and Staff Q entered the resident's room to take the resident to the bathroom. Staff O placed a gait belt around the resident's chest and pulled the wheelchair into the bathroom. The staff assisted the resident to stand from chair and pivot turned to front of the toilet, Staff Q pulled the resident's clothing down and assisted the resident onto the toilet. The staff incorrectly placed the gait belt around the resident's chest to perform the transfer. Review of the clinical record on 07/25/12 revealed a notation dated 1/22/12 at 4:20 p.m. that indicated the resident had been found with a 15 by 15 centimeter dark purple bruise to the left upper arm. The notation indicated the bruise covered the circumference of the resident's arm and thought to be the exact size of a blood pressure cuff. On 01/22/12 a nursing home patient report to the physician informing him of the bruise noted the resident had been taking Coumadin (a blood thinner) 4 milligrams every day. Nurse's notes dated 1/31/12 through 02/03/12 documented resident had been treated for [REDACTED]. Nurse's notes dated 02/17/12 at 10:50 a.m. documented the resident had a green/purple bruise starting at the lower left neck extending to the posterior left shoulder green/yellow in color then extending to anterior shoulder, bright red and warm with three dark purple streaks noted. The bruise extended to the middle of the left upper arm with a dark purple color to the mid forearm yellow green in color. The area to the top of the left shoulder swollen and warm. The notes documented the area to be 56 by 40 centimeters in size. The staff documented the resident had been able to move the arm/shoulder freely, had brisk capillary refill, positive radial pulse and denied pain. The note also documented a fading light purple bruise to the lateral side of the resident's left breast. Nurse's notes dated 02/17/12 at 2:20 p.m. revealed the resident transferred to the hospital for x-rays and blood work. At 4:25 p.m. a notation indicated a major injury form had been faxed to the physician due to a report of a left humeral fracture. A nurse's note dated 02/17/12 at 3:50 p.m. indicated the facility received a report from the emergency room stating the resident had a third degree (complete separation) AC (acromio-clavicular) separation and humoral head with chronic subluxation (looseness). At 4:30 p.m. the resident had returned to the facility with a sling intact to the left arm. On 07/30/12 at 9:05 a.m. the resident's primary care provider stated, regarding the resident ' s dislocated shoulder, we are not sure if the injury was chronic or traumatic. He did not believe this injury was a fracture and it was not caused by the staff at the facility. The physician stated they had three different radiologists say three different things regarding the incident. The primary physician stated it was not a fracture and did not heal like a fracture. He stated the resident had severe arthritis and he believed the injury to be a result of degenerative changes from the arthritis. A radiology report dated 02/17/12 noted an abnormal lucency (degree of blackness on an x-ray, an area absorbing less radioactive energy, meaning less bone mass) of the of the superior humeral head which is concerning for a fracture. There are chronic degenerative changes of the left humeral head but these findings appear more prominent than those seen previously and are concerning for a fracture. The Glenohumeral (shoulder joint) alignment is abnormal and it is not clear if this is a chronic finding versus traumatic dislocation. The acromioclavicular joint (top joint of the shoulder) is also abnormally widened. A hand written note dated 02/20/12 attached to the report indicated the radiology report confirmed a third degree AC separation, and fractured humeral head with chronic subluxation. A radiology report dated 04/30/12 for revaluation of humeral head fracture, previous separation. The report indicated medial dislocation of subluxation of the humeral head with respect to the glenoid. The humeral head not well defined with lucencies consistent with a subacute fracture. The report indicated the appearance of the humeral head and it is alignment with the glenoid is similar to the study from 02/17/12. The internal investigation conducted by the facility director of nursing (DON) from 02/17/12 to 02/20/12 revealed that although the care plan directed staff to use a gait belt and two staff assistance for transfers, three of the four certified nursing assistants (CNA) Staff P, Staff R, and Staff V, interviewed stated they did not always use a gait belt when transferring Resident #3 although all stated they transferred with two staff. Staff R stated that at times if the resident had scooted down in the wheelchair staff may reach around from behind to pull th

Based on observation, staff interveiw and review of the menu, the facility failed to provide the meat specified by the menu, and failed to provide an egg option for residents recieving altered diets. The facilty census included 66 residnets. Findings included: 1. Observation on 7/24/12 at 7:30 a.m. showed the steam table contained a pureed substance identified as pureed sausage and toast. The menu indicated the ground diets should receive ground sausage, however, the menu signed by the dietitian directed one serving of pureed bacon for the pureed diets. The residents receiving regular diets received two slices of bacon for a serving. At 7:45 a.m. Staff A stated when asked, "pureed can't have bacon, it doesn't puree as well, it stays in chunks." The dietitian did not change and sign the menu for the substitution of pureed sausage for bacon, therefore the pureed diet residents did not recieve the meal according to the menu.

Based on observation, staff interview and menu review, the facility failed to ensure the residents received portions as specified by the menu, the menu failed to clearly identify the portion size for the noon meal entree', and failed to offer substitutions to the residents not able to speak for themselves, similar to those receiving regular diets who could state their preferences. The facility identifed a census of 66 residents. Findings included: 1. Observation on 7/24/12 at 7:30 a.m. showed hard boiled eggs offered for residents who ate independently and could state their preferences or wants. The steam table contained no pureed eggs or scrambled eggs. Staff A, cook, stated when asked; the eggs were an option and she did not have any prepared for pureed diets. She stated if they ask she would scramble some eggs for them. When asked if the people who received pureed diets were able to ask for an egg if they wanted one, Staff A confirmed not all of them would be able to ask. Since eggs were an available option, but not prepared in a manner in which those receiving pureed or altered diets could consume, if the residents did not consume the pureed sausage toast mixture, they would not have gotten a protein for breakfast. Observation on 7/24/12 at the noon meal, the menu directed to serve "one square" of meatloaf per resident. The menu did not specific ounces or dimensions of the size square to serve. The menu was signed by the dietitcian. The meatloaf was prepared in long round shapes and was cut with a spatula into portions. The portions were not weighed so there was no way to be certain what the residents received or what they should have received.

Based on observation of the breakfast meal the facility failed to ensure the dry cereal was served in a sanitary manner. The facility identified a census of 66 residents. Findings included: 1. Observation at 7:40 a.m. showed dry cereal in bowls stacked according to kinds, Cheerios, Captain Crunch, corn flakes, Bran Buds, and Cocoa Krispies; with the cereal in one bowl in contact with the bottom of the next bowl. Staff A, cook, would serve the top bowl of a stack, and the next bowl showed there was nothing to prevent the cereal from coming into contact with the bottom of the bowl she had just removed. Any debris possibly on the bottom of a bowl on top could contaminate the cereal in the bowl beneath it.

Based on observation and staff interview the facility failed to ensure Lantus insulins were discarded after twenty-eight days if not used entirely. The facility also failed to ensure refrigerator medications such as suppositories were monitored and discarded when expired. The facility identified a census of 66 residents. Findings included: 1. According the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] from 3:38 P.M. to 5:10 P.M. during the Environmental Tour and routine check of the medication rooms, the vial of Lantus insulin marked for Resident #9 was dated as opened on [DATE] and Staff B confirmed she had administered the daily insulin dose to Resident #9 from that vial on [DATE]. Lantus insulin should be discarded 28 days after opening. A vial of Lantus insulin for Resident #17 dated as opened on [DATE]. The [DATE] MAR indicated [REDACTED].M. The facility policy for safe use of medical liquids and ointments directed staff dates must be put on all vials, and bottles whem opened, and if a container is found without a date it must be destroyed. Insulin: 28 days after seal is removed. In Medication Room C/D 5 unopened stock bottles of Good Neighbor Pharmacy liquid antacid 130 milliliter (ml) bottles were found with expired dates-expiration ,[DATE] (3 bottles), expiration ,[DATE] (one bottle), expiration ,[DATE] (one bottle). In Medication Room A/B 5 unopened bottle of Good Neighbor Pharmacy liquid antacid 130 milliliter (ml) bottles were found with expired dates-expiration ,[DATE] (4 bottles), expiration ,[DATE] (one bottle). In Medication Room A/B a total of 75 stock doses of biscodyl suppositories with expiration dates of ,[DATE] and ,[DATE] were found in the refrigerator. In Medication Room A/B in the refrigerator four doses of biscodyl suppositories for Residnet #18 were found with expiration dates of ,[DATE]. An interview with Staff C revealed Resident #18 had a suppository in July. The resident's MAR indicated [REDACTED].

Based on observation, clinical record review and interviews, the facility failed to report a injury of unknown origin for 1 of 15 (Resident #3)standard sampled residents. The facility reported a census of 66 residents. Findings included: 1. The annual MDS (Minimum Data Set) with an assessment reference date of 07/06/12 documented Resident #3 with a BIMS (brief interview for mental status) score of three (3) which indicated severely impaired cognition. The MDS indicated the resident required total assistance for all activities of daily living including toileting, mobility, transfers, grooming and personal hygiene. The MDS indicated the resident had difficulty with balance unless stabilized by staff. The MDS indicated the resident showed functional limitations in one side of the upper extremities and both sides of the lower extremities. The resident required a wheelchair for mobility propelled by self or staff. The MDS indicated the resident had frequent urinary incontinency and bowel incontinence. [DIAGNOSES REDACTED]. The resident's individual care plan with a initiation date of 08/31/10 instructed staff assist to the toilet with two or more staff before and after meals and two times during the night and as needed. The MDS instructed staff to transfer the resident with a gaitbelt and two staff assistance, to utilize a high/low bed in the low position, place fall mat at bedside whenever in bed. The care plan indicated the resident utilized a body pillow on outside of bed and to make sure the resident was scooted back in bed. The fall risk assessment dated [DATE] scored the resident at 14 with 10 and above being a high risk for falls. Observations on 07/23/12 at 7:45 a.m. revealed Staff O and Staff Q entered the resident's room to toilet resident. Staff O placed a gaitbelt around the resident's chest and pulled the wheelchair into the bathroom. The staff assisted the resident to stand from chair and pivot turned to front of the toilet, Staff Q pulled the resident's clothing down and assisted the resident onto the toilet. The staff incorrectly placed the gaitbelt around the resident's chest to perform the transfer. Review of the clinical record on 07/25/12 revealed a notation dated 1/22/12 at 4:20 p.m. that indicated the resident had been found with a 15 by 15 centimeter dark purple bruise to the left upper arm. The notation indicated the bruise covered the circumference of the resident's arm and thought to be the exact size of a blood pressure cuff. On 01/22/12 the facility completed a nursing home patient report for the physician informing him of the bruise and noted the resident had been taking [MEDICATION NAME] (a blood thinner) 4 milligrams every day. Nurse's notes dated 1/31/12 through 02/03/12 documented resident had been treated for [REDACTED]. Nurse's notes dated 02/17/12 at 10:50 a.m. documented the resident had a green/purple bruise starting at the lower left neck extending to the posterior left shoulder green/yellow in color then extending to anterior shoulder, bright red and warm with three dark purple streaks noted. The bruise extended to the middle of the left upper arm with a dark purple color to the mid forearm yellow green in color. The area to the top of the left shoulder swollen and warm. the notes documented the area to be 56 by 40 centimeters in size. The staff documented the resident had been able to move the arm/shoulder freely, had brisk capillary refill, positive radial (at wrist) pulse and denied pain. The note also documented a fading light purple bruise to the lateral side of the resident's left breast. Nurse's notes dated 02/17/12 at 2:20 p.m. revealed the resident transferred to the hospital for x-rays and blood work. At 4:25 p.m. a notation indicated a major injury form had been faxed to the physician due to a report of a left humeral fracture. A nurse's note dated 02/17/12 at 3:50 p.m. indicated the facility received a report from the emergency room stating the resident had a third degree (complete separation) AC (acromio-clavicular) separation and humoral head with chronic subluxation (looseness). At 4:30 p.m. the resident had returned to the facility with a sling intact to the left arm. A radiology report dated 02/17/12 noted a abnormal lucency (degree of blackness on an x-ray, an area absorbing less radioactive energy, meaning less bone mass) of the of the superior humeral head which is concerning for a fracture. There are chronic [MEDICAL CONDITION] changes of the left humeral head but these findings appear more prominent than those seen previously and are concerning for a fracture. The Glenohumeral (shoulder joint) alignment is abnormal and it is not clear if this is a chronic finding versus traumatic dislocation. The acromioclavicular joint (top joint of the shoulder) is also abnormally widened. A hand written note dated 02/20/12 attached to the report indicated the radiology report confirmed a third degree AC separation, and fractured humeral head with chronic subluxation. A radiology report dated 04/30/12 for revaluation of humeral head fracture, previous separation. The report indicated medial dislocation of subluxation of the humeral head with respect to the glenoid. The humeral head not well defined with lucencies consistent with a subacute fracture. The report indicated the appearance of the humeral head and it is alignment with the glenoid is similar to the study from 02/17/12. On 07/25/12 at 11:30 a.m. Staff S, DON (director of nursing) stated that she did conduct an investigation into circumstances of the injury but could not determine a cause. She stated the facility did not report the injury because the physician signed that the injury was not a major injury. Both Staff T, Administrator and Staff U, the facility Nurse Consultant agreed with the DON that they had followed the major injury determination sheet. On 07/26/12 at 8:30 a.m. Staff S stated the facility had no incident reports on this injury and the documentation that they had regarding the injury could be found in the nurses notes and from her internal investigation. The internal investigation conducted by the DON from 02/17/12 to 02/20/12 revealed that although the care plan directed staff to use a gaitbelt and two staff assistance for transfers, three of the four certified nursing assistants (CNA) Staff P, Staff R, and Staff V, interviewed; stated they did not always use a gaitbelt when transferring the resident although all stated they transferred with two staff. Staff R stated that at times if the resident had scooted down in the wheelchair staff may reach around from behind to pull the resident up in the chair. Staff C stated a family member of the resident told her that he/she adjusted the resident in the wheelchair by lifting the resident from behind. On 07/26/12 at 12:20 p.m. Staff M, CNA stated that the resident had a history of [REDACTED]. They had discontinued exercises to the right upper extremity but continued with the left to the resident's comfort level. Staff M stated that the resident scoots to the front of the wheelchair but she always uses a gaitbelt to adjust the resident. On 07/26/12 at 12:45 p.m. Staff C, (RN) Registered Nurse, stated she did not believe she had been the first nurse who assessed the bruising to the resident. Staff C stated a member of the resident's family told her when pulling the resident up in the chair he/she would reach the resident from behind under the resident's arms, pulling the resident up and back. Staff C stated she expected the staff to use a gait belt and use two staff assistance to transfer or to pull a resident up in a wheelchair. On 07/26/12 at 1:00 p.m. Staff P stated initially, the resident denied discomfort from the bruise on his/her arm, but about a week later; did start to complain of discomfort. Staff P stated prior to the resident's injury to the shoulder she did not always use a gaitbelt when transferring the resident. She also noted, prior to the injury, staff would lift the resident under the arms to adjust in the wheelchair although now, they always used a gaitbelt and two staff to adjust the resident in a chair or for transfers. On 07/26/12 at 1:15 p.m. Staff B, LPN (licensed practical nurse), stated the resident had shoulder problems and would complain of discomfort. She stated initially the bruising showed up, but it was after the resident started to complain of pain; and was sent to the emergency room for x-rays which showed the fracture and dislocation. Staff B stated the expectation is all staff use gaitbelts and assistance of two on dependent residents. Staff b stated she has never seen any staff lifting residents or transferring without a gaitbelt. On 07/26/12 at 1:30 p.m. Staff R stated she had seen the bruise on the resident's shoulder and upper arm and informed the nurse who had already been made aware of the bruise. Staff R stated she had not heard the resident complain of pain to the shoulder. Staff R stated that she uses a gaitbelt and two staff or pulls on the back of the residents pants to adjust residents sitting in wheelchairs. Staff R stated she had viewed the resident's family member lift the resident under the arms to adjust in the wheelchair a "couple of times." Staff R stated she transferred the resident one time without a gaitbelt when the resident had been sliding out of the wheelchair. On 07/30/12 at 12:30 p.m. Staff X stated she vaguely remembered the resident wearing a sling on her shoulder. She stated she doesn't know how the injury occurred but someone told her it happened during a transfer. Staff X stated if the resident was having a good day, she would transfer the resident with a gaitbelt and one assist; but if the resident was unsteady, she would get another staff to help her. Staff X stated she had seen the resident's family readjust the resident in the wheelchair by pulling the resident up and back by lifting under the arms. On 07/30/12 at 9:05 a.m. the resident's primary care provider stated he did not believe this injury was a fracture and not had been caused by the staff at the facility. He stated the resident had severe arthritis and believed the injury to be a result of [MEDICAL CONDITION] changes from the arthritis. The primary care provider stated he did not believe the injury to be a major injury and that was why the facility did not report the injury.

Based on observation, clinical record review and staff interview the facility staff failed to maintain the dignity of 1 resident, Resident #1, of 16 sampled residents by not protecting personal privacy during toileting. The facility reported a census of 76 residents. Findings included: 1. The Minimum Data Set (MDS), with a reference date of 03/04/11, documented Resident #1 had a brief interview for mental status (BIMS) score of 12 which indicated the resident to have moderately impaired cognition. The MDS indicated the resident required extensive assistance from one staff member for activities of daily living including toilet use, personal hygiene,and transfers. The MDS indicated the resident had inability to stabilize self without assistance from staff. The MDS documented the resident [DIAGNOSES REDACTED]. The MDS documented the resident as frequently incontinent of urine. The resident's care plan with a goal date of 6/01/11 instructed staff to provide extensive assist with toileting and personal hygiene. The care plan instructed staff to place a commode at bedside after resident was in bed for the night. On 06/01/11 at 6:45 a.m., after knocking on the door, and having Staff G bid permission to enter, this surveyor entered the Resident #1's bed room. Observations revealed Resident #1 sitting on the commode (a portable toilet) located at bedside. The privacy curtain had not been pulled around the resident's bed. The resident's roommate lay sleeping in the next bed. After explaining to the resident and the staff that the surveyor would be observing staff care for the resident, Staff G stated she needed to get supplies, exited the room leaving the bedroom door to the hallway opened exposing the resident to persons passing in the hallway. Staff H entered the room, immediately closed the door and pulled the privacy curtain around the resident. As Staff G re-entered the room, Staff H instructed her to always make sure the to close the door and close the privacy curtain when a resident was using the toilet. The facility policy for perineal care dated 12/02/09 instructed to staff to provide privacy prior to providing personal care for residents. On 06/02/11 at 9:45 a.m. Staff I stated she would expect the staff to always provide privacy by pulling the privacy curtain and/or closing the bedroom door to any resident that had been receiving toileting or personal hygiene.

Based on observation, review of clinical records, facility policy/procedures and manufactures recommendations and staff interviews, the facility failed to provide adequate supervision for Resident #2 which resulted in a fall with major injury and failed to provide safe transfer techniques for 2 of 6 residents reviewed (Resident #1, #3). The facility reported a census of 74 residents. Findings include: 1. The admission Minimum Data Sheet (MDS) assessment with a reference date of [DATE] identified Resident #2 with moderately impaired cognitive skills for daily decision making with long and short term memory loss. The MDS revealed the resident required limited to extensive assistance from staff for bed mobility, transfers, toilet use, dressing, and bathing. The MDS documented the resident [DIAGNOSES REDACTED]. The care area assessment dated [DATE] indicated the resident had been admitted to the facility following falls at home and had increased memory loss and lack of safety awareness. A Care Plan with a focus target date of [DATE] identified the resident with potential for falls/injury related to a history of falls at home, weakness, and impaired cognition. The Care Plan directed staff as follows: activate chair alarm when in wheelchair or recliner, use assistance of one staff, gaitbelt and walker with all transfers and ambulation, and use non skid footwear with transfers and ambulation. A care plan revision dated [DATE] directed staff to toilet the resident after supper and place in a recliner or bed. A second revision dated [DATE] directed staff to use a high/low bed in low position when the resident in bed and to take to the toilet every 2 to 3 hours and before meals. A third revision [DATE] directed staff to use a lap buddy when in a wheelchair but could be off for meals or during one to one interactions with staff. A Fall Risk Assessment could not be located in the resident's clinical record. A Radiology Report [DATE] documented an impression as a varus angulated left femoral neck fracture (fractured hip). A Nurses Notes entry dated [DATE] at 9:00 a.m. indicated the resident was found on the floor in hallway. The resident could not bend/straighten the left leg. A bruise was noted to the left hip area. The resident could not bear weight on the left leg. The nurse received a telephone order from the doctor to send the resident to the emergency room and resident to use lap buddy. At 9:35 a.m. resident left the facility per ambulance and went to the emergency room . A Nurses notes entry dated [DATE] at 1:15 p.m. indicated the family notified the facility the resident had been transferred to another hospital for treatment of [REDACTED]. A Nurses note entry dated [DATE] at 10:00 p.m. indicated the hospital notified the facility that the resident had died at 9:25 p.m. A Tracking Report dated [DATE] indicated Resident #2 was found on the floor in the hallway. The resident laid on her/his back and voiced complaints of left hip discomfort, had a 2.5 centimeter light blue bruise was present. Range of motion revealed to be within normal limit. No other injuries were observed. An additional notation added to the report by Staff A indicated the resident had been in the wheelchair by the nurses station when the event occurred, alarm sounded and the resident wore non skid footwear. The tracking report indicated the resident had similar falls on [DATE], [DATE], and [DATE]. The report indicated Staff A had stated the resident had cognition deficits affecting safely awareness and extent of limitations. The tracking form indicated the facility corrected or prevented another incident by applying a lap buddy to the wheelchair to prevent the resident from leaning forward from the wheelchair. The tracking form also noted the resident had other interventions in place at the time of the fall such as chair alarm, toileting every 2 to 3 hours and before meals, medications and a high/low bed in the lowest position. In a telephone interview with the resident's primary physician on [DATE] at 4:50 p.m., the physician affirmed hip fractures do contribute to a high mortality rate for the elderly but could not confirm this hip fracture contributed to the resident's death. On [DATE] at 5:15 p.m. Staff A (Director of Nursing) was interviewed and revealed she/her heard a page for a nurse to C-wing. Staff A stated she/he could not respond immediately as the call came but followed up in a few minutes to see the resident on the floor by the north nurses station. Staff A stated she saw two of the staff nurses assessing the resident with other staff present. Staff A stated she spoke with the staff nurses shortly after they transferred the resident to his/her bedroom. The staff prepared the resident to be sent to the hospital. The staff obtained orders for a lap buddy for when the resident returned from the hospital. Staff A stated she had checked with the staff to find out their location during the incident and discovered Staff L and one C.N.A. with a resident on C-Wing, Staff M was in the shower room by the nurses station, Staff H was cleaning a room midway down on C-wing. Staff I, on B-wing responded to the page to C-wing. Staff A stated with the resident's episodes of increased anxiousness and bouts of restlessness, staff were used the current interventions already established. Staff A noted with the resident's increased anxiety would have wanted the staff to place the resident where he/she could be monitored or ask activity staff to see if their department could help provide some one on one to help calm the resident down. During an interview on [DATE] at 8:00 a.m. Staff H (housekeeping and Certified Nursing Assistant) stated on [DATE] she/he made beds on C-wing, two doors away from the resident's room when she/he heard an alarm sounding. Staff H stated she/he went into the room and found the resident standing up in the corner beside a wheelchair and the wall. Staff H stated she/he could not reach the resident, so left the alarm sounding to summon additional assistance. Staff H stated a physical therapy (PT) aide entered the room and able to get into the corner and assisted the resident to sit back into the wheelchair. Staff H stated the PT aide propelled the resident to the nurses's station. Staff H stated she/he continued with housekeeping duties and then heard an alarm sounding about 5 minutes later. Staff H stated she waited to see if any one at the nurses station responded and stated when she/he didn't hear any one after 1 to 1 ,[DATE] minutes, she/he went to see what had happened. Staff H identified about midway down the hallway and could see the resident on the floor flailing. Staff H stated the resident's wheelchair was located about 6 steps away from where the resident was located on the floor. Staff H stated she/he went to the resident and tried to calm the resident while searching for any nursing staff around but could not locate any staff. Staff H stated she left the alarm sounding to summon help and a minute or so later Staff M poked her head out of the shower room, and she/he hollered for her/him to summon help. Staff M then paged for assistance over the intercom, and one of the nurses responded within a minute. Staff H stated the resident had been down on the floor for 5 to 7 minutes total time before assistance arrived. Staff H noted that it was unusual at that time of day that no staff had been at the north nurses station. In an interview on [DATE] at 9:17 a.m. Staff M, Certified Nursing assistant CNA) stated on [DATE] at approximately 9:30 a.m. she/he assisted a resident to shower in the bath/shower room by the north nurses station. Staff M stated when she/he exited the shower room she/he noticed the resident on the floor in front of the wheelchair with the alarm sounding and Staff H kneeling on the floor beside the resident. Staff H told Staff M needed help so switched off the alarm and paged for nursing assistance over the intercom. Staff M stated Staff J (CNA) and Staff K (CNA) came out of another resident's room to assist and Staff I, Licensed Practical Nurse (LPN) arrived with another nurse to assist. Staff M stated the staff assessed the resident and the resident seemed anxious to get up. Staff M stated since there was enough staff helping the resident, she/he returned to give showers.. During an interview on [DATE] at 9:26 a.m. Staff I (LPN) stated on [DATE] she had been assigned to work on the A-wing and heard a page for a nurse to C-wing Stat (immediately). Upon going down the hallway Staff I stated Staff M (CNA) and Staff H attended to the resident who was on the floor in front of a wheelchair and next to the nurses' station. Staff I stated it was approximately 20 seconds from the time of the page until she arrived on C-wing. Staff I stated the C-wing nurse who had been attending to another resident, arrived to the resident also. Staff I stated the staff made the resident comfortable on the floor, assessed the range of motion and for any skin or head injuries. Staff I stated the resident complained of pain with range of motion on the left leg. Staff I stated the resident insisted he/she needed to use the bathroom. Upon standing the resident up with the gaitbelt, the resident could not bear weight on the left leg. Staff I stated the resident had a bruise on the left hip. Staff I stated the resident was taken into the shower room to use the bathroom. Staff I stated the resident had a constant need to get up and down from chair to use the restroom. The resident required a chair alarm and would climb over the bedrails at night. Staff I stated the staff had tried several interventions with the resident including placing the resident in the hallway around the nursing station for additional supervision. During an interview on [DATE] at 9:45 p.m. Staff J (CNA) stated on [DATE] she had been attending another resident when she heard the page for a nurse to C-wing stat. She stated she ran out into the hallway and viewed the resident on the floor in front of a wheelchair with a couple of nurses and some aides took vitals and helped the resident into the wheelchair using a gaitbelt. Staff J stated this happened between 9:00 a.m. to 9:20 a.m. Staff J stated the staff took the resident into the showeroom because the resident needed to have a bowel movement. After the resident had finished toileting he/she was taken to the bedroom to get ready for transfer to the hospital. Staff J stated the resident left by ambulance about 15 to 20 minutes later. In an interview on [DATE] at 10:19 a.m. Staff K (CNA) stated on [DATE] Resident #2 fell in front of the nurses station from the wheelchair. Staff K described the resident as anxious and confused and would often try to stand or lift off of the wheelchair alarm pad so as an intervention, the CNA's were told to place the resident in the wheelchair and to let the resident propel self in the hall and to carefully watch and allow some freedom. On the day of the fall, Staff K stated she/he and Staff J attended to another resident when heard the page for assistance. Staff K stated both Certified Nursing Assistants poked their heads out of the door and saw the resident lying on the floor in front of the wheelchair with Staff H next to the resident and Staff M joined her. Staff K stated other staff were going toward the resident and Staff J went to assist as she/he (Staff K) finished with the resident they had assisted. Staff K stated when she/he completed the task and joined the other staff, Resident #2 had already been moved from the floor into the wheelchair. Staff K stated the staff took the resident into the shower room to use the bathroom and then into the bedroom to prepare for transfer to the hospital. On [DATE] at 10:42 a.m., Staff L, (Registered Nurse) had heard the page when in another resident's room. Staff L stated she immediately went down the hall way and saw Resident #2 lying on the floor in front of the wheelchair in front of the north nurse's station. Staff L stated other staff were around the resident. Staff L stated she and Staff I proceeded to assess the resident. Staff L stated prior to the incident, she/he saw the resident propelling self in the wheelchair by the nurses station. Staff L stated the resident did not ask for anything or say that he/she needed to use the bathroom. Staff L stated the resident had episodes of confusion and anxiety, always had to be doing something and did not like to sit still in the wheelchair. 2. Resident #1 had an Minimum Data Sheet (MDS) Assessment with a reference date of [DATE] which identified [DIAGNOSES REDACTED]. The MDS identified a BIMS ( Brief Interview for Mental Status) summary score of 4, which indicated moderately impaired cognitive status. The MDS identified the resident totally dependant on two staff for bed mobility, transfers, toilet use, dressing, and bathing. According to the MDS the resident weighed 191 pounds and height of 65 inches and required The MDS documented the resident had medications in the antipsychotic and antidepressant categories. A Care Plan with a Focus target date of [DATE] identified a problem with with self-care deficit due to impaired cognition, weakness, incontinence of bladder and impaired mobility. The Care Plan directed staff as follows: a. The resident may use active (sit to stand) lift or passive (Hoyer) lift for transfers. The Care Plan revision date of [DATE] revealed the facility discontinued the active lift and directed staff to only use the passive (Hoyer) lift for transfers. Observations on [DATE] at 3:40 p.m. revealed Staff C and Staff G transfer the resident from the bed to a wheelchair with the use of a passive (Maxi Mover) lift. Staff C positioned the wheelchair at the end of the bed and moved the lift over the bed which was in a high position. The lift sling had previously been placed under the resident and hooked to the lift spreader bar. Staff G controlled the lift and raised the resident approximately 18 to 24 inches off the bed. As Staff G pulled the lift away from the bed, the position of the resident revealed to be approximately 4 feet in the air. Staff G pivot turned the lift as Staff C stood behind the unlocked wheelchair, reached over and grabbed the back of the lift sling to guide the resident into the wheelchair, reaching down and locking the wheel brakes as the resident was lowered into the chair. On [DATE] at 5:00 p.m. Staff A stated when transferring a resident with a passive lift, the expectation is the bed should be placed in a low position and the resident raised to clear the bed just enough to prevent sheering. When Staff A observed the high bed position placement during the transfer, Staff A acknowledged the resident too high and unaware of a reason staff would have left the bed that high with transfers. On [DATE] at 5:15 p.m. when asked why the bed had been in the high position during the transfer, Staff C stated personal care had just been performed and had not lowered the bed. Staff G and Staff C stated had not thought about the potential for injury with the bed in a high position during transfers with the life. 3. Resident #3 had an MDS assessment performed with a reference date of [DATE]. The MDS identified a BIMS summary score of 6 which which revealed a cognitive status of moderately impaired. The MDS revealed the resident totally dependant on two staff for bed mobility, transfers, toilet use, dressing, and bathing. The MDS documented the resident required limited assist of one staff for eating. The MDS revealed the resident totally dependant on one staff for personal hygiene. The MDS documented the resident had difficulty with balance during ambulation or transfers. The MDS indicated the resident to have impairment on both sides of the body in functional range of motion. The MDS documented the resident [DIAGNOSES REDACTED]. The care plan with a Focus target date of [DATE] identified the resident with potential for falls/injury secondary to impaired cognition with [DIAGNOSES REDACTED]. The Care Plan directed staff as follows: Requires total assistance of two staff with transfers and ambulation in room. The Care Plan revision date of [DATE] revealed the need to use active lift and directed that wheelchair is the only mode of locomotion with staff propelling wheelchair majority of time. A Fall risk assessment dated [DATE] documented a score of 14 which indicated a high risk for falls. Observation on [DATE] at 8:45 a.m. revealed CNA Staff D and CNA Staff E entered the resident's room to transfer the resident from the wheelchair to the bathroom using a Sara Stand lift (active lift). Staff E placed the lift waist strap around the resident's waist as Staff D brought the active lift into the room and pushed it up to the wheelchair. The staff placed the resident's left foot on the lift platform. The resident's right leg with a contracture bent backward at the knee with the foot bent to the side. Staff placed the legs against the knee support. The resident could not straighten the leg to place right foot on the platform. Staff E obtained a small pillow and placed it between the resident's knees. The left foot was not flat on the platform. The staff placed the leg strap around the resident's lower legs. With Staff E running the lift controls, the resident was raised to a standing position, with the resident's left foot not flat on the platform, pulled the resident with the lift across the floor and maneuvered the lift into the bathroom. The lift placed against the stool and staff pulled the resident's clothing down lowered the resident onto the stool. The staff left the resident attached to the lift sitting on the stool. The staff closed the bathroom door, sanitized their hands and exited the room. When asked if the resident would call for assistance Staff E stated "either that or we will just come back pretty soon". At 8:55 a.m. the CNAs returned to the resident's room with Staff F LPN. Staff E noted the resident would be cleaned up and then Staff F would apply ointment to the resident. The staff entered the bathroom after donning gloves. Staff F running controls raised the resident into a standing position as Staff D and Staff E prepared for and provide pericare for the resident. As the resident maintained the standing position, the waist sling had displaced up moved around his/her chest area with the belt digging into the axilla. The residents arms bent into an awkward position and resident supporting his/her weight on the arms. The resident remained standing on one foot in the position described for approximately 15 during the pericare. After completing the pericare,the staff propelled the resident out of the bathroom and over to a recliner, lowered the resident into the recliner, removed the straps and pulled the lift away. The Manufactures operating instructions for the Sara Lift instructed that a full clinical assessment of the resident condition and suitability must be carried out by a qualified person. The instructions directed lift operators that when raising , check to ensure that the resident's feet do not lift from the foot support and if they do, lower the resident immediately until the resident's feet fully reach the foot support. On [DATE] at 9:15 a.m. when asked if they realized the location of the waist strap and how the resident's arms were bent during the transfer; staff acknowledged that they did not and agreed that the position could not have been comfortable for the resident. The staff stated they did not realize the transfer to be unsafe and a potential source for injury to the resident. On [DATE] at 1:00 p.m., Staff B stated that after the staff informed her of the surveyor's concerns regarding the resident's transfer, the facility requested a physical therapy consult to evaluate the resident's abilities.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision and provide a safe transfer technique for 1 of 6 residents reviewed (Resident #1). The facility reported a census of 76 residents. Findings include: 1. A History and Physical report dated 01/03/11 identified Resident#1 had [DIAGNOSES REDACTED]. The History and Physical indicated the resident to be lifted with a mechanical lift device at the nursing home facility. On 01/02/11 staff reportedly transferred the resident with the assist of two staff persons and the resident was lowered to the ground due to inability to bear weight. The resident resident immediately voiced complaints of pain. Resident #1 experienced pain throughout the nights and was transferred to the hospital on [DATE] for a femur x-ray. The x-ray displayed a distal femur fracture, distal to the intermedullary rod. The resident was admitted for pain control and an orthopedic consult. The History and Physical reported the resident to have significant Alzheimer ' s dementia, and was not able to describe the events of 1/02/11; however the resident had pain with any kind of movement. The Minimum Data Set (MDS) Assessment, with a reference date of 10/20/10 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) summary score of 8, which revealed a cognitive status of moderately impaired. The MDS revealed the resident totally dependent on two staff for bed mobility, transfers, toilet use, dressing, and bathing. A Care Plan with a Focus initiated date of 11/02/10 identified the resident with self-care deficit related to impaired cognition, weakness with [DIAGNOSES REDACTED]. The Care Plan directed staff as follows: May use active (sit to stand) lift or passive (Hoyer) lift for transfers. The Care Plan revision date of 01/04/11 revealed the active lift discontinued and directed staff to only use the passive (Hoyer) lift for transfers. The Therapy Discharge Summary dated 5/17/10 had recommendations for staff to use passive (Hoyer) lift for transfers with the resident. The Fall Risk assessment dated [DATE] identified the resident score as 15; a total score of 10 or above represented high risk. A Radiology Report dated 01/03/11 indicated a nondisplaced supracondylar fracture of the distal femur. (fracture of the upper leg bone nearest to the knee area). The Tracking Report dated 1/02/11 documented under section titled describe exactly what happened: Resident #1 was assisted by two staff with a gait belt to the bathroom, and then the staff attempted to transfer the resident back to the wheelchair, the resident ' s knees became weak and the resident was lowered to the floor with assist of the two staff. The Tracking Report revealed a question as follows: Was there anything that attributed to this incident The response documented the staff did not use active or passive lift for transfer- and used 2 staff with a gait belt per staff report due to the resident crying and not wanting to use the lift, and needed to use the bathroom. Observation on 01/18/11 at 9:30 a.m. revealed Resident #1 sitting in the wheelchair starring off into space; the resident did not maintain eye contact. Observation on 01/19/11 at 10:45 a.m. Staff D and Staff E both Certified Nurse ' s aides (CNA's) assisted the resident from the bed to the wheelchair with use of a passive lift with a safe technique used. The resident did moan during the transfer with a soft voice in which the resident stated " it hurts it hurts". Staff D and E both informed the nurse immediately of the resident ' s complaint of pain. During an interview on 1/19/11 at 11:00 a.m. with Staff D, CNA reported Resident #1 had never refused the lift. Staff D reported if a resident refused to use a lift she would educate the resident why the lift would be needed or get the nurse. Staff D reported Resident #1 had increased complaints of pain since the incident. During an interview on 1/19/11 at 11:10 a.m. with Staff E, CNA reported Resident #1 had never refused a lift transfer. Staff E reported if a resident refused to use the lift for transfers she would encourage the resident to use the lift. Staff E reported good judgment would be needed and the only way to transfer Resident #1. Staff E reported Resident #1 had complained of more pain since the incident. During an interview at 11:10 a.m. on 01/20/11, Staff A Certified Nurse ' s Aide (CNA) reported on 01/20/11, she and Staff C, CNA attempted to transfer the resident from the toilet to a wheelchair with a gait belt. Staff A reported when she pulled the wheelchair closer, the resident became weak. Staff A reported telling Staff C that the resident needed to be lowered to the floor. Staff A reported the resident was transferred to the floor. Staff A reported her legs were used to slide the resident to the floor. Staff A reported that the two man transfer with the gait belt technique was used because the resident was crying and did not want to use the lift. Staff A reported she and Staff C should have used a lift and she will always use a passive lift now with the resident. Staff A reported the Care Plans and ADL sheets are where staff can review and know how to transfer or provide care for the residents. During an interview at 3:38 p.m. on 01/19/11 Staff C, CNA reported she and Staff A, CNA had to lower the resident to the floor on 01/02/11 during a two man gait belt transfer. Staff C reported what happened with the resident was not right, she has apologized to her fell ow coworkers for not being a good example, and feels she would go on to be an advocate for transferring residents as they should be. Staff C reported she had trained new staff and aware of proper transfer techniques. Staff C reported new CNA ' s are oriented to transfer techniques. During an interview at 12:05 p.m. on 01/18/11 Staff J, Licensed Practical Nurse reported staff can find out how to transfer residents either from the care plans on the chart, the ADL books at the nurses ' station, or from report at shift change. Staff J reported Staff D and Staff E should have used the active or passive lift to transfer Resident #1. During an interview at 1:27 p.m. on 01/18/11 the Director of Nursing (Health Service Supervisor) reported if a resident refused to use a lift she would expect staff to educate the resident about why the transfer would be needed and also to get a nurse to assist with resident education as well. During an interview at 9:28 a.m. on 1/19/11, Staff L (Registered Nurse) reported if a resident refused to use a lift for a transfer then she/he would expect the staff member to report this so the resident could be asked the reason. During an interview at 12:50 p.m. on 01/19/11 Staff I, Licensed Practical Nurse, reported if a resident refused to be transferred with a lift she would expect the CNA's to notify the nurse. Staff I reported correcting staff to do proper transfers as per care plan. ADL (Activities of Daily Living) sheets inform staff how to transfer as per the care plan. The ADL sheets are at located at every nurses ' station and the care plans are in the resident ' s charts. At the time of the fall Resident #1 had plan of care to be transferred with the use of a lift. During an interview at 1:35 p.m. on 01/19/11 Staff M, CNA reported if a resident refuse to use a lift for a transfer, she would leave and return later to try again. Staff M reported the information about how to transfer residents are on the ADL sheets at the nurses stations. Staff M reported Resident #1 as confused, anxious, has poor judgment skills and would refuse cares sometimes. During an interview at 1:49 p.m. on 01/19/11 Staff H, CNA reported if a resident refused to use a lift for transfers she would approach the resident later and try again. Staff H reported Resident #1 did refuse to use the lift and so she/he just came back later and the resident was cooperative. Staff H reported the ADL sheets at the nurses ' stations show how the residents are transferred. During an interview at 2:07 p.m. on 01/19/11 Staff N, CNA reported if a resident refused to be transferred with a lift she would notify the nurse. Information about how to transfer a resident would be located in the ADL books at the nurses ' stations. Staff N stated Staff B, physical therapist, would post updates at the nurses ' station if changes in transfer techniques, and nurses also can inform staff how to transfer a resident. Staff N reported during orientation, CNA's are taught how to use all types of transfer techniques, including the lifts. During an interview at 2:29 p.m. on 1/19/11 Staff K, CNA reported Resident #1 to be confused, and anxious, but has never refused to use a lift with a transfer. Staff K reported if a resident refused to be transferred with a lift, then would inform the charge nurse. Staff K reported transfers of different types are covered in CNA orientation. Staff K reported it would not be safe to transfer Resident #1 with a gait belt and two staff members. Staff K stated the resident could not bear weight very well. During an interview at 9:00 a.m. Staff B, (Physical Therapist Assistant) reported Resident #1 refused therapy frequently, would have difficulty following directions during therapy, and had poor weight bearing even before the recent fall. Staff B reported recommendations for transfers would be located in the resident ' s charts on the discharge summary forms.