Every finding on record at Sunnyside Presbyterian Retirement Community

Based on staff interview, clinical record review, and facility document review, the facility failed to obtain a medical provider ordered lab test for (1) one of (23) twenty-three sampled residents, Resident #47. The findings included: For resident #47 the facility failed to obtain a complete blood count (CBC), a comprehensive metabolic panel (CMP) and a lipoprotein (LP) level ordered by the medical provider on 12/2/2025.Resident #47's diagnoses included but were not limited to Parkinson's, dementia, high, cholesterol, hypertension and malnutrition.According to the annual minimum data set (MDS) assessment with an assessment reference date of 1/13/26 resident #47 was assigned a brief interview for mental status score of 8 out 15 indicating moderate cognitive impairment.During a review of the clinical record a medical provider order for lab work was reviewed. The order was dated 12/2/25 and read in part, CBC, CMP, LP q HS for six months. The start date for the order was 12/3/25. There were no lab results in the record for these labs.On 3/25/26 at 12:34 PM spoke with the Director of Nursing (DON) who stated they would look for the results of the ordered lab work.On 3/25/26 at 2:46 PM the DON stated that the ordered lab work for resident #47 was not done. The DON stated they were not sure why and that they could not find where the provider was notified that the labs were not obtained. The DON stated that they made the provider aware and are beginning education with the nursing staff regarding the lab process. When asked what happened that the lab wasn't drawn, the DON stated, I'm not sure. They stated that the resident historically refuses care but there is no documentation in the record to verify that. When asked how the nursing staff knows to obtain labs on a resident they stated, It should come up on the MAR (medication administration record. The DON provided an Inservice Documentation form that read in part, Information: if a lab specimen is unable to be obtained for any reason (missed draw, resident refusal, resident not available, etc.), the provider must be notified of the lab not being drawn. If there is a new order for lab to be obtained, please enter the order and notify your Clinical Coordinator.The policy entitled Laboratory and Diagnostic testing/reporting with an effective date of 10/2025 was requested and provided. The document read in part, Diagnostic testing is important for determining the appropriate treatment for different illnesses or ailments. The physician who treats a patient must order all diagnostic x-rays, diagnostic lab tests, and other diagnostic tests for a specific medical problem. They use the results to manage the patient's specific medical problem and may provide consultation. Under the heading Procedures, the document read in part, Provide or obtain laboratory services only when ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.On 3/26/26 at 11:48 AM the survey team met with the Administrator, DON, Regional Director of Clinical Integration and Chief Executive Officer. The above concern was reviewed at that time.No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that a Level I PASRR (preadmission screening and resident review) was completed for one of 18 residents (Resident #49). Findings include: Resident #49 did not have a PASRR completed upon admission. Diagnoses for Resident #49 included; Dementia, anxiety, abnormal posture, major depression, and osteoarthritis. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 11/29/22. Resident #49 was assessed with short and long-term memory problems with moderately impaired cognition. During the LTCSP [long term care survey process] on 2/7/23, the review for Resident #49 triggered for No PASRR level II with a diagnosis. Review of Section A1510. titled Preadmission Screening and Resident Review (PASRR). of the current MDS was blank. On 2/8/23, Resident #49's clinical records were reviewed. Resident #49 had an active diagnosis of major depression and was receiving medication for the diagnoses. Resident #49's clinical record also did not evidence documentation that a level 1 PASRR had been completed. On 02/08/23 10:06 AM, the social worker (other staff, OS #2) was asked to review Resident #49's medical record for the PASRR. OS #2 reviewed the medical record and verbalized that Resident #49 was living in the assisted living part of the campus and was sent to the hospital. OS #2 stated that after being discharged from the hospital, Resident #49 was admitted to the facility on [DATE]. OS #2 added that during the time of admission to the hospital, the hospital was not completing PASRR's due to COVID. On 2/08/23 at 11:19 AM, OS #2 said that she had followed up with another social worker and was unable to provide documentation that the PASRR had been completed. 02/08/23 04:51 PM, the above finding was presented to the director of nursing and administrator. Review of the facility's policy titled Preadmission Screening and Resident Review Process read in part Medicaid screening teams will conduct Level 1 screening for those individuals who are Medicaid members . No other information was provided prior to exit conference on 2/9/23.

Based on staff interview, employee record review, and facility document review, the facility staff failed to ensure that professional licenses were current for one of 25 employee files reviewed. CNA (certified nursing assistant) #1's license expired in [DATE]. Findings were: As part of the survey process, a list of new hires was requested. Twenty-five employee files were randomly chosen for review. On [DATE] at approximately 1:00 p.m., the Senior Human Resources Business Partner (Other staff #1) brought the selected files for review. Other staff (OS) #1 stated, Here are the files you requested. I'm just going to tell you one of the staff that you picked has an expired license. When asked if the expired license had been verified through the state website, OS #1 stated, Yes. Asked if the employee was working, OS #1 stated, She was, but we took her off the schedule. She renewed it today, but we won't allow her to work until we can verify that it is current. When asked if the CNA had been actively on the schedule from the end of December, OS #1 stated, Yes. A review of the employee files found that CNA #1's license/certification expired on [DATE]. The facility abuse policy was reviewed and contained the following: State licensure and certification agencies, and applicable registries, will be contacted, prior to employ to validate current licensure or certification requirements and to determine if the employee is in good standing with registry. An additional policy: Professional Licenses and Certification contained the following: .[Facility name] require a certification or a license to perform the work .to assure proper licensing and certification, [Name of facility] verified the certification or license of individuals at hiring and periodically during employment as necessary Employees are responsible for maintaining current and active license and certifications. Currency of licenses and certifications is a condition of continued employment .failure to do so shall result in immediate unpaid suspension from job duties . OS #1 was interviewed on [DATE] at approximately 1:00 p.m. When asked what the process was to ensure all licenses and certifications were current, OS31 stated, We've had a lot of transition in this department .I took this over about a week ago .what is suppose to happen is I run a report and it goes to the departments to make sure they are renewed. The above information was discussed during an end of day meeting with the administrator and the DON (director of nursing) on [DATE] at approximately 5:15 p.m. No further information was obtained prior to the exit conference on [DATE].

Based on clinical record review, staff interview and facility document review, the facility staff failed to ensure two of 20 residents in the survey sample were free from unnecessary [CONDITION(S)] medications, Resident # 30 and #65. Resident #30 had physician orders for as needed (PRN) Lorazepam that extended for more than 14 days without a stop date. Resident #65 had physician orders for as needed (PRN) [MEDICATION(S)] that extended for more than 14 days without a stop date. The findings include: Resident #30 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included [CONDITION(S)], hospice encounter, anxiety, depression, neuromuscular dysfunction bladder, and right arm/humerus fracture. The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #30 as severely impaired for daily decision making with a score of 5 out of 15. On 05/19/2021, Resident #30's clinical record was reviewed. Observed on the physician's order sheet was the following: Lorazepam 2mg/ml (milligrams/milliliters) oral concentrate (0.5mg) CONCENTRATE, ORAL. Q4 (every 4) hours PRN (as needed) for anxiety/restlessness. Order date: 3/11/2021 . There was no documented stop date for the PRN (as needed) Lorazepam order. A review of the medication administration records (MARs) for the months of March 2021 through May 2021 did not document Resident #30 received any doses of the PRN Lorazepam. A review of the Consultant Pharmacist's Medication reviews did not document any recommendations regarding the PRN Lorazepam. On 05/20/2021 at 8:50 a.m., the unit manager (LPN #1) where Resident #30 resided was interviewed regarding the PRN Lorazepam order. LPN #1 stated she thought the order had been written when the resident was admitted to hospice. LPN #1 was asked if Resident #30 displayed behaviors and symptoms that would require the PRN Lorazepam. LPN #1 stated, no, [Resident #30] generally doesn't complain or display behaviors at all, she is a sweet lady. On 05/19/2021 at 9:30 a.m. the administrator and DON (director of nursing) were informed of the above findings during a meeting. 2. Resident #65 was admitted to the facility on [DATE] with diagnoses that included generalized weakness, dementia, chronic [CONDITION(S)], [CONDITION(S)], chronic kidney disease, [CONDITION(S)], heart failure, [CONDITION(S)], depression and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #65 with moderately impaired cognitive skills. Resident #65's clinical record documented a physician's order dated 1/27/21 for the medication [MEDICATION(S)] 5 milligrams (mg) to be administered as needed (prn) for anxiety. This current order had been in place since 1/27/21 and had no 14-day limit or end date associated with the order. A psychiatric progress note dated 4/27/21 documented concerning Resident #65's [MEDICATION(S)] use, Continue [MEDICATION(S)] 5 mg prn for now if helpful. If staff do not feel this is helpful for her anxiety/agitation, could consider replacing it with [MEDICATION(S)] 100 mg. There was no documented stop date or end date for the prn [MEDICATION(S)]. Resident #65's medication administration record documented the [MEDICATION(S)] was administered to Resident #65 five times during April 2021 and five times from 5/1/21 through 5/19/21. On 5/19/21 at 2:50 p.m., the licensed practical nurse unit manager (LPN #1) was interviewed about Resident #65's [MEDICATION(S)] order. LPN #1 stated she knew the resident was seen recently by psychiatry but she was not sure about why there was no end date or limit on the prn [MEDICATION(S)] order. On 5/19/21 at 4:10 p.m., the director of nursing (DON) was interviewed about Resident #65's prn [MEDICATION(S)] order. The DON stated she thought there was a misconception that if the resident was assessed as still needing the medication, no end date was required. The Nursing 2017 Drug Handbook on page 256 describes [MEDICATION(S)] as an anxiolytic used for the treatment of anxiety disorders. (1) This finding was reviewed with the administrator and director of nursing during a meeting on 5/19/21 at 4:20 p.m. (1) [NAME], [NAME], [NAME] [NAME] and [NAME] Ann [NAME]. Nursing 2017 Drug Handbook. Philadelphia: Wolters Kluwer, 2017.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to revise the comprehensive care plan for one of twenty residents in the survey sample. Resident #65's care plan was not updated regarding care of extensive bruising a fall. The findings include: Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #65 with moderately impaired cognitive skills. On 5/19/21 at 8:38 a.m., Resident #65 was observed in bed. The resident had black/dark purple bruising extending from the right elbow area along the underside of her right forearm down to her wrist. There was a white gauze dressing on the right elbow. Resident #65 was interviewed about the dark bruising. Resident #65 stated she attempted to walk without assistance and fell about a week ago. Resident #65 pulled back the covers and displayed her right knee that had bruising around the circumference of the joint that extended from above to below the knee area. The bruising was black/dark purple in color. Resident #65 stated she took a blood thinning medication and obtained the bruising in the days following the fall. The resident stated the right elbow, arm and knee still had swelling and were sore/painful when she moved. Resident #65's clinical record documented the resident's most recent fall was on 5/11/21 at 6:30 p.m. after getting up without requesting assistance. The record documented the resident had five previous falls during April 2021. Resident #65's plan of care (print date 5/19/21) included no problems, goals and/or interventions regarding the resident's bruising. There was no mention of the fall of 5/11/21 or the black/purple bruising on her right arm and leg. The care plan documented the resident had potential for falls with injury due to history of frequent falls, weakness, [CONDITION(S)] medications and poor safety awareness. The care plan listed the resident was at risk of bleeding/bruising due to prescribed anticoagulant use. On 5/19/21 at 2:36 p.m., the licensed practical nurse unit manager (LPN #1) was interviewed about a plan of care regarding the bruising. LPN #1 reviewed the care plan and stated the plan was last updated on 5/7/21 to keep writing material within reach of the resident. LPN #1 stated the bruising had not been added to the plan. This finding was reviewed with the administrator and director of nursing during a meeting on 5/19/21 at 4:20 p.m.

Based on observation, staff interview and facility document review, the facility staff failed to ensure a dignified dining experience during lunch in the dining room on the second floor. Staff were observed feeding and assisting more than one resident at the same time. A dietary aide was heard making comments regarding how a resident was eating a sandwich. The findings include: Resident # 61, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE], was a quarterly assessment and assessed Resident #61 as being severely cognitively impaired for daily decision making. Under Section G (Functional Status), at item G0110 (H), Eating, the resident was assessed as requiring total assistance with one person physical assistance for eating. Resident #61's care plan was reviewed and documented the resident required meal set up and assistance with eating. Resident #61's orders were reviewed and documented a pureed diet. A dining observation was conducted during lunch on 04/23/19 in the second floor dining room at 12:05 p.m. Residents were observed seated at various tables around the dining room. CNA #2 (certified nursing assistant) was observed seated between two residents at table number one in the dining room. There was a total of four residents at table number one. CNA #2 was observed feeding and assisting two residents at the same time. She alternated between the two residents giving Resident #61 a few bits of food and/or drink and then cutting up the other resident's food, leaving the table to get additional beverages and silverware for other residents at the table. During the meal observation, Resident #61 would close her eyes and CNA #2 was observed as saying hey, hey (Resident 61s name) several times during the meal observation which would prompt Resident #61 to open her eyes and continue eating. CNA #2 did not converse with Resident #61, however Resident #61 would smile while CNA #2 was talking with the other residents at the table. This continued for approximately 25 minutes. Other staff members were observed walking around in the dining room, assisting various residents with lunch and by bringing additional food and drinks to the various tables. On 04/23/19 at approximately 12:35 p.m., CNA #2 was interviewed regarding the lunch observation and which residents needed assistance for meals. CNA #2 stated Resident #61 required feeding assistance with all meals. She stated the other resident she was seated beside liked to chat and talk during meals and only required cueing and encouragement during meals. A resident who was seated at table number one and was observed eating a sandwich for her lunch. The resident was eating the sandwich slowly with her hands. A dietary aide who was passing out meal trays was overheard saying it's just ridiculous, I don't know why they give people like that a sandwich to eat. These administrator and the assistant DON (director of nursing) were notified of the above findings during a meeting on 04/23/19 at approximately 5:00 p.m. The administrator stated recently she had conversations with staff and implemented finger foods and sandwiches as preferences for resident's food choices and this comment was inappropriate. No further information and/or documentation was presented prior to the exit conference on 04/25/19 at 10:00 a.m.

Based on observation, staff interview and clinical record review, the facility staff failed to assess one of 20 residents prior to self-administration of medications. Resident #47 was observed self-administering the medication [MEDICATION NAME] sulfate with use of a nebulizer. There was no prior assessment or review by the interdisciplinary team to determine Resident #47's ability to self-administer the medication. The findings include: Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #47 with severely impaired cognitive skills. On 4/24/19 at 2:00 p.m., Resident #47 was observed in his room unattended with a nebulizer mask on his face and the nebulizer machine operating. There was no nurse in the room or in the hallway outside the resident's room. Resident #47's clinical record documented a physician's order dated 2/5/19 for [MEDICATION NAME] sulfate 2.5 milligrams/3 milliliters (0.083%) solution, one vial via nebulizer three times per day for treatment of [REDACTED]. The clinical record documented no physician's order regarding self-administration of medications. The resident's plan of care (revised 4/2/19) included no problems, goals and/or interventions regarding self-administration of medications. On 4/24/19 at 2:07 p.m., the licensed practical nurse (LPN #1) caring for Resident #47 was interviewed about the resident observed unsupervised with the nebulizer. LPN #1 stated the Resident #47 was getting the ordered medication [MEDICATION NAME] sulfate with the nebulizer. LPN #1 stated she usually placed the mask on the resident, started the machine and then went back and took the mask off when the medication was done. LPN #1 stated it usually took about 15 minutes for the administration of the medication. LPN #1 stated she was not aware of any assessment for the resident to self-administer the medication. LPN #1 stated she did not think Resident #47 took the mask off during the nebulizer treatment but could see where that might be an issue due to his dementia. On 4/24/19 at 2:12 p.m., the registered nurse unit manager (RN #1) was interviewed about any assessment for Resident #47 to self-administer medications. RN #1 stated she did not have an assessment regarding Resident #47's ability to self-administer medications. On 4/24/19 at 2:15 p.m., the director of nursing (DON) was interviewed about Resident #47's self-administration of the [MEDICATION NAME] sulfate. The DON stated Resident #47 did not have a physician's order or assessment regarding self-administration of medications. The DON stated the interdisciplinary team was supposed assess and determine if residents were appropriate to self-administer medications. These findings were reviewed with the administrator and DON during a meeting on 4/24/19 at 5:30 p.m.

Based on resident interview, staff interview, and clinical record review, facility staff failed to review and revise a CCP (comprehensive care plan) for one of 20 residents in the survey sample, Resident #222. Facility staff failed to review and revise the CCP for Resident #222 regarding his dietary status. Findings included: Resident #222 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 4/11/19. Resident #222 was assessed with [REDACTED]. Resident #222 was interviewed on 04/23/2019 at 3:30 p.m. During this interview Resident #222 showed his teeth and stated, Seems like every time I eat something I lose a tooth. They have put me on a pureed diet and I don't care for it. I do have trouble chewing, but I don't want pureed food. When asked if he had any swallowing problems, he stated, No, I don't think so. I would like to have a soft diet if possible. The clinical record for Resident #222 was reviewed on 04/24/19 at 10:00 a.m. The original diet order dated 04/04/19 was for a Mechanical Soft diet. A physician order [REDACTED].#222's diet to Pureed. Resident #222 stated, I don't know why they changed my diet to pureed. I didn't ask them to. A dietitian note dated 04/05/19 included, .Diet=Mech soft. No food allergies [REDACTED].PLAN: obtained diet preferences .GOAL: meal intake as desired by resident without chewing or swallowing issues, continue feeding self . A second dietitian note dated 04/12/19 included, .Diet changed from Mech soft to Puree (4/6/19) due to chewing difficulties. Missing several teeth .Feeds self. No swallowing issues noted or reported .GOAL: meal intake as desired by resident without chewing or swallowing issues to maximize comfort, continue feeding self . Subsequent review of the CCP included, .Provide a mechanically altered diet (grind meat) .Incorporate food/bev (beverages) prefs (preferences) into meals .Respect (Name) right to choose the amt (amount)/type of food to consume . The Administrator and DON (director of nursing) were informed of the above during a meeting with the survey team on 04/24/19 at approximately 5:00 p.m. The Administrator was interviewed on 04/25/19 at 9:30 a.m. regarding who updates care plans. The Administrator stated, MDS and the Unit Managers update care plans. (Name) (MDS) brings her computer to morning meeting and tries to update them during the meeting. No further information was received by the survey team prior to the exit conference on 04/25/19.

Based on observation, staff interview, and clinical record review, the facility staff failed to follow physician's orders for one of 20, Resident #172 Resident #172 did not have physician ordered TED (compression) hose in place. The Findings Include: Resident #172 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 4/19/19. Resident #172 was assessed with [REDACTED]. On 04/23/19 at 3:28 PM, Resident #172 was interviewed. During the interview Resident #172's legs were observed showing signs of [MEDICAL CONDITION]. Resident #172 was asked about [MEDICAL CONDITION] in her (Resident #172) legs. Resident #172 verbalized that staff had came in the room a couple of days ago and took measurements for TED hose. Resident #172 verbalized that her legs had been weeping but had gotten better because the doctor had increased the dosage of [MEDICATION NAME]. On 4/23/19 Resident #172's medical chart was reviewed. An order dated 4/19/19 read TED hose on in AM, off in PM. Resident #172's treatment administration record (TAR) was also reviewed but did not evidence that the order had been transcribed onto the TAR. On 4/24/19 at 9:40 AM, Resident #172 was observed in a recliner without TED hose in place. On 04/24/19 at 9:47 AM, certified nursing assistant (CNA) #1, assigned to Resident #172, was interviewed regarding Resident #172's TED hose. CNA #1 verbalized that she (CNA #1) was new to the floor and was unaware that Resident #172 had an order for [REDACTED]. On 04/24/19 at 9:52 AM, licensed practical nurse (LPN) #1, assigned to Resident #172, was interviewed regarding Resident #172's TED hose. LPN #1 verbalized that she was aware that Resident #172 had an order but was not aware that Resident #172 did not have TED hose in place. 04/24/19 05:05 PM during an end of day meeting with administrator and DON the above information was presented. No other information was presented prior to exit conference on 4/25/19.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed, for one of 20 residents in the survey, to assess for entrapment risks and obtain informed consent regarding bed rail use. Resident #23, with cognitive impairment and multiple unwitnessed falls, had bed rails in use without a prior assessment for safety, informed consent from the resident or family representative and without prior attempts of appropriate alternatives. The findings include: Resident #23 was admitted to the facility 10/30/18 with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #23 with severely impaired cognitive skills. On 4/24/19 at 7:40 a.m., Resident #23 was observed in bed. There were quarter length bed rails in the up position on both sides, near the head of his bed. Resident #23's clinical record documented a physician's orders [REDACTED]. Resident #23's clinical record documented no bed rail assessment for entrapment risks. There was no informed consent from the resident or his family representative regarding use of the bed rails. The resident's plan of care (revised 2/19/19) listed the resident had potential for injury due to repeated falls, decline in functional mobility and impaired cognitive status. The care plan listed bilateral grab bars among interventions for injury prevention but included no problems, goals and/or interventions regarding use of the rails or of any attempted alternatives. The clinical record documented the resident had experienced eight falls since his admission on 10/30/18. All of the falls involved the resident getting out of bed or chair without requesting staff assistance. On 4/24/19 at 10:26 a.m., Resident #23 was interviewed about his bed rails. Resident #23 stated he thought the bed rails were decorative and were there to hold the bed controller. On 4/24/19 at 2:45 p.m., the licensed practical nurse unit manager (LPN #2) was interviewed about an assessment and informed consent regarding Resident #23's use of bed rails. LPN #2 stated the side rail assessment and consents were part of the admission packet and were supposed to be completed at the time of admission. LPN #2 stated she would look for Resident #23's assessment and consents. On 4/24/19 at 3:27 p.m., the director of nursing (DON) was interviewed about Resident #23's bed rail use and any assessments regarding safety, consents or attempted alternatives to the rails. The DON stated assessments were done at the time of admission. The DON stated the resident signed the consent if oriented or the family representative consented if the resident was unable to sign. The DON stated side rails were not to be in place unless deemed safe for the resident. On 4/24/19 at 4:18 p.m., LPN #2 stated she looked and did not find an assessment or informed consent for Resident #23's bed rail use. LPN #2 stated the resident had bed rails in place since his admission on 10/30/18. LPN #2 stated the assessment and consent were missed during the admission process. There was no mention of any attempted alternatives prior to installation of Resident #23's bed rails. This finding was reviewed with the administrator and director of nursing during a meeting on 4/24/19 at 5:30 p.m.

Based on observation, staff interview, and facility document review the facility failed to procure, store and serve food in a sanitary manner in the main kitchen. The dining staff did not follow proper hand hygiene, raw meat was stored thawing, not dated or labeled for three days in the walk-in refrigerator, and the meat served from the steam table on unit two's kitchenette was not served at the proper temperature. The findings include: 1. The kitchen was inspected on 04/10/18 beginning at 11:35 a.m. with the Dining Services Director (DSD). At the start of the initial tour, the DSD was observed washing her hands in a sink where the water was standing and not draining from the sink. The dirty water was splashing from the accumulated water during the hand washing. On 04/10/18 at 11:35 a.m., the DSD was interviewed about the water not draining from the sink. The DSD stated she believed she just ran the water too fast, which caused the water to back up in the sink. On 04/11/18 at 7:50 a.m., the DSD was interviewed about the water not draining from the sink. The DSD said she was just nervous and thought she had turned on both faucets at the same time, which caused the sink not to drain. The facility's dining services policy titled Hand Washing (revised 7/3/09) states hand washing will be conducted to insure safety of food products and infection control. The policy states to turn on the water slowly. 2. On 04/10/18 at 11:45 a.m., during the inspection, a large clear plastic container of raw pork chops was observed in the walk-in refrigerator. The raw pork chops were not dated or labeled. On 04/10/18 at 11:50 a.m., the DSD was interviewed about the undated and unlabeled raw pork. The DSD said the pork chops were pulled on Saturday, 04/07/18 to thaw because they would be used for Tuesday night's (04/10/18) dinner service. The DSD said the dates were documented on a food production sheet. On 4/11/18 at 7:57 a.m., the DSD was interviewed about the container of raw pork chops not being dated and labeled. The DSD said the bag which contained the date and label had already been removed from the container. The facility's dining services policy titled Food Storage (revised 1/15/09) states all foods should be covered, labeled, and dated. All food items must have a label that includes the in date and the out date. On 04/12/18 at 10 a.m., the DSD was interviewed about how long items were allowed to thaw before cooking. The DSD said normally 24-48 hours. The DSD said the pork chops were pulled on Sunday, 04/08/18. This surveyor provided the DSD with the copy of the facility's week one production sheet which noted the raw pork chops were pulled on Saturday, 04/07/18. The DSD had no further response why the pork chops had been thawing for 72 hours. The facility's dining services policy titled Food Storage (revised 1/15/09) states frozen meat, poultry and fish should be defrosted in refrigerator for 24 to 48 hours and to be used immediately after thawing. 3. On 04/10/18 at 11:55 a.m., food temperature checks were measured on the steam table on unit two, half way through the lunch meal service. Temperature checks were competed on 10 food items, with four out of the ten items below 135 degrees. The following foods were below temperature: 1. Baked chicken - 120 (F) degrees 2. Ground chicken - 125 F) degrees 3. Ground beef - 127 (F) degrees 4. Beef - 130 (F) degrees On 04/10/18 at 12:03 p.m., the DSD was interviewed about the food temperature checks on the steam table. The DSD said she was not aware of any problems but she would place a call to the steam table vendor. On 04/10/18 at 12:20 p.m., the DSD advised this surveyor the vendor checked the steam table and an element was blown. The facility's dining services policy titled Health Care Food Temperature Recording (revised 7/09) states the following: 1. Cooks will record temperatures of hot and cold foods on production sheets. Cold foods need to be below 40 degrees and hot foods needs to be above 140 degrees. 2. Dining Services Assistants will record steam line temperature and take the temperature of the cold and hot foods and record on the temperature log. 3. If food is not in acceptable range, the Dining Service Assistant is to notify the Supervisor and pull the food item from the line. These findings were reviewed with the administrator and director of nursing during a meeting on 04/11/18 at 5:27 p.m.

Based on staff interview, and clinical record review, facility staff failed to develop a comprehensive care plan (CCP) for one of 21 residents in the survey sample, Resident #76. Facility staff failed to develop a CCP for the care and maintenance of a port-a-cath for Resident #76. Findings included: Resident #76 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 03/27/18. Resident #76 was assessed as moderately impaired in his cognitive status with a total cognitive score of 11 out of 15. Resident #76's clinical record was reviewed on 04/11/18 at 9:30 a.m. The (MONTH) POS (physician order [REDACTED].Port A Cath care Notes: Collect supplies - Wash your hands with soap & (and) water, apply gloves, remove old dressing. Cleanse Port A Cath site for 3 minutes following instructions, using chlora prep swab start in center and clean outward in a circle. Allow area to dry completely. Using sterile gloves - Open Huber PRO infusion set, remove cap and, connect a 10ml (milliliter) NSS (normal sterile saline) IV (intravenous) flush to tubing. Insert Huber needle in center of port a cath through skin until you feel back of port a cath against (sic) hitting against needle, open the tubing clamp, and pull back on syringe, if you have blood in the tubing and syringe you are in the correct place. Remove this syringe and discard. Flush Port a Cath with another 10ml NSS. After NSS, flush port a cath with 5ml [MEDICATION NAME] (100 units per 1ml). While applying pressure to end of syringe clamp tubing and pull back on Huber needle to remove. Blot site with sterile gauze if bleeding noted . Every Four Weeks Starting 06/19/2017 Morning . The (MONTH) (YEAR) TAR (treatment administration sheet) was reviewed and included: .Port A Cath care Every Four Weeks Starting 06/19/2017 Order Date: 5/19/2017 . The care was initialed as being done on 03/26/18. (MONTH) (YEAR) TAR was reviewed and showed the Port A Cath care was scheduled for 04/23/18. Subsequent review of the CCP for Resident #76 did not include any problems, goals or interventions for the care and maintenance of a Port-a-Cath. There was no mention of Resident #76's Port-a-Cath in his CCP. The DON was interviewed on 04/12/18 at 9:50 a.m. regarding the CCP for Resident #76. The DON stated, We refer care of a port back to the MAR (medication administration sheet) or TAR. The DON then showed this surveyor an intervention on the CCP that stated, Administer medication as ordered. (See MAR) . The DON stated, The care plan is a continuation of care. It's an evolving circle. The care plan is part of the care process. This system (referring to the computer documentation program) doesn't allow us to add nursing orders. The only thing in here (referring to the care plan) is to refer to the MAR/TAR. The Administrator was informed of the above during a meeting with the survey team on 04/12/18 at approximately 11:55 a.m. No further information was received by the survey team prior to the exit conference at 12:30 p.m.

Based on observation, staff interview and clinical record review, the facility staff failed to implement interventions for pressure ulcer prevention for one of 21 residents in the survey sample. Resident #44 did not have a foot cradle and protective booties in use as required in her plan of care. The findings include: Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #44 with severely impaired cognitive skills. This MDS listed the resident as totally dependent upon two people for transfers and as requiring the extensive assistance of two people for bed mobility. On 4/10/18 at 3:00 p.m., Resident #44 was observed in bed. The bed covers were positioned directly over the resident's feet without use of a bed cradle. A pair of protective booties were not on the resident but were positioned on the sofa in the resident's room. On 4/11/18 at 2:00 p.m., accompanied by the certified nurses' aide (CNA #1) caring for Resident #44, the resident was observed in bed without the protective booties in place. CNA #1 was interviewed at this time about the bed cradle and booties. CNA #1 stated the resident was supposed to have the booties and bed cover cradle in place when in bed to protect her skin. CNA #1 stated Resident #44 was assigned to students this week. CNA #1 stated the students must not have put the booties on Resident #44 when she was assisted to bed. Resident #44's plan of care (revised 3/20/18) listed the resident was at risk of impaired skin integrity due to poor bed mobility, frequent incontinence, thin skin and impaired circulation. Care plan interventions to maintain skin integrity included a bed cradle and heel lift boots when in bed. These findings were reviewed with the administrator and director of nursing during a meeting on 4/11/18 at 5:30 p.m.

Based on staff interview, facility document review and clinical record review, the facility staff denied one of 18 residents in the survey sample the right to refuse medications. Resident #2, with a history of medication refusals, was unknowingly administered at least 10 doses of the medication [MEDICATION NAME] mixed into her food and/or drink. The findings include: Resident #2 was admitted to the facility on [DATE] with a re-admission on 11/12/16. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #2 with moderately impaired cognitive skills. Resident #2's clinical record documented a physician's orders [REDACTED]. The record documented the resident frequently refused other medications as well. The MAR from 2/1/17 through 2/21/17 documented the following medication refusals by Resident #2: two doses of [MEDICATION NAME] 50 mg; six doses of [MEDICATION NAME] 25 mg (for neuropathic pain); eleven doses of [MEDICATION NAME] 100 mg; five doses of [MEDICATION NAME] 50 mg; two doses of [MEDICATION NAME] 25 mg (for depression); nine doses of [MEDICATION NAME] 4 mg; three doses of [MEDICATION NAME] 5 mg (for [MEDICAL CONDITION]). Nursing notes documented the following concerning the resident behaviors and medication refusals. 2/3/17 - Resident called out most of the shift .She (Resident #2) refused all of her 2000 (8:00 p.m.) medications this shift. Encouraged her on several occasions to take her medications. She said, I will not take any medications from you .Resident only slept for approximately 30 minutes. Resident refused her graham crackers and ginger ale. Resident stated, 'I don't need anything, I just wanted you to come in here . 2/3/17 - .Continued to intermittently call out loudly with random names asking/calling for 'help me' .Took 1/2 of her po (oral) meds and spit the rest out. 2/4/17 - Resident refused afternoon [MEDICATION NAME] medication. Resident stated, 'I want to sleep tonight. I don't want to feel this medication in my stomach all night.' This writer encouraged resident to take medication, however resident declined. A nurse practitioner's note dated 2/6/17 assessed the resident with increased agitation and [MEDICAL CONDITION]. This note stated, According to nurse's notes, resident has had increased anxiety and [MEDICAL CONDITION] this weekend, but generally since .(psychiatrist) .took her off all prn (as needed) [MEDICATION NAME]. She has also routinely been refusing her bedtime medication with included Trazadone and [MEDICATION NAME], as well as her afternoon dose of [MEDICATION NAME]. Nursing stated she has slept perhaps 30 minutes during nighttime hours in the last 2 days. She has been waking up and disturbing several other residents down the same hall in the night with her cryig (crying) out .Spoke with pharmacist .He will work on compounding a solution of Trazadone 50 mg that we can perhaps get resident to take and aid in her [MEDICAL CONDITION]/anxiety issues . (sic) New orders were entered by the nurse practitioner that included instructions to disguise the compounded liquid [MEDICATION NAME] in her drink. Resident #2's clinical record documented a physician's orders [REDACTED]. The record documented a physician's orders [REDACTED]. An additional order dated 2/7/17 was documented for [MEDICATION NAME] (compounded solution) 50 mg to be given at each bedtime with instructions that medication may be given with food or fluid. The resident's care plan (print date 2/22/17) documented the resident rejected medications and care at times. Interventions to minimize the negative effects of refused medications included, Disguise medications in food or fluids to improve the resident's quality of life. The resident's MAR indicated [REDACTED]. As needed doses of the liquid [MEDICATION NAME] 25 mg was given to the resident mixed in her food and/or drink on 2/7/17, 2/9/17, 2/11/17, 2/12/17, 2/15/17, 2/17/17, 2/18/17 (3 doses) and 2/20/17. Nursing notes documented the following about the administration of the liquid [MEDICATION NAME]. 2/9/17 at 11:26 p.m. - .Took medication in liquid . 2/11/17 at 10:54 p.m. - .She (Resident #2) did take her [MEDICATION NAME] in Ginger-ale this shift . (sic) 2/12/17 at 6:39 a.m. - .She (Resident #2) was attempting to get out of bed at 0015 (12:15 a.m.) & calling out to staff members. I instructed her to use her call bell not to call out. At 0021 (12:21 a.m.) - [MEDICATION NAME] 25 mg given po (by mouth) in juice . 2/12/17 at 10:30 p.m. - .Res (resident) refused scheduled 2000 medications x 2 attempts. Res is sleeping in bed at this time . 2/15/17 at 6:47 p.m. - .Resident given PRN (as needed) Trazadone disguised in her food. Resident ate all of the food. No effect has been noted from PRN. Resident still calling out . (sic) 2/16/17 at 10:17 p.m. - .At HS (bedtime), resident refused her pills, but did drink the ginger ale that contained her trazadone . (sic) 2/17/17 at 4:49 p.m. - .Patient continued to call out. PRN trazadone administered in patient ginger ale . (sic) 2/18/17 at 3:15 a.m. - Resident denied taking her 20:00 (8:00 p.m.) medications. Resident stated that she is done taking her medicines . 2/18/17 at 4:17 a.m. - Resident calling out loudly .Resident was offered a snack, and she asked for ginger ale. PRN trazadone given in the ginger ale. Resident continuing to call out . (sic) On 2/21/17 at 3:50 p.m. the licensed practical nurse (LPN #2) administering medications to Resident #2 was interviewed about the medication refusals and liquid [MEDICATION NAME]. LPN #2 stated the resident frequently refused some or all of her medications and at other times she took them without any problem. LPN #2 stated she usually attempted at least three times to get Resident #2 to take her medications. LPN #2 stated the resident recently had been up at night, called out for help and yelled out at times. LPN #2 stated the resident lots of times just wants company. LPN #2 stated at times they provided one to one visits with the resident. LPN #2 stated the resident liked ginger ale with a snack in the evenings. LPN #2 stated the resident frequently refused the scheduled [MEDICATION NAME] and they received a physician's orders [REDACTED]. LPN #2 stated used a syringe to measure the correct dose of liquid [MEDICATION NAME] and usually added it to the resident's ginger ale when administered. On 2/21/17 at 3:55 p.m. the registered nurse unit manager (RN #1) was interviewed about Resident #2's liquid [MEDICATION NAME] administration. When asked how if Resident #2 was given the opportunity to refuse the liquid [MEDICATION NAME], RN #2 stated they had a physician's orders [REDACTED]. RN #2 stated the resident enjoyed her snacks and ginger ale and if their redirection was not effective in calming the resident, the [MEDICATION NAME] was administered in her drink. On 2/22/17 at 8:10 a.m. LPN #2 was interviewed again regarding Resident #2's [MEDICATION NAME] administration. When asked if Resident #2 was made aware that the [MEDICATION NAME] was in her drink when administered, LPN #2 stated No. LPN #2 stated to her knowledge the resident was not told the medication was added to her drink. On 2/22/17 at 9:15 a.m. the director of nursing (DON) was interviewed about Resident #2's liquid [MEDICATION NAME] administration. The DON stated the resident had extreme anxiety, was not resting or sleeping and at times was delusional. The DON stated she met with the physician, nurse practitioner and consulted with the psychiatrist to figure a way to get her to take her medications. The DON stated the nurses were not specifically telling Resident #2 the [MEDICATION NAME] was in her drink but brought her drink in with other medications. On 2/22/17 at 4:00 p.m. the administrator stated the nurse practitioner wrote the order that included the instruction to disguise the medication in her drink of choice. The administrator stated there was a misinterpretation by the nurses because of the way the order was written. The facility's policy titled Residents' Right and Responsibilities (revised Sept. 2009) stated, The resident has the right to exercise his or her rights as a resident of the facility and as a citizen of the United States .The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive. The Nursing 2017 Drug Handbook 37th edition on page 1454 describes [MEDICATION NAME] as an antidepressant used for the treatment of [REDACTED]. (1) These findings were reviewed with the administrator and director of nursing during a meeting on 2/22/17 at 11:30 a.m. (1) Rader, Janet, Dorothy Terry and Leigh Ann Trujillo. Nursing 2017 Drug Handbook. Philadelphia: Wolters Kluwer, 2017.

Based on clinical record review and staff interviews, the facility staff failed, for three of 18 residents in the survey sample (Residents # 4, 6 and 16), to ensure the residents' clinical records were complete and accurate. Resident # 4 had a current medication that was identified on the E-MAR (Electronic Medication Administration Record) as [DIAGNOSES REDACTED].# 6 had a current medication that was identified on the E-MAR as Dx. (Diagnosis) Exempt. Resident # 16 had five medications that were identified on the E-MAR as [DIAGNOSES REDACTED]. The findings include: 1. Resident # 4 had a current medication that was identified on the E-MAR (Electronic Medication Administration Record) as [DIAGNOSES REDACTED]. Resident # 4 in the survey sample, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/3/17, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 00 out of 15. Review of Resident # 4's E-MAR revealed the following current medication order, dated 10/21/16: [MEDICATION NAME] 100 mg/5 ml (milligrams per milliliter), oral liquid, (10 mg) as needed every four hours. The order on the E-MAR also bore the notation Dx exempt. The order for [MEDICATION NAME] on the Physician order [REDACTED]. (NOTE: [MEDICATION NAME] is an [MEDICATION NAME] used to help loosen phlegm and thin [MEDICATION NAME] secretions to make coughs more productive. Ref. www.drugs.com) At 2:00 p.m. on 2/22/17, RN # 1 (Registered Nurse), the Unit Manager on the second floor, was asked about the [DIAGNOSES REDACTED]. RN # 2 indicated the [DIAGNOSES REDACTED]. At 4:00 p.m. on 2/22/17, during a meeting with the facility Administrator, Director of Nursing (DON), and the survey team, the DON was asked about the [DIAGNOSES REDACTED]. According to the DON, the computer system allows staff the option to enter a [DIAGNOSES REDACTED]. They (staff) opted to enter [DIAGNOSES REDACTED]. 2. Resident # 6 had a current medication that was identified on the E-MAR as Dx. (Diagnosis) Exempt. Resident # 6 in the survey sample, [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent MDS, a Quarterly with an ARD of 1/3/17, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 12 out of 15. Review of Resident # 4's E-MAR revealed the following current medication order, dated 11/11/14: Vitamin D-3 2000 units - 1 capsule oral, one time daily. The order on the E-MAR also bore the notation Dx exempt. The order for Vitamin D-3 on the Physician order [REDACTED]. 3. Resident # 16 had five medications that were identified on the E-MAR as [DIAGNOSES REDACTED]. Resident # 16 in the survey sample, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent MDS, a 30-Day with an ARD of 1/4/17, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively intact, with a Summary Score of 15 out of 15. Resident # 16 was discharged to her home on 1/31/17. Review of the E-MAR for January 2017 in the closed electronic health record of Resident # 16 revealed orders for the following medications: [REDACTED] [MEDICATION NAME] 250 mg capsule - 1 capsule by mouth two times a day - Dx exempt. (NOTE: [MEDICATION NAME] is a daily [MEDICATION NAME] supplement. Ref. www.[MEDICATION NAME].com.) Thera Tablet - 1 by mouth daily - Dx exempt. Refresh Tears 0.05% eye drops - 1 drop both eyes as needed every 6 hours - Dx exempt. The order also included the notation, As needed for dry eyes. [MEDICATION NAME] 10 ml - 100 mg/5 ml (10 mg) syrup by mouth PRN (as needed) - Dx exempt. The order also included the notation, [MEDICATION NAME] 10 ml by mouth four times a day for cough. [MEDICATION NAME] 50 mg tablet - 1 tablet by mouth at bed time - Dx exempt. The order also included the following notation, Instructions - Dx [MEDICAL CONDITION]. (NOTE: [MEDICATION NAME] is an antidepressant with an unlabeled use for [MEDICAL CONDITION]. Ref. Mosby's 2017 Nursing Drug Reference, 30th Edition, page 1189.) All five of the listed medications included the notation Dx exempt.

Based on a medication pass and pour observation, staff interview, clinical record review, and facility document, the facility staff failed to follow physician's orders [REDACTED].# 11 and Resident # 14. 1. The facility staff failed to obtain an apical pulse on Resident # 11, prior to the administration of [MEDICATION NAME]. 2. Resident #14 was not wearing physician ordered TED ([MEDICAL CONDITION] hose) on 02/22/2017. Findings include: 1. The facility staff failed to obtain an apical pulse on Resident # 11, prior to the administration of [MEDICATION NAME]. Resident # 11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) assessment was a significant change assessment dated 10/30/16. This assessment assessed the resident as having a cognitive score of 15, indicating the resident was cognitively intact. The resident was also assessed on this MDS as requiring extensive assistance from staff for most all ADL's (activities of daily living). During a medication pass and pour observation on 02/22/17 at approximately 7:45 a.m., LPN (Licensed Practical Nurse) # 1 prepared medications for Resident # 11; one of the medications was [MEDICATION NAME] 0.125 mg (milligrams). LPN # 1 mixed the medications (pills) whole in applesauce and proceeded to Resident # 11's room. The LPN entered the room and asked Resident # 11 how he was feeling, the resident responded, Not good. LPN # 1 told the resident that she needed to check his pulse. The resident was observed with visible tremors to bilateral hands and arms, with the greater degree on the right hand and arm. The LPN took the resident's wrist to check a radial pulse, while the resident's hands continued with a slight tremor. The LPN silently counted for 15 seconds and stated to this surveyor that the resident's pulse was 100. At approximately 8:45 a.m., a medication reconciliation was completed on Resident # 11. Resident # 11's current physician's orders [REDACTED].[MEDICATION NAME] 125 mcg (micrograms) tablet (give 1/2) .hold and alert MD if pulse is less than 50 BPM (beats per minute) apically . At approximately 10:30 a.m., LPN # 3 was interviewed regarding Resident # 11. LPN # 1 was asked how she took the resident's pulse prior to giving the resident [MEDICATION NAME]. LPN # 1 stated, I think we were told we could do it either way (apical or radial). The LPN was asked who told her that. The LPN did not respond. The LPN was asked if she knew or had knowledge, whether it be from nursing school or clinical practice, that prior to administering [MEDICATION NAME] the resident's pulse should be checked a specific way. The LPN stated, I don't know. The LPN was asked if she had heard of checking a resident's pulse apically prior to administration of [MEDICATION NAME]. The LPN stated, I thought we could do it either way, apical or radial. The LPN was made aware of concerns regarding Resident # 11, specifically that the resident had recently had a pacemaker/defibrillator placed (less than a month ago), the resident has a [DIAGNOSES REDACTED]. The LPN was asked when an apical pulse is taken how long is it timed. The LPN stated, Normally a minute. The DON (director of nursing) and the administrator were made aware of the above concerns regarding Resident # 11, in a meeting with the survey team on 02/22/17 at 11:35 a.m. The DON stated that the physician's directive for the nurses was to either do an apical or radial pulse for all heart medications, including [MEDICATION NAME]. The DON and administrator were made aware that was not the physician's orders [REDACTED]. At approximately 2:30 p.m., a policy was presented titled, Administration of Medications with the most current revision date of 2/2017. The policy documented, .Medication administration is an important responsibility of the licensed nurse. The goal is to assure that the right resident is receiving the right drug prescribed for him, in the right dose, by the right route, at the right time .follow general rules for administering medications safely .14. [MEDICATION NAME] or [MEDICATION NAME] drug administration a. Prior to administering the drug, obtain apical pulse for one full minute. b. If pulse is below 50 or above 110 hold and call MD (medical doctor). c. Document in the MAR (medication administration record) .Revised Date: 2/2017 (initials of administrator and DON). No further information and/or documentation was presented prior to the exit conference on 02/23/17 at 10:00 a.m. 2. Resident #14 was not wearing physician ordered TED ([MEDICAL CONDITION] hose) on 02/22/2017. Findings were: Resident #14 was most recently admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The initial MDS (minimum data set) with an ARD assessment reference date) of 12/24/2016 assessed Resident #14 as being cognitively intact with a cognitive summary score of 14. On 02/22/2017 at approximately 1:00 p.m., the electronic clinical record was reviewed. Observed on the physician order [REDACTED]. The Problems column contained the following: (Resident #14) is at risk for alteration in cardiac output r/t (related to)[MEDICAL CONDITION](hypertension), A fib ([MEDICAL CONDITION]), HX [MEDICAL CONDITION](history of [MEDICAL CONDITION]) . Interventions included but were not limited to: Encourage use of compression hose (TEDs), on in AM and off @ (at) HS (hour of sleep). On 02/22/2017 at approximately 1:50 p.m., Resident #14 was observed sitting up in a recliner at bedside. He was eating lunch. His TED hose were not on. Resident #14 was asked why his TED hose were not on. He stated, I don't know. He was asked if he had told the staff he didn't want them on. He shook his head side to side indicating No. CNA (certified nursing assistant) # 1 was interviewed regarding Resident #14. She stated, We had a call out today, I took him over at about 9:00 this morning he was already up in the chair when I got here (Name of CNA # 2) got him up before I got here. CNA # 1 was asked if she had applied or taken TED hose off of Resident #14 since she took over his care. She stated, No. She was asked if she knew Resident #14 had orders for TED hose to be applied in the morning and removed at bedtime. She stated, No, I've honestly never worked with him before today. CNA # 2 was interviewed at approximately 2:00 p.m. She stated, I took care of him this morning .he was already up in the chair when I took him over. She was asked if she had applied or taken off his TED hose. She stated, No. LPN (licensed practical nurse) # 1 was interviewed at approximately 2:05 p.m. She was asked if she had applied or removed the TED hose during the current shift. She stated, No. She went to the computer and pulled up the electronic TAR (treatment administration record) and stated, There are equal marks here for the day shift time .I don't know what that means. The DON (director of nursing) and the administrator were notified of the above information on 02/22/2017 at approximately 4:00 p.m. No further information was obtained prior to the exit conference on 02/23/2017.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure the dignity for one of 18 residents in the survey sample, Resident #14 Resident #14's Foley catheter bag was not placed in a privacy bag. Findings were: Resident #14 was most recently admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The initial MDS (minimum data set) with an ARD assessment reference date) of 12/24/2016 assessed Resident #14 as being cognitively intact with a cognitive summary score of 14. On 02/22/2017 at approximately 1:00 p.m., the electronic clinical record was reviewed. Observed on the physician order [REDACTED]. Report refusal to use privacy bag. On 02/22/2017 at approximately 1:50 p.m., Resident #14 was observed sitting up in a recliner at bedside. He was eating lunch. An empty privacy bag for his Foley catheter drainage bag was observed on the bed frame. His Foley catheter drainage bag was observed hanging from his rolling walker beside of his recliner. CNA (certified nursing assistant) # 1 was interviewed regarding Resident #14. She stated, We had a call out today, I took him over at about 9:00 this morning he was already up in the chair when I got here (Name of CNA # 2) got him up before I got here. CNA # 1 was asked if she had noticed that his Foley drainage bag was not in a privacy bag. She stated, No. CNA # 2 was interviewed at approximately 2:00 p.m. She stated, I took care of him this morning .he was already up in the chair when I took him over. I didn't get him up. She was asked if she had noticed that his Foley drainage bag was not in a privacy bag. She stated, No. LPN (licensed practical nurse) # 1 was interviewed at approximately 2:05 p.m. She was asked if she had noticed the Foley bag hanging on Resident #14's walker and not in a privacy bag. She stated, No. She was asked if it had been reported to her that he had refused to have the privacy bag used. She stated, No. The DON (director of nursing) and the administrator were notified of the above information on 02/22/2017 at approximately 4:00 p.m. No further information was obtained prior to the exit conference on 02/23/2017.

Based on a medication pass and pour observation, staff interview, clinical record review, and facility document, the facility staff failed to follow professional standards of nursing practice for one of 18 residents in the survey sample, Resident # 11. The facility staff failed staff failed to obtain an apical pulse, prior to the administration of [MEDICATION NAME]. Findings include: Resident # 11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) assessment was a significant change assessment dated [DATE]. This assessment assessed the resident as having a cognitive score of 15, indicating the resident was cognitively intact. The resident was also assessed on this MDS as requiring extensive assistance from staff for most all ADL's (activities of daily living). During a medication pass and pour observation on 02/22/17 at approximately 7:45 a.m., LPN (Licensed Practical Nurse) # 1 prepared medications for Resident # 11; one of the medications was [MEDICATION NAME] 0.125 mg (milligrams). LPN # 1 mixed the medications (pills) whole in applesauce and proceeded to Resident # 11's room. The LPN entered the room and asked Resident # 11 how he was feeling, the resident responded, Not good. LPN # 1 told the resident that she needed to check his pulse. The resident was observed with visible tremors to bilateral hands and arms, with the greater degree on the right hand and arm. The LPN took the resident's wrist to check a radial pulse, while the resident's hands continued with a slight tremor. The LPN silently counted for 15 seconds and stated to this surveyor that the resident's pulse was 100. At approximately 8:45 a.m., a medication reconciliation was completed on Resident # 11. Resident # 11's current physician's orders [REDACTED].[MEDICATION NAME] 125 mcg (micrograms) tablet (give 1/2) .hold and alert MD if pulse is less than 50 BPM (beats per minute) apically . At approximately 10:30 a.m., LPN # 1 was interviewed regarding Resident # 11. LPN # 1 was asked how she took the resident's pulse prior to giving the resident [MEDICATION NAME]. LPN # 1 stated, I think we were told we could do it either way (apical or radial). The LPN was asked who told her that. The LPN did not respond. The LPN was asked if she knew or had knowledge, whether it be from nursing school or clinical practice, that prior to administering [MEDICATION NAME] the resident's pulse should be checked a specific way. The LPN stated, I don't know. The LPN was asked if she had heard of checking a resident's pulse apically prior to administration of [MEDICATION NAME]. The LPN stated, I thought we could do it either way, apical or radial. The LPN was made aware of concerns regarding Resident # 11, specifically that the resident had recently had a pacemaker/defibrillator placed (less than a month ago), the resident has a [DIAGNOSES REDACTED]. The LPN was asked when an apical pulse is taken how long is it timed. The LPN stated, Normally a minute. The DON (director of nursing) and the administrator were made aware of the above concerns regarding Resident # 11, in a meeting with the survey team on 02/22/17 at 11:35 a.m. The DON stated that the physician's directive for the nurses was to either do an apical or radial pulse for all heart medications, including [MEDICATION NAME]. The DON and administrator were made aware that was not the physician's orders [REDACTED]. At approximately 2:30 p.m., a policy was presented titled, Administration of Medications with the most current revision date of 2/2017. The policy documented, .Medication administration is an important responsibility of the licensed nurse. The goal is to assure that the right resident is receiving the right drug prescribed for him, in the right dose, by the right route, at the right time .follow general rules for administering medications safely .14. [MEDICATION NAME] or [MEDICATION NAME] drug administration a. Prior to administering the drug, obtain apical pulse for one full minute. b. If pulse is below 50 or above 110 hold and call MD (medical doctor). c. Document in the MAR (medication administration record) .Revised Date: 2/2017 (initials of administrator and DON). No further information and/or documentation was presented prior to the exit conference on 02/23/17 at 10:00 a.m.

Based on staff interview, family interview, clinical record review, and facility document review, the facility staff failed to ensure one of 15 residents were free from unnecessary medications. (Resident #10) Resident #10 was inadvertently administered another resident ' s medication, [MEDICATION NAME] 60 mg (milligrams), a long-acting medication. The resident was sent to the emergency room , administered the medication, [MEDICATION NAME] and was admitted to the telemetry unit. The findings include: A facility reported incident regarding Resident #10 being administered another resident's physician ordered medication, [MEDICATION NAME], and subsequent transfer and admission to a local hospital after this incident was received in the state survey office during a standard survey from 2/10/15 through 2/12/15. "Describe incident, including location, and action taken: On 2/7/15 the narcotic count (was found to be) off at 3 p.m. (Licensed practical nurse and registered nurse supervisor names here) surmised Resident #10 may have received 1 60 mg long acting [MEDICATION NAME] tab by error. MD (medical doctor) called at that time. Pt. lethargic in AM 2/8/15 - MD called, sent to ER and admitted ." The electronic clinical record was reviewed 2/11/15 and 2/12/15. Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), a quarterly with an assessment reference date (ARD) of 12/16/14 with a brief interview for mental status (BIMS) score of 13 out of 15, meaning the resident has mild cognitive impairment. The progress notes documented "2/5/15 10:38 p.m. Resident alert, confused this evening as to time and place (sic)." "2/7/15 10:17 p.m. Resident very lethargic today, had difficulty paying attention and keeping her eyes open. Resident came to dining room but was fed by sitters and did not consume much. Difficulties with transfers. Continuing to monitor." "2/8/15 8:17 a.m. Resident lethargic this am and hardly able to walk. Needing to be assisted with breakfast. MD made aware and sitter spoke with brother (POA) and have agreed to send her to ED (emergency department) for eval dt (due to) change in mental status. BP (blood pressure) 100/60, P (pulse) 90, R (respirations) 20, O2 (oxygen saturation) 90% RA (room air). (Transport company) notified and will transport to ED (sic)." "2/10/15 10:21 p.m. Resident arrived at facility at 1945 (7:45 p.m.) via transport services and stretcher, alert and oriented (sic)." A 2/8/15 8:19(am) physician's order [REDACTED]. (evaluation) Decrease level of consciousness The 2/15 Medication Administration Record [REDACTED]. For the date of 2/7/15, the resident received Klonopin 0.5 mg 1/2 tablet administered at 8:00 a.m. and 8:00 p.m., Klonopin 0.5 mg 1 tablet administered at 2:00 p.m.; [MEDICATION NAME] ER (Extended Release) 37.5 mg tablet and [MEDICATION NAME] ER 225 mg (to be administered together to equal 262.5 mg) administered at 8:00 a.m.; [MEDICATION NAME] 25 mg 1/2 tablet administered 3:00 p.m., [MEDICATION NAME] 25 mg 1 tablet administered 8:00 p.m.; and [MEDICATION NAME] 0.25 mg 1 tablet administered at 4:00 p.m. Klonopin is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott. page 338 as an anticonvulsant used for [MEDICAL CONDITION], panic disorder, and restless leg syndrome. Adverse reactions of the central nervous system include drowsiness. Respiratory system include respiratory depression. [MEDICATION NAME] XR is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.page 1389 as an SSRI antidepressant with clinical indications for depression, anxiety, panic disorder, social anxiety disorder and hot flashes. Adverse reactions of the central nervous system include dizziness and somnolence. Under section " Contraindications & Cautions " documented " Overdose S&S: Altered level of consciousness, [MEDICAL CONDITION] mydriasis, [MEDICAL CONDITION], vomiting, ECG changes, [MEDICAL CONDITION], liver necrosis, rhabdomylosis, serotoni[DIAGNOSES REDACTED], [MEDICAL CONDITION], death. " [MEDICATION NAME] is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.page 1151 as an antipsychotic used to treat [MEDICAL CONDITIONS] associated with [MEDICAL CONDITION] I disorder, depression associated with [MEDICAL CONDITION] disorder, major [MEDICAL CONDITION], and obsessive-compulsive disorder. Adverse reactions of the central nervous system include dizziness and somnolence. [MEDICATION NAME] is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott.page 94 as an anxiolytic with clinical indications for anxiety and panic disorders. Adverse reactions to the central nervous system include dizziness, confusion, drowsiness, sedation, somnolence and fatigue. There was no mention of the medication [MEDICATION NAME]([MEDICATION NAME]) being administered on 2/7/15 in the clinical record. [MEDICATION NAME] defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott. pages 928 and 929 as an opiod [MEDICATION NAME]. The extended release form's duration in the system is 12-24 hours, with peak between 3 to 4 hours. Adverse reactions of the central nervous system include dizziness, sedation, and somnolence. Respiratory system includes apnea, respiratory arrest, and respiratory depression. On 2/11/15 at 3:15 p.m., the administrator and director of nurses reviewed the facility reported incidents with this surveyor. The director of nurses stated, "the nurse and supervisor determined that another resident's [MEDICATION NAME] was given to Resident #10. The other resident's [MEDICATION NAME] and Resident #10's narcotic medications were in the locked box next to each other. The [MEDICATION NAME] had two doses missing instead of one and a different medication belonging to Resident #10 had no pills missing for the 7-3 shift, when there should have been one missing." When asked when the administrator and director of nurses were made aware of the medication error, they advised this surveyor "we were made aware of it Sunday when Resident #10 was being sent to the hospital." This surveyor then asked when they should have been notified and they replied, "when it was found." The administrator and director of nurses were asked if the facility had received the hospital records for the resident's admission. They advised this surveyor they "could get them." This surveyor asked to see the locked narcotic drawer and the director of nurses brought this surveyor to that medication cart. This surveyor asked how the narcotic lock box was set up and the director of nurses stated, "the narcotic lock box does not have dividers between the residents to separate the medications. We could probably add a second draw to divide the medications by resident." At 3:45 p.m., the narcotic locked box was open and this surveyor observed the narcotics without dividers between resident medications. The other resident's [MEDICATION NAME] was still right next to Resident #10's morning medications, which the director of nurses found and showed to this surveyor. The hospital records were provided to this surveyor. The "ED Provider Report" documented under "History of Present Illness: This (age here) female presents for mental status change. Apparently she had been in her usual state of health until yesterday morning. Apparently, our nurse called (facility name) and learned through discussion there that the patient had been inadvertently administered 60 mg of long acting [MEDICATION NAME]. It seems that the patient's mental status worsened around that time, although it is not clear to me exactly when this event happened." Documented under section " Social History: Presents alone, she resides here locally at (facility name here). " After the labs and data, documented the use of Sodium Chloride (0.9% Sodium Chl (Bolus)) 500 mL Once IV and Naxalone HCl ([MEDICATION NAME] (Use For)) 0.4 mg (milligrams) Once IV - both with start times of 10:15 (am) then documented "Oxygen was provided given her [MEDICAL CONDITION], fortunately after [MEDICATION NAME] ([MEDICATION NAME]) her O2 (Oxygen) requirement was diminished and respirations were appropriate." Under " Medical Decision Making: The patient seems to improve after [MEDICATION NAME] treatment in the emergency department. However she was hypoxic prior to arrival and mental status has not completely returned to baseline. Furthermore she has acute [MEDICAL CONDITION] with a creatinine of 2.0. Significantly changed from her baseline. Given these concerns I have asked the hospitalist to consult on this case to provide continued management and Guidance (sic). " Under "[DIAGNOSES REDACTED]." Naxalone HCl ([MEDICATION NAME]) is defined in Nursing 2012 drug handbook. (2012). Columbia: Lippincott. pages 946 and 947 as an opioid antagonist. With the " Action - May displace opioid [MEDICATION NAME] from their receptors (competitive antagonism); drug has no pharmacologic activity of its own. " An " Alert " under " Nursing Considerations " documented " Drug is only effective for reversing respiratory depression caused by opioids and not for other drug-induced respiratory depression, including that caused by benzodiazepines. " The medications, [MEDICATION NAME], and Klonopin, are benzodiazepines. The medication, [MEDICATION NAME], is a Dibenzothiazepine, and the medication, [MEDICATION NAME] XR is an SSNRI (Selective Serotonin-[MEDICATION NAME] Reuptake Inhibitor). The hospital's "History and Physical" documented "Assessment: 1. Narcotic overdose; 2. Altered mental status secondary to narcotic overdose; 3. Acute hypoxic respiratory distress secondary to narcotic overdose (sic)." Under "Plan: Patient is going to be admitted to telemetry due to her lethargic mental status and respiratory depression secondary to narcotic overdose. We will hold all her psychiatric medication for now and restart when patient's medical condition improves (sic)." On 2/11/15 at 4:30 p.m., registered nurse (RN) #1 was asked about the medication error for Resident #10 on 2/7/15 and transfer to ER (emergency room ) and subsequent hospital admission on 2/8/15. RN #1 stated the LPN (licensed practical nurse) working the 7-3 shift thought she had given Resident #10 her 9:00 a.m. dose of Klonopin (1/2 tablet) , she did receive her 2:00 p.m. dose of Klonopin (1 tablet). RN #1 stated I called the doctor and advised him that was determined and there were no new orders at that time. " She went on to state "When I left, the resident she appeared a little sleepy, but was not lethargic." When asked what the resident's baseline status was, she stated, "she is not always oriented." When asked how the resident appeared when she (the RN) was called the morning of 2/8/15, she stated, "the resident was very lethargic. She was being prepped to go when I got to the unit." She went on to state, "I then called the director of nurses." When asked if the director of nurses was made aware of the medication error prior to this time, RN #1 stated, "No, I did not call her until the resident was being sent out." She went on to state, "We now have a new form for medication incidents that include contacting the administrator, director of nurses and the resident's responsible party." She then stated, "this was my second weekend as on site supervisor." RN #1 was then asked about the documentation from the 3-11 nurse that stated the resident was very lethargic and that the MAR indicated [REDACTED]. RN #1 stated, "Apparently (the nurse) gave (the resident) her evening meds even though she was lethargic. She is working right now, would you like to speak with her? " This surveyor advised the desire to speak with this staff member and RN #1 went and got the nurse. On 2/11/15 at 4:55 p.m., licensed practical nurse (LPN) #1 was asked about the resident's status on 2/7/15. LPN #1 advised this nurse that she worked both the 3-11 and 11-7 shifts 2/7/15, so she was "with the resident from 3:00 p.m. on 2/7/15 until 7:00 a.m. on 2/8/15." LPN #1 stated, "She was sleepy but did not appear lethargic. She needed help eating and the sitter put her to bed right after dinner. She was sleepy but took her meds at 8:00 p.m. and 6:00 a.m." This surveyor read the nurse's 10:17 p.m. progress note that documented the resident was very lethargic, and asked LPN #1 if the resident was lethargic or not, to which LPN #1 stated "Well after dinner she became very lethargic, but the sitter was in there and would alert us of any changes." When asked if the sitter was someone familiar with the resident, LPN #1 stated, "I do not know." When asked why there was no documentation for the 11-7 shift, LPN #1 stated, "We do not bother the resident during the evening, she has requested for us to not bother her when she is sleeping." When asked if she (the nurse) was concerned about the resident displaying lethargy prior to bed and the comment about continuing to monitor, LPN #1 had no response. On 2/11/15 at 5:10 p.m., the attending physician that saw the resident for her readmission came in and spoke with this surveyor while the survey team was present. The physician spoke about how the resident ' s psychoactive medications have been changed and are being monitored by the resident ' s psychiatrist. The physician stated the resident " had more of a delay with responses today. " The physician made no mention of the possible, inadvertent administration of another resident ' s [MEDICATION NAME]. On 2/12/15 at 8:00 a.m., the sitter was asked if she was with the resident on 2/7/15 and 2/8/15 and how familiar she is with the resident. The sitter stated, "Yes I was, I have been with her for three years." When asked when she first noticed changes in the resident, the sitter stated, "After lunch, she started becoming unresponsive when asked questions, speaking very little and not making much sense as the day went on. I asked the staff to take her vitals on the 7th, but they didn't, not once that day." When asked what her hours for sitting with the resident are, the sitter stated I come in at 7 am and leave at 5 pm." When asked when she was made aware of the medication error, the sitter stated, "not until I was at the hospital, after a while." This surveyor asked the resident how she was feeling; she stated "alright." This surveyor then asked the resident how she felt over the weekend with having to go to the hospital. The resident did not respond and had a look on her face that she did not understand the question or was not aware that she was at the hospital over the weekend. On 2/12/15 at 9:45 a.m., Resident #10's power of attorney (POA) was asked when he was made aware of the medication error for Resident #10. The POA stated, "the first contact from the facility came on 2/8/15 at 1:07 p.m. The administrator had called and left a message. We then connected at 1:17 p.m. This is when I was made aware of the medication error. They never contacted me that she was being sent to the hospital, the sitter (name) kept me posted about that, not the facility." On 2/12/15 at 10:55 a.m., the administrator was asked about the notification to the POA for the medication error for Resident #10. The administrator stated, "He was made aware on 2/8/15." She went on to state, "He was concerned that we were trying to hide something, I told him that was not the case." When asked when should the staff had contacted the administrative team, the administrator stated, "When it happened. We have changed the form so they know who all needs to be contacted, the director of nurses, administrator and responsible party." This surveyor asked for the facility's policies for medication administration to include narcotics. This surveyor asked to speak to the nurse that made the medication error. At 11:05 a.m., the administrator brought this surveyor the nurse's contact number and stated that she had left a message to call the facility. The facility's policy titled "Medication Error/Occurrence" documented under "General Information: Types of Medication Errors: Unauthorized Drug Error: The administration of a medication to a resident for which the physician did not write an order (sic)." Documented under the section "Specific Procedures/Requirements: 3. Nursing service must immediately implement and follow the physician's orders [REDACTED]. A. Clinically relevant information about follow-up of the resident must be recorded in the clinical chart, including: 1) The date and time of the occurrence; 2) the kind of medication error or adverse reaction; 3) The name, date and time the physician was notified; 4) The physician's orders [REDACTED]. Example: vital signs, level of alertness/confusion, behavior and presence/absence of potential side effects, etc. (sic)." The facility's policy titled "Administration of Controlled Substances" documented under "Procedure: 6. If an error is found in the count the DON (director of nurses) must be notified immediately. Off-going nurses may not leave the unit until the error is corrected." On 2/12/15 at 11:00 a.m., this surveyor was provided with the physician ' s note with a date of service of 2/11/15. Under " S (Subjective): On 2/7/15, she accidentally received another patient ' s [MEDICATION NAME] mg. Over the ensuing 24 hours, (s)he was noted to be more sedated and was sent to the emergency roiagnom on [DATE]. She was brought for observation secondary to altered mental status and sedation. She stabilized without significant intervention. She did receive one dose of [MEDICATION NAME] in the emergency room (sic). " On 2/12/15 at 11:55 a.m., the administrative team was made aware of the findings during a meeting with the survey team. The administrator advised this surveyor that the nurse had not returned her call as of that time. No other information was provided to this surveyor prior to the exit conference on 2/12/15

Based on observations, staff interviews, and facility document review, the facility staff failed to store, prepare, procure, and serve food in a sanitary manner by improper use of hair nets in the main kitchen. The findings include: On 2/11/15 at 11:00 a.m., facility dietary staff were observed taking food temperatures and handling food while hair nets where not covering all of the hair of four staff members. Three of these staff members had the front of their hair not covered by the hair net. A fourth staff member had the hair net only over the bun at the back of their head, while the rest of the hair was exposed. The staff members were asked individually why their hair was not covered completely by the hair nets. Two of the staff members stated "I use hairspray on the sections that are not covered by the hairspray to keep it in place. Another staff member stated "the hair net needs to cover the back of the hair since that is where most of the hair loss occurs. There is hardly any hair loss from the front." All of the staff members were asked what the purpose of the hairnet is. They all stated that "it is used to stop the hair from gonig into the food." This surveyor asked for the facility's policy on hair net use. The facility's policy titled "Personal Appearance-Dress Code" was provided to this surveyor. Under the section "Procedure 1. c)" documented "Hair protection is required. Hairnets are to be worn by all employees with hair below the collor. Paper hats (or hairnets) are to be worn for hair above the collar. Hairnets may be purchased from the Dining Services Supervisor." On 2/11/15 at 11:30 a.m., the administrative team was made aware of the observation and were asked what their expectation of the kitchen staff with regards to hair net use and what should be covered. The administrative team stated they "expected the facility staff to cover all of their hair with the hair nets to ensure hair did not get into the food." On 2/11/15 at 1:45 p.m., the registered dietitian asked this surveyor if the "facility could change their policy." This surveyor advised the registered dietitian that "the facility is responsible for their policies and procedures and whatever they felt needed to be included they can determine and revise to meet their needs. The registered dietitian stated "The hair nets are to cover all of the hair and the policy will reflect that. This will be taken care of." No other information was provided to this surveyor prior to the exit conference on 2/12/15.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide adequate supervision and/or assistive devices for the prevention of an accident for two of 15 residents in the survey sample (Resident # 2 and Resident # 11). 1. The facility staff failed to provide supervision for Resident # 2 after the resident had been identified to have poor safety awareness. Resident # 2 was left alone on the toilet; the resident got up off of the toilet without assistance and fell . As a result of the fall, Resident # 2 sustained a left hip fracture. 2. Resident #11 fell while being assisted from the bathroom without use of a gait belt or a bedside commode as required in her plan of care. Resident #11 sustained a finger laceration requiring sutures, a hematoma/abrasion to her head and multiple contusions/abrasions to her arm, knee and shoulder as a result of the fall. Findings include: 1. Resident # 2, an [AGE] year old female was originally oradmitted to the facility on [DATE] (from the Assisted Living after a fall), with the most current readmission on 10/05/13. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) with CAAS (care area assessment summary) was a significant change assessment dated [DATE]. Resident # 2 was assessed as having a cognitive score of "5", which indicated the resident had severe impairment in daily decision making skills. The resident was also assessed on this MDS as requiring extensive to total assistance from staff for most all ADL's (activities of daily living) including transfers and toileting. Resident # 2's admission MDS assessment dated [DATE], was reviewed for comparison. This MDS assessed the resident with a cognitive score of "3", which indicated the resident was severely impaired in daily decision making skills. This MDS also assessed the resident as requiring extensive to total assistance for most all ADL's including transfers and toileting. Additionally, this MDS assessed the resident as having a fall in the last month (prior to admission-08/02/13) and as having a fall in the last 2-6 months (prior to admission-08/02/13), and as having sustained a "Major Injury" as a result of the fall. On 12/03/13, Resident # 2's POS's (physician's orders [REDACTED]. The September POS documented: "...Fall Precautions...ACTIVITY: GAIT BELT W (with) 1-2 PERSON ASSIST, RW (rolling walker) USE W (with) ASSIST...09/06/13: Pressure sensitive chair alarm when in chair check placement/function Q (every) shift...09/15/13: Pressure sensitive bed alarm when in bed check placement and function Q shift..." Resident # 2's "Ancillary" order records were reviewed for September and October 2013. The September records documented: "...Activity: Gait belt w/ 1-2 person assist, RW use w/ assist...Pressure sensitive chair alarm when in chair to alert staff of unsafe solo ambulation...Pressure sensitive bed alarm when in bed..." The October records documented: "...Activity: Gait belt w/ 1-2 person assist, RW use w/ assist..." Additionally, the October records documented: "Fall Precautions." The resident's CCP (comprehensive care plan) was then reviewed. The CCP, dated 08/22/13 documented: "...BONE: Right humerus fracture (upon admission-08/02/13) Resident will be free of preventable crisis related to right humerus fracture through next review (Goal Date: 11-12-13)...VISUAL: ...Keep resident's environment free of potential hazardous substances...COMMUNICATION: ...Place call bell within resident's reach...check on resident frequently throughout shift...ADL: ...Alerts staff of toileting needs at times. Is frequently incontinent of bowel and bladder and wears adult incontinence products in which she requires staff assist in managing. Uses bed pan...Ensure that call bell is within reach of resident when in bed/room. Check on resident frequently as she does not always remember to use her call bell to alert staff of needs...Check resident frequently for incontinence and provide incontinence care as indicated to help keep her clean and dry...Provide continuity of care through consistent patient assignment...Falls: At risk for injury related to weakness, decreased mobility, impaired ROM (range of motion) of upper extremity, history of falls, use of psychotropic medication, impaired safety awareness and a fall risk assessment score...Resident to transfer as ordered by physician; 1-2 assist RW (rolling walker) and gait belt...09/05/13 chair alarm...to alert staff of unsafe solo ambulation...09/14/13 resident bent over stationary chair...had to be assisted back to chair...falling star...09/15/13 bed alarm in bed...10/01/13 Resident fell over w/c (wheel chair) self ambulating out of bathroom 11:45 a.m...staff education..." Nursing notes for Resident # 2 were then reviewed from admission (08/02/13) up to present. Nursing notes documented the following, evidencing the resident frequently attempted to transfer without assistance: "...08/13/13...up solo to bathroom..." "09/05/13...transferred self to another resident's toilet..." "09/06/13...transferred self X 2 (times 2)..." "09/16/13...standing in front of chair..." "10/01/13 (12:30 p.m.) Alerted to resident room by house keeping that resident had fallen at 11:45 a.m. Upon arrival discovered resident on floor complained of 9/10 pain in left hip...left leg has outward rotation and is abducted...resident was removed from floor with vanderlift and placed in bed...transferred resident to ER (emergency room )...resident was solo ambulating from bathroom to wheelchair..." On 12/04/13 at approximately 8:15 a.m., the U2M (Unit 2 Manager) who was RN (Registered Nurse) # 2 was asked for the investigation regarding Resident # 2's fall on 10/01/13, in addition to the resident's fall risk assessments. At 9:30 a.m. on 12/04/13, the DON (director of nursing) presented the investigation for review. The investigation included a facility reported incident, as well as statements from the staff. The investigation documented: "...solo ambulating off toilet tripped on w/c...resident fell leaving bathroom solo ambulating without staff...staff in hall talking to someone...CNA (certified nursing assistant) left resident in room alone...there is ongoing education with all staff on resident safety and policies..." The DON was asked for evidence of staff education. The DON stated, "...we educated (name of CNA responsible for leaving Resident # 2 alone) and terminated her..." The DON was asked if she (the CNA) was the only staff educated. The DON stated that other staff were educated and she (the DON) would check with RN # 2 (U2M) to see if she had anything. At 9:40 a.m., RN # 2 was interviewed and stated, "I didn't think to have them (staff) sign anything I just spoke with them verbally and reminded them not to leave anyone unattended...should have known better, I'll know for next time, if it's not documented it's not done..." At approximately 9:45 a.m. CNA # 6 was interviewed. CNA # 6 was asked if she knew of Resident # 2. CNA # 6 stated, "Yes, I sure do." CNA # 6 was asked if she had received any education after the fall/incident regarding Resident # 2. CNA # 6 stated, "No, I'm not working with her...I did not." At 10:15, Resident # 2's Fall Risk Assessment was presented and reviewed. The "Fall Assessment: Predisposition For Falling" documented: "....Admission 08/02/13 Total Score=16...09/14/13 Total Score=16...A score of 10 or above indicates a risk for falling: Increased risk of falling to be added to Care Plan with nursing actions." A physician's progress note (dated 10/07/13) for Resident # 2 was reviewed and documented: "...10/07/13..XXX[AGE] year old female who was admitted to (name of facility) about 3 months ago with a right humeral fracture...She had subsequently had a fall and fractured her left hip..." The Emergency Department Report was reviewed and documented: "..XXX[AGE] year old female who comes in after a fall. The patient reports that she was walking when she tripped on a throw rug. The patient landed on left hip...unable to walk after the accident...The patient is on Pradaxa (blood thinner) for anticoagulation for Atrial Fibrillation. The patient reports she hit her head, but does not have a headache..." On 12/04/13 at approximately 12:00 noon, the administrator, DON (director of nursing), and the RN # 2 (U2M) were made aware of concerns regarding Resident # 2's fall with significant injury, in a meeting with the survey team. The DON stated that staff were educated primarily by verbal reminders and that they (the facility) felt it was an isolated event. The DON additionally stated that, "...It (education) wouldn't have hit all of them (all staff on 3 different shifts)..." At approximately 2:00 p.m., the administrative staff (Administrator, DON, RN # 2) were again made aware of concerns regarding Resident # 2 in a meeting with the survey team. A communication book was presented. The Administrator was asked what the communication book was for. The Administrator stated that the communication book was for basically any changes going on with the residents. The Administrator was asked if the communication book was used for education or in-servicing purposes, the Administrator stated, "No, it would not be used for that." No further information or documentation was presented prior to the exit conference on 12/05/13. 2. Resident #11 was admitted to the facility on [DATE] with a re-admission no 2/6/13. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills for decision-making. This MDS assessed Resident #11 to require the extensive assistance of one person for transfers and toileting. Resident #11's clinical record was reviewed on 12/4/13. A nursing note dated 1/27/13 stated, "Writer was in another room when I heard someone screaming...found resident and CNA (certified nurses' aide) on the floor resident has a laceration to R (right) side of face Above eyebrow and cut to R hand and c/o (complaint of) R hip pain...911 called..." Resident #11 was transported to the hospital emergency room for assessment/treatment of [REDACTED]. The emergency department report dated 1/27/13 documented the resident sustained [REDACTED]. The emergency department report documented, "The patient has a large right frontal hematoma with abrasion...The patient has a right fifth digit proximal 3 cm (centimeter) laceration at the base of the proximal phalanx. There is a laceration at the lateral aspect of the finger...Patient has surrounding hematoma through the lateral proximal forearm plus ecchymosis. Skin exam also shows that the patient has ecchymosis and abrasion to the right knee as well as ecchymosis and contusion to the right shoulder..." This emergency department report documented the right finger laceration was repaired with three sutures. The resident returned to the facility after treatment in the emergency room . Upon return from the emergency room the facility documented the following assessment of the resident's injuries resulting from the fall on 1/27/13: Bruise with abrasion above right eyebrow - "8 cm x 3 cm (length by width)...Area is purplish (with) reddened abrasions in center 2.0 x 2.0 cm..." Laceration to right palm - "area has 3 steristrips and 3 stitches..." Right elbow - "11 x 6 (cm)...skin tear...covered (with) 5 steristrips...Telfa Kling..." Bruise on right wrist - 2.0 x 2.0 cm "bruise purplish circular..." Right shoulder abrasion - "3 x 3 (cm)...circular abrasion (abrasion) purplish red..." (sic) Right shin bruise - "6 x 2 cm...midline purplish red bruise..." Right shin bruise - "5 x 5 (cm)...diffused areas of bruises purplish red bruises..." Knee abrasion - "3 x 2 (cm)...abrasion reddend (reddened) covered (with) Telfa..." (sic) Knee lateral side abrasion - "2 x 1 (cm)...abraison (abrasion) reddend covered (with) Telfa..." (sic) The facility's post fall investigation report dated 1/27/13 documented CNA #3 was assisting Resident #11 from the bathroom at the time of the fall. CNA #3's written statement dated 1/27/13 stated, "I was going to help South hall CNA...As we passed (Resident #11) she was about to get up. South CNA asked me to assist her, so I did. I assisted Resident to the bathroom, but I forgot to put gait belt on Resident...As we were heading out of the bathroom we were at the door. Resident took a step, as we took the step she tripped on divider-strip. As she was falling, I grabbed a hold of her legs and chest, but I could not get a hold of her head. We both fell to the floor. She also fell on her walker." Resident #11's clinical record documented the resident was at risk for falls. The clinical record documented a physician's orders [REDACTED]. The order stated, "May ambulate to BSC (bedside commode) with 1... assist of 1 with gait belt...Transfer with 1 assist, gait belt." The resident's plan of care at the time of the fall (revised 11/20/12) documented the resident had a history of [REDACTED]." The care plan interventions to prevent falls/injury included, "Use BSC (bedside commode) in resident's room...Resident to ambulate/transfer with... (walker), gaitbelt and assist of 1..." This care plan documented the resident required extensive assistance with toileting. Interventions for toileting assistance included, "Uses BSC (bedside commode)..." On 12/4/13 at 4:15 p.m. the director of nursing (DON) and the registered nurse unit manager (RN #2) caring for Resident #11 as the time of the fall were interviewed. RN #2 stated CNA #3 saw Resident #11 trying to get up and went in to assist the resident as the resident's assigned CNA was busy. RN #2 stated CNA #3 was not familiar with Resident #11's requirement for the use of the bedside commode and assisted the resident to the bathroom. RN #2 stated the resident fell while being assisted by the CNA when returning from the bathroom. RN #2 stated a gait belt was not in use with the resident at the time of the fall as required. The DON stated the use of the gait belt was a "universal policy" in the facility for residents requiring assistance. The DON stated, "If assisting somebody not independent, we are supposed to use a gait belt with transfers or walking." The facility's policy titled "Gait Belt Use" issued 1/09 stated, "Nursing staff will use gait belts when ambulating or transferring residents who require 1 or 2 person assistance...The gait belt gives staff members 'handles' around resident's middle enabling staff to respond to changes in balance/ability to bear weight faster...Gait belt use allows staff to keep the back erect, in 'natural' position...The nursing staff will assist the resident in ambulation or transfer by holding onto the gait belt..." These findings were reviewed with the administrator, director of nursing and unit managers on 12/4/13 at 4:30 p.m.