Every finding on record at Sunrise Terrace Nursing & Rehabilitation Center

Based on record review, staff interviews, and the facility policy, the facility failed to address an antipsychotic on a resident's care plan for 1 of 5 residents reviewed for unnecessary medications (Resident #5). The facility reported a census of 36 residents. Findings include: Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 scored a score of 99, indicating severe cognitive impairment. The MDS indicated active diagnoses for severe vascular dementia (brain damage from impaired blood flow) with other behavioral disturbance, and anxiety disorder (excessive worry or fear). The MDS revealed Resident #5 took an antipsychotic on a routine basis. The Care Plan Focus revised 6/3/25 indicated Resident #5 had impaired cognition related to vascular dementia. The Care Plan lacked documentation for antipsychotic medication, triggers, side effects, and interventions when an antipsychotic medication was used. The Electronic Health Record (EHR) revealed a Physician Order dated 6/16/25 for haloperidol lactate oral concentrate 2 mg/ml (milligrams/milliliters) (an antipsychotic medication used to treat mental or mood disorders) - give 0.5 ml by mouth four times a day related to vascular dementia. On 8/26/26 at 3:08 PM, the Director of Nursing (DON) stated the facility conducted audits to make sure the medications were on the care plan. The DON reviewed Resident #5's care plan and confirmed the medication and interventions were not on the care plan. The DON stated the antipsychotic should be on the care plan along with the side effects addressed on the psychotropic consent. The DON stated Resident #5 had a long history of behaviors, but since taking the haloperidol, Resident #5's behaviors improved and so the care plan did not address the behaviors since Resident #5 was stable. The undated facility policy titled Facility Comprehensive Care Plan instructed staff to conduct a thorough assessment of the resident's current health status, including any changes in their condition, medications, or treatments. The policy directed staff to review the resident's current care plan to determine if any revisions were needed. The policy instructed staff to revise the care plan based on the assessment and review to reflect any changes in the resident's health status or care needs, including specific goals and interventions to address the resident's physical, emotional, and social needs.

Based on observations, policy review, resident and staff interviews, the facility failed to maintain palatable food at minimum safe temperatures for 1 of 1 meals observed. The facility reported a census of 36 residents.Findings include:1. During an observation on 7/7/25 at 11:43 a.m., Staff A, [NAME] started to serve lunch. The meal included breaded fish, green beans, and french fries. During the service, the lights of the steam table were not illuminated. During an interview on 7/7/25 at 12:37 p.m., Staff A stated she completed serving the meal. The State Agency (SA) requested a test tray. With the Certified Dietary Manager present and with the use of a facility thermometer the following food temperatures were obtained: a. Breaded fish 132.5 degrees F (Fahrenheit). b. [NAME] beans 126 degrees F. c. French fries 93 degrees F. During the observation, the CDM stated the temperatures should be at a minimum of 135 degrees Fahrenheit and stated the steam table was not on.Review of the undated facility policy titled Standard Operating Procedure (SOP) For Holding Hot and Cold Potentially Hazardous Foods (PHFs)”, revealed a Purpose statement which declared To prevent foodborne illness by ensuring that all potentially hazardous foods are held under the proper temperatures. The Instructions section directed staff, in part: #2. Hold hot foods at 135 degrees or above. a. Preheat steam tables and hot boxes. 2. The Minimum Data Set (MDS) assessment, dated 6/16/25, identified Resident #22 with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. During an interview on 7/7/25 at 11:05 a.m., Resident #22 stated food that was supposed to be hot was served cold. She reported having been served cold scrambled eggs for breakfast on 7/7/25. 3. The MDS assessment dated [DATE] revealed Resident #6 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. During an observation of lunch on 7/7/25 at 11:52 a.m., Resident #6 took a bite of a french fry and commented to her tablemate that the french fries were not really hot. During an interview on 7/7/25 at 2:28 p.m., Resident #6 queried on her lunch stating the french fries were cold. 4. The MDS assessment dated [DATE] revealed Resident #11 scored a 12 out of 15 on the BIMS exam, which indicated cognition moderately impaired. During an interview on 7/7/25 at 10:26 a.m., Resident #11 stated she ate in her room. Resident #11 asked about the temperature of the food and Resident #11 stated the food was sometimes cold, and rarely was it a good temperature.

Based on clinical record review, observation, resident and staff interviews, the facility failed to provide adequate supervision for 1 of 1 residents who eloped (Resident #1). The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of dementia, depression, and anxiety. Resident #1 had short and long-term memory impairment and walked independently without the use of mobility devices. The resident had not wandered during the 7-day look-back period and used a wander/elopement alarm daily. The Care Plan identified wandering as a focus area on 12/31/18 with interventions: a. Resident to wear a Wanderguard (a type of wander alarm), which is checked for placement and functioning, to ensure safety. b. Attempt to redirect resident if wandering. The Care Plan further identified risk for elopement as a focus area, initiated 2/27/20 with interventions: a. Wanderguard on right ankle checked for placement and working. b. Identify pattern of wandering. c. Provide structured activities. Review of the facility's Elopement Evaluation for Resident #1 dated 4/22/21 revealed the resident wandered aimlessly or non-goal-directed and had no history of elopement. On the Treatment Administration Record for July 2021, staff documented Wanderguard in place and functioning every shift. Observations on 7/21/21 at 11:35 AM and 7/22/21 at 10:15 AM revealed Resident #1 walked independently in the facility with staff cueing her where to go. An observation on 7/22/21 at 11:50 AM revealed the resident walked unattended into an occupied office, talking nonsensically, carrying a rolled up newspaper and a baby doll, and pointing outside. On 7/20/21 at 5:03 PM the facility's Progress Notes documented staff observed the resident outside of the facility, went to her, and brought her back inside. Staff noted the resident wore a light sweater, appropriate footwear, and a functioning Wanderguard. Review of the Nursing Schedule for 7/20/21 showed the following staff scheduled at 5:03 PM: Staff A, Registered Nurse (RN); Staff B, Certified Nurse Aide (CNA); Staff C (CNA); and Staff D (CNA). On 7/21/21 at 3:00 PM, Staff A, RN, reported Resident #1 wandered daily and had pushed on exit doors in the past. Staff A reported being in a resident's room in the 100 hall when she heard a door alarm sound. The alarm stopped before Staff A arrived at the panel indicating the affected door, and the panel did not show an open door. The phone did not register a door being open. Staff A stated the only way the alarm is supposed to stop is if a staff member shuts it off and so felt the alarm had been responded to. As she continued working, she looked out a window and observed Resident #1 outside. Staff immediately re-directed the resident inside, within 5 minutes of the alarm sounding. After the resident returned inside, the staff checked the doors and noted the skilled south door alarming, not audible off the skilled unit. On 7/21/21 at 4:20 PM, Staff B, CNA, reported Resident #1 wandered frequently. She stated she went on break just prior to the resident exiting the facility and never heard an alarm sound. On 7/22/21 at 8:53 AM, Staff C, CNA, reported being in the dining room when Staff A observed the resident outside. Staff C had not heard a door alarm nor received a phone notification of an open door. On 7/22/21 at 11:00 AM, Staff D, CNA, stated she walked a resident to supper around 5:00 PM the evening Resident #1 walked outside and did not hear any door alarm nor receive a phone notification of an open door. On 7/21/21 at 1:35 PM, Resident #4 reported seeing Resident #1 walking outside for about 3-4 minutes around 5:00 PM on 7/20/21. Resident #4 had been seated in her recliner next to her window and saw Resident #1 walking approximately 5-10 feet from the exit door slowly around the cement edge of the parking lot and into a grassy area towards some trees. Resident #4 had lost sight of the Resident #1 as staff came out a different door and walked Resident #1 inside. Resident #4 could not recall hearing a door alarm. On 7/21/21 at 11:50 AM, the Administrator demonstrated the proper functioning of the facility's alarm system at the Skilled Unit South exit door following technician repair earlier that morning. The Administrator explained the following: a. The currently unoccupied skilled unit is divided from the 100 wing by closed double doors. b. The exit door has a Wanderguard system in place and locks when anyone with a Wanderguard is near. c. Override of the Wanderguard system is done with the fire egress, by pushing on the door for 15 seconds until it opens. d. An alarm sounds at the door and, through a relay, into the 100 hall when the door is pushed. e. After 15 seconds the door opens and the alarms become louder at the door and in the 100 hall. f. When the door opens, it registers at a panel in the center of the facility and also sends an alert to the phones the staff carry. g. Once any door alarm sounds, it stops when staff enter a code at the alarming door. A signed statement by a technician from the door alarm company dated 7/21/21 stated upon investigation that morning, he noted a relay controlling the Skilled Unit South door's local sounder had failed. The failure meant no loud, 115 decibel, alarm sounded once the door opened, no alarm sounded in the 100 hall when the door opened, and no notification went to the staffs' phones. On 7/21/21 at 3:17 PM the Maintenance Director reported during his daily door alarm checks, the South Skilled Unit exit door had alarmed appropriately on the morning of 7/20/21. Relays only have a certain life span. The undated facility Elopement Protocol/Policy stated: a. Appropriate staff will monitor resident whereabouts at the time of wandering. b. Multi-faceted approaches used to assure resident safety include alarmed doors, Wanderguard system, signage, and elopement prevention drills. On 7/22/21 at 10:50 AM, the Maintenance Director reported he trained all new staff on the door alarm system and responding immediately to alarms. Staff should always follow-up that someone checked the door. On 7/22/21 at 11:10 AM, the Director of Nursing reported, expected staff run to a door alarm unless it is unsafe to leave a resident. If uncertain which door alarmed, staff should check all doors and complete a head count.

Based on observation, record review and staff interview, the facility failed to store and administer insulin by professional standards and per facility protocol for 2 of 7 residents that received insulin (Resident's #7 and #11). The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had [DIAGNOSES REDACTED]. A physician order [REDACTED].#7 daily in the evening. The September, 2016 Medication Administration Record [REDACTED]. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had [DIAGNOSES REDACTED]. A physician order [REDACTED].#11 daily in the evening. A physician order [REDACTED].#11 for a blood sugar of 553 (normal blood sugar range 70 to 110), recheck blood sugar at 5:30 p.m. and administer the scheduled 4 units Novolog insulin in the evening if blood sugar greater than 250. A physician order [REDACTED].#11 for a blood sugar of 499. The September, 2016 Medication Administration Record [REDACTED] Observation in the medication storage room on [DATE] at 7:30 a.m. with the assistant director of nursing (ADON) revealed: 1. A vial of Lantus insulin, labeled with Resident #7's name and notation the vial was opened on [DATE]. 2. A Novolog insulin pen, labeled with Resident #11's name and notation the pen was activated on [DATE]. A Diabetes Injectable Medications reference, identified as the facility's policy, revealed both Lantus and Novolog insulin expire 28 days after opened (both insulins expired on [DATE] per facility policy). During an interview on [DATE] at 7:30 a.m., the ADON stated staff should review insulin medication for date initiated, follow facility policy for expiration date prior to administration and discard medications when expired. During an interview on [DATE] at 10:11 a.m., the facility nurse consultant and ADON stated nurses were required to check insulin for outdate prior to administration, and the Diabetes Injectable Medication documents provided served as the facility's policy for insulin administration.

Based on record review and interview, the facility failed to follow protocol for the administration of laxatives for 2 of 4 residents with orders for MOM (Milk of Magnesia) and [MEDICATION NAME] suppositories (Residents # 6 and #10). The facility reported a census of 45 residents. Findings: 1. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #6's [DIAGNOSES REDACTED]. The MDS indicated the resident totally depended on 2 staff for toilet use and personal hygiene. The MDS documented the resident's BIMS (Brief Interview for Mental Status) score as 8, indicating moderately impaired cognition. The MDS documented the resident as always incontinent of bowel and not currently on a toileting program to manage the resident's bowel incontinence. Review of the physician's orders [REDACTED]. Review of the June 2015 MAR (Medication Administration Record) revealed no administration of the physician ordered MOM before the administration of a [MEDICATION NAME] suppository on 6/13/15 and 6/27/15. Review of the July 2015 MAR indicated [REDACTED]. Review of the August 2015 MAR indicated [REDACTED]. Review of the September 2015 MAR indicated [REDACTED]. The facility Resident BM Schedule/Protocol, dated 4/16/13, directed staff to administer MOM in the evening shift if the resident had gone 2 days with no bowel movement. If the resident had no results from the MOM by the next morning, the protocol directed staff to then give a suppository. During an interview on 9/15/15 at 6:50 a.m., Staff B, RN (Registered Nurse), stated Resident #6 did not like her; and thought it was because she was the nurse who always gave the suppositories. During an interview on 9/17/15 at 7:15 a.m., the Director of Nursing stated he would expect staff to follow the facility policy on the administration of laxatives. 2. Resident #10 had [DIAGNOSES REDACTED]. The MDS documented the resident with short and long term memory problems and severely impaired decision making skills. The MDS documented the resident as occasionally incontinent of bowel and not currently on a toileting program to manage the resident's bowel incontinence. Review of physician's orders [REDACTED]. Review of the June 2015 MAR indicated [REDACTED]. Review of the July 2015 MAR indicated [REDACTED]. Review of the August 2015 MAR indicated [REDACTED]. Review of the September 2015 MAR indicated [REDACTED].

Based on observation and interview, the facility failed to provide ADL(Activities of Daily Living) assistance for 2 out of 11 residents reviewed (Residents #6 and #7). The facility reported a census of 45 residents. Findings: 1. The Minimum Data Set (MDS) for Resident #6 dated 7/13/15 documented [DIAGNOSES REDACTED]. The MDS documented the resident required the extensive assistance of 2 staff for bed mobility and totally depended on 2 staff for transfers, dressing, toilet use, personal hygiene, and bathing. The MDS documented the resident's BIMS (Brief Interview for Mental Status) score as 8, indicating moderately impaired cognition. During an observation on 9/14/15 at 4:46 p.m., Resident #6 had a black substance embedded under each fingernail. During an observation on 9/15/15 at 6:53 a.m., Resident #6 had a black substance embedded under each fingernail. During an observation on 9/17/15 at 8:30 a.m., Resident #6 had a black substance embedded under each fingernail. 2. The Minimum Data Set (MDS) for Resident #7 dated 9/1/15 documented [DIAGNOSES REDACTED]. The MDS documented the resident required the extensive assistance of 2 staff for dressing and personal hygiene, and totally depended on 2 staff for transfers, toilet use, and bathing. The MDS documented the resident's BIMS (Brief Interview for Mental Status) score as 3, indicating severely impaired cognition. During an observation on 9/16/15 at 8:15 a.m., Resident #7 had a brown substance embedded under each fingernail of the right hand. During an observation on 9/17/15 at 8:25 a.m., Resident #7 had a brown substance embedded under each fingernail of the right hand. During an interview on 9/17/15 at 10:45 a.m., the Director of Nursing stated nails should be cleaned regularly when needed.

Based on observation, record review, and interview, the facility failed to administer medications correctly for 1 of 1 residents receiving eye drops (Resident #13). The facility reported a census of 45 residents. Findings include: 1. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #13's [DIAGNOSES REDACTED]. The MDS indicated the resident required supervision and setup assistance of 1 staff member for dressing, eating, and personal hygiene and required assistance of 1 staff member for bathing. The MDS listed the resident's cognitive skills as intact. During the medication pass observation for Resident # 13 on 9/14/15 at 2:39 p.m., Staff A, RN (Registered Nurse), instilled 1 drop of [MEDICATION NAME] P Solution 0.1% into the left eye. Staff A did not wait 5 minutes before instilling the next eye drop. During the medication pass observation for Resident #13 on 9/14/15 at 2:41 p.m., Staff A instilled 1 drop of Dorzolamide HCl Solution 2 % into the left eye. Staff A did not hold the lacrimal sac for 1 minute as directed in the facility medication handbook or have the resident hold the lacrimal sac for 1 minute. Resident #13's physician's orders [REDACTED]. Resident #13's physician's orders [REDACTED]. A review of Resident #13's September Medication Administration Record [REDACTED]. A review of Resident #13's September Medication Administration Record [REDACTED]. The Wolters Kluwer 2016 Drug Handbook utilized by the facility as a medication resource manual directed staff to wait 5 minutes after administering [MEDICATION NAME] P before giving another eye drop. The manual also directed staff to apply light finger pressure on the lacrimal sac for 1 minute after instilling Dorzolamide HCl to minimize systemic absorption. During an interview on 9/16/15 at 11:30 a.m., the Director of Nursing stated he would expect staff to wait 5 minutes after giving [MEDICATION NAME] before giving another eye drop and would expect staff to hold the lacrimal sac for 1 full minute after giving Dorzolamide.

Based on observation and staff interview, the facility failed to post or prominently display written information regarding how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. The facility reported a census of 45 residents. Findings Include: 1. Observations throughout the survey and with the facility Administrator on 9/16/15 at 3:00 p.m. during the environmental tour revealed the facility did not have the required posting related to how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. During an interview during the environmental tour on 9/16/15 at 3:00 p.m., the Administrator stated the facility usually displayed the Medicare and Medicaid information on the bulletin board but someone must have accidentally removed the posting. During a meeting to discuss findings on 9/17/15 at 11:30 a.m., the Administrator stated the facility again posted the required Medicare and Medicaid information on the bulletin board.

Based on observation, record review and staff interviews, the facility failed to implement fall precaution interventions to provide a safe environment for 1 of 5 residents reviewed with fall histories (Resident #2). The facility reported a census of 46 residents. Findings Include: The Minimum Data Set (MDS) assessment tool dated 4/17/12 revealed Resident #2 had [DIAGNOSES REDACTED]. The 4/17/12 assessment identified that Resident #2 had experienced 2 falls without injury since the previous assessment completed on 1/17/12. Fall investigation reports provided by the facility revealed Resident #2 had experienced falls on 5/10/12, 5/6/12, 9/4/11 and 8/5/11. The 5/10/12 fall investigation report revealed the resident sustained [REDACTED]. Documentation recorded on 5/10/12 at 2:45 p.m. by Staff B, Registered Nurse, revealed Resident #2 found on the floor laying on his/her right side in the room, the bruise with opened area and blood present. Two steri strips applied to the area, the resident complained of pain in the right upper arm, physician notified and order received to administer Hydrocodone 5/325 (Vicodin - a strong analgesic) 1 tablet oral every 4 hours as needed, and personal chair alarm with increased observation added as fall precaution interventions. A nursing care plan dated 4/24/12 included a problem identified as dementia with fall history, a 7/23/12 goal that the resident would not have an injury from a fall, and interventions that included: 1. Make sure my alarms are on at night. 2. Have alarms under me when not supervised (added on 5/11/12). Observations of Resident #2 revealed: 5/22/12 at 3:42 p.m. Seated in the assisted dining room/activity room by a table with a pressure alarm pad beneath him/her but not connected to an alarm box and no staff in the room. 5/22/12 continuous observation between 3:55 p.m. and 4:58 p.m., the resident remained seated in the assisted dining room with a pressure alarm positioned beneath him/her but not connected to an alarm box. 5/22/12 at 4:57 p.m., an unidentified certified nursing assistant (CNA) looked at Staff E, another CNA, and pointed with his/her finger at Resident #2's pressure alarm wire not connected to an alarm box. Staff E left the dining room and returned at 4:58 p.m. with an alarm box and connected to Resident #2's pressure alarm. 5/23/12 at 7:06 a.m., Resident #2 positioned in bed, pressure alarm pad on bed with wire laying upon the floor and no alarm box connected. 5/23/12 at 7:19 a.m., Pressure alarm on Resident #2's bed without an alarm box connected to the wire that laid on the floor beside the bed. 5/23/12 at 7:25 a.m., Pressure alarm remained disconnected from alarm box. 5/23/12 at 7:40 a.m., Resident #2 remained in bed with pressure alarm on bed not connected to an alarm box. During an interview on 5/23/12 at 3:10 p.m., the Director of Nursing (DON) stated an overlap of shifts enables the CNA's to make rounds together and the expectation that they check and ensure that alarms are in place as ordered. During an interview on 5/24/12 at 3:15 p.m., Staff B, a registered nurse, stated that he/she added the chair alarm intervention to the resident's nursing care plan on 5/11/12 after the resident was found on the floor on 5/10/12. During an interview on 5/25/12 at 9:30 a.m., the DON stated that Resident #2 required bed and chair alarms for safety and staff responsible to ensure alarms were in place/functioning properly.

Based on observation, record review and staff interviews, the facility failed to follow physician orders [REDACTED]. The facility reported a census of 47 residents. Findings Include: The Minimum Data Set (MDS) assessment tool dated 3/20/12 revealed Resident #1 had [DIAGNOSES REDACTED]. A physician order [REDACTED]. A controlled Drug Receipt/Record Disposition Form labeled with Resident #1's name and Hydro/APAP 5/325 revealed 1 tablet administered on 5/7/12 at 8:06 p.m. by Staff B, a registered nurse. During an interview on 5/24/12 at 3:15 p.m., Staff B stated that he/she administered only 1 tablet of Hydro/APAP 5/325 to Resident #1 on 5/7/12 at 8:06 p.m. and did not administer 2 pills as ordered by the physician. During an interview on 5/25/12 at 8:05 p.m., the Director of Nursing stated he/she expected nursing staff to follow physician orders.

The following information relates to # -I Based on record review and staff interview, the facility failed to plan for and direct services designed to alert staff of supervision needs and provide adequate supervision for two (2) of five (5) residents. Resident #1 fell and sustained a fractured hip, with no safety intervention functioning to alert the staff of his/her supervision needs.Resident #3's safety intervention failed to alert staff of his/her supervision needs during a fall with no injury. The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool with a reference date of 10/11/11 revealed Resident #1 with a BIMS (Brief Interview Mental Status) score of 4. The assessment indicated the resident had [DIAGNOSES REDACTED]. The MDS documented the resident required one person to assist with bed mobility, transfers, ambulation, dressing, eating, toilet use, and personal hygiene. The assessment determined Resident #1's balance as not steady, only able to stabilize with human assistances when moving from seated to standing, when walking, when turning around and during surface to surface transfer (between bed and chair or wheelchair). The Resident #1 Care Plan with a start date of 6/18/08 listed a problem of vision impairment, on a diuretic and requiring help with cares. The Goal/Approaches included: a. Staff are to assist with activities of daily living, keep personal items in the same place at all times, keep routine consistent as possible every day. b. 12/17/11 staff are to ensure a tab alarm is on and in place on the resident at all times, this was discontinued on 12/28/11. After Resident #1's fall on 12/28/11, the care plan was updated to use a chair alarm and bed alarm at all times. Review of Occurrence Report dated 12/17/11 at 6:40 a.m. revealed Resident #1 fell while ambulating in room. Staff documented the resident sustained [REDACTED]. Tab alarm applied for resident's safety and due to resident not using call light. Review of the Charting notes dated 12/17/11 indicated Resident #1 found on the floor in room around 6:40 a.m. Staff assessed resident and noted to have a contusion to left forehead, scrapes to right and left back upper mid section. Resident's physician and family notified. Staff placed tab alarms on resident due to increasing unsteady gait and resident not using call light to request assistance from staff for ambulation and transfers. Review of Occurrence Report dated 12/28/11 revealed Resident #1 had a fall in room at 2:35 p.m. and sustained a laceration to the forehead above the right eye and x-rays taken with results being a femoral neck fracture. Review of the X-ray Patient Report dated 12/28/11 revealed impressions of garden classification III subacute to acute femoral neck fracture (hip fracture), moderate degree of osteoporosis, moderate degenerative arthritis. Review of Resident #1 History and Physical dated 12/29/11 revealed a history of the resident living at the facility and she has been having trouble with his/her balance. Resident had a fall today landing on his/her right side and now having right hip and shoulder pain. The resident had already been treated in the emergency room for a scalp laceration. X-Ray examination revealed a right subcapital femoral neck fracture which is displaced and impacted. The resident will be admitted for surgical treatment of [REDACTED]. According to the Change Observation Sheet dated 12/28/11, the alarm was in place but not sounding. Review of the facility's Investigation of Incident dated 12/28/11 involving Resident #1 indicated staff heard a noise from resident's room and entered. Resident found lying on right side on floor. Nurse called to room and performed assessment and first aid, assessment revealed no signs of injury at that time and resident assisted to bed and alarm applied. Tab alarm had been in place and working. Resident then complained of right knee pain. Physician notified and x-ray ordered and done and results received at 8:30 p.m. Results called to physician and family and family requested resident not be sent to hospital until the following morning. Staff reported resident slept well all night without complaint of pain or discomfort. Resident transferred to hospital at 7:00 a.m. on 12/29/11. Staff reported resident had last been assisted to toilet prior to fall at 1:15 p.m. and assisted to bed after. The tab alarm in place and working and call light in reach but resident doesn't remember to use it. Interview on 1/19/12 at 10:26 a.m., Staff B reported he/she had been assigned to care for Resident #1 on 12/28/11 and around 1:15 p.m. he/she assisted Resident #1 to the bathroom and then to bed. Staff #1 stated he/she hooked up the resident's tab alarm when the resident had been in bed lying on his/her right side. Staff B connected the tab alarm to the resident's clothes and the alarm box in the case had been connected to the side rail of the bed. Staff B placed the resident's call light in reach, however Staff B indicated the resident does not use the call light. Staff B reported after the resident had been assisted to bed he/she walked passed the resident's room and seen the resident lying on right side sleeping. Staff B stated he/she left work that day around 2:00 p.m. Interview on 1/19/12 at 2:29 p.m., Staff A reported she came into work at 2:00 p.m. on 12/28/11 and was assigned to care for Resident #1. Staff A stated at 2:00 p.m. the resident had been sleeping and again he/she seen the resident around 2:20 p.m. and the resident remained asleep and the alarm in place. Staff A stated a short time later he/she had been in the hallway one door away from the resident's room when Staff A heard the resident fall, no alarm sounding. Staff A went to the resident's room and found the resident lying on the floor on right side with face down. Staff A indicated the tab alarm had still been connected to the resident and the alarm box but the alarm box case still connected to the side rail of the bed. Staff A stated he/she called out to the nurse who responded immediately. Interview on 1/19/12 at 2:50 p.m., Staff C reported he/she came into work on second shift on 12/28/11 and had been the nurse assigned to care for Resident #1. Staff C indicated he/she first seen the resident around 2:25 p.m. and at that time the resident had been sitting on side of the bed. Staff C further reported he/she never stopped in the resident's room at that time. Staff C indicated the resident had a fall about a week prior and had a tab alarm in place. Staff C stated it is normal for the resident to sit on the side of the bed or the chair in room. Staff C stated after seeing the resident sitting on the side of the bed he/she continued to walk in the hall towards the nurse ' s station. Staff C stated when he/she got to the nurse ' s station he/she heard Staff A yell out for help from the resident's room. Staff C responded to the resident's room and found the resident lying on the floor on right side. Staff C reported no alarm was sounding when Resident #1 fell . Staff C indicated he/she assessed the resident, contacted the physician and received orders for X-Rays and also contacted the family. Staff C reported prior to this incident, Resident #1 had activated the alarm when he/she turned over in bed. Interview on 1/19/12 at 3:23 p.m., with the Director of Nursing, indicated he/she would expect staff to go into a resident's room after seeing a resident that is a fall risk and having alarms in place sitting on the edge of the bed, to go in and check on the resident and to see if the resident needed any assistance for their safety. Prior to Resident #1's fall he/she could get him/her (self) from a lying position to a sitting position.The DON stated Resident #1 often sat on the side of the bed. The DON stated she would not tell a resident that had an alarm that they could not sit on the side of the bed but she would ask if they needed anything for their safety. A follow up written by the DON , with Fax date 12/29/11 identified the tab alarm box was attached to side rail on the bed with a Velcro strap and when Resident #1 attempted to get up, he/she pulled the Velcro box off the rail so it did not sound. The DON documented the alarm was on and in working order when the resident was in bed, but did not sound since he/she pulled the box with him/her. 2. Record review for Resident #3 identified his/her tab alarm had been attached to the side rail on 1/12/12, and did not sound when he/she fell to the floor. Resident #3's care plan dated 10/25/11, revealed he/she had a fall with no injury on 10/3/11 and 11/3/11. A care plan directed staff to make sure his/her alarms are on. A typed document with Resident #3's name dated 1/12/12 identified the tab alarm to side rail, resident sleeps on the opposite side. When Resident #3 fell to the floor, the alarm did not sound as it did not disconnect. The intervention was to apply bed/chair alarm. The DON stated on 1/19/12 at 2:15 p.m., Resident #3's had a fall on 1/12/12 and the tab alarm did not sound when he/she fell . The DON stated Resident #3 had been sleeping on his/her right side, with tab alarm located on the upper back left side. The DON stated when Resident #3 slid to the floor and landed on left side, there was not enough tension applied to the string to activate the alarm. The DON stated they switched Resident #3 to a pressure alarm after this incident.

Based on observations, clinical record review, and staff interviews, the facility failed to obtain a physician's order for a indwelling bladder catheter, failed to follow physician order to apply Bio Freeze (topical [MEDICATION NAME]) before performing stretching exercises, failed to have an order for [REDACTED]. The facility reported a census of 38 residents. Findings included; 1. Resident #2 had a quarterly MDS (Minimum Data Set) with an assessment reference date of 2/22/11, which indicated the resident totally dependent on staff for bed mobility and transfers and did not walk. The MDS failed to indicate the resident had limitation in range of motion. The MDS indicated the resident received passive range of motion six (6) days a week as a restorative nursing program. The care plan run 4/27/11 indicated [DIAGNOSES REDACTED]. A physician order dated 3/9/11 indicated to use Biofreeze or the equivalent prior to attempting to do stretching for Resident #2. The Physician's Orders for 3/29/11 indicated the Biofreeze to be applied topically PRN (as needed) and apply to extremities prior to attempting stretching for restorative. A review of the treatment administration record for April 2011 for Resident #2 failed to indicate the application of Biofreeze ointment on any day in the month of April 2011. The computer print out of restorative nursing range of motion Staff B (CNA) exercised the resident 15 times during the month of April and Staff I exercised the resident 4 times during the month of April, without the indication of the use of Biofreeze. Observation of Staff B made on 4/26/11 at 10:30 a.m. performing range of motion for Resident #2 laying in bed. She raised the right arm, and the resident kept the elbow bent. The resident unable to extend and/or straighten the right arm with assistance. The passive range of motion performed by Staff B on right arm with limited movement. She performed passive range of motion with left arm, but unable to fully extend arm. The resident's right leg very contracted and unable to extend the leg during exercises. The left leg was able to extend during passive range of motion. Staff B indicated during an interview on 4/27/11 at 7:15 a.m. that she uses massage on resident arms sometimes prior to stretching and did use Biofreeze sometimes. Staff A indicated during an interview on 4/27/11 at 2:40 p.m. that she thought Staff B was using the Biofreeze, because Staff B would say that she had to have the nurse apply it. Staff B is an CMA (certified medication aide) and would be able to apply the ointment herself prior to exercising the resident. 2. Resident # 8 had a quarterly MDS with an assessment reference date of 4/05/11, which indicated the resident had a [DIAGNOSES REDACTED]. The physician's order sheet printed 3/24/11 indicated the medication for [MEDICAL CONDITION] reflux was [MEDICATION NAME] (used for acid reflux) 40 mg (milligrams) orally everyday. The MAR (medication administration record) for April 2011 indicated the resident was receiving [MEDICATION NAME] Complete one tablet every day, and to do so until supply runs out and then discontinue. [MEDICATION NAME] 40 mg every day on MAR indicated [REDACTED]. A review of the physician orders revealed on 3/10/11 to discontinue [MEDICATION NAME] Complete when supply runs out and start [MEDICATION NAME] (used for acid reflux) 30 mg every day. On 3/21/11 the pharmacy notified the facility that the resident's insurance would not cover [MEDICATION NAME] , but [MEDICATION NAME] would be covered. The physician changed order to [MEDICATION NAME] 40 mg daily. During an interview on 4/27/11 at 1:15 p.m. Staff A (director of nursing) indicated [MEDICATION NAME] was written on April MAR indicated [REDACTED]. The staff did not realize that the [MEDICATION NAME] was still being given. 3. The quarterly MDS (Minimum Data Set) with an assessment reference date of 04/09/2011 revealed Resident # 4 demonstrated both long and short term memory deficits. The MDS documented the utilization of an indwelling urinary catheter to remove the urine from the body under the bowel and bladder section. Pertinent [DIAGNOSES REDACTED]. The plan of care with a run date of 02/25/2011 directed facility staff to empty the catheter and change from straight drainage to a leg bag during the day. The plan failed to provide the staff with the size of the catheter to be utilized or any directions for changing the indwelling catheter. The current Physician's orders dated 03/15/2011 contained an order for [REDACTED]. The Physician's orders failed to provide the size of catheter and bulb to be utilized when changing the indwelling catheter. The April 2011 TAR (Treatment Administration Record) documented the order for a Foley catheter and the changing of the indwelling urinary catheter on April 10, 2011, but failed to identify the size of the urinary catheter and bulb utilized. During an observation on 04/26/2011 at 9:25 A.M., Staff C and Staff D entered the resident's room, washed their hands and donned gloves. While Staff D performed the perineal/catheter cares, and observation of the size stamped on the indwelling urinary catheter revealed it to be a 16 French with a 10 millimeter bulb. Staff C verified the size of the catheter. During an interview on 04/27/2011 at 4:20 P.M., Staff A verbalized obtaining an order for [REDACTED]. On 04/27/2011 after the interview with Staff A, the facility obtained an order from the Physician for a 16 French catheter to be changed every month. 4. The MDS (Minimum Data Set) with an observation date of 02/07/2011 indicated Resident # 10's memory recall remained intact. [DIAGNOSES REDACTED]. The plan of care with a run date of 04/27/2011 failed to provide facility staff with any direction for discharge plans for the resident. During observations of the resident's closed chart on 04/27/2011, a Post-Discharge Plan of Care dated 04/11/11 revealed a notation under the medication section telling the reader to see the attached medication list. The post discharge plan failed to have an attached medication list. A review of the Physician's orders revealed a telephone order for Resident # 10 to be sent home with home health care services. The telephone order failed to provide any order for what medications the resident would take at home. The medical record did have an order for [REDACTED]. When asked, the pharmacy utilized by the facility sent a fax on 04/27/2011 verifying what medication prescriptions the resident received. The facility failed to document any orders from the Physician for the medication orders supplied to the pharmacy upon discharging the resident from the facility. During an interview on 04/27/2011 at 2:50 P.M., Staff A checked through Resident # 10's medical record but failed to find orders for discharge medications from the Physician. Staff H verbalized he usually obtained an order from the Physician for what medications to include at discharge on the discharge sheet. Staff H did not document receiving an order for [REDACTED].

Based on observation, record review, staff interview, and facility policy, the facility staff failed to place a clean barrier on an over the bed table utilized for perineal supplies while giving indwelling urinary catheter cares for 1 resident (Resident # 5) out of 2 residents with urinary catheters. The resident sample included 10 residents. The facility reported a census of 38 residents. Findings include: 1. The MDS (Minimum Data Set) dated 02/15/2011 indicated Resident # 5 required some cues for memory recall, but could remember the date and year. The resident required the assistance of 2 facility staff persons for transfers, bed mobility, toilet use, and personal hygiene. The documentation revealed the utilization of an indwelling urinary catheter for the release of urine from the body. Current [DIAGNOSES REDACTED]. The plan of care dated 06/21/2010 failed to provide facility staff with any direction for performing/completing catheter cares. During an observation on 04/27/2011 at 6:50 A.M., Staff E and Staff F entered the resident's room and placed a basin of water, soap, and cloths on an over the bed table after removing the resident's personal items and water cup. Facility staff failed to place a clean barrier on the over the bed table. Staff E and Staff F washed their hands and donned gloves. Resident # 5 laid in bed. Staff E performed catheter cares for the resident. Soapy water from the wash cloths dotted the surface of the over the bed table. Upon the completion of the perineal cares, Staff E emptied the basin in the bathroom and removed the soap and remaining washcloths from the over the bed table. Staff E returned the resident's personal items to the over the bed table without cleansing the table. The areas of soapy water from the personal cares remained on the over the bed table after staff left the room. During an interview on 04/27/2011 at 4:45 P.M., Staff A verbalized it would be her expectation that facility staff would use a sani-cloth or other cleansing agent to clean the over the bed table off after utilizing it for the catheter/perineal cares. The undated facility Skills Checklist for Pericare directed facility staff to clean equipment used when performing perineal cares.