Every finding on record at The Gardens at Aldersgate

Based on observation, record review, and interviews, the facility failed to ensure adequate narcotic reconciliation when nursing staff failed to sign-off and sign-on each shift on the Narcotic Shift Sheet on two of three units reviewed.Findings included:- On 06/29/2026 at 10:00 AM, on the Mulvane unit's medication cart in the narcotic count book, the Narcotic Shift Sign-in/Sign-off Sheet from 05/26/2026 to 06/28/2026 revealed that on 52 of 152 opportunities, nursing staff failed to sign-off or sign-on each shift. On 06/29/2026 at 10:15 AM, on the Elmhurst unit's medication cart in the narcotic count book, the Narcotic Shift Sign-in/Sign-off Sheet from 06/03/2026 to 06/28/2026 revealed on 56 of 152 opportunities nursing staff failed to sign-off or sign-on each shift. On 06/29/2026 at 10:15 AM, on the Elmhurst as needed (PRN) nurse units' medication cart in the narcotic count book the Narcotic Shift Sign-in/Sign-off Sheet from 05/31/2026 to 06/29/2026 revealed on 32 of 152 opportunities, nursing staff failed to sign-off or sign-on each shift. On 06/29/2026 at 10:29 AM, Licensed Nurse (LN) G stated nursing staff count all narcotic cards. She stated the nurse coming on and the nurse or certified medication aide (CMA) going off shift count together and sign the narcotic count sheet. She stated there was no way of ensuring a staff member was not taking medications and not giving the medication to the residents. LN G stated the CMA or nurse signs for the medication on the narcotic count and signs for the medication in Medication Administration Record (MAR) in the Electronic Medical Record (EMR). She stated the pharmacy would catch a discrepancy if the medication was ordered too soon. LN G stated she had not had training since she started in 02/2026. LN G stated she would notify the unit nurse or the director of nursing as soon as she found a discrepancy in the medication count.On 06/29/2026 at 11:35 AM, LN H stated each nurse going off shift and the nurse coming on shift count the narcotics. She stated each card was counted with the correct pill count.On 06/29/2026 at 11:50 AM, LN I stated nurses were to count each narcotic card. She stated nurses or med aides sign the narcotic sheet when the nurse comes on shift and signs the narcotic sheet when the nurse leaves her shift.On 06/29/2026 at 01:47 PM, Administrative Nurse D stated the expectation was the narcotic cards were counted every shift by the nurse coming on shift, and the nurse going off shift. She stated the Unit Manager was to spot check the count sheets daily and check the narcotic box daily.The facilities Controlled Substance Administration & Accountability policy dated 01/01/2020 documented the charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify medications removed from either the automated dispensing system or medication cart/cabinet have a documented physician order. An inventory count was prompted by the system each time a controlled drug or narcotic access key was used. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.

Based on observation, record review, and interview, the facility failed to ensure that medications were stored safely and securely as required. Findings included:- On 06/29/2069 at 11:35 AM, on the Mulvane Unit, the keys to the medication cart were placed in the Narcotic Count Sheet white three ring binder. The keys for the medication cart were not secured. The treatment cart in the same area was unlocked. The treatment cart contained prescription creams and dressings.On 06/29/2026 at 11:37 AM, Licensed Nurse (LN) H stated the keys were left in the narcotic count binder due to there being two LN's on the medication cart. She stated the treatment cart should be locked if the treatment cart was not in the view of nursing staff. LN H stated medication cart keys should always be on the nurse and should not be left on the medication cart.On 06/29/2026 at 01:47 PM, Administrative Nurse D stated the expectation was medication cart keys were to always be on the nurse or Certified Medication Aide (CMA). She stated carts should always be locked.The facility's Medication Storage policy dated 01/01/2020 documented it was the policy of this facility to ensure all medications housed on the premises would be stored in the medication carts or medication rooms to ensure proper security. Narcotics and controlled substances are stored under double-lock and key. Only authorized personnel have access to medication storage areas.

Based on observation, record review, and interview, the facility failed to ensure residents remained free from abuse when Resident (R) 1 and R2's medications were misappropriated. Findings included:- The facility's investigation report 3047869 dated 06/17/2026 documented on 06/17/2026 around 11:15 AM, Administrative Staff B was notified by Licensed Nurse (LN) K that R1's clonazepam (antianxiety medication a class of medications that calm and relax people) 0.5 milligrams (mg) had extra dose signed for on the narcotic sheet; the extra does were not on his scheduled times. The extra nonordered doses were signed for on 06/03/2026, 06/04/2026, 06/05/2026, 06/08/2026, 06/09/2026, 06/10/2026, 06/11/2026, 06/12/2026, 06/15/2026, and 06/16/2026. The investigation further documented R2 also had extra doses of narcotics signed out, clonazepam 0.5 mg on 06/11/2026, and oxycodone (schedule II opioid pain medication with high use for misuse or addiction) 5mg on 06/11/2026, 06/15/2026, and 06/16/2026. The investigation documented Certified Medication Aide (CMA) R was the CMA that signed out these medications. The facility obtained a witness statement from CMA R. CMA R was immediately suspended pending the investigation. The investigation further revealed the facility would replace all the missing medication for R1 and R2, and a psychosocial follow-up would be done by the social worker for R1 and R2. The durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) and the physician were notified for R1 and R2. Administrative Nurse D stated law enforcement was notified. Administrative Nurse D stated the following residents were affected by misappropriation:R1's clonazepam 0.5mg-10 tablets,R2's clonazepam 0.5mg-one tablet, oxycodone 5mg-three tablets. On 06/29/2026 at 10:29 AM, LN G working on Elmhurst Unit stated the nurse or CMA coming on shift and the nurses or CMA going off shift count together and sign the narcotic count sheet. LN G stated the narcotic count sheets should be filled out at the end of each shift. LN G stated the CMA or nurse signs for the medication on the narcotic count sheet, and signs for the medication in Medication Administration Record (MAR). She stated the pharmacy would catch a discrepancy if the medication was ordered too soon. LN G stated she had not had training for the six rights of medication administration, since she started in 02/2026. LN G stated she would notify the unit manager or the director of nursing as soon as she found a discrepancy in the medication count.On 06/29/2026 at 11:50 AM, LN I stated nurses were to count each narcotic card. She stated nurses or CMA sign the narcotic sheet when the nurse comes on shift and signed the narcotic sheet when the nurse leaves her shift. She stated she had not had any training on the six rights of medication pass. LNI stated she did not work for the facility, she stated she was agency and had not had any training from the facility since she had worked at this facility. LN I stated she works at the facility often.On 06/29/2026 at 12:00 PM, Administrative Staff B stated the facility had not done any training with the agency nurses at this time. She stated the facility had put a packet together and was sending the packet to the agency's the facility uses. Administrative Staff B stated the nurse would have to read and sign the packet before working in the facility. Administrative Staff B stated most of the nurses and CMAs had finished the training for the six rights of medication pass.The facility's Abuse, Neglect and Exploitation policy, undated, The Facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This policy applies to all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the Facility (Associates).

Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2 received activities of daily living (ADL) assistance with personal hygiene when staff did not provide her scheduled showers. Findings included:- R2's Electronic Medical Record (EMR) recorded a diagnosis cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and hemiplegia (paralysis of one side of the body). R2's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. R2 had no rejection of cares during the observation period. The MDS noted R2 was dependent on staff for most ADL including showering. R2's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 11/14/25 documented R2 required total dependent assistance with her ADLs. R2's Quarterly MDS dated 01/28/26 documented a BIMS score of 15 indicating intact cognition R2 had no rejection of cares during the observation period. The MDS noted R2 was dependent on staff for most ADL including showering. R2's Care Plan dated 11/25/24 directed staff R2 was dependent on staff assistance for shower/bath. R2's Care Plan dated 12/06/25 directed staff R2 would often refuse bathing/showers. Continue to offer bathing/showers and remind R2 of the importance of hygiene. The Shower List dated 02/25/26 had R2 scheduled for a shower on Tuesday, and Friday day shift. R2's Shower Sheets reviewed from 02/06/26 through 04/01/26 revealed R2 had five shower sheets completed on 02/06/26, 02/10/26, 02/13/26, 02/17/26, and 03/13/26. R2's EMR Shower Task reviewed from 03/03/26 through 04/01/26 revealed that staff had signed off shower task completed on 03/03/26, 03/13/26, 03/20/26, 03/27/26 and 03/31/26. Total of 16 showers were scheduled from 02/06/26 through 04/01/26 though R2 received nine showers. During an observation/interview on 04/01/26 at 10:59 AM, R2 sat up in her bed watching her tablet. R2 reported that she had not received her shower on her scheduled shower day on Tuesday for the past three weeks. R2 reported she had only received her scheduled bath on Fridays and reported she did not know why she was not offered her shower and reported she did not refuse her showers, and no staff offered her a bed bath. During an interview on 04/01/26 at 01:33 PM, Certified Nurse Aide (CNA) P reported shower sheets were completed on paper each time a resident was offered a shower or bed bath. CNA P revealed if a resident refused a shower or bed bath it would be documented on the shower sheet and in EMR under tasks. CNA P reported that the charge nurse would also be updated on refusal. During an interview on 04/01/26 at 01:50 PM, Licensed Nurse (LN) H revealed the shower schedule was last updated on 02/05/26 as LN H reported she was the Unit Manager at that time. LN H reported that the shower sheets would be with the new Unit Manager Administrative Nurse E as she reported there were no complete shower sheets on the unit. LN H revealed the CNAs documented in EMR under the tasks for bathing each time a bath is offered and refused she also reported that the CNAs would fill out a shower sheet for each bath/shower offered and document on the shower sheet if the shower was refused.During an interview on 04/01/26 at 02:58 PM, Administrative Nurse D reported that she expected the staff to complete/offer a shower to the resident when they are assigned for one or if the resident asks for one. She expected the staff to complete a shower sheet and document in EMR if a resident received a shower, bath or if they refused. Administrative Nurse D reported that Administrative Nurse E would continue to look for more documented shower sheets for R2. During an interview on 04/01/26 at 04:00 PM, Administrative Nurse D reported that the shower sheets that were obtained were the only shower sheets that could be located and confirmed that R2 did not receive her showers as per her scheduled shower days. The facility's policy Activities of Daily Living (ADLs) dated 2025 documented the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activity of daily living which includes bathing. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming, and personal hygiene.

The facility identified a census of 161 residents. The facility identified 34 residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP and personal protective equipment (PPE) for Resident (R) 113. The facility additionally failed to store R11, R63, R14, R104, R43, and R9's respiratory equipment in a sanitary manner. The facility further failed to ensure linen carts were transported in a sanitary manner. The facility further failed to ensure a process was put in place for water management for Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations).Findings Included:- On 01/05/26 at 07:05 AM, a walkthrough of the facility was completed. An inspection of R113's room revealed no EBP indicator signage or personal protective equipment in or around the room related to his suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder).On 01/05/26 at 07:30 AM, an inspection of the Elmhurst Unit revealed uncovered clean linen carts next to utility closets 413 and 441 with no protective barrier for the linen. On 01/05/26 at 09:26 AM, R11's nasal cannula laid directly in the trash can and tubing connected to oxygen concentrator.On 01/05/26 at 09:38 AM, R63's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) and her nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) laid directly on her bedside table, unbagged.On 01/05/26 at 09:44 AM, R14's CPAP device laid directly on her bedside table.On 01/05/26 at 09:51 AM, R104's nasal cannula and oxygen tubing was wrapped around the handles of the wheelchair.On 01/06/26 at 09:50 AM, R43's nebulizer laid directly on the seat of his walker.On 01/06/26 at 10:12 AM, R9's CPAP laid on his bedside table. R9's CPAP mask was not contained in a sanitary manner.On 01/06/26 at 02:25 PM, R9's CPAP laid on his bedside table. R9's CPAP mask was not contained in a sanitary manner. On 01/07/26 at 08:22 AM, Certified Nurse's Aide (CNA) Q stated all oxygen tubing and equipment should be in the resident's drawer, or in a bag. CNA Q stated all rooms have signs and PPE for each resident on EBP. She stated staff follow the signs as to what PPE to wear when taking care of residents. CNA Q stated she does not do anything with laundry.On 01/07/26 at 09:45 AM, Licensed Nurse (LN) L stated any resident with open wounds or stoma (surgical opening), or catheters should be on EBP. She stated signs should be posted outside the rooms, and PPE made available during care. She stated linens should be covered when distributing. LN L stated CPAP tubing should be cleaned and placed on the bedside table, and the machines could be placed in a drawer.On 01/07/26 at 12:55 PM, Administrative Nurse D stated EBP signage should be placed outside of each room, each time a resident was admitted , and that the resident required EBP. Administrative Nurse D stated the signage would be done by the nurse in charge; she stated the unit nurses could check to ensure the signage was in place. Administrative Nurse D stated respiratory equipment not in use should be stored in a sanitary bag.On 01/06/26 at 08:57 AM, Maintenance Supervisor U stated the facility had a process in place for Legionella a couple of years ago. He stated the facility was unable to find the documentation upon request. Maintenance Supervisor U stated the facility did not have a process to track Legionella at this time.The facility's Handling Clean Laundry policy, dated 03/04/25, documented it was the policy of the facility to handle, store, process, and transport clean linen in a safe and sanitary manner to prevent contamination that could lead to infection.The facility's Legionella Surveillance policy, dated 11/01/19, documented surveillance was one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems.The facility's Enhanced Barrier Precautions policy, dated 06/14/23, documented it was the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.The facility's Infection Prevention and Control Program policy, dated 10/23/23, documented the facility had established and maintained an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.The facility's 'Oxygen policy, dated 03/04/25, documented oxygen was administered to residents who needed it consistent with professional standards of practice, the comprehensive person-centered care plans, the residents' goals and preferences.

The facility identified a census of 161 residents. The facility had one main kitchen and six kitchenette areas. Based on observation, record review, and interview, the facility failed to ensure food was properly labeled and stored in refrigerated areas. The facility failed to ensure the kitchenette areas and refrigerators were clean. Findings included:- On 01/05/26 at 07:05 AM, during the initial tour of the main kitchen area, an observation in the walk-in refrigerator, it was noted that a plastic vat container sat on a cart with what looked like prepared tuna salad. The container lacked any labeling, dates, or a cover. There was a scoop present in the container. The walk-in refrigerator had a clear container with a lid on it that was not labeled or dated, which contained what looked like prepared salsa. A refrigerator used for food prep and serving items contained an unlabeled, undated, and uncovered metal storage container that contained what looked like solidified grease. On 01/05/26 at 07:08 AM, the 400-hall dining room kitchenette had a black side-by-side refrigerator/freezer, that had a yellowish stain approximately three inches by three inches in the bottom drawer. Underneath the bottom shelf glass had numerous different-sized red dried stains. The refrigerator kick plate was off and lying on the floor in front of the refrigerator and had numerous different sizes of grayish fuzzy substances on it. The refrigerator contained eight (4 fluid ounce) undated vanilla Mighty Shakes. In the cabinet of the kitchenette was an open 27.1-ounce box of Raisin Bran; the plastic was not sealed in the box. On 01/05/26 at 09:11 AM, the refrigerator on the Mulvane Unit had eight frozen hamburger patties in the ice tray of the freezer. The hamburger patties were not dated, labeled, or in a sealed package. On 01/05/26 at 07:15 AM, Licensed Nurse (LN) I stated that kitchen staff were responsible for the cleaning, labeling, and dating of food items in the refrigerator in the kitchenette on the 400 hall. On 01/05/26 at 07:20 AM, Dietary CC stated that all items in any storage area of the kitchens should have a label, be dated, and have an expiration date if applicable, and be covered either with a lid or in a sealed bag. Dietary CC stated that dietary staff were also responsible for the cleaning of items in the kitchenette areas. Dietary CC stated staff would put the grease used from cooking in a metal container to cool in the refrigerator and then would dispose of it daily. On 01/07/26 at 10:30 AM, Dietary BB stated that kitchen staff were responsible for labeling, dating, and ensuring all items in the kitchen and kitchenette area were covered or in a sealed container. Dietary BB stated some of the dining areas on each hall did have refrigerators just for the residents' personal food items, but those all should be labeled with the residents' names. The undated facility's Food Storage (Dry, Refrigerated, and Frozen) policy documented food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All food items would be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Leftover contents of cans and prepared food would be stored in covered, labeled and dated contains in refrigerators and/or freezers.

The facility had a census of 161 residents. The sample included 34 residents. Based on the record review and interview, the facility failed to consistently deliver residents' mail on Saturdays.Findings included:- On 01/06/25 at 11:00 AM, during the resident council meeting, Resident (R) 141 stated the facility did not deliver residents' mail on Saturdays.01/07/25 at 08:00 AM, Administrative Staff B stated she was responsible for delivering mail to residents. She sorts out the mail for each unit and delivered it to the unit manager during the week; if they were busy, she delivered it to the residents. Administrative Staff B stated the residents' mail did not get delivered consistently on Saturdays unless she happened to come in.On 01/07/25 at 12:50 PM, Administrative Nurse D stated that the admission receptionist should deliver residents' mail during the week, and the unit nurse manager should deliver it on Saturday.The facility's Communications Within and External to the Facility Policy, implemented 03/04/25, documented the facility would ensure the resident had the ability to send and receive mail, letters, packages, and other materials delivered to the facility for the resident through a means other than a postal service.

The facility identified a census of 161 residents. The sample included 34, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area and out of reach of 16 cognitively impaired, independently mobile residents. The facility additionally failed to ensure Resident (R) 50's specialized call light was in place after her room transfer, resulting in a non-injury fall. Findings Included: - On 01/05/26 at 07:10 AM, a walkthrough of the facility revealed an unlocked rehab therapy room. An inspection of the therapy room revealed an unsecured closet with a hydrocollator (a heating device that uses water baths to heat up hot pads) in the room and turned on. An inspection of the closet door revealed the lock was broken and did not work. At 07:15 AM, Consultant GG entered the rehab room and verified the lock did not function. He stated the lock had been broken for a while. On 01/07/26 at 07:40 AM, a walkthrough of the Transitional Care revealed an unsecured exterior door propped open about five inches with a weighted dumbbell. No staff or residents were in the halls or outside area while the door was observed open. The exterior door led to an open field area. The door alarm had been turned off by staff when the door was opened for a resident. Staff conducted a resident head count with all the residents located.On 01/07/26 at 07:48 AM, Administrative Staff A was notified and shown the unsecured door. She removed the dumbbell and closed the door. She stated the door was not to be propped open and had an alarm. She stated staff may have propped it open to escort a resident outside and forgot to ensure it was closed. She stated the door required a code to open. On 01/07/26 at 10:35 AM, Certified Nurse's Aide (CNA) M stated the exterior doors and exit doors were to always be locked. On 01/07/26 at 12:43 PM, Administrative Nurse D stated the exterior doors were supposed to be locked, and staff were never to prop them open. She stated residents were not to have unsupervised access to the rehab room, and the hydrocollator should be locked.The facility's Accident and Supervision policy, revised 02/2020, indicated the facility will provide an environment that implements adequate supervision, interventions, and assessment to minimize the risks of hazards, accidents, preventable injuries, and falls.- The Medical Diagnosis section within R50's Electronic Medical Records (EMR) included dementia (a progressive mental disorder characterized by failing memory and confusion), chronic kidney disease, and major depressive disorder (major mood disorder). R50's admission Minimum Data Set (MDS) completed 12/02/25 indicated a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. The MDS indicated she had no upper or lower extremity impairments. The MDS noted she required partial to moderate assistance with dressing, transfers, bathing, personal hygiene, and her footwear. The MDS indicated she had no prior fall history.R50's Care Area Assessment (CAA) completed 11/21/25 triggered for falls, indicated she had severe cognitive impairment with short and long-term memory impairments. The MDS noted she required occasional cues (verbal direction) from staff to stay on task. The CAA noted she was at risk for falls and incontinence.R50's Care Plan documented the following interventions:11/21/25- R50 required staff assistance for oral hygiene, toileting, bathing, dressing, personal hygiene, and transfers.11/21/25- R50's plan encourages staff to anticipate her care needs, ensure she wears appropriate footwear, and to ensure her call light remains within her reach.12/07/25- R50's plan noted she was found by staff as she sat on the floor in her room. The plan noted her call light was replaced with a special flat call light.12/15/25- R50's plan noted she was found as she lay on the floor. The plan noted she changed rooms recently, and her special call light was not moved to her new room. The plan noted the special call light was moved to her new room.R50's EMR documented on 01/05/26, she was transferred to an acute medical facility due to ongoing health concerns.On 01/05/26 at 07:12 AM, R50 lay in her bed. Her flat call light rested beside her in bed.On 01/07/26 at 10:11 AM, Certified Nurses [NAME] (CNA) O stated all staff were responsible for ensuring the fall interventions were in place after residents moved rooms. She stated staff were to ensure the rooms were inspected during each encounter.On 01/07/26 at 12:43 PM, Administrative Nurse D stated each shift was to ensure the call lights were within reach and functional every time they entered the rooms.The facility's Accident and Supervision policy, revised 02/2020, indicated the facility would provide an environment that implements adequate supervision, interventions, and assessment to minimize the risks of hazards, accidents, preventable injuries, and falls.

The facility identified a census of 161 residents. The facility had one main kitchen and six kitchenette areas. Based on observation, record review, and interview, the facility failed to ensure essential kitchen and kitchenette equipment were in proper working condition. Findings included:- Upon the initial tour of the facility's main kitchen on 01/05/26 at 07:08 AM, it was observed that in the dishwashing room, the three-bin dishwashing sink had a dripping faucet for the sanitizing sink bin, and the faucet was not functional to fill the sink with hot water. The support pipes for the three-bin sink had numerous rusted-out areas. The main dishwashing machine had noted dripping hot water from a pipe spigot on the inside of the machine. On 01/05/26 at 07:45 AM, inspection of the 100-hall kitchenette area revealed the ice machine was not working, so dietary staff obtained ice from a portable chest cooler in the kitchenette area. The scoop was stored in a separate container outside of the cooler. On 01/06/26 at 09:05 AM, Dietary DD stated she was working on putting in work orders at this very time for the sanitizer sink faucet and to have someone look at the dishwashing machine leak. Dietary DD stated on 12/31/25, a work order had been placed to fix the ice machine in the 100-Hall. Dietary DD stated they had been using bagged ice and a large portable ice cooler to put ice in to use at mealtimes for the 100-Hall. On 01/07/26 at 10:30 AM, Dietary BB stated she had just been made aware yesterday about the dishwasher issue and the faucet not working for the sanitizer bin for the dishwashing sinks. Dietary BB stated an outside company would have to come look at the dish machine, and the order had been put in for the repair. Dietary BB stated a work order had been placed for the ice machine on 12/29/25 and is awaiting an outside source to come repair it. A policy for essential equipment was requested on 01/07/26, but was not received.

The facility identified a census of 161 residents. The facility had one main kitchen and six kitchenette areas. Based on observation, record review, and interview, the facility failed to ensure dietary staff had and used the provided recipe to specify instructions on the preparation of pureed foods for nine residents.Findings included:- On 01/06/26 at 09:20 AM, Dietary CC began to prepare the pureed chicken pot pie for the lunch meal. Dietary CC had a clean Robo Coupe machine, container, and lid on the counter. Dietary CC had a metal container that contained the chicken pot pie mixture in it and scooped out 10 servings into the Robo Coupe container. He placed the lid on the container and started the machine. Dietary CC did not have the recipe for the puree diet present.On 01/06/26 at 09:25 AM, Dietary CC stated that the facility normally only added chicken or beef stock or milk to foods they pureed to maintain the flavor. Dietary CC stated the pureed food should be a pudding consistency, and the liquid should not separate from the food. Dietary CC stated normally the menu/recipe binder did have the puree recipe in it and did not know why they were not there for this week's meals.On 01/07/26 at 10:30 AM, Dietary BB stated that normally the cook should be following the recipe for the pureed diets, but had been made aware that those recipes were not in the binder for this week's menus. Dietary BB stated that the recipes were on the lead dietary manager's desk and had not been put into the recipe binder. Dietary BB stated the recipes should be followed to ensure nutritional value and flavor were preserved.The facility's Puree Food Preparation policy (undated) indicated all pureed food would be prepared using standard recipes to maintain quality, flavor, palatability, and maximum nutritive value.

The facility identified a census of 161 residents. The sample included 34 residents, with seven reviewed for unnecessary medication. Based on record review and interviews, the facility failed to ensure Resident (R) 9's as-needed clonazepam (antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date.Findings included:- R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), retention of urine, end-stage renal disease (ESRD- a terminal disease of the kidneys), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R9 had an impairment of both sides of his lower body. The MDS documented R9 was dependent on staff for toileting, bathing, and needed set up or clean up assistance from staff with eating. The MDS documented R9 received an antidepressant (a class of medications used to treat mood disorders) and antianxiety medication during the observation period.R9's Psychotropic Use Care Area Assessment (CAA) dated 12/28/25 documented R9 was a new admission following a hospital stay. The CAA documented R9 required oxygen at baseline and continues to require oxygen. The CAA documented R9 required substantial-dependent assistance with his activities of daily living (ADL). The CAA documented R9 had bowel incontinence. The CAA documented that R9 received hemodialysis (a procedure where impurities or wastes are removed from the blood) three times weekly. The CAA documented R9 received clonazepam.R9's Care Plan documented:12/08/25- R9 used anti-anxiety medications related to anxiety disorder.12/08/25- Directed staff to administer anti-anxiety medications as ordered by the physicians and monitor for side effects and effectiveness every shift.12/08/25 - Directed staff to educate caregivers about the risks, benefits, and side effects of anti-anxiety medication.R9's EMR under Orders documented the following physician's order: Clonazepam oral tablet 0.5 milligrams (mg), give one tablet by mouth as needed for anxiety twice daily, dated 12/18/25.R9's Clonazepam lacked a 14-day stop date.The EMR lacked a rationale for extended use, past 14 days.On 01/06/26 at 10:20 AM, R9 laid flat on his bed. R9's eyes were open and had his nasal oxygen in place. R9 was in a pleasant mood. R9 stated starting dialysis has made him very anxious.On 01/07/26 at 08:42 AM, License Nurse (LN) L stated all anti-anxiety medication should have a 14-day stop date. She stated it was the physicians writing the order, and the nurse entering the orders responsibility to ensure all medication was documented in the residents EMR correctly.On 01/07/26 at 12:55 PM, Administrative Nurse D stated clonazepam should have a 14-day stop date. She stated it was the nurse's responsibility that was taking the order from the physician to ensure the order was correct.The facility's Use of Psychotropic Drugs policy dated 01/01/20 documented residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition. The policy documented a diagnosis would be documented in the clinical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident.

The facility identified a census of 161 residents. The sample included 34 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 7 and R90 and their representatives were provided a written notification of transfer, as soon as practicable, upon their transfer to the hospital.Findings included:- R7's Electronic Medical Record (EMR) recorded Discharge Minimum Data Set (MDS) dated 04/28/25, which documented an unplanned discharge to an acute hospital with a return anticipated.R7's Entry MDS dated 05/08/25 documented a re-entry to the facility from an acute hospital.The facility lacked the required written notification of transfer, as soon as practicable, upon his transfer to the hospital between 04/28/25 to 05/08/25.R7's Discharge MDS dated 06/12/25 documented an unplanned discharge to an acute hospital with a return anticipated.R7's Entry MDS dated 06/19/25 documented a re-entry to the facility from an acute hospital.The facility lacked the required written notification of transfer for R7, as soon as practicable, upon his transfer to the hospital between 06/14/25 to 06/19/25.R7's Discharge MDS dated 08/07/25 documented an unplanned discharge to an acute hospital with a return anticipated.R7's Entry MDS dated 08/14/25 documented a re-entry to the facility from an acute hospital.The facility lacked the required written notification of transfer for R7, as soon as practicable, upon his transfer to the hospital between 08/07/25 to 08/14/25.R90s Discharge MDS's, dated 08/14/25, 09/04/25, and 12/30/25, documented an unplanned discharge to an acute hospital with a return anticipated.R90's Entry MDS's, dated 08/19/25, 09/09/25, and 01/03/26, documented a re-entry to the facility from an acute hospital.A review of R90's EMR revealed a lack of a written notification of transfer was provided to his representative, as soon as practicable, when R90 was transferred to the hospital on the above dates.On 01/07/26 at 10:49 AM, Social Services X stated that she would educate social workers about completing the written notification of transfers as required when a resident was discharged and/or transferred to the hospital. Social Services X stated a Performance Improvement Plan (PIP) had not been put in place regarding the required written notification of transfer yet.On 01/07/26 at 11:40 AM, Social Services X verified the facility lacked documentation regarding the resident representative's written notification when R90 was transferred to the hospital.On 01/07/26 at 12:15 PM, Administrative Staff A stated that the PIP had been put in place for the Bed Hold, but one had not been put in place for the written notification. Administrative Staff A stated she would get one put in place to ensure the written notification of transfer was completed as required.The facility's Bed Hold policy dated 02/05/25 documented as part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility would provide the resident and/or the resident representative written information that specifies: the duration of the stated bed-hold policy, during which the resident is permitted to return and resume residence in the nursing facility; the reserve bed payment policy in the state plan policy; the facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. In the event of an emergency transfer of a resident, the facility would provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. The facility would document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility would keep a signed and dated copy of the bed-hold notice information given to the resident and/or representative in the resident's file and/or medical record. The facility would provide this written information to all facility resident, regardless of their payment source.The facility's Transfer and Discharge policy dated 02/01/20 documented for emergency transfers/discharges initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident shall obtain a physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. The facility would notify the resident and/or representative. A notice of the resident's bed hold policy would be provided to the resident and representative at the time of transfer, as soon as possible, but not later than 24 hours after the transfer. Provide a transfer notice as soon as practicable to the resident and representative. The social services director, or designee, shall provide notice of transfer to a representative of the state long-term care ombudsman via a monthly list.

The facility identified a census of 161 residents. The sample included 34 residents, with six residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 8 with bathing as needed and as scheduled.Findings Included: - R8's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure ulcer of sacral region (triangular area at the base of the spine), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (elevated blood pressure), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid).The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R8 was dependent on staff for toileting and needed substantial to maximal staff assistance for bathing.R8's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/07/25 documented R8 was a new admission following a hospitalization. The CAA documented R8 was having recurring falls at home. R8's CAA documented R8 required substantial-dependent assistance with ADLs. The CAA documented R8 was incontinent of bowel and bladder. The CAA documented R8 was admitted with a multitude of wounds to his feet and a skin tear and was treated by the facility's wound care team.R8's Care Plan documented the following:10/06/25- Directed staff R8 needed substantial to maximal assistance from staff with his showers.10/06/25- Documented R8 needed partial to moderate assistance from staff for all toilets and showers.10/08/25- Documented R8 had an open skin tear, right and left heel, and a coccyx (area at the base of the spine) wounds.R8's EMR under Report Bathing documented not applicable on R8's shower record, from 12/16/25 to 01/05/26.On 01/05/26 at 08:22 AM, R8 sat in his recliner looking at his laptop. R8 sat in his recliner, wore a dirty shirt, and smelled of sweat. R8 stated he did not get his showers. He stated he was unsure if he was supposed to ask staff if he could have his shower on his shower day. R8 stated his shower days were Tuesday and Saturday. R8 stated staff told him he could not have a shower because there was not enough staff. R8 stated he liked his showers as he had wounds, and he was incontinent of bowel and bladder.On 01/07/26 at 08:25 AM, Certified Nurse Aide (CNA) Q stated residents were to have two showers a week. She stated the CNA Q would ask the resident what time the resident would like their shower and try to give the shower at that time. CNA Q stated there were times a resident did not get a shower due to pain or behaviors. CNA Q stated there are Saturday's that there were call-ins and showers were not given. CNA Q stated the process was if the shower was not given, the information would be reported to the next shift, and the next shift would give the shower.On 01/07/26 at 12:55 PM, Administrative Nurse D stated she was not aware of showers not given to residents. She stated the facility did have enough staff to give showers. Administrative Nurse D stated showers should be given; if a shower was not given on the scheduled day, the shower was rescheduled for the next day or the following day.The facility's Bathing a Resident policy dated 01/09/24 documented it was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues.

The facility identified a census of 161 residents. The sample included 34 residents, with two residents reviewed for bowel and bladder incontinence, and a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, record reviews, and interviews, the facility failed to provide appropriate treatment for Resident (R) 4's indwelling catheter (tube placed in the bladder to drain urine into a collection bag). The facility also failed to ensure R4's drainage bag was not resting on the floor.Findings included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of encephalitis (inflammatory condition of the brain), kidney disease (damaged and cannot filter blood effectively, leading to waste buildup), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and hypertension (elevated blood pressure). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R4 was dependent on staff for all activities of daily living (ADL) except eating and required assistance with cleanup or setup. The MDS documented R4 had an indwelling catheter during the observation period. R4's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 12/15/25 documented that R4 had returned from the hospital and was now requiring increased assistance with activities of daily living (ADL). The CAA documented R4 had cognitive impairment (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The CAA documented R4 had an indwelling catheter. R4's Care Plan documented the following:12/16/25- Documented R4 had an indwelling catheter related to urinary retention.12/16/25- Directed staff to provide catheter care every shift and as needed.12/16/25- Directed staff to monitor urinary output every shift.12/16/25- Directed staff to monitor for signs and symptoms of discomfort and frequency of urination.12/17/25- Documented R4 had a urinary tract infection and would be on an antibiotic for seven days. 12/23/2025 - Directed staff to anchor R4's catheter tubing to prevent injury. Catheter care every shift and as needed. R4's EMR under Orders documented:Indwelling catheter care with soap and water every shift and as needed when soiled, dated 12/09/25.Monitor output every shift, dated 12/09/25. On 01/05/26 at 07:25 AM, R4 laid on his bed with his head elevated and the bed in a low position. R4's catheter did not have a privacy bag, and the bag was placed at the bottom of the bed. R4's catheter was on the floor. On 01/07/26 at 08:22 AM, Certified Nurse Aide (CNA) Q stated that catheters should be placed below the bladder, in a privacy bag, and not drag the floor. CNA Q stated R4 moves around in his bed and can move his own catheter. CNA Q stated staff tried to watch to ensure the bag did not drag the floor. On 01/07/26 at 08:42 AM, Licensed Nurse (LN) L stated that catheters should be in a privacy bag if the resident was out of his room. She stated the catheter bag should not touch the floor. On 01/07/26 at 12:55 PM, Administrative Nurse D stated the catheter bag should be off the floor and below the bladder. The facility's Catheter Care Policy, revised 01/09/24, documented that it was the policy of the facility to provide catheter care to all residents who have an indwelling catheter to reduce bladder and kidney infections.

The facility identified a census of 161 residents. The sample included 34 residents, with one resident reviewed for dialysis (a procedure where impurities or wastes are removed from the blood) and end-stage renal disease (ESRD- a terminal disease of the kidneys). Based on observation, record review, and interviews, the facility failed to provide standards of care related to Resident (R) 9's dialysis.Findings included:- R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), retention of urine, end-stage renal disease (ESRD- a terminal disease of the kidneys), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS documented R9 had an impairment of both sides of his lower body. The MDS documented R9 was dependent on staff for toileting, bathing, and required assistance with set-up and clean-up with eating. The MDS documented R9 received dialysis during the observation period.R9's Functional Abilities (Self-Care and Mobility Care Area Assessment (CAA) dated 12/28/25 documented R9 was a new admission following a hospital stay. The CAA documented R9 required substantial to dependent assistance with activities of daily living (ADL). R9's CAA documented he had an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) in place and received hemodialysis (a procedure where impurities or wastes are removed from the blood) three times a week. R9 planned to return home with his spouse.R9's Care Plan documented the following:12/18/25- R9 had a history of renal disease with dialysis. R9 would start dialysis on 12/19/25.12/19/25- R9's dialysis chair time would be 02:05 PM on Monday, Wednesday, and Friday. Staff were to plan rest periods.R9's EMR under the physicians' Orders tab lacked direction for staff to monitor R9's port site. The EMR lacked a physician order for R9's dialysis.The EMR lacked direction to staff for R9's dialysis location, transportation provider, and the date and times that R9 received dialysis.The EMR for R9 lacked orders prior to the start of the survey on 01/05/26. On 01/07/26 at 08:42 AM, Licensed Nurse (LN) L stated an order for dialysis should have been placed in the chart when the resident was admitted or became dependent on dialysis. LN L was unsure if the times the resident went to dialysis, and where he went to dialysis, should be in the orders, as she knew that information was in the plan of care. LN L stated checking the dressing should be an order, and if the resident had a fistula, the bruit and thrill should be checked and documented.On 01/07/26 at 12:43 PM, Administrative Nurse E stated there should be an order in the resident's EMR. Administrative Nurse E stated the dialysis port dressing should be checked every shift.The facility's Hemodialysis policy, dated 01/01/20, documented the facility would provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of the resident receiving hemodialysis.

The facility identified a census of 161 residents. The sample included 34 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer or obtain an informed declination for influenza for Resident (R) 72 and the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) vaccination for R72, R16, and R4. Findings included:- Review of R72's clinical record revealed no documented PCV20, and last documented influenza vaccine was 12/14/22. R72's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician documented contraindication.Review of R16's clinical record revealed the PCV13 was administered on 03/10/13, and the PSV23 was administered on 03/17/17. R16's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician documented contraindication.Review of R4's clinical record revealed the PCV13 was administered on 01/18/16, and the PSV23 was administered on 11/17/03 and 03/13/17. R4's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician documented contraindication.On 01/07/26 at 10:09 AM, Administrative Nurse E stated she would investigate the PCV20 declinations and stated R72 was on the next list for influenza vaccines to be given in the facility. Administrative Nurse E was unable to provide declination or consents for PCV20 or influenza as requested on 01/06/25 at 12:30 PM.The facility's Pneumococcal Vaccine policy dated 01/13/22 documented it was the policy of the facility to offer residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current Centers for Disease Control (CDC)guidelines and recommendations.The facility's Influenza Vaccination policy dated 05/31/22 documented it was the policy of the facility to minimize the risk of acquiring, transmitting, and experiencing complications from influenza by offering residents, staff members, and volunteers immunizations against influenza.

The facility had a census of 161 residents. The sample included 34 residents. Based on observation, record review, and interview, the facility failed to keep Resident (R) 24's protected health information (PHI) private on a medication cart parked in the main dining room. The facility also failed to provide privacy for R113 during activities of daily living.Findings included:- On 01/05/26 at 10:45 AM, an observation revealed a medication cart parked in the Elmhurst hallway with a laptop computer sitting on the top; the computer screen was unlocked and open with R24's PHI on the screen, visible to all who passed by the medication cart. The information visualized included R24's medications, date of birth , allergy information, and code status. No nursing staff were in view of the medication cart. Licensed Nurse (LN) J exited another room into the hallway.On 01/05/26 at 10:57 AM, Certified Nurse Aide (CNA) M entered R113's room to provide assistance with personal hygiene. CNA M failed to close R113's curtains when providing peri-care, exposing R113's buttocks to the open window. On 01/06/26 at 09:35 AM, Certified Medication Aide (CMA) R stated R113's curtains should be closed during personal hygiene and dressing.On 01/05/26 at 10:49 AM, LN J stated the computer should be cleared and not have PHI on the screen. LN J stated that the Certified Medication Aide (CMA) was responsible for that medication cart. LN J stated that she would do some education with the CMA about PHI. On 01/06/26 at 09:50 AM, LN G stated the window curtains should be closed when staff provided care for the residents to provide privacy.On 01/07/26 at 12:55 PM, Administrative Nurse D stated she would expect the window curtains to be closed during personal care.The facility's Resident Rights policy dated 08/01/19 documented the facility would inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility would ensure that all staff members were educated on the rights of residents and the responsibility of the facility to properly care for its residents.

The facility identified a census of 161 residents. The sample included 34 residents, nine medication carts, eight treatment carts, and nine medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in two of the eight treatment carts.Findings included:- During the initial tour on 01/05/26 at 07:04 AM, a treatment cart on the Transitional Care Unit was unlocked and unattended in an unlocked storage room. The treatment cart contained medicated ointments and creams.On 01/06/26 at 07:20 AM, an unattended and unlocked treatment cart was on the Sunflower hallway. The treatment cart contained medicated ointments and creams.On 01/05/26 at 07:10 AM, Licensed Nurse (LN) JJ stated they never locked that treatment cart because they did not have a key to unlock the cart. LN JJ stated yes, the cart should be locked.On 01/07/26 at 12:55 PM, Administrative Nurse D stated she would expect all the medication and treatment carts to be locked when not being used.The facility's Medication Storage, dated 01/01/20, documented it is the policy of this facility to ensure all medications housed on our premises would be stored in the medication carts or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

The facility identified a census of 161 residents. The sample included 34 residents, with three sampled residents reviewed for dignity. Based on observation, record review, and interview, the facility failed to preserve Resident (R) 7's dignity while hospice staff transported him on a shower chair from his room to the shower. The facility failed to ensure R16's dignity while assisting him with dressing, when staff left R16's door open.Findings included:- On 01/06/26 at 07:20 AM, an unidentified hospice staff member pushed R7, whose room was on the Cambridge unit, from his room, seated on a shower chair, down the hallway with a hospital gown tied at the neck. R7's lower extremities, back, and buttocks were exposed as the hospice staff pushed R7 down the hallway. The hospice staff turned R7, seated on the shower chair, around backwards through the double doors that led into the [NAME] Unit. Facility staff Certified Medication Aide (CMA) S, and an unidentified male Certified Nurse Aide (CNA) stood in the hallway and noticed R7 was not completely covered, but did not intervene or stop the hospice staff and R7 to ensure he was completely covered.On 01/06/26 at 07:25 AM, observation revealed Certified Medication Aide (CMA) O knocked on R16's closed room door and entered the room. R16 sat on the bedside in his underwear with the lower back, buttocks, and extremities exposed. Observation revealed CMA O left the room door wide open and assisted the resident in putting on his pants.On 01/07/26 at 07:30 AM, CMA O verified she had left the door open when assisting R16 with putting on his pants. CMA O stated she should have closed the door. On 01/08/26 at 10:15 AM, CMA T stated when a resident was transferred down the hall in a shower chair, the resident should be completely covered so no private areas were visible or exposed during the transfer.On 01/08/26 at 10:17 AM, LN H stated that privacy must be maintained any time a resident was being transferred to the shower and should be appropriately covered with no private areas exposed.On 01/07/26 at 12:50 PM, Administrative Nurse D stated she would expect staff to close the room door when staff assisted R16, who sat on the bed with his underwear on, with putting on his pants.On 01/08/26 at 12:51 PM, Administrative Nurse D stated that any staff or outside services, including hospice staff, should ensure that a resident was fully covered by a bath sheet, gown, or blanket, without any private areas exposed, before being transferred out into a hallway or public area.The facility's Promoting/Maintaining Resident Dignity policy, dated 09/20/20, documented it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhanced resident's quality of life by recognizing each resident's individuality. Resident's privacy would be maintained.

The facility had a census of 161 residents. The sample included 34 residents, with two reviewed for accommodation of needs for assistive devices. Based on observation, record review, and interview, the facility failed to utilize foot pedals during wheelchair transports for Residents (R) 34 and R33. Findings Included: - On 01/05/26 at 09:15 AM, R34 (A severely cognitively impaired resident) sat in the dining room in the facility's [NAME] Unit. Licensed Nurse (LN) LL walked over to R34 and informed him that he had a phone call at the nurse's station. LN LL proceeded to push R34 to the nurse's station without foot pedals on his wheelchair. R34 placed his feet down several times while in transport.On 01/06/26 at 07:54 AM, R33 (a resident with noted impaired mobility and weakness) wheeled herself into the large common area next to the Sunflower Unit. An unknown staff member walked up to R33 and asked if R33 was tired from wheeling herself. R33 stated Yes, and asked if staff could push her. The unknown staff member proceeded to push R33 from the common area to her room. R33's wheelchair had no foot pedals, and her feet slid on the ground as staff pushed her. R33 wore slip-on shoes.On 01/07/26 at 10:11 AM, Certified Nurses [NAME] (CNA) O stated all the wheelchairs had foot pedals but some of the residents preferred to wheel themselves. She stated staff were expected to use them while pushing the wheelchair. She stated the resident's feet should never touch the ground while being pushed.On 01/07/26 at 12:43 PM, Administrative Nurse D stated staff were expected to use the wheelchair foot pedals while pushing residents.The facility's Accident and Supervision policy, revised 02/2020, indicated the facility would provide an environment that implemented adequate supervision, interventions, and assessment to minimize the risks of hazards, accidents, preventable injuries, and falls. The policy noted the facility would implement the appropriate assistive devices to prevent falls and injuries.

The facility identified a census of 152 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to ensure Resident (R) 1 remained free from avoidable accidents when staff failed to provide care safely using the required number of staff per the resident's plan of care. Subsequently, R1 sustained a dislocated right shoulder and a fractured right humerus (upper arm bone). This deficient practice also placed R1 at risk for increased pain and impaired well-being. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of polyosteoarthritis (a condition characterized by inflammations, stiffness, and pain in five or more joints simultaneously), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) without dyskinesia (inability to execute voluntary movements), dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, and fibromyalgia (inability to execute voluntary movements). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R1 displayed no behaviors. R1 was dependent on staff for oral hygiene, toileting hygiene, showering or bathing, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. R1 was dependent on staff for mobility in bed, all transfers, and mobility in her wheelc hair. The MDS recorded R1 had no falls since admission. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 04/01/24 documented R1 as dependent on staff assistance with ADLs and transfers. R1 was monitored for changes in functioning. Staff were to ensure R1's needs were met and R1's room was kept free from clutter. The Falls CAA dated 04/01/24 documented R1 was dependent on staff assistance with ADLs and with transfers. R1 was a fall risk due to weakness and was monitored for changes in functioning. The Pain CAA dated 04/01/24 documented that R1 complained of pain and received scheduled and as-needed medications. The Quarterly MDS dated [DATE] documented a BIMS score of three, which indicated severely impaired cognition. R1 displayed no behaviors. R1 had no changes in her level of assistance needed from staff from the previous MDS. The MDS recorded R1 had two or more falls with no injury, and two or more falls with injuries. R1's Care Plan implemented on 04/10/23 documented R1 required maximum assistance of two staff members for all bed mobility and showering. An intervention implemented on 12/01/23 documented that staff would provide care in pairs for R1 so that R1 felt safe. An intervention implemented on 05/15/24 documented that staff would provide care in pairs so R1 felt safe. An intervention revised on 06/03/24 documented that R1 required the maximum assistance of two staff members with dressing, personal hygiene, and oral care. A review of the Staffing Care Sheet updated on 07/22/24 documented R1's fall interventions and directed staff to have two aides with care at all times. On 09/27/24 at 02:48 PM a Nurse's Note documented R1's representative expressed concerns about R1 being transferred with a mechanical lift and felt it was not being used consistently by all facility staff. R1's representative requested an order to have physical therapy screen R1 for falls, transfers, and recliner safety. On 09/27/24 at 04:54 PM a Weekly Skin Check documented R1 had extensive bruising to her face and forehead due to a fall the prior week. R1 also had a large hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to her posterior (back) right forearm. On 09/28/24 at 07:57 AM a Nurse's Note documented R1 was on the floor in her room. R1 laid flat on her abdomen and face down, with her head towards the bed, and R1 had no skid socks on her feet. When R1 was asked what happened, R1 stated she fell , and her right arm was hurting. Staff rolled R1 to her back and assessed her. R1 was visibly agitated and continuously waving her right arm around. R1 had a hematoma forming on her head. Certified Nurse Aide (CNA) M stated she was assisting R1 to change her clothing, while she was in the recliner. R1 leaned forward and fell out of the recliner onto the floor. R1's provider was notified and ordered R1 to be sent to the emergency room (ER) to be evaluated. On 09/28/24 at 08:35 PM a Nurse's Note documented R1 returned from the ER very agitated and inconsolable. R1 had a closed fracture of her right shoulder, with a new order for pain medication, and an order to keep her right arm in a sling until she followed up with orthopedics (a branch of medicine that focuses on the care of the skeletal system and its interconnecting parts). R1 was very frustrated due to her good arm being injured. R1's Care Progress Note dated 10/01/24 documented R1 was seen in theER on [DATE] and found to have a dislocation of the right shoulder with a fracture of the proximal (nearer to a point of reference or attachment) end of the humerus. R1's shoulder was reducted (to restore a fracture or dislocation to the correct alignment) at the bedside. On 10/02/24 at 12:40 PM, R1 sat in her wheelchair at the nurse's station with her right arm in a sling. Her right hand was swollen and bruised throughout her hand. R1 had a hematoma, dark purple in appearance, approximately two to two and a half inches in diameter above her right eye. R1 stated that she fell out of her recliner when CNA M was helping her. R1 stated CNA M did not have a hold of her and she jerked and fell to the floor. R1 revealed that it was only CNA M helping her when she fell . R1 called out in pain and asked Licensed Nurse (LN) H for a pain pill. R1 stated it was for her right shoulder because it was hurting and broken since shefell . R1 stated she was glad she did not have to have surgery but was upset her arm needed to stay in the sling. R1 stated she just saw the orthopedic doctor that morning and was told about what was being done with her arm. On 10/02/24 at 01:20 PM CNA M stated that when working on the hall that R1 lived on, staff were given a staffing care sheet, so staff know of knew what was going on with the residents. CNA M stated she received report when she got onto the unit. CNA M was told R1 required a Hoyer lift (full-body mechanical lift) for transfers. CNA M stated she went to provide R1 with peri care and change her clothing but was not getting R1 up, so CNA M did not get another staff member to assist with R1. When CNA M turned R1 in her recliner, R1 jerked and then fell . CNA M stated sometimes she could get into the residents' Point Of Care (POC) or Kardex (a nursing tool that gives a brief overview of the care needs of each resident) and sometimes she would get locked out. CNA M stated she was able to get into the POC and Kardex but it was not until halfway into her shift. On 10/02/24 at 03:17 PM, CNA N stated she heard that CNA M was not fully aware of how R1 transferred or how R1 received care. CNA N stated she was working a different hall when CNA M told her about R1's fall. On 10/02/24 at 03:21 PM LN G stated that she had not witnessed R1's fall, but CNA M alerted her to the fall around 06:00 AM. LN G arrived at R1's room and R1 was lying on the floor on her stomach, face down, with her right arm extended straight out, her head towards her bed and her feet towards the recliner. LN G said CNA M informed her that CNA M attempted to get R1's wet gown off, when R1 jolted forward, and the CNA could not catch R1. LN G revealed the CNAs gave report to oncoming CNAs before their shift started and there was also a staffing care sheet to tell the CNAs how to care for the residents. On 10/02/24 at 04:05 PM Administrative Nurse D stated she expected staff to follow the resident's care plan. Administrative Nurse D stated with R1, she expected two staff members at all times to go into R1's room to provide care. Administrative Nurse D stated R1 did not always listen to staff, and that is why Administrative Nurse D informed the staff there were to be two staff members entering R1's room to care for her. On 10/02/24 at 04:21 PM Administrative Staff A stated he expected staff to follow the residents' care plan and Kardex when providing care for the residents. The facility's policy Accidents and Supervision dated 02/01/20 documented a resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision to prevent accidents. The policy documented facility-based interventions may include educating staff, implementing specific interventions as part of the plan of care, supervising staff and residents, and facility records documenting the implementation of these interventions. The facility's policy documented that monitoring was a process of evaluating the effectiveness of the interventions and modification of adjusting the interventions as needed to address hazards and risks. The facility failed to ensure R1 remained free from avoidable accidents resulting in a dislocated right shoulder and a fracture of the humerus. This deficient practice also placed R1 at risk for increased pain and impaired well-being.

The facility identified a census of 145 residents. The sample included three residents reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure an environment free from accidents for Resident (R)1. As a result, R1 sustained an avoidable injury to her leg, which required sutures. This also placed R1 at risk for increased pain and impaired well-being. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of Bell's palsy (paralyzed on one side of the face), localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), chronic pain, and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R1 was dependent on staff for showers, upper body dressing, lower body dressing, and toileting hygiene. R1 was dependent on staff for transfers. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 07/11/23 documented R1 required extensive to total assistance with ADLs including transfers. The Pressure Ulcer CAA dated 07/11/23 documented R1 as at risk for skin breakdown due to decreased mobility. The Quarterly MDS dated [DATE] documented a BIMS score of 11, which indicated moderately impaired cognition. R1 was dependent on staff for showers, upper body dressing, lower body dressing, and toileting hygiene. R1 was dependent on staff for sit to lying, sitting, and transfers. R1's Care Plan revised on 03/07/24 documented R1 needed two staff members to help her transfer using the Hoyer lift with a full-body, large sling. R1's Nurse's Note dated 05/02/24 at 12:39 PM documented R1 had skin tears to her left and right lower legs. Staff assessed, cleaned, and covered the skin tears. R1 received orders to be sent to the emergency room for evaluation and treatment. R1's Skin and Wound Evaluation dated 05/02/24 documented a left shin skin tear. R1's skin tear was 10.8 centimeters (cm) in length, 4.3 cm in width, by 0.1 cm in depth: there was bleeding with a moderate amount of exudate (a fluid that leaks out of body vessels and tissues). R1's Skin and Wound Evaluation dated 05/02/24 documented a right shin skin tear. R1's skin tear was 3.9 cm in length, 5.2 cm in width, by 0.2 cm in depth; there was bleeding with a moderate amount of exudate. The Facility Investigation dated 05/02/24 documented R1 was assisted up in the Hoyer lift from her wheelchair into R1's recliner. While Certified Nurse Aide (CNA) M lowered R1 into the recliner, CNA N placed her hands on R1's right and left lower legs and pushed back to assist R1 to get further back into the recliner. CNA N then noted R1's lower legs were bleeding. Licensed Nurse (LN) G was notified, came to the room, and assessed R1's bilateral lower legs. CNA M's undated Unnotarized Witness Statement documented R1 wanted to sit in her recliner. CNA M pulled back on the hook of the sling to get R1's bottom back in the seat of the recliner. CNA N pushed on R1 a little to help R1 reach the recliner. CNA N noticed that R1's legs were bleeding where CNA N had placed her hand to push R1 closer to her recliner. CNA N's Unnotarized Witness Statement dated 05/01/24 documented R1 wanted to get into her recliner. CNA M and CNA N got R1 into the Hoyer lift and up against the recliner. CNA M pulled R1 back by the sling, but CNA N noted it was not back far enough. CNA N then pushed R1's legs, so R1 could go back further. CNA N noticed R1's legs were bleeding. R1's Hospital Discharge Paperwork dated 05/02/24 documented R1 had a laceration (a deep cut or tear in the skin) repair to her right lower leg. The paperwork documented R1 had a 13 cm laceration that required 15 sutures. On 05/09/24 at 11:45 AM R1 sat in her recliner with her legs elevated. LN G performed R1's dressing changes to the bilateral lower legs. R1 had a Versatel dressing (contact layer dressing coated with silicone) applied to the lacerations on both legs that would not be removed for seven days as ordered. R1 lifted her left leg and grimaced while LN G applied Kerlix (gauze) around her left leg. On 05/09/24 at 12:50 PM, R1 stated that CNA M and CNA N upset her while transferring her because they did not listen when she asked them to guide her using her heels and not her lower legs. R1 stated that her lower legs hurt. R1 also stated that her feelings were hurt because the staff did not listen to her. R1 revealed that there was a great deal of pain when the injury occurred. On 05/09/24 at 01:13 PM LN G stated that R1 historically had tender legs and that was why R1 wanted staff to use her heels instead of her legs. On 05/09/24 at 01:20 PM, CNA O stated that two staff members were required to use a Hoyer lift to transfer a resident. CNA O stated to get a resident into position in a chair or wheelchair, one staff member pulled on the sling from behind while the second staff member lowered the sling with the Hoyer controls. CNA O stated staff should not push on a resident's legs to get the resident further back into the chair as this action had the potential to cause bruising or injuries. On 05/09/24 at 01:40 PM Administrative Nurse D stated that staff informed Administrative Nurse D that CNA N pushed R1 on her legs while R1 was being lowered into the recliner. Administrative Nurse D stated that she was unsure exactly what happened, but R1 had a history of lower leg pain. Administrative Nurse D stated CNA M and CNA N received transfer training. Administrative Nurse D stated that the staff were being trained on transfers, but the training was not yet completed. The facility's policy Mechanical Lift undated, documented a mechanical lift was used appropriately to facilitate transfers of residents. The policy directed staff to use the lever to gently raise and move the resident to the destination. Once at the destination, staff were to lower the resident and position comfortably. The facility failed to ensure R1 remained free from avoidable accidents. As a result, R1 sustained a laceration to her leg which required sutures. This also placed R1 at risk for increased pain and impaired well-being.

The facility reported a census of 148 residents. The sample included eight residents. Based on record review, observation, and interviews, the facility failed to ensure a safe environment free from preventable accidents for Resident (R) 1, when R1 slipped from the sling during a staff-assisted transfer using a Hoyer lift (full body mechanical lift). On 03/04/24 at 08:20 AM Certified Nurse Aide (CNA) M and CNA O attempted to transfer R1 from his bed to his chair using the Hoyer lift with a toileting sling. R1 slipped out of the opening in the toileting sling and fell to the floor. R1 hit his head on the metal leg of the Hoyer lift. As a result of the fall, R1 was admitted to the Intensive Care Unit (ICU) with a head laceration, a thoracic (mid-spine) fracture, and an intracranial (inside the skull) hemorrhage. The facility failed to ensure R1 remained free from preventable accidents when staff used the wrong sling during a mechanical lift transfer. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, listed diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), vascular dementia (a progressive mental disorder characterized by failing memory, and confusion), lumbar region spondylosis (a degenerative condition that affects the lower spine and causes back pain), epilepsy (brain disorder characterized by repeated seizures), and paroxysmal atrial fibrillation (a type of irregular heartbeat). The Annual Minimum Data Set (MDS) dated [DATE] recorded R1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated R1's cognition was moderately impaired. The MDS recorded R1 required the total assistance of two staff members with transfers; R1 was unable to stabilize without assistance, and used a wheelchair for mobility, The Falls Care Area Assessment [CAA] dated 04/07/23 recorded R1 was at risk for falls and required assistance of one staff with activities of daily living (ADL) and two staff with transfers using a sit-to-stand lift with transfers. The CAA recorded R1 was monitored for changes in functioning and staff would ensure R1's needs were met. The Quarterly MDS dated [DATE] recorded R1 had a BIMS score of 13, which indicated intact cognition. R1 required extensive assistance of one to two staff members with most ADL and total assistance of two staff with transfers. The resident was six feet tall and weighed 249 pounds. R1's Care Plan documented an intervention dated 06/04/20 and revised on 01/05/23 directed staff that due to weakness on R1's left side and poor balance, staff used a Hoyer lift with two staff for transfers. The plan recorded R1's last fall was on 07/31/23 when R1 fell out of R1's Broda chair (special wheelchair with tilt and recline capability). R1's Care Plan recorded an intervention initiated on 07/12/18 and revised on 03/04/24 that documented: due to weakness on R1's left side and poor balance, R1 used a full body mechanical lift with two staff assistance for transfers. R1's Care Plan documented an intervention added on 03/05/24 that noted on 03/04/24, R1 was transferred with the Hoyer lift when R1's body folded in half and fell from the sling. R1's bottom hit the floor first. R1's legs ended up on the legs of the lift. R1's head landed on the leg of the lift. Staff noted the back of R1's head was bleeding, and staff applied pressure. Staff did not move R1 because of a potential for injury to R1's neck. Emergency Medical Services (EMS) services applied a cervical collar and transported R1 to the hospital. R1's Care Plan lacked documentation of the specific size and type of sling used to transfer the resident. The facility Incident Report Investigation documented on 03/04/24 at 08:20 AM Certified Nurse Aide (CNA) M notified Licensed Nurse (LN) G of a fall. LN G immediately went to the room and observed R1 lying on his back. The back of R1's head rested against the leg of the Hoyer lift. R1's legs were lying on top of the Hoyer lift. There was a significant amount of blood coming from the back of R1's head. LN G immediately applied pressure and did not move the resident's head or neck. R1 was alert and oriented to his name, birth date, and year. Staff reported the resident was in the (lift) sling and staff were transferring R1 to his wheelchair. R1 folded in the sling and slid out, hitting his buttocks on the floor first, then hitting the back of his head on the corner of the leg of the Hoyer lift. Staff initiated neurological checks and continued until EMS arrived; R1's neurological checks were stable per the resident's baseline. Staff monitored R1's vital signs. R1 was able to answer questions appropriately, his speech was clear and coherent. EMS arrived, applied a neck collar then transferred R1 to the gurney. R1 complained of pain in his head. A review of the hospital's Trauma Services History and Physical dated 03/04/24 revealed R1 was dropped during a transfer with a Hoyer lift at the facility. R1 was a poor historian and did not answer questions surrounding the event. R1 confirmed he had a headache, back pain, and left lower quadrant (LLQ) abdominal pain. He had a cervical collar in place. The radiographic (X-ray) and computed tomography (CT scan- a test that uses X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scans revealed R1 sustained a subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane), bilateral (both sides) frontal subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain), and a nondisplaced fracture through the T8 vertebrae (bone of the spine). CNA M's Witness Statement from 03/04/24 recorded CNA M, along with CNA N, dressed R1 and hooked up the Hoyer machine. The staff crisscrossed the bottom half of the sling between R1's legs and hooked the sling by the top to the machine, then proceeded to transfer R1 to his chair. CNA N raised the Hoyer, and CNA M grabbed R1's wheelchair and started to place it under the Hoyer machine. R1 slipped out the sling and his bottom backside first, then hit his neck and the back of his head on the corner of the Hoyer. CNA M ran and got the nurse. CNA N's Witness Statements from 03/04/24 recorded CNA and CNA M went into R1's room to get R1 up for breakfast. The CNA staff got R1 in the Hoyer lift and when CNA M was about to put his chair under him, R1 started sliding out of the sling. R1 landed on his buttocks and then hit his head on the edge of the Hoyer lift. CNA M ran to go get the nurse while CNA N held R1's head; CNA N noticed all the blood on the floor coming from the back of R1's head. Observation on 03/06/24 at 03:00 PM of the lift used for R1 revealed a standard full-body Hoyer l lift in good repair. Observation of the sling used to transfer R1 revealed a standard divided leg sling also called a shower or toilet sling. The sling had a V or U shape, with two points of contact in the back and two at the front. Interview on 03/06/24 at 12:17 PM revealed CNA M acknowledged the resident fell out the bottom of the lift sling where there was an opening around the buttocks. CNA M stated CNA N and she attached the same sling they always saw used for R1. CNA M acknowledged she subsequently received instruction on the lift use and the appropriate sling used. CNA M stated a full-body sling was to be used, not the toileting sling. Interviewed on 03/06/24 at 12:07 PM, LN G stated she was alerted by CNA M that a nurse was needed immediately in R1's room. LN G stated when she entered, she observed R1 hit the left side of his head on the lift leg, and there was a puddle of blood on the floor. LN G said she applied pressure to the back of R1's head while the CNA got a phone and LN G started neurological checks. LN G said R1 was talking after the incident and LN G could see that R1 was scared. LN G reported R1 complained of head pain, but R1 laughed a little and LN G felt like R1 was going to be ok. LN G went on to say R1's hand grips were equal bilaterally, his pupils were ok, and R1's blood pressure was elevated, but LN G attributed that to R1's fall. When LN G rechecked R1's blood pressure, it came down. LN G reported she assured R1 that emergency services were on the way. LN G stated the CNAs involved told her R1 had folded or went completely relaxed and fell through the bottom of the lift sling. LN G stated the moment she came in and visually surveyed the room, she thought the problem was the sling that was used, as she noted staff had used a toileting sling. Interview on 03/06/24 at 11:20 AM with Administrative Nurse E revealed therapy staff reviewed sling and lift use with CNA M and CNA N. Administrative Nurse D said the therapy and administrative nursing staff were working on building a wide in-service related to lift and sling use for all staff. Interview on 03/06/24 at 11:20 AM with Administrative Nurse D revealed the toileting sling had an opening around the legs and Administrative Nurse D said R1 must have had his arms inside the lift sling, relaxed, and fell through the bottom of the sling. Administrative Nurse D acknowledged the staff used the wrong sling when they transferred R1 from the bed to his wheelchair. A review of the facility's undated Patient Lifts Safety Guide revealed photographic tutorials on bed-to-chair transfers, toileting, and/or bathing transfers as well as the various types and sizes of slings used. This documentation also directed staff to make sure sling opening is not large enough to let patient slip out or too small to let the patient fall out. The facility's Safe Resident Handling / Transfers policy dated 11/29/23 documented the facility would ensure the sling designed for the lift is utilized with that specific lift; and staff would be educated on the use of safe transfer/handling practices to include the use of the mechanical lift devices upon, hire, annually and as need arises or changes in equipment occur. The facility failed to ensure R1 remained free from preventable accidents when staff used the wrong sling during a mechanical lift transfer, and R1 fell through the sling. As a result of the fall, R1 admitted to the ICU due to a head laceration, a spinal fracture, and brain bleed and bruising. This failure placed R1 in immediate jeopardy. The facility implemented the following actions to remove the immediacy on 03/07/24: The facility retrained the staff on using the proper lift and sling for Hoyer transfers. The facility compiled a list of residents that utilized the Hoyer lift for transfers. The Kardex for each of those residents was updated to include the proper size/type of sling. The Patient Lift Safety Guide was reviewed with the nursing staff. The facility completed education on the current policy. The above actions to remove the immediacy were verified during an onsite inspection conducted on 03/07/24. The scope and severity of the deficient practice remained at a G.

The facility had a census of 148 residents. The sample included 32 residents with nine reviewed for pressure ulcers. Based on observation, interview, and record review the facility failed to provide off-loading interventions to prevent the re-opening of a healed pressure ulcers for Resident (R)13 and failed to implement interventions immediately upon discovering the pressure injury. The facility also failed to ensure staff completed a weekly wound assessment which included wound measurements for R82 who had multiple skin issues. This deficient practice placed R13 and R82 at risk for complications resulting from pressure injuries and/or delayed healing. Findings included: - R13's Electronic Medical Record documented diagnoses of lymphedema (swelling caused by accumulation of lymph) and a history of cerebrovascular accident (CVA, stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The MDS documented R13 required set up assistance for eating and substantial to maximum assistance for all other activities of daily living (ADL), including mobility. The MDS documented R13 had one Stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure ulcer (PU-localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) on admission. R13 had a pressure relief device on his bed and chair and received pressure ulcer care and dressings to his feet. R13's Skin Integrity Care Plan, dated 01/17/24, directed staff to ensure R13 wore appropriate footwear when ambulating or mobilizing in the wheelchair, initiated 05/05/23. R13 had a pressure relieving device on his chair and bed. His heels required elevation from the bed. He had a pressure reducing mattress and a cushion in his chair, initiated 05/05/23. The plan directed staff to cleanse R13's left heel wound with gauze and wound cleanser, apply Skin-prep (liquid skin protectant) to the peri-wound and collagen (protein derived wound treatment used to promote wound healing) to the wound bed followed by a cut-to-fit piece of Derma Blue (highly absorbent dressing embedded with antimicrobials), secure with a bordered foam dressing. Change daily and as needed if soiled or dislodged, initiated 06/20/23. The plan directed R13 had Prevalon boots (special pressure reducing heel protectors) on while in his recliner or bed and a Derma Saver bootie (cushioning boot) when he ambulated in his wheelchair, initiated 12/14/23. The Weekly Skin Assessment, dated 10/02/23 noted the left heel wound was resolved. The note documented there was a covering of skin with darker red underneath. The Weekly Skin Assessment, dated 12/01/23 at 08:30 AM, documented New skin concerns identified. R13's EMR lacked further note or mention of the new issues until the 12/04/23 wound care assessment. The Wound Care Note, dated 12/04/23, documented a total area of 4.72 centimeters (cm) with 0.2 cm depth on the left lower extremity (LLE). The left heel wound was 2.5 cm by 2.6 cm by 0.2 cm with 10 percent (%) eschar (dead tissue), 10% granulation (new tissue formed during wound healing), 10% slough (dead tissue, usually cream or yellow in color) and 70% eschar. There was moderate serosanguineous (semi-thick blood-tinged drainage) drainage. The wound care orders directed to cleanse the wound with gauze and wound cleanser, apply Skin-prep to peri-wound (skin surrounding the wound) and collagen to the wound bed followed by an absorbent dressing, rolled gauze, and tape. Change daily and as needed if soiled or dislodged. The Wound Care Note, dated 12/11/23, documented the R13's PU had a total area of 12.32 cm, with 0.2 cm depth. The Physician Order, dated 12/13/23, directed staff to ensure the resident wore Prevalon boots while in the recliner or bed and a Derma saver bootie when ambulating in his wheelchair. The Progress Note, dated 12/14/23 at 01:40 PM, documented the day shift nursing staff had not changed the dressing as ordered. The note recorded the dressing was dated 12/12/23. R13's December Treatment Administration Record (TAR) lacked evidence staff completed the left heel wound treatments on 12/11/23, 12/14/23, 12/15/23, 12/16/23, 12/21/23, 12/26/23, and 12/31/23. The treatment on 12/13/24 was recorded as refused. The Nutritional Assessment, dated 12/18/23, documented R13 met 100% of his nutritional needs, but his Stage 3 heel wound had deteriorated since the last evaluation and R13 had increased protein needs. The assessment recommended to try cottage cheese with lunches for wound healing needs. The Wound Care Note, dated 12/18/23, documented the PU had a total area of 8.9 cm. The Physician Order, dated 12/19/23, directed staff to provide Med Pass (a protein supplement) 60 milliliters (ml), twice daily. The Progress Note, dated 12/22/23 at 02:38 PM, documented R13 showered that shift, and his wound began to bleed. Upon inspection the nurse noted the peri-wound had lost integrity and appeared to be advancing in size and severity. The nurse noted the resident was non-compliant with the treatment of pressure relieving boots while in his recliner and was frequently noted sitting with his feet propped up in his recliner with his heels as the pressure point. Staff educated the resident on boot use. The Wound Care Note, dated 12/26/23, documented the PU had a total area of 12.33 cm. R13's December 2023 TAR lacked evidence R13 refused to wear the Prevalon boots or derma saver. The Registered Dietician Note, dated 01/15/24, revealed R13 had a Stage 3 left heel wound. R13 weighed 190 pounds and had weight gain over the past couple of months. R13's current diet order was carbohydrate controlled with 60 ml of Med Pass twice daily, cottage cheese with lunch, and ice cream twice daily. The note documented the dietician did not recommend supplements at that time; R13's intake with supplements was sufficient to meet needs, however his wound healing was delayed. The Progress Note dated 01/16/24, documented staff reminded R13 to let staff know if he had received his wound care changes daily. The note documented the resident was non-compliant with moon boot use and often sat in his recliner with his full weight on his heels and buttocks. R13's January 2024 and February 2024 TAR lacked evidence R13 refused to wear the Prevalon boots or derma saver. On 02/19/24 at 04:04 PM, observation revealed R13 sat in his recliner with his feet elevated on the footrest. He wore large foam boots. He stated his pressure ulcer developed after he admitted to the facility. On 02/20/24 at 03:52 PM, observation revealed Administrative Nurse E, the facility wound nurse, and Consultant Nurse HH performed wound care for R13's left heel. R13 wore a pressure relieving boot on his left foot. Administrative Nurse E removed the boot and a three-by-three dressing which had a small smear of drainage on it. Administrative Nurse E then cleansed the wound. R13's ulcer was beefy red and located on the back, bottom side of R13's heel. Consultant HH stated the wound was from pressure. Consultant HH said the wound was larger and had healed over, at one point. On 02/21/24 at 11:50 AM, Administrative Nurse E verified there were no offloading boots or floating of the heels after R13's PU resolved in October 2023. Administrative Nurse E said the wound consultant ordered to continue with the padded heel protector (Derma saver) but did not order any Prevalon boots or floating or off-loading of R13's heels. The facility's Pressure Injury Prevention and Management policy, dated 11/29/23, stated the facility would utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. A full body skin assessment would be conducted by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. The assessment may be performed after a change in condition or after any newly identified pressure injury and documented in the medical record. Evidence based interventions for prevention would be implemented for all residents who are assessed at risk or have a pressure injury. The policy stated the Unit Manager or designee would review all relevant documentation regarding skin assessments, progression towards healing and compliance at least weekly and document a summary of findings. Interventions on a resident's plan of care would be modified as needed. The facility failed to provide off-loading and/or pressure relieving interventions to prevent the re-opening of a healed Stage 3 pressure injury for R13. The facility further failed to implement interventions immediately upon identification of the new wound. As a result, R13's pressure ulcer returned as a Stage 3 which also placed him at risk for pain and other complications related to the PU. - R82's Electronic Medical Record (EMR) documented diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) on the left side, hemiplegia affecting right dominant side, pressure-induced deep tissue damage of right heel, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with skin complications, and bullous pemphigoid (a rare skin condition that causes large, fluid-filled blisters). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R82 required supervision for eating but was totally dependent on staff for all activities of daily living (ADL) and mobility. The MDS documented R82 had one Stage 2 pressure ulcer (PU-partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters), one unstageable PU (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus), one diabetic ulcer, and one open lesion. R82 had pressure relief devices to his chair and bed. R82 received PU care and application of dressings to his feet. The Pressure Ulcer Care Area Assessment (CAA), dated 01/30/24, documented R82 returned from his second hospitalization that month related to syncope (fainting or passing out). He was dependent on staff for ADLs. He had multiple wounds from pressure and diabetes. He received treatments and was seen at the wound clinic. R82's Skin Integrity Care Plan, dated 02/15/24, documented R82 had skin breakdown related to a left side affected cerebrovascular accident (CVA, stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The care plan directed staff to observe and assess skin weekly and ensure R82 wore a black off-loading boot on his left foot when he was up in his electric wheelchair; off load his heels on pillows when in bed, revised on 05/16/23. The 02/21/24 care plan update directed staff to assess, record and monitor wound healing, measure length, width, and depth where possible. Assess and document the status of the wound perimeter, wound bed, and healing progress. Staff were to report improvements and declines to the physician. The plan directed weekly treatment documentation should include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate (drainage). R82's Braden Scale (tool to determine risk for PU) Assessments, dated 10/10/23 listed the resident had a score of 14 which indicated moderate risk and on 01/07/24 he scored a 12 which indicated high risk for pressure injuries. The Weekly Skin Assessment, dated 12/25/23, noted R82 had a right thigh rash, an abrasion to the left little toe, an abrasion to the right little toe, and both heels had small openings. There were no wound bed or peri-wound assessments and no measurements noted. The Weekly Skin Assessment, dated 12/28/23, documented R82 continued with a rash on his right thigh and both heels had small openings. He also had small blisters to both hands. There were no wound bed or peri-wound assessments and no measurements noted. The Progress Note, dated 01/01/24, documented R82's buttocks had minor redness. His heel dressings were changed and showed some exudate. R82 denied pain and the note recorded his wound healing was progressing. The Weekly Skin Assessment, dated 01/07/24, documented previously identified areas, see notes. There were no wound bed or peri-wound assessments and no measurements noted. There were no further notes related to the assessment. The Weekly Skin Assessment, dated 01/14/24, documented see skin notes. There were no wound bed or peri-wound assessments and no measurements noted. There were no further notes related to the assessment. The Weekly Skin Assessment, dated 01/31/24, documented previously identified areas. R82 had pink healed skin on his scrotum and buttocks, and open wounds on both heels and toes. There were no wound bed or peri-wound assessments and no measurements noted. The Weekly Skin Assessment, dated 02/08/24, documented staff applied Skin-prep (liquid skin barrier) to R82's right great toe and received a new order to address itching on his arms and legs. There were no wound bed or peri-wound assessments and no measurements noted. The Wound Care Center Documentation, dated 02/13/24, documented the diabetic wound on the left calcaneus (heel) was open with an acquired date of 12/16/23, and the wound had been treated for four weeks. The wound measured 1.2 centimeters (cm) by 2.8 cm by 0.2 cm depth with a fat layer exposed, and a medium amount of drainage. The wound bed was 67-100 percent (%) necrotic (dead tissue). The left heel wound directions included to apply Hydrofera Blue (a type of moist wound dressing that provides wound protection and addresses bacteria and yeast) to the wound bed, PolyMem (non-adhesive dressing) three times weekly, and cover with gauze. The right heel wound was resolved, however, the note directed staff to keep the right heel in a suspension boot. R82's EMR Wound Assessments documented R82's wounds had resolved, and he had no current wounds being addressed in the Wound Assessments. On 02/19/24 at 10:40 AM, observation revealed R82 sat in his electric wheelchair in his room and visited with his spouse. He wore cushioning boots to both feet. He gave permission to observe wound care. He stated sometimes staff do not have all the supplies they need. He did say it was better after telling Administrative Staff A about it. On 02/20/24 at 08:20 AM, observation revealed R82 laid in bed and Certified Nurse Aide (CNA) P and CNA Q removed the pillows from his right side and from under his knees and heels. He also had a bed bolster under his lower legs. His ankles and heels were wrapped with gauze. The CNAs transferred R82 from his bed to the wheelchair with a sit to stand lift. His wheelchair had a three-inch cushion. On 02/22/24 at 08:55 AM, Administrative Nurse E, the facility wound nurse, performed a dressing change on R82's left heel. She set a clean field on the bedside table and put her supplies there. She removed the soiled dressing, cleansed the area, changed gloves and washed her hands. She applied a Hydrofera Blue dressing and a foam bordered dressing and secured with gauze wrap. She checked the right foot and found no issues. On 02/21/24 at 12:53 PM, Administrative Nurse E stated R82's physician would not allow the facility staff to assess or change orders on his patients and the physician had the resident go to his wound clinic weekly. She verified the facility staff had not documented assessment of the wounds weekly during wound care and dressing changes, since the resident went to the wound clinic. On 02/22/24 at 12:00 PM, Consultant Nurse GG verified weekly wound assessments should be done by the facility nurse. The facility's Pressure Injury Prevention and Management policy, dated 11/29/23, stated the facility would utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. A full body skin assessment would be conducted by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. The assessment may be performed after a change in condition or after any newly identified pressure injury and documented in the medical record. Evidence based interventions for prevention would be implemented for all residents who are assessed at risk or have a pressure injury. The policy stated the Unit Manager or designee would review all relevant documentation regarding skin assessments, progression towards healing and compliance at least weekly and document a summary of findings. Interventions on a resident's plan of care would be modified as needed. The facility's Skin Assessment, dated 01/01/20, stated it was the facility's policy to perform a full body skin assessment as part of a systematic approach to prevent pressure injury. A full body skin assessment would be conducted by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. The assessment may be performed after a change in condition or after any newly identified pressure injury. The policy directed staff to document observations of skin conditions, type of wound, measurements, color, type of tissue, drainage, odor, and pain. The facility failed to ensure staff completed a weekly skin assessment for R82 who had existing skin issues. This deficient practice placed R82 at risk for complications resulting from pressure injuries and/or delayed healing.

The facility reported a census of 176 residents. The sample included 5 residents. Based on record review and interview the facility failed to initiate timely interventions to maintain acceptable parameters of nutrition for 1 of 5 sampled residents when resident #1 had a significant weight loss of 23 pounds (lb.) or 13 percent (%) in 90 days. Findings included: - The August 2017 physician's orders [REDACTED].# 1 included [DIAGNOSES REDACTED]. The admission 5 day Minimum Data Set ((MDS) dated [DATE] recorded resident #1 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severely impaired cognition, short/long term memory impairment and poor decision making skills. He/she required extensive to total assistance of 1or 2 staff with most activities of daily living (Adls), and had limited mobility. The resident was 5 feet 5 inches tall, weighed 175 pounds (lbs.), required assistance with eating, and received a therapeutic diet. The discharge MDS dated [DATE] revealed a BIMS score of 6 (severely impaired cognition) and a decrease in his/her weight to 149 lbs. for a total weight loss of 26 pounds or 14.8%. The Care Area assessment dated [DATE] for nutrition recorded a Body Mass Index (BMI-a measure of body fat based on height and weight that applied to adult men and women.) greater than 25 was normal for the resident. He/she received a mechanical soft diet and thickened liquids due to a [DIAGNOSES REDACTED]. The resident's initial nutrition care plan dated 1/24/17 and revised on 2/28/17 directed staff to provide a mechanical soft diet with nectar thick liquids, honor the resident's food preferences, provide snacks per protocol, provide necessary assistance and/or cueing at mealtimes, and between meals as needed. Staff was to allow the resident to eat at his/her own pace, monitor his/her weight monthly, monitor his/her oral intake of food and fluid, with documentation on the meal intake record and monitor his/her laboratory tests as ordered. The care plan lacked any added interventions after the resident continued to experience weight loss on 3/10/17. The initial dietary note dated 2/6/17 at 2:41 P.M. recorded the resident's current body weight was stable at 181 lbs. since admission (This conflicts with documented weights of 175 lbs. on 1/20/17.). He/she ate better at meals, often ate in the main dining room rather than his/her room, and received assistance from staff, but could feed him/herself if food was cut for him/her. He/she received a mechanical soft diet. The dietician's note dated 2/20/2017 at 10:50 A.M. recorded the resident's weight was stable at 174 lbs. He/she ate well, tolerated his/her diet, and did not have chewing or swallowing difficulties. This note documented the resident received a controlled carbohydrate meal with thin liquids. The dietician's note dated 4/18/2017 2:24 P.M. recorded he/she reviewed the resident's nutritional needs and recommended Ensure (a high calorie/protein supplement) twice a day. The dietician's Nutrition Alert note dated 4/21/17 at 2:36 P.M. recorded the resident's current weight was 152 lbs. and he/she received Ensure twice a day. The note failed to recommend additional interventions, as the resident continued to experience weight loss. The electronic health record (EHR) revealed the resident's weights as follows: 1/20/17 175 lbs. 2/24/17 170 lbs. 3/24/2017 160.0 lbs. 7/21/2017 152.0 lbs. According to this weight record the resident had a 23 lb. weight loss from 1/20/17 to 4/21/17 or a 13% weight loss in 3 months. The clinical record lacked documentation of meal and fortified food intakes. On 8/7/17 at 10:43 A.M. the resident's spouse confirmed the resident lost weight while at the facility. Spouse stated the resident's normal weight was approximately 220 lbs. On 8/8/17 at 11:00 A.M. direct care staff Q stated the resident frequently asked for a soda pop, and did not want to eat. 8/7/17 at 3:29 P.M. licensed nurse N denied a noticeable difference in weight, and stated the resident had an adequate appetite. On 8/8/17 at 10:54 A.M. licensed nurse A stated the resident did not like to eat, did not like the diet, and did not drink well. Nurse A said the resident frequently requested a soda pop. Nurse A further stated the dietician reviewed all of the resident's orders upon admission and periodically. On 8/8/17 at 11:20 A.M. administrative nurse C stated the resident did not want to eat. Staff found it difficult to find food he/she wanted to eat. On 8/8/17 at 3:10 P.M. dietician DD stated he/she reviewed the resident's medical record and performed a full assessment. Dietician DD further stated if the resident had a nutrition alert, he/she implemented nutrition alert interventions as needed. On 8/8/17 at 3:22 P.M. dietician DD stated initially, the resident received a mechanical soft with nectar thick liquids upon admit, with interventions of fortified foods and assistance at meals. The fortified foods included power potatoes, whole milk and super cereal. On 3/14/17 the resident passed a swallowing test, so his/her diet was advanced to thin liquids. Dietician DD sated he she was aware of the resident's 5 lb. weight loss between 2/8/17 and 2/20/17, but thought this was a normal fluctuation in the resident's weight. On 8/9/17 at 12:58 P.M. nurse practioner Y stated staff made him/her aware of the resident's weight loss and the resident was started on [MEDICATION NAME]. The facility Height and Weight procedure approved 7/10/12, recorded: residents would be reweighed if their weight changed plus/minus three pounds over 100 pounds or plus/minus two pounds if under 100 pounds. The facility Nutrition Interventions policy revised 1/2017 recorded: Resident progress would communicate to the interdisciplinary team at resident care conference or monitored thru Nutrition Alert Program and through written updates in the medical record and care plan. The facility failed to implement interventions to prevent a significant weight loss for resident #1, who was cognitively impaired and dependent on staff.

The facility reported a census of 169 residents. The sample included 3 residents reviewed for pressure ulcers. Based on record review and interview, the facility failed to provide appropriate interventions to prevent the development of an avoidable pressure area from an assistive device for one resident (#1) related to skin integrity and infections when resident #1 admitted to the hospital for an open and infected neck wound on 2/17/17. Findings included: - The March 2017 physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively intact, and required assistance with most activities of daily living (ADLs) including bed mobility, transfers, toilet use, dressing and personal hygiene. He/she had one unstageable pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and received antibiotic medication (medication to destroy bacteria). The care area assessment (CAA) dated 1/24/17 for ADLs recorded the resident fell at home and suffered a broken neck and numerous trauma wounds. The care plan created on 1/31/17 documented the resident had skin integrity problems, which staff identified on 1/29/17 on his/her right forearm, two areas on the left lower leg, right lower leg, right cheek and clavicle (collarbone). The care plan directed staff to refer to the resident treatment orders and wound care log. The resident's primary care physician and wound care physician documented evaluations of the wound sites, which included the coccyx (small triangular bone at the base of the spine), right lower leg, two areas on the left lower leg, and right clavicle from the resident's neck brace (this was identified 5 days after admission to the facility). The documentation included the clavicle site had declined and there were now 2 open areas, new treatment orders were recommended and directed staff to refer to the wound log and POS for orders and information regarding treatment for [REDACTED]. The admission nursing assessment, dated 1/24/17 at 7:36 PM, documented bruising on the back of the left hand, coccyx wound, left shin and left calf wounds, right elbow and right side of face scabs, and skin tears on the right hand and right forearm. The assessment lacked identification of wounds on the neck area or under the neck brace. The assessment further documented no skin areas identified related to a medical device like oxygen, splint, orthotic, etcetera. The nurse's notes dated 1/29/17 at 5:46 PM documented the resident had a 2 centimeter (cm) by 1.5 cm open area to the right clavicle and the resident complained of discomfort from his/her neck collar. Staff administered treatment to the wound. The physician visit report, dated 1/31/17, documented the resident developed an unstageable pressure ulcer under the neck collar on the right collarbone as well as an abrasion of the right cheek from the neck brace. Orders were given for wound treatment of [REDACTED]. The wound physician's progress note dated 2/7/17 documented the resident wore a neck brace, which caused the neck wound. The wound evaluation flow sheet dated 2/7/17 documented a right clavicle wound, which measured 2.5 cm by 3.1 cm with no depth. Staff recorded the wound status as a decline. The information about the surrounding tissues was not documented. The wound evaluation flow sheet dated 2/14/17 documented a right clavicle wound, which measured 3.7 cm by 4.1 cm, with no depth. The surrounding tissues were red and macerated (softening and breaking down of skin as a result from prolonged exposure to moisture). Lab results dated 2/13/17 documented an elevated white blood cell (a sign of infection) count (WBC) of 23,600, with a normal range of 3,500 to 10,500. The clinical record lacked evidence staff notified the physician of the abnormal lab results on 2/13/17. The hospital physician's history and physical dated 2/17/17 documented the resident required admission to the hospital for treatment of [REDACTED]. On 2/28/17 at 2:27 PM, licensed nursing staff J stated the resident fell at home and fractured the first cervical vertebra. The resident wore a neck brace. Staff J stated the resident's neck wound developed shortly after admission on 1/24/17. Staff J further stated the resident received an antibiotic due to the infected neck wound from 1/31/17 through 2/6/17 and staff were to change the IV lines every 3 days. On 2/28/17 at 5:03 PM, administrative nursing staff D stated he/she expected staff to timely notify the physician of abnormal lab results. On 3/1/17 at 2:32 PM, physician L stated he/she discovered the critical lab results while reviewing the resident's chart on 2/17/17, 4 days after the facility had the lab results. Physician L expected to be notified right away of critical lab results, but confirmed he/she was not notified of the results. The facility provided policy for Pressure Ulcer Prevention and Management, dated 8/16/16, documented a head to toe skin assessment would include use of medical devices and staff were to remove any or all medical devices unless medically contraindicated. The facility failed to thoroughly assess and implement timely interventions to prevent the development of wounds for this dependent resident who wore a neck brace and developed an unstageable pressure ulcer.

The facility identified a census of 179 residents. The sample included 4 residents. Based on observation, interview, and record review the facility failed to provide adequate supervision and orientation to new licensed staff to prevent the (significant medication error) wrong administration of another resident's medications, without physician orders, to a cognitively impaired resident (#2). This resulted in the transfer of the resident by emergency services to an acute care hospital and admission to an intensive care unit for treatment with intravenous medications to counter the effect of those medications. Findings included: - The clinical face sheet documented the facility admitted resident #2 with [DIAGNOSES REDACTED]. nose), and [MEDICAL CONDITIONS] (thickening and hardening of the walls of the coronary (heart) arteries). The quarterly Minimum Data Set assessment dated [DATE] recorded the resident's Brief Interview for Mental Status (BIMS) score of (6), which indicated severe cognitive impairment. The resident required extensive to total assist for activities of daily living, except supervision with eating. The residents care plan dated 2/22/16 documented the resident required assistance with activities of daily living and staff administered [MEDICATION NAME] (pain relief) medications as ordered by the physician for right knee [MEDICAL CONDITION]. Nursing notes (NN) dated 3/21/16 at 10:46 A.M., recorded at approximately 9:15 A.M. nursing staff observed the resident moaning and leaning over in his/her chair in the dining room. Licensed nursing staff K assessed the resident and asked license nursing staff I what medications he/she administered to the resident before breakfast. Licensed nursing staff K observed the medication administrator record, which included heart medications, were for resident #1, with the same first name. Licensed nursing staff I reported, he/she had given these medications to resident #2. Licensed nursing staff K called emergency medical services to transfer the resident to an emergency room for treatment, and notified the resident's primary care physician. The facility investigation documented staff administered the following medications, recorded on resident #1's medication administration record to resident #2 (in error): [MEDICATION NAME] HCL ([MEDICATION NAME]) ER (extended release) 24 hours tablet, 240 milligrams (mg), an antiarrhythmic calcium channel blocker (a prescription medication that relaxes blood vessels and increased the supply of blood and oxygen to the heart while also reducing the heart's workload, used to treat high blood pressure, and [MEDICAL CONDITION] (a condition with low heart output and the body becomes congested with fluid), and [MEDICAL CONDITION] (abnormal condition that may affect the flow of oxygen to the heart); Carvedilol ([MEDICATION NAME]) 25 mg, a beta-blocker, a prescription medication that reduces the workload of the heart, and affects the blood flow through arteries and veins), used to treat hypertension (high blood pressure); [MEDICATION NAME]-[MEDICATION NAME] 25/100 mg, a prescription medication used to relieve the symptoms of [MEDICAL CONDITION] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike face, shuffling gait, muscle rigidity and weakness); Requip (ropinirole) 4 mg, a prescription medication used to relieve the symptoms of [MEDICAL CONDITION]; [MEDICATION NAME] ER 90 mg, a prescription medication, [MEDICATION NAME]/[MEDICATION NAME] (directly opens the blood vessels), used to treat hypertension; Aspirin-[MEDICATION NAME] ER 12-hour, 25-200 mg, a prescription medication, antiplatelet (prevent the formation of blood clots) -[MEDICATION NAME] to prevent [MEDICAL CONDITION] and [MEDICAL CONDITION]; [MEDICATION NAME] HCL 75 mg, a prescription medication used to treat depression; [MEDICATION NAME] 40 mg, a prescription diuretic medication to promote the formation and excretion of urine. An acute care hospital history and physical dated 3/21/16 timed 2:16 P.M., documented the resident was admitted with low blood pressures in the 50's and 70's (normal systolic blood pressure 90 to 120), and had nausea and vomiting. An acute care hospital discharge summary dated 3/24/16 timed 1:33 P.M., documented the resident with the admission [DIAGNOSES REDACTED]. The resident accidently ingested a different resident's medications, developed [MEDICAL CONDITION] (low blood pressure), and [MEDICAL CONDITION] (slow heart rate). The resident was admitted through the emergency room and monitored in the intensive care unit (ICU). The medications, which were all new to the resident, could affect his/her blood pressure adversely and his/her regular medications were held. The resident continued on a [MEDICATION NAME] infusion (chemical neurotransmitter used to treat shock and low blood pressure caused by [MEDICAL CONDITION] and trauma) and [MEDICATION NAME] (a vasoconstrictor medication which makes blood vessels narrower and increases blood pressure) and gentle intravenous fluid hydration, with gradual improvement in his/her heart rate and blood pressure and was transferred to medical floor. The resident received an antibiotic empirically because of the [MEDICAL CONDITION], and placed on a pureed diet after speech valuation for a risk of aspiration. The resident received an IJ (internal jugular intravenous line, a catheter placed in the veins of the neck) because of the emergent low blood pressure and poor intravenous access. NN dated 3/24/16 at 2:02 P.M., recorded the resident returned from the hospital. A physician exam note dated 3/25/16 documented the resident returned to the facility after hospitalization from an overdose of cardiac medications that resulted in [MEDICAL CONDITION], nausea, and vomiting. Observation on 4/14/16 at 9:15 A.M. revealed resident #1 and #2 rooms were located next to each other on the same unit at the facility. Observation of the resident's #1 and #2 paper chart record in the nursing station revealed an orange sticker, that documented name alert on the outside of the binder. Observation on 4/14/16 at 11:10 A.M. revealed the resident sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) of the unit living room and watched the group activity. During an interview on 4/14/16 at 9:43 A.M., direct care staff N, reported staff used the resident's picture on the electronic Medication Administration Record (EMAR) to identify the residents when passing medications. Direct care staff N revealed the door name plaque also posted each resident's photo. There are two sets of residents with the same names on his/her unit. Interview on 4/14/16 at 9:55 A.M., licensed nursing staff J revealed he/she was hired the second week of March. Staff rechecked the medication administration record three times with the orders, medication card, and asked the resident his/her name if the resident could tell him/her. Staff verified the resident room number and the EMAR posted a photo of the resident. Interview on 4/14/16 at 10:05 A.M., licensed nursing staff G revealed he/she received supervision and training for medication administration, when hired by the facility. Licensed nursing staff G reported, when two residents had the same first name, he/she asked their nickname. The resident's MAR and chart recorded both the name and the nickname for the resident. Interview on 4/14/16 at 10:15 A.M., direct care staff O, reported he/she received orientation and training for medication administration during orientation. Direct care staff O always looked at the resident's photo on the EMAR prior to administering medications and the doors have photos and names of the residents. Direct care staff O revealed three residents on this unit had the same first name. Interview on 4/14/16 at 2:30 P.M., administrative nursing staff E revealed during the orientation process, new licensed staff trained with their preceptor/mentor and worked one on one during the orientation. Administrative nursing staff E reported, staff attempted to keep residents with the same name separated from hall to hall or moved one resident to another hall. Staff revealed the unit secretary kept photos up to date for the resident's clinical record. Interview on 4/14/16 at 2:55 P.M., licensed nursing staff H reported the resident sat in a wheelchair in the hallway the morning of 3/21/16 when licensed nursing staff I was in orientation. Licensed nursing staff H revealed the facility placed name alert stickers on resident's physical charts for residents with similar names. However, the EMAR did not distinguish between residents with similar names. Licensed nursing staff H revealed during breakfast the morning of 3/21/16, he/she heard the resident moaning, and observed the resident exhibit uncontrollable tremors of the left arm and hand for a few seconds before he/she went limp. The resident moaned in response to his/her name, was pale with a droopy face and his/her eyes barely open. Interview on 4/14/16 at 2:51 P.M., licensed nursing staff I revealed on 3/21/16, he/she was on day 3 of orientation for medication administration. Licensed nursing staff I asked the resident his/her name and the resident answered with the correct first name. Licensed nursing staff I administered what staff I believed was the resident's medications on 3/21/16 at 8:43 A.M. The electronic record did not identify an alert for residents with the same name and he/she was unaware there were two residents with the same first name. Licensed nursing staff I reported the system he/she was familiar with included the scanning of the medications and resident identification into the system to prevent errors. Licensed nursing staff reported the EMAR posted a photo of the resident. Interview on 4/14/16 at 3:05 P.M., licensed nursing staff K reported he/she was providing orientation with licensed nursing staff I on 3/21/16. Licensed nursing staff K revealed, he/she went into a residents room to help assist with a transfer while licensed nursing staff I passed medications. Licensed nursing staff K reported resident #1 and #2 rooms are right next to each other. The binding of the resident's hard chart contained the similar name alert tag. The EMAR displayed a photo the resident, however did not identify residents with similar names. Interview on 4/14/16 at 3:45 P.M., administrative nursing staff D reported during the orientation process, the preceptor/mentor was expected to stay with the new staff during medication administration. Interview on 4/15/16 at 1:50 P.M., physician consultant FF revealed the resident would not have been able to stay at the facility for treatment. Basically, the resident's blood pressure bottomed out, and he/she was admitted to the ICU for treatment, fluids, and after about 24 hours the situation reversed. The facility lacked a policy to ensure mentors/preceptors supervised the orientation of new licensed nursing staff with medication administrator. The facility provided undated policy Medication administration, general guidelines, documented medications were administered as prescribed in accordance with good nursing principles and practices and only by a person legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Staff checked residents' identification before medication was administered. Methods of identification included: 1) checking identification band (none in this facility); 2) checking photograph attached to the medical record; 3) calling resident by name; 4) if necessary, verifying resident identification with other facility personnel. The facility failed to ensure staff correctly identified the resident prior to administration of medications. The deficient practice of medication administration for this cognitively impaired resident resulted in an avoidable significant medication error that required the resident transfer to an acute care hospital, admission to the intensive care unit, and treatment with intravenous medications to counteract the effects of the cardiovascular medications which were administered in error to this resident.

The facility identified a census of 176 residents. The sample included 11 residents. Based on observation, interview, and record review, the facility failed to provide supervision and assistive devices to prevent accidents for 6 of 8 residents reviewed. Resident #7, a cognitively impaired dependent resident identified as a fall risk, from experiencing an avoidable injury fall including multiple rib fractures and a wrist fracture; resident #10, a cognitively impaired dependent resident that experienced multiple falls including an avoidable fall which results in a neck fracture; resident #8 a cognitively impaired dependent resident that experienced a fall that resulted in an inoperable subdural hematoma; resident #11 a cognitively impaired dependent resident dropped from a mechanical lift and experienced a compression fracture of the lumbar spine; resident #1 identified at risk for falls and unsteady balance, transferred without a gait belt as planned, fell and experienced a hematoma; and resident #9 a cognitively impaired dependent resident left unsupervised on a commode for 4 hours and 40 minutes. Findings included: - According to the clinical face sheet, the facility admitted resident #7 on 11/11/14 from an acute care hospital with a cervical (neck) fracture and a history of falls. Review of the Electronic Health Records on 2/10/16 documented [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident with short- and long-term memory impairment, severely impaired decision-making. The resident required extensive assistance for dressing, walking, toileting, personal hygiene, and bathing. The resident had unsteady balance and was only able to stabilize with staff assistance, functional impairment of range of motion to the upper extremity of one side, used a walker and wheelchair for mobility and experienced two or more non-injury falls since the previous assessment. Review of the significant change MDS dated [DATE] recorded the resident with short- and long-term memory impairment, severely impaired decision-making, rejected cares 4 to 6 days of the assessment period and current behaviors were worse compared to the previous assessment. The resident required extensive assistance with activities of daily living except for eating. The resident had unsteady balance and was only able to stabilize with staff assistance, functional impairment of range of motion to the upper extremity of one side used a walker and wheelchair for mobility and experienced one non-injury, and two or more minor injury falls since the previous assessment. Review of the fall Care Area Assessment (CAA) dated 9/30/15 for documented the resident with significant cognitive losses due to the progression of Alzheimer's disease and he/she required staff assistance with all daily care needs including transfers and mobility. The resident was at risk for falls due to multiple risk factors including significant cognitive losses, long/short term memory problems, poor safety awareness/safety judgements, poor insight into his/her limitations/abilities, and impulsiveness. The resident had episodes of behavioral symptoms, agitation, anxiety, and restlessness, which add to his/her risk for falls. The resident had a decreased ability to communicate his/her needs to staff including when he/she needed to use the toilet, and when he/she had pain due. Staff had tried multiple interventions to decrease the risk for falls and the resident had recently been working with physical and occupational therapy to increase his/her strength and improve overall ability to participate in transfers. The cognition CAA dated 9/30/15 documented the resident with difficulty making decisions, impaired judgment, impaired thought processes, and required assistance with all activities of daily living. The behavior CAA dated 9/30/15 recorded the resident had significant cognitive losses due to the progression of Alzheimer's disease. The resident had frequent episodes of resistance/refusal of care, which included striking out/hitting out at staff, restlessness, agitation, grabbing at staff, refusing to take medications, and refusing to eat. The resident had episodes of agitation, anxiety, and inability to communicate his/her needs to staff, which placed the resident at risk for behavioral symptoms. In addition yelling out help or hollering, the resident could become physically combative with staff during care, refused to eat/take his/her medications, and became restless. Staff implemented multiple non-pharmacological interventions to attempt to decrease behavioral symptoms; however, interventions were not always effective. Fall Assessments reviewed included the following: 11/12/14 scored (18) high risk for falls 1/19/15 scored (23) high risk for falls 4/14/15 scored (16) high risk for falls. The fall risk assessment dated [DATE] recorded a score of (16), which placed the resident at high risk for falls. This assessment documented the resident experienced 1 to 2 falls in the last 6 months, exhibited loss of balance while standing, strayed off the straight path of walking, required hands on assistance to move from place to place, and used and an assistive device for mobility. Fall risk assessment continued: 7/15/15 scored (15) high risk for falls 7/24/15 scored (23) high risk for falls 7/30/15 scored (24) high risk for falls 10/8/15 scored (20) high risk for falls 10/15/15 scored (19) high risk for falls 11/5/15 scored (20) high risk for falls 11/13/15 scored (19) high risk for falls The fall risk assessment dated [DATE] recorded a score of (25), which placed the resident at high risk for falls and documented multiple falls in the last 6 months. The resident was unable to stand independently, exhibited loss of balance while standing, required hands on assist to move from place to place, exhibited jerking or instability when making turns, used an assistive device for mobility and had a decrease in muscle coordination. A fall risk assessment dated [DATE] scored (27) high risk for falls. The resident ' s plan of care dated 2/18/15, identified the resident was at risk for falls related to significant cognitive losses (long and short term memory problems, poor safety awareness, poor insight into limitations, abilities, can be impulsive). The resident exhibited increased anxiety/agitation, decreased mobility to right shoulder, frequent episodes of urinary incontinence, hearing loss, and decreased ability to communicate needs to staff, and a history of falls. The plan of care included the following dated interventions: 11/12/14 Antiroll backs added to the wheelchair 12/30/14 move resident ' s bed against the wall 2/19/15 document if the resident reported pain using 0-10 scale as resident is able to report it; use mild to severe scale if resident was unable to rate pain or use estimate of pain with nonverbal signs and symptoms of pain. The resident received scheduled analgesics (pain mediation) and oral medication for pain, and has a PRN (as needed) medication for breakthrough pain. 6/10/15, staff to re-direct and bring the resident to day area when restless 7/24/15, address need for scheduled pain med to decrease anxiety 8/10/15, check last on rounds; if restless do not lay back down 8/13/15, when restless, toileting should be first intervention 9/30/15, physician to evaluate and treat 10/3/15, bed controls Velcro to end of bed. The resident required one to one for mobility and dependent care. The resident could self-propel in the wheelchair at times. The resident required one to one extensive assistance for transfers. 10/8/15, evaluate sleep/wakefulness, schedule for 7 days. 10/15/15, slipper nonskid socks or shoes at all times. 10/19/15, monitor bruising until resolved to back of left hand 11/5/15, staff on 11pm/7am shift to change sides during med pass so both halls are covered 11/13/15, when resident ' s (family member) leaves, place resident in wheelchair 11/29/15, soft touch call light pinned to mattress when in bed 12/2/15, transfer the resident from wheelchair to recliner right after meals 12/4/15, uses standard wheelchair 12/9/15, resident may use Broda chair (specialized wheelchair with the ability to tilt and recline) for comfort PRN (as needed). The plan of care for skin care and pressure ulcer prevention dated 10/8/15 documented a toileting program, habit/scheduled at: 2:30 A.M. - 3:00 A.M., 4:30 A.M. - 5:30 A.M., 6:30 A.M. - 7:30 A.M., 10:00 A.M. - 11 A.M., 3:00 P.M. - 4:00 P.M., 5:30 P.M. - 6:30 P.M. Staff toileted the resident if he/she was awake on night rounds, otherwise use a check and change method. Staff provided one to one extensive assistance with toileting. The November 2015 physician order [REDACTED]. The resident's care plan last updated 12/2/15 lacked this intervention. Nursing note dated 7/24/15 at 1:21 A.M., recorded the staff found the resident laying on the floor mat on his/her right side next to the window near the bed. A nursing assessment revealed injuries to the resident ' s arm, elbow, shoulder, hip, and knee, all on the right side. The resident complained of pain in his/her right arm and staff offered PRN pain medication. The skin assessment revealed multiple skin tears above and below the resident's right elbow; abnormal discoloration on the resident's right shoulder, upper right arm, right knee, ribs, and right hip; and an abrasion on the right knee. A fall investigation dated 7/24/15 1:18 A.M., documented staff took the resident to restroom at about 1:00 A.M. and he/she tried to get out of bed on his/her own. The resident was very nervous, agitated at times, alert to self with confusion, would not follow directions, and had mild weakness in all extremities. The fall audit recorded the resident already with alarms, and staff needed to address the resident ' s anxiety related to pain. Nursing note dated 7/25/15 at 3:45 A.M. documented the resident tried to climb out of bed without staff assistance. Two staff attempted to help resident into wheelchair, but the resident pushed staff away and attempted to get behind the wheelchair. Staff guided the resident into the wheelchair for safety due to his/her unsteady gait and weak/shaking legs. Staff placed the resident in the living area and placed the resident one to one with staff for safety. Nursing note dated 8/10/15 at 5:40 A.M., the resident's alarm sounded while staff was doing rounds. When staff entered the room, they observed the resident sitting on his/her bottom on the floor mat next to his/her bed. The resident was unable to state what happened. Staff assisted the resident up to bed with no apparent injuries. Nursing note dated 8/12/15 at 1:45 P.M. recorded a physical and occupational therapy evaluation and treatment for [REDACTED]. Nursing note dated 8/13/15 at 11:15 P.M., documented at about 9:15 P.M., during the shift change narcotic count, direct care staff T went to answer the resident's alarm. Direct care staff T assisted the resident back in bed. After shift count, nursing staff assisted another staff with a resident who was a two-person assist. Approximately 10 minutes after shift count, nursing staff heard the resident's alarm again and found the resident on the floor in his/her room. Staff observed the resident on his/her hands and knees, hand up on the windowsill, trying to stand and put him/herself back to bed. The resident complained of right hip, shoulder and right sided back pain. The resident said he/she had to go to the bathroom and reported he/she could stand. Staff assisted the resident to the toilet and returned the resident to bed. Nursing staff notified the physician and received ordered to send the resident to the emergency room for evaluation of right hip and right sided back pain after a fall. An emergency room discharge transfer form dated 8/14/15 documented the resident with a contusion (bruise) of the left hip; and compression fracture of lumbar vertebra (portion of the spinal column between the ribs and pelvis). A quarterly nursing assessment note dated 9/26/15 at 4:23 A.M., documented the staff attempted to redirect the resident and at times provided 1:1 supervision for safety. The resident required one to one assistance with transfers and toileting. Nursing note dated 9/30/15 at 6:24 A.M., documented the resident sat in the day room recliner with one to one staff assistance. During early morning, the resident slept and staff attempted to make rounds while the resident slept. Nursing staff heard a noise and found the resident out of the recliner on his/her right side. The nursing assessment revealed the resident had a raised area on forehead. The facility fall investigation lacked evidence of a root cause for the resident's fall. The fall audit report recorded the staff had not placed a chair alarm. A physician progress notes [REDACTED]. The resident has had recurrent falls and advanced dementia with behaviors. Nursing note dated 9/30/15 at 1:27 P.M., recorded the resident had no complaints of pain or discomfort, however staff administered scheduled pain medication. Nursing note dated 10/1/15 at 11:09 A.M. documented a follow up from the resident's fall and assessed the resident with a bruise to right side of forehead, purple color measured 7 cm by 4.5 cm. Another bruise identified on the resident's right elbow, purple in color, measured 2.5 cm by 2.6 cm. Nursing note dated 10/15/15 at 1:07 A.M., at 12:20 A.M. direct care staff notified licensed nursing staff on another unit, he/she needed assistance due to resident getting up and needing help. Upon arrival to the unit at 12:30 A.M., licensed nursing staff observed the resident on the floor. Direct care staff had answered the resident's request for toileting and then laid the resident back down. While the direct care staff went to assist another high fall risk resident who was wandering, the resident's bed alarm sounded. Direct care staff ran down to help the resident and found him/her standing next to his/her bed and he/she fell as direct care staff entered the room. Direct care staff reported the resident fell backwards, his/her bottom hit the bed, rolled back and hit his/her back on the headboard, then slid off the bed and hit his/her head on the window ledge. Nursing staff assessed the resident with pinkness to the right shoulder blade and administered as needed pain medication for the resident's back pain. The fall audit dated 10/15/15 documented the resident was not brought to the television area and included the intervention of slipper socks. Nursing notes dated 10/16/15 at 2:09 P.M. recorded a physician visit with new orders that include: laboratory tests; increase of the medications, Buspar (antianxiety medication) to 10 milligram (mg) three times daily for agitation; Trazodone (antidepressant medication used to treat anxiety) 25 mg at bedtime for agitation/combativeness/dementia; and Tramadol (pain medication) to 50 mg three times daily for chronic pain. Review of a behavior note dated 10/26/15 at 3:15 A.M. recorded staff provided one on one supervision for the resident after administering as needed medications for anxiety/pain and resident's continued attempts to get out of his/her wheelchair. Nursing note dated 11/5/15 at 7:59 A.M., recorded at 6:40 A.M. staff found the resident on the floor. Nursing note recorded the medication aide passed medications and direct care staff answered call lights, both on the east hall (opposite hall the resident resided on). Nursing staff administered the resident's medications at 6:10 A.M., and offered toileting, which the resident declined. Nursing staff documented the new intervention for falls, was for direct care staff to come to the south hall while the medication aide was on the east hall passing medications, for safety. The fall audit dated 11/5/15 documented education to night shift staff of switching sides of the hall at medication administration times. Nursing note dated 11/13/15 at 6:29 P.M. documented at 4:40 P.M. the resident attempted to stand from the recliner in the day area, fell to his/her knees and rolled on his/her left side. The resident immediately attempted to stand up. The resident had been visiting with his/her (family member) approximately 5 minutes before the fall. Staff offered toileting to the resident and he/she refused. Nursing staff documented the new intervention for falls, was to assist the resident into the wheelchair when his/her family left. In an untimed communication note to the physician on 11/13/15, the physician responded to discontinue the wireless bed and chair alarms and place the resident on 15-minute checks. On 11/29/15 at 2:19 A.M. nursing staff documented that direct care staff found the resident on the floor in his/her room after staff rounded on the other resident hall. The fall investigation dated 11/29/15 at 2:17 A.M., recorded staff checked on the resident approximately 5 minutes prior to the fall. Staff documented the resident was anxious, confused and calling out. The fall audit form documented the intervention of a soft touch call light pinned to side of mattress to alert nursing staff of resident trying to get up. Nursing note dated 11/29/15 at 5:02 P.M. documented when checking on the resident, he/she was standing, holding onto the window ledge, exposed his/her (genitals), and was urinating on the floor. This staff member came up behind the resident slowly and braced his/her hips against the resident trying not to startle him/her (to prevent a fall). The resident was agitated with this intervention and staff had to call for additional staff to help assist the resident back to bed. The nursing note lacked evidence the soft touch call light activated to alert staff when the resident stood up from bed. A physician note dated 11/30/15 documented the resident with advanced dementia with episodes of agitation and combativeness in the evenings. Nursing note dated 12/2/15 at 10 A.M., documented guests observed the resident walking across living area without assistance. The resident attempted to sit in a recliner, missed the recliner, fell backwards slowly, and then rolled to his/her left side. Nursing staff documented the new intervention to prevent falls, was to transfer the resident out of the wheelchair right after meals. The fall audit report documented the new intervention to prevent falls, for staff to toilet the resident and put in recliner after meals. The clinical record documented the resident with a fall on 12/2/15 at 9:05 P.M. Nursing note dated 12/3/15 at 12:55 A.M. recorded at 9:05 P.M. staff reported the resident with an unwitnessed fall in the living room. Staff observed the resident on the floor in front and to the left of a Broda chair on his/her right side. The resident complained of pain in the right wrist and held his/her wrist, stating oww . The resident refused to let staff perform range of motion on the right wrist, arm, and shoulder due to pain. Nursing staff notified the physician and at 9:40 P.M. received orders for immediate x-rays of the resident's right shoulder and right wrist due to pain related to a fall. The fall investigation documented the nurse and a direct care staff assisted a resident that required two staff assistance and the other direct care staff assisting a resident in a room, and left the resident unattended. The fall investigation recorded nursing staff observed the resident in the Broda chair in living room most of evening and was last observed at 8:45 P.M. The incident occurred at 9:05 P.M. Staff documented the resident held his/her right arm and wrist repeating oww , ugg and would not use or allow anyone to touch his/her arm. The resident remained in a wheelchair next to nursing staff from 9:10 P.M. to 11:15 P.M., and constantly attempted to stand and ambulate independently. The fall audit report documented the new intervention included, Broda (specialized wheelchair with the ability to tilt and recline) chair for comfort, recliner after meals, and pain management. The stat mobile x-ray report 12/2/15 timed 11:56 P.M., documented the resident with acute right lower rib fractures and degenerative joint disease (degenerative changes to one or many joints characterized by swelling and pain) of right shoulder. The resident had a right wrist fracture. Nursing note dated 12/3/15 at 3:07 A.M. documented the results of the resident ' s x-rays at 1:00 A.M. The physician and responsible party, upon notification, made the decision to send the resident to the emergency room for treatment at 7:00 A.M. nursing staff administered PRN pain medication at 11:11 P.M. and the resident remained seated in the recliner with staff in the living area. Nursing notes dated 12/3/15 at 12:00 P.M. documented the resident returned from the emergency room at approximately 11:15 A.M. with a sling to the right arm. In a statement on 12/2/15 at 9:05 P.M. direct care staff BB reported the resident sat in a Broda chair in the evening. Direct care staff BB did not witness the resident's fall as he/she assisted another resident to bed. On 2/12/16 at 6:20 A.M. licensed nursing staff I reported the resident's alarms were discontinued. Licensed nursing staff I reported nursing staff kept the resident close to the desk at night for supervision to anticipate his/her needs, as the resident was impulsive and had frequent falls. Licensed nursing staff I reported he/she covered two separate units and at times covered three separate units. On 2/12/16 at 4:00 P.M. direct care staff T reported the resident sat in a Broda chair after the evening meal. The resident was more lethargic (drowsy, sluggish, inactive) and in the commons area. Some of the times, the resident required one on one staff supervision to prevent falls. Just prior to the resident's fall on 12/2/15 at 9:05 P.M., the other two staff on the unit, a nurse and direct care staff, were in a room transferring a resident with a mechanical lift. Direct care staff T reported he/she was watching the residents in the common areas when an unsampled resident got up and decided to go to bed. When this resident decided to go, staff had to assist this resident to prevent him/her from falling. While assisting the unsampled resident in his/her room, direct care staff T reported he/she could peek out the door at the other residents several times and the resident remained in the Broda chair. However, when he/she came out of the room, the resident was on the floor. The resident laid on his/her right side and held his/her wrist. The facility provided policy Fall Prevention and Management dated February 2014, documented when the resident expressed a need, the staff should assist the resident promptly or immediately find another staff member that can perform the task for the resident. It was the responsibility of all staff to stay alert to these specific residents and report to the nursing staff immediately when a high-risk resident was or attempted to ambulate or transfer without assistance. The policy directed that staff performed an assessment to identify contributing factors for the fall. Staff conducted a post-fall huddle, involving all staff from the neighborhood, to identify causative factors and develop interventions to reduce the risk of further falls, and continue to ask why until staff identified a root cause. Staff communicated fall occurrence and interventions implemented to all pertinent staff. The clinical record revealed from 7/1/15 to 12/20/15, the resident experienced 9 falls. The facility failed to provide supervision and assistive devices to prevent this cognitively impaired dependent resident identified as a fall risk, from experiencing an avoidable injury fall including multiple rib fractures and a wrist fracture. - Review of resident #10's Electronic Health Records documented [DIAGNOSES REDACTED]. mental disorder characterized by a gross impairment in reality testing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychosis (any major mental disorder characterized by a gross impairment in reality testing), and a history of falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) 7, which indicated severe cognitive impairment. The resident required extensive assistance from staff for transfers, bed mobility, dressing, toileting, and personal hygiene. The resident exhibited unsteady balance and required staff to stabilize, used a wheelchair for mobility, and experienced 2 or more non-injury falls since the prior assessment. The significant change MDS dated [DATE] recorded the resident with a BIMS score of 5, which indicated severe cognitive impairment, exhibited behaviors, rejected care and required extensive assistance for ADLs. The resident experienced 2 or more non-injury falls since the previous assessment and was recently admitted under hospice services. Review of the cognition Care Area Assessment (CAA) dated 10/20/15 documented the resident had a [DIAGNOSES REDACTED]. Review of the falls CAAs dated 10/20/15 documented the resident with the potential for falls and injury related to his/her history of recent falls, impaired cognition, impaired mobility, required extensive assist of two staff with transfers, incontinence, psychoactive medications, and medical diagnoses. The resident had a history of [REDACTED]. Staff would develop a care plan to monitor and provide interventions needed to prevent injuries. Review of the behaviors CAA dated 10/20/15 documented the resident had a long history of mental illness and the progression of dementia which brings out some inappropriate behaviors. The quarterly MDS dated [DATE] documented the resident with a BIMS score of 3, required extensive assistance with ADLs and experienced 2 or more non-injury falls. Review of the fall assessments 5/29/15, 7/15/15, 7/20/15, 8/4/15, 8/29/15, 9/4/15, 10/2/15, 12/1/15, 12/18/15, 12/23/15, 1/28/16 (revealed scores of 19-28) high risk for falls, and indicated a total score greater than 10 placed the resident at high risk for falls. Review of the care plan dated 1/28/16 identified the resident was at risk for injury related to falls and injury with multiple risk factors related to progression of dementia, memory loss, chronic pain, use of medications. The plan of care included the following: On 12/18/14 Perimeter mattress to bed. Noninjury fall on 5/29/15 with the intervention low bed. Noninjury fall 7/15/15 directed staff not to lay resident down when agitated and moved the bed against the wall. An injury fall resulting in bruising to back on 7/20/15 (and hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on forehead) directed staff to place a mattress on the floor beside the bed. Noninjury fall on 8/4/15 added a flat call light in resident ' s room. Noninjury fall on 8/29/15 ordered and completed a hospice consult. Noninjury fall on 9/4/15 (twice) directed staff not to leave resident alone when the resident was trying to get up and staff should use the call light to ring for assistance. Noninjury fall on 10/2/15 (no intervention recorded on the care plan). Noninjury fall on 10/22/15 directed a hospice completed a medication review. Noninjury fall on 12/1/15 (no intervention recorded on the care plan). Intervention on 12/18/15 removed the perimeter mattress to bed. Noninjury fall on 12/23/15 nonskid socks and toilet the resident prior to lying him/her down. Noninjury fall on 1/10/16 directed staff to encourage resident to get up for all meals, provide 15-minute checks if he/she refused to get up for breakfast. Injury fall on 1/28/16 resulted in a cervical fracture C2-T4 with facial bruising directed staff to provide one on one care twenty-four hours a day. Additional interventions added on 12/28/15 included Velcro the bed controls to the end of the bed, transfer bar on the left side of the bed, provide one to one extensive assistance with transfers, one to one dependent care for mobility with a standard wheelchair. Document the resident ' s pain per his/her report or estimate using nonverbal cues. Administer antianxiety and antidepressant medications as physician ordered. Administer antipsychotics mediation as physician ordered. Administer scheduled and PRN (as needed) pain medication as physician ordered. The plan of care for behaviors dated 1/28/15 directed staff the resident did well with one to one, assist with brushing hair, applying makeup, talk him/her down from anxiety episodes, or use music. The resident's anxiety appeared to decrease with music and singing, and he/she enjoyed singing songs from musicals such as Sound of Music and Oklahoma. Assign consistent caregiver to provide resident cares. A nursing note dated 7/15/15 at 8 A.M., recorded at 7:30 A.M. the resident experienced an unwitnessed fall and staff found the resident on the floor sitting on his/her bottom, three feet from the bed. Nursing staff assessed the resident with no new injuries and then transferred the resident from the bed to the wheelchair and positioned the resident in the hallway next to medication cart. The facility investigation dated 7/15/15 at 7:30 A.M. documented at approximately 5:30 A.M. the resident received PRN Ativan (antianxiety medication) for agitation and yelling out. Nursing staff transferred the resident to bed at 6:45 A.M., and reported the resident was asleep in bed at 7:05 A.M. Nursing staff then found the resident on floor 2-3 feet from bed. The resident stated, My mother is still under there and looked at the bed. The investigation documented the resident was agitated, confused, yelling at staff, and would not stay in one place. Staff implemented the intervention to move the resident ' s bed against the wall. The investigation lacked evidence of a root cause analysis of the resident ' s fall. Nursing note dated 7/20/15 at 10:04 A.M., documented at approximately 8:00 A.M. nursing staff observed the resident sleeping in bed. At 8:45 A.M. staff found the resident on the floor and before finding the resident on the floor, staff heard the resident yelling, Come get me! Nursing staff had entered the room to get the resident out of bed. Staff found the resident lying on his/her left side with his/her feet under the bed and his/her head resting on the wheel of wheelchair. The resident was awake, kept saying, I hit my head , and was holding his /her forehead. Nursing assessment revealed a large hematoma on the resident ' s forehead. Nursing staff obtained a physician and sent the resident by ambulance to an acute care hospi

The facility identified a census of 184 residents. The sample included 20 residents. Based on observation, record review, and interview the facility failed to thoroughly assess the skin, consistently document their findings, and prevent the development of an unstageable pressure ulcer for 1 (#49) sampled resident of 3 residents reviewed for pressure ulcers. Findings included: - The admission Minimum Data Set ((MDS) dated [DATE] for resident #49 revealed a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. He/she required extensive assistance from 1 staff member for bed mobility, transfer, and toilet use. The resident was frequently incontinent of bladder and was at risk for the development of pressure ulcers but had none at the time of the assessment. The 1/28/15 Care Area Assessment (CAA) regarding pressure ulcers revealed the resident had a potential for pressure ulcer development related to impaired mobility from a femur (thigh bone) fracture and wore an immobilizer. Staff provided a pressure relief mattress and turning every 2 hours. The initial care plan dated 1/20/15 revealed staff provided repositioning every 2 hours and the resident wore an immobilizer but lacked the location of the immobilizer. Staff reminded the resident to reposition. Staff avoided restrictive clothing, kept his/her heels free from the bed surface, provided a pressure redistribution mattress and seat cushion, kept skin clean and dry, applied moisture barrier after incontinent episodes, encouraged fluids, and observed for changes. Staff inspected the skin under braces, splints, and medical devices. The comprehensive care plan initiated 1/23/15 revealed the resident was at nutritional risk related to chronic obstruction [MEDICAL CONDITION] disease ([MEDICAL CONDITION]; progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), hip pain, and poor appetite. Staff provided a nutritional supplement, repositioning every 2 hours, and elevation of the resident's legs. The care plan revised 1/29/15 revealed staff provided pressure wound treatment related to impaired skin integrity from a brace on his/her right lower extremity. Staff monitored for signs and symptoms of healing and applied dressings to open blisters. The care plan revised 2/3/15 revealed the resident had impaired skin integrity related to an unstageable wound on his/her right posterior calf. Staff provided treatments as ordered, provided a pressure redistributing cushion to his/her wheelchair, positioned the resident off the affected area, off-loaded his/her heels while he/she was in bed, provided pain relief, elevated his/her lower extremities while he/she sat unless it was contraindicated, kept his/her leg as straight as possible, and discontinued his/her immobilizer on 2/4/15. The resident was being evaluated by a wound physician. Staff monitored for signs and symptoms of improvement or deterioration and wound status weekly in the wound book. An addition to the care plan dated 2/24/15 revealed staff provided a pressure redistributing mattress to his/her bed, repositioned him/her every 2 hours, and the resident ' s primary care physician managed his/her [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues). The Braden Assessments (scale for predicting pressure sore risk) dated 1/23/15, 1/28/15, 1/31/15, 2/7/15, and 2/14/15 revealed scores of 13 to 14, indicating the resident was at moderate risk. The initial nutrition risk assessment dated [DATE] revealed the resident weighed 114 pounds. He/she was at risk for weight fluctuations due to [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues) and was at risk for pressure ulcers due to limited mobility, use of an antidepressant (medication used for the treatment of [REDACTED]. The laboratory blood test results dated 1/29/15 revealed a low [MEDICATION NAME] (blood test used to measure the amount of protein in the blood, used in part to determine a person ' s nutritional status) level of 3.0 when a normal range was 3.4 to 4.8 and a low total protein level of 5.2 when the normal range was 6.4 to 8.3. These results indicated the resident ' s nutritional status was compromised putting him/her at greater risk for skin impairment. The skin section of the skilled nursing daily assessments dated 1/23/15 through 1/27/15 showed he/she had generalized bruising to his/her upper and lower extremities but lacked evidence of areas of concern to the resident right posterior (directed toward or situated at the back) calf. The skin section of the skilled nursing daily assessment dated [DATE] revealed staff noted 2 open areas to the resident ' s right ankle measuring 2 centimeters (cm) by (x) 1 cm and 5 cm x 2 cm. The nurse ' s note dated 1/28/15 at 10:22 A.M. revealed a physician assessed the resident and ordered staff to apply meplix (a type of wound dressing) to 2 open areas on the resident ' s right posterior calf. The skin section of the skilled nursing daily assessment dated [DATE] revealed the resident had wound dressings to 2 open areas on his/her right posterior calf. The nurse ' s note dated 1/29/15 at 6:00 P.M. revealed the facility received new orders due to an open area on the resident ' s right posterior calf: 1.) check under the immobilizer every shift, 2.) immobilizer on during the day and off at night. The skin section of the skilled nursing daily assessments dated 1/30/15 through 2/3/15 failed to address the open areas to the resident ' s right posterior calf. The wound evaluation flowsheet for the resident revealed he/she acquired a pressure ulcer in the facility to his/her posterior calf dated 2/3/15. The following dates and information were on the flowsheet: 2/3/15: Week 1. The wound was unstageable and measured 9.6 cm x 1.4 cm x unable to determine/assess (UTA). The wound presented with heavy, thick serosanguineous (semi-thick reddish drainage) exudate (is fluid, such as pus or clear fluid, that leaks out of blood vessels into nearby tissues) with a mild odor and the wound bed was 100 percent (%) covered in slough (dead tissue, usually cream or yellow in color). 2/10/15: Week 2. The wound was unstageable and measured 8.5 cm x 1.7 cm. The wound presented with a small amount of thick serosanguineous exudate without odor and the wound bed was 100 % covered with yellow adherent slough. 2/17/15: Week 3. The wound was unstageable and measured 7.3 cm x 1.8 cm x UTA. The wound presented with a moderate amount of thick serosanguineous exudate and the wound bed was covered with 75 % with slough and 25 % with [MEDICATION NAME] (tissue that forms a thin protective layer on exposed bodily surfaces and forms the lining of internal cavities, ducts, and organs) tissue. 2/24/15: Week 4. The wound was unstageable and measured 7 cm x 1.9 cm x UTA. The wound presented with a heavy amount of thin serous (clear) exudate and the wound bed was covered with 75 % slough and 25 % [MEDICATION NAME] tissue. 3/3/15: Week 5: The wound was unstageable and measured 7.6 cm x 1.5 cm x UTA. The wound presented with a heavy amount of thin serous exudate and the wound bed was covered with 75 % slough and 25 % [MEDICATION NAME] tissue. Observation on 3/10/15 at 5:04 P.M. revealed the wound physician measured the resident ' s pressure wound to his/her right posterior calf. The physician removed the old dressing and revealed 2 open areas measuring 1 cm x 2 cm and 4.3 cm x 1 cm x 1.1 cm. During the observation the physician stated the wound had separated into 2 wounds. Interview on 3/10/15 at 5:10 P.M. with physician GG revealed he/she frequently saw wounds that had developed from use of immobilizers and braces. He/she recalled the resident had substantial [MEDICAL CONDITION] when admitted to the facility and felt that may have contributed to the pressure ulcer development. He/she stated the facility may have discovered the wound sooner if the skin under the immobilizer had been thoroughly monitored. Interview on 3/11/15 at 9:17 A.M. with administrative nursing staff D revealed he/she acknowledged documentation lacked evidence of the presence of the resident ' s pressure wound on some of the skilled nursing daily assessments. Staff D acknowledged the wound was not discovered by staff until it was unstageable and large in size, he/she stated he/she thought staff would have been caught it sooner. Interview on 3/11/15 at 1:22 P.M. with licensed nursing staff I revealed the nursing staff were to remove all clothing and devices when performing skin assessments. He/she stated the skin assessment should include documentation of any pressure ulcers, bruises, blisters, and/or skin tears. Interview on 3/11/15 at 2:31 P.M. with direct care staff P revealed he/she worked with the resident upon admission and remembered that he/she wore an immobilizer on his/her leg. Interview on 3/11/15 at 2:38 P.M. with licensed nursing staff J revealed the nursing staff were to remove any immobilizers every shift to complete a full skin assessment. Staff J reported he/she was not working when staff discovered the resident ' s wound but he/she was under the impression it started as a blister. Staff J said he/she would expect the skin section of the skilled nursing daily assessment to show if a blister or wound was present. Interview on 3/11/15 at 3:42 P.M. with administrative nursing staff E revealed he/she expected the nursing staff to remove devices such as splints and assess the skin under the devices. Staff E expected the skin assessments to include all findings on the residents ' skin. The policy provided by the facility with a revision date of 12/2013 regarding pressure ulcer prevention and management revealed staff assessed residents for risk of developing pressure ulcers on admission then weekly for four weeks, quarterly, and upon indication of a significant change. The policy also shows the licensed nurse performed skin assessments on residents on skilled care daily, and all other resident weekly. The facility failed to provide a policy regarding skin assessments. The facility failed to prevent the development of a large, unstageable pressure ulcer and failed to consistently assess and document regarding the wound until the resident was reviewed by a wound physician for this cognitively impaired resident with a known risk for skin impairment.

The facility identified a census of 186 residents. The sample included 22 residents. Based on observation, interview, and record review the facility failed to prevent the development of pressure ulcers, and failed to provide timely interventions after the development of pressure ulcers for 3 of 4 residents reviewed for pressure ulcers. (#196, #53, #222) Findings included: - Resident #196's quarterly Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented the resident with short and long term memory loss and severe cognitive impairment. The resident required extensive staff assistance with activities of daily living (ADLs) and limited assistance of staff with eating. The resident was incontinent of bowel and bladder, had physical and verbal behaviors toward others, wandered and rejected cares on a daily basis. The resident did not have any pressure ulcers, but was at risk for the development of a pressure ulcer. The 8-8-13 Pressure Ulcer Care Area Assessment (CAA) documented the resident did not have any current skin breakdown, but was at risk due to his/her age, incontinence and diminished mobility. The resident repositioned him/herself, wore incontinent products that wicked away moisture, and had pressure reducing devices in his/her bed and wheelchair. The Cognition CAA dated 7-24-13 documented the resident had a [DIAGNOSES REDACTED], [MEDICAL CONDITION] (progressive mental deterioration characterized by confusion and memory failure) or other dementia (progressive mental disorder characterized by failing memory, confusion). The 10-13-13 Braden Assessment ( a rating scale to determine a resident's risk for development of a pressure ulcer. The lower the score, (the lower the level of functioning which indicated a higher risk for the development of a pressure ulcer) documented the resident's skin was occasionally moist, and required an extra linen change approximately once daily. The resident walked occasionally during the day, short distances and spent most of his/her time in his/her bed or chair. The assessment documented the resident was able to move in his/her bed and chair independently and had sufficient muscle strength to lift his/herself up. The total score was 19, which indicated the resident was not at risk for the development of a pressure ulcer. The 10-17-13 care plan documented the resident at risk for the development of pressure ulcers and documented the following interventions: Treatment and dressing changes as directed. Monitor for signs/symptoms of improvement/deterioration and wound status. Provide a pressure redistributing mattress to the bed. Position the resident off the affected side as much as possible. Provide pain relief, coordinate painful dressing changes, therapies or procedures by providing medication as prescribed. Provide nutritional support. Obtain laboratory/diagnostic work as ordered and follow up as indicated. Refer to the non temporary skin/pressure care plan for further preventive measures. On 11-7-13 the updated care plan documented the resident had a stage 3 pressure ulcer on his/her left hip. Interventions included the following: Ensure the resident's nails were kept trimmed to avoid unintentional skin tears from scratching. Obtain laboratory/diagnostic work as ordered and follow up as indicated. The resident wore incontinent products that wicked moisture away from the skin. Remind and assist the resident to reposition at least every one to two hours if not doing it on his/her own. Observe for [MEDICAL CONDITION] and report to the nurse. Provide wound rounds with the wound nurse and provide weekly ulcer report. Reposition the resident every one to two hours and consider a Broda (a special type chair used to redistribute pressure on the buttocks) chair. On 11-8-13 the care plan was updated to use [MEDICATION NAME] (a specialized dressing for wounds) dressing to the open areas on the resident's left hip, and change every 5 days and PRN. On 11-12-13 the care plan was updated to discontinue the previous treatment to the left hip and provide Collagen (a specialized product to promote wound healing) treatment to the wound with a [MEDICATION NAME] (a specialized product to promote wound healing) dressing, change the dressing every 7 days and as needed (PRN). The care plan directed staff to offload this site as much as possible while the resident was in his/her chair. On 11-2-13 the Risk Assessment form documented the resident's groin area was pink and staff applied a moisture barrier cream. On 11-6-13 the Risk Assessment form documented the resident developed two half centimeter (cm) open areas on his/her left hip. On 11-9-13 the Risk Assessment form documented the resident's groin was pink. Staff provided perineal care and a moisture barrier cream. The assessment lacked documentation of the two pressure ulcers on the resident's left hip. On 11-16-13 the Risk Assessment form documented the resident's groin area was pink, staff provided perineal care and applied moisture barrier cream. The assessment lacked documentation of the two pressure ulcers on the resident's left hip. On 11-5-13 at 3:04 P.M. the nutrition note documented the resident received Magic Cup (a fortified nutritional supplement) daily, Med Pass (a fortified nutritional supplement) 2.0, 60 milliliters (ml) twice daily, had good acceptance of the supplements and did not have weight loss. On 11-6-13 at 9:57 P.M. the nurse's note (NN) documented the resident had two one half cm open areas on the resident's left lower hip. Staff applied [MEDICATION NAME] dressing (a specialized moisture absorption dressing) on the open areas. On 11-12-13 the Wound Report documented the resident with a left hip ischial (the lower and back part of the hip bone) wound. The Pressure Ulcer Scale for Healing (PUSH) tool documented the resident's wound score of 4, which indicated the resident's wounds length by (x) width measured 1.1 x 2.0 centimeters (cm). On 11-12-13 the wound record documented the resident had 2 areas on his/her left hip and together the wounds measured 2.4 cm length (L) x 0.4 cm width (W) x 0.1 cm depth (D). The resident complained of pain with touch, had unattached wound margins and the current treatment included collagen with a [MEDICATION NAME] dressing changed every 7 days and to offload the area with a pillow while the resident was in his/her wheelchair. On 11-18-13, the wound care physician saw the resident and documented the resident with two stage 3 to unstageable pressure ulcers on the resident's left hip/ischial area. The resident received Med Pass twice daily and Magic cup daily. The resident started a multi vitamin today. The resident's dietary intake was 75%. One wound measured 0.9 cm x 0.6 cm, was a stage 3 to unstageable wound and the other measured 0.9 cm x 0.7 cm and was a stage 3 to unstageable wound. The physician documented the resident's periwound (the skin that surrounded the ulcers) was [DIAGNOSES REDACTED]tous (red, inflamed) rash with yeast and needed to be cleared prior to treating the pressure ulcers. He/she ordered an antifungal ointment. The physician documented staff was unable to keep a dressing in place due to the resident's constant incontinent episodes. Record review of the laboratory results on 6-3-13 included the resident's protein (a blood test to measure the amount of protein in the blood to determine a person's nutritional status) level was 5.3 grams per deciliter (g/dl) which was low. The normal value is 6.4 - 8.3 g/dl. The resident's [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person ' s nutritional status) level was within the normal range. The record lacked any further laboratory tests that included the resident's [MEDICATION NAME] or protein levels. On 11-18-13 at 1:05 P.M. the hospice note documented the facility reported the need for a Broda chair and the resident's wounds needed to be addressed. Continuous observation on 11-18-13 at 8:10 A.M. revealed the resident sat in his/her high back wheelchair with a yellow gel type cushion on the wheelchair. The resident sat at the dining table. The resident had scrambled eggs, 2 pieces of bacon, a slice of toast with butter and jelly cut in half, and 2 tall glasses with screw top lids and hard plastic straws. Both glasses were filled approximately one third of the way with fluid. The resident managed to unscrew the lid from one glass and spilled the liquid on the table and the floor. Direct care staff P cleaned the table and floor, and removed the glass from the table. Staff did not refill the glass or provide assistance with the resident's meal. On 11-18-13 at 8:20 A.M., 8:25 A.M., 8:30 A.M., 8:35 A.M., 8:40 A.M., and 8:45 A.M., the resident continued to play with everything on the table. At 8:46 A.M. the resident made multiple attempts to tip the glass to drink from it, but was unable . At 8:52 A.M. dietary staff informed the resident they were going to take his/her napkin and placed it in a bag. The resident spilled the food remaining on his/her plate. On 11-18-13 at 8:52 A.M. dietary staff informed the resident they were going to take his/her napkin and placed it in a bag. The resident spilled food from his/her plate onto the table and the plate was empty. The resident ate the bacon and half of the toast. The resident did not drink any fluids during the observation period. On 11-18-13 at 8:55 A.M. direct care staff O informed the resident he/she was going to move the resident from the table. As direct care staff O attempted to move the resident, he/she grabbed to hold onto the table and when the resident was away from the table grabbed at another chair. Direct care staff O held the resident's hands to prevent him/her from grabbing anything else and positioned the resident in the living area. On 11-18-13 at 8:59 A.M. direct care staff O and P took the resident to his/her room, placed a gait belt around the resident and lifted the resident to place a small pillow under his/her left hip. Direct care staff O stated it was to relieve pressure because the resident had a sore on his/her bottom. On 11-18-13 at 1:01 P.M. observation revealed the resident sat in his/her high back wheelchair with a gel cushion. Direct care staff P sat beside the resident and attempted to feed the resident. The resident refused and played with the food and napkin. Direct care staff P handed the resident a tall glass with a screw top lid and hard plastic straw and the resident was not able to suck from the straw. Dietary staff removed the resident's plate with direct care staff P's permission. Direct care staff P did not offer the resident an alternate and did not assist the resident with his/her fluids at this time. When direct care staff P removed the resident from the table, the resident attempted multiple times to grab for the table. Observation on 11-18-13 at 2:50 P.M. revealed the resident laid in bed. The wound care physician entered the resident's room along with the hospice nurse and administrative nurse F. Administrative nurse F removed the resident's dressing from his/her left hip. Observation revealed the resident had 2 open areas, each with a whitish wound bed. The resident's perineal area was inflamed, bright red and had multiple whitish pinpoint areas. Administrative nurse F informed the physician the resident scooted in his/her wheelchair and that is how he/she developed the pressure ulcers. He/she informed the physician the wounds appeared worse, and the rash appeared like yeast today, unlike last week when he/she last saw the area. Administrative nurse F informed the physician hospice brought a Broda chair today to help relieve pressure to the left hip and staff offloaded the area with a pillow when the resident was in the chair. Administrative nurse F informed the physician the resident had constant incontinence and was difficult to keep a clean, dry dressing on the resident's wounds. On 11-18-13 at 2:36 P.M. during an interview, direct care staff P stated resident was not able to state his/her toileting needs and was incontinent. On 11-18-13 at 2:53 P.M. during an interview, consultant physician KK stated the wounds were pressure ulcers and did not want to provide aggressive treatment until the yeast infection cleared. He/she stated the wounds were not deeper than a stage 3, however because of the slough, they were unstageable. On 11-18-13 at 3:09 P.M. during an interview, administrative nurse F stated he/she first saw the wounds on 11-12-13 upon his/her return from leave and because the edges of the wounds were rolling, he/she notified the wound physician to see the resident today. On 11-18-13 at 3:23 P.M. during interview, licensed staff H stated prior to the development of the pressure ulcers the resident ambulated with a walker at times but had not ambulated since his/her last day of therapy in July 2013. He/she stated the resident had a reclining chair to relieve pressure also. Licensed nurse H stated there was not a change in the pressure ulcers since staff first observed them. On 11-18-13 at 3:41 P.M. during interview, licensed nurse I stated staff placed a pillow under the resident's hip to offload the pressure when the resident was up in his/her wheelchair. On 11-19-13 at 9:47 A.M. during an interview, direct care staff O stated the resident often refused cares that included bathing. He/she stated when staff bathed the resident and noticed an area, they informed the nurse and the nurse assessed the area at that time. On 11-19-13 at 1:20 P.M. during an interview, administrative licensed staff D reviewed the resident's ADL sheet and acknowledged the resident did not receive any bathing from the facility during the month of November 2013 and received a bath from the hospice care attendant on 11-8-13. On 11-19-13 at 3:50 P.M. during an interview, administrative nurse F stated staff placed the resident in a Broda chair yesterday and it belonged to the facility. He/she stated the resident had a cushion in the other chair also. He/she stated the resident had predisposing factors that made the resident a high risk for the development of pressure ulcers that included the use of diuretic medication and steroid medication for the treatment of [REDACTED]. The 11-1-10 facility provided Pressure Ulcer Prevention and Management Policy and Procedure documented all residents who were chairfast or had an alteration in skin were considered high risk for the development of pressure ulcers regardless of the risk assessment score and limited chair sitting for those individuals with ischial ulcers to one hour or less. The facility failed to prevent the development of two unstageable pressure ulcers on the resident's left hip ischeal area and failed to provide timely interventions to promote wound healing. - Resident #222's Admission Minimum Data Set (MDS) 3.0 dated 10/12/13 identified the resident scored 15 (cognition intact) on the Brief Interview for Mental Status, required extensive staff assistance with bed mobility, transfers, dressing, toilet use, and did not walk in the room/corridor. The MDS coded the resident was totally dependent upon staff with locomotion on/off unit, was independent with eating, and was occasionally incontinent of urine. The MDS identified the resident weighed 181 pounds and had not experienced a weight loss. The MDS recorded the resident had a Stage 1 or greater pressure ulcer, was at risk for the development of pressure ulcer, utilized a pressure ulcer device for the bed and chair and was not on a repositioning/turning program. The MDS did not identify the stage of the pressure ulcer. The resident's Pressure Ulcer Care Area Assessment (CAA) dated 10/16/13 documented the resident had an unstageable pressure ulcer behind his/her left ear and staff felt the ear piece on the resident's glasses was the cause of the pressure ulcer. The resident had oxy ears (cushioning to prevent pressure ulcers) on the left side on his/her ear piece to assist with decreasing pressure to the area. The CAA included the resident's buttock had MASD (moisture associated skin damage) upon admission, which since resolved. The CAA documented the resident was at risk for additional areas of skin breakdown due to multiple risk factors and the resident had one episode of urinary incontinence noted during the 7 day observation period. The CAA included the resident attempted to shift his/her weight when he/she sat in his/her wheelchair or recliner, but due to his/her limitations, he/she required extensive assistance from staff with turning/repositioning when in bed and in chair. The CAA included staff assisted the resident with turning/repositioning every 2 hours and as needed. The resident had a pressure reducing mattress in place on his/her bed and a pressure reducing cushion in place for his/her wheelchair. The resident's Activities of Daily Living (ADL) CAA dated 10/15/13 included the resident required extensive staff assistance with most of his/her daily care needs. The CAA included the resident had decreased mobility to his/her bilateral shoulders and experienced pain all over. The resident's care plan dated 10/16/13 addressed the resident had actual skin breakdown, required staff assistance with turning/repositioning, was continent of urine and bowel and had an unstageable pressure ulcer behind his/her left ear. The care plan included the resident liked to sit in his/her electric recliner after each meal, the resident attempted to shift his/her weight by himself/herself when he/she sat in the recliner, and staff assisted the resident with repositioning/turning every 2 hours and as needed. The care plan included an entry dated 10/22/13 which included the resident had an unstageable pressure ulcer on his/her right scapula (shoulder blade) staff placed pillows to the back rest of the resident's Broda chair to offload the area and staff repositioned the resident every 1 1/2 to 2 hours, and off loaded the resident's heels when the resident was in bed. The care plan included staff did not leave the resident in the Broda after meals. An entry dated 11/13/13 included the resident had a deep tissue pressure ulcer on his/her left scapula. The resident's nutrition care plan dated 10/23/13 addressed the resident was a nutritional risk related to multiple factors, he/she weighed 181 pounds, liked ice cream and staff should offer it at lunch and dinner. The care plan did not include the resident experienced a weight loss. The resident's nursing admission assessment dated [DATE] documented the resident had a pressure ulcer on his/her left buttock that measured 3.0 centimeters (cm) by 2.0 cm and a pressure ulcer on his/her right buttock measuring 3.0 cm by 3.0 cm. The resident's risk screening form dated 10/7/13 documented the resident had a scab behind his/her left ear which measured 1.0 cm by 1.0 cm. The resident's risk screening form dated 10/14/13 included the resident had a red area on the upper right of his/her back measuring 2.5 cm by 1.0 cm and a small scab area behind the resident's left ear. The resident's risk screening form dated 10/20/13 documented the posterior (back part) aspect of the resident's right shoulder (shoulder blade) was open and the area measured approximately 0.5 cm in width and redness surrounded the area. The form included the resident's left shoulder blade reddened and the area of redness measured approximately 3.0 cm in width. The resident's risk screening form dated 10/28/13 documented the posterior aspect of the resident's right shoulder had a bruise/scrape that measured 1.5 cm by 2.0 cm. The resident's risk screening form dated 11/4/13 did not identify the resident continued with the pressure ulcers on his/her left and right buttock (the pressure ulcers healed between 10/28/13 and 11/4/13). A wound evaluation flow sheet dated 11/11/13 documented the unstageable pressure ulcer on the posterior aspect of the resident's right shoulder measured 3.2 cm by 2.1 cm, depth undetermined, and the wound bed contained dark tan eschar (dead tissue). The sheet included the unstageable pressure ulcer on the posterior aspect of the resident's left shoulder measured 0.8 cm by 1 cm, and the wound bed was gray-dark and boggy. The resident's risk screening form dated 11/18/13 documented the posterior aspect of the resident's right shoulder had an open area that measured 2.0 cm by 2.0 cm. The posterior aspect of the resident's left shoulder had a red area measuring 1.0 cm by 1.0 cm. A Physician's Visit Communication note dated 10/22/2013 and timed 10:48 A.M. documented staff received a signed communication sheet from the resident's physician which included for staff to clean the area on the resident's right shoulder with normal saline, apply triple antibiotic ointment, cover with [MEDICATION NAME] (a wound dressing that absorbs fluid), and change every 5 days. The note included the physician ordered for staff to apply [MEDICATION NAME] (dressing used to heal pressure ulcers) to the red area on the resident's left shoulder and change the dressing every 5 days. A physician's orders [REDACTED]. The order included the resident had a suspected deep tissue injury pressure ulcer on his/her left scapula. A physician's orders [REDACTED]. Staff transferred the resident to the bed or the recliner after meals. On 11/13/13 the physician ordered the resident to receive Mighty Shakes (nutritional supplement that provided extra calories and protein). The resident's laboratory report dated 10/3/13 recorded the resident's [MEDICATION NAME] level (indicator of one type of protein in the blood) at 3.6 grams/deciliter (g/dL), normal reference range 3.4-4.8 g/dL. The report recorded the resident's protein level at 6.3 g/dL, normal reference level 6.4-8.3 g/dL. Review of the resident's weights revealed the resident weighed 181 pounds on 10/2/13 and weighed 159 pounds on 11/15/13. This represented a significant weight loss of 22 pounds and/or 15 percent (%) of the resident's body weight. During this time the resident developed a nonstageable pressure ulcer on his/her right scapula and a suspected deep tissue pressure ulcer on his/her left scapula. The resident's clinical record did not support the facility performed a tissue tolerance tissue to determine if the 1 1/2 to 2 hour turning/repositioning program was sufficient to minimize pressure on the resident's bony prominences. On 11/18/13 at 7:30 A.M. the resident laid in bed on his/her back. Observation revealed a pressure relieving device on the resident's bed. The resident reported he/she had pressure ulcers on the posterior aspect of his/her shoulders. Observation on 11/18/13 at 12:20 P.M. revealed the resident had an unstageable pressure ulcer on the posterior aspect of his/her right scapula measuring approximately 1.0 cm by 2.0 cm. Observation revealed the wound bed contained yellow slough (non-viable tissue). Observation also revealed the posterior aspect of the resident's left scapula had a pressure ulcer red in color with a dark center and the area measured approximately 0.5 cm by 0.5 cm. On 11/18/13 at 1:17 P.M. the resident sat in the Broda chair in the dining room and staff assisted the resident with the lunch meal. Observation revealed no pillows in the Broda chair to offload the pressure ulcers on the scapula. Observation on 11/18/13 at 1:22 P.M. revealed the resident sat in his/her room in the Broda chair and with no pillows to offload the pressure ulcers. On 11/18/13 at 2:00 P.M., 2:10 P.M., 2:15 P.M., 2:30 P.M., 2:40 P.M., 2:50 P.M., 3:05 P.M., 3:16 P.M., 3:30 P.M., 3:45 P.M., 4:00 P.M. and 4:30 P.M. (duration of 2 hours and 30 minutes) the resident sat in the recliner, in his/her room without a change in position. On 11/1/13 at 9:30 A.M. the resident sat in the Broda chair at a dining room table. Observation revealed a small pillow behind the resident's back. On 11/19/13 at approximately 10:45 A.M. administrative nursing staff JJ stated the unstageable pressure ulcer on the resident's right scapula and the suspected deep tissue injury pressure ulcer on the resident's left scapula were facility acquired. Administrative nursing staff JJ stated the resident reported he/she required 2 staff to transfer him/her, therefore he/she had to sit for extended periods of times in the Broda chair and the resident felt that was the cause of the pressure ulcers. On 11/19/13 at approximately 11:50 A.M. physician staff JJ stated he/she was aware of the pressure ulcers. Physician staff JJ stated when the resident sat in the Broda chair staff should place large, fluffy pillows to offload the pressure. On 11/19/13 at approximately 12:50 P.M. licensed nurse N stated the resident sat in a hunched position and when he/she sat in the Broda chair it caused pressure on the resident's back which contributed to the pressure ulcers. Licensed nurse N stated staff repositioned the resident at least every 2 hours, placed the resident in the recliner after meals and when the resident sat in the Broda chair, staff now placed pillows to offload the area. On 11/19/13 at approximately 1:08 P.M. direct care staff U stated staff repositioned the resident every 2 hours. On 11/19/13 at approximately 2:45 P.M. the resident stated prior to the development of the pressure ulcers, he/she expressed concerns regarding his/her back hurting when he/she sat in the Broda chair. The resident stated he/she required staff assistance with transfers and he/she spent an excessive amount of time in the Broda chair without repositioning. On 11/19/13 at approximately 3:10 P.M. administrative nursing staff G stated staff repositioned the resident every 2 hours and when the resident sat in the Broda chair staff placed pillows to offload the areas. Administrative nursing staff G stated the resident had a hunch in his/her back, the strap of the Broda chair placed pressure on that area which he/she felt contributed to the development of the pressure ulcers. The facility's Pressure Ulcer Prevention and Management Policy approved on 11/1/10 included all residents were assessed for risk of developing pressure ulcers and interventions initiated to prevent impaired skin integrity. Residents admitted with or developed pressure ulcers received appropriate monitoring and treatment to promote healing. The facility promoted nutrition/hydration health which may include supplements. The facility failed to perform a tissue tolerance test, failed to timely implement nutritional supplements, failed to timely assess and determine if the Broda chair provided effective pressure relief, failed to reposition every 1 1/2 to 2 hours as planned for this resident dependent upon staff for transfers and bed mobility. - Resident #53's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident had moderately impaired cognition and short and long term memory problems. The MDS recorded the resident required extensive staff assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and did not walk in the room/corridor. The MDS coded the resident was totally dependent upon staff for locomotion on/off the unit, independent with eating, utilized a wheelchair and was frequently incontinent of urine. The MDS coded the resident did not have unhealed pressure ulcers, was at risk for the development of pressure ulcers, utilized a pressure relieving device for his/her wheelchair and was not on a turning/repositioning program. The resident's Activity of Daily Living Care Area Assessment (CAA) dated 2/14/13 documented the resident required staff assistance with activities of daily living. The resident's Urinary Incontinence CAA dated 2/14/13 documented the resident was incontinent of urine, and staff toileted the resident every 2 hours. The resident's Pressure Ulcer CAA dated 2/14/13 documented the resident was at risk for an alteration in skin integrity. The resident was unable to turn/reposition himself/herself without staff assistance, utilized a pressure reducing mattress in on his/her bed and sat in a Broda chair on a daily basis. The CAA included the Broda chair had lateral supports to assist the resident with sitting up straighter, was constructed with pressure relief as part of its design and therefore the resident did not require an additional pressure reducing cushion. Staff repositioned/turned the resident every 2 hours and as needed in bed and in the Broda chair. The resident shifted his/her weight some on his/her own as well. Licensed staff performed weekly skin assessments and staff monitored the resident's skin daily during daily care and bathing. The resident's Braden Scale (scale used to predict the development of pressure ulcers) identified the resident scored 13 on 7/16/13 and 10/9/13. A score of 13 represented the resident was at moderate risk for the development of pressure ulcers. The resident's care plan reviewed on 10/9/13 addressed the resident was at risk for alteration in skin integrity related to decreased mobility, cognitive impairment and requiring staff assistance with repositioning/turning. A licensed nurse assessed the resident's skin on a weekly basis, staff assisted the resident with repositioning/turning at least every 2 hours and as needed when in bed, chair, or recliner, the resident shifted his/her weight slightly on his/her own when sitting, and the Broda chair had a pressure reducing cushion built into the design. A physician's visit communication form dated 11/13/2013 and timed 8:54 P.M. documented the wounds (moisture associated skin damage) to the resident's buttock and inner thigh had resolved, and for staff to discontinue the treatment. The form included for staff to assist the resident with repositioning/turning and to check the resident for incontinence every 2 hours. The resident's risk screening form dated 11/16/13 documented the resident had a small open sore on his/her coccyx, and staff applied [MEDICATION NAME] ointment (used for treatment of [REDACTED]. The form did not document size, appearance, or the type of open sore. The resident's clinical record did not support the facility performed a tissue tolerance test to determine if the 1 1/2 to 2 hour turning/repositioning program was sufficient to minimize pressure on the resident;s bony prominence's. The resident's laboratory report dated 10/18/13 recorded the resident's [MEDICATION NAME] (indicator of protein) level at 3.5 grams/deciliter (g/dL), normal reference range 3.4-4.8 g/dL. The report recorded the resident's protein level at 6.8 g/dL, normal reference range 6.4-8.3 g/dL. On 11/18/13 at 8:32 A.M. staff pushed the resident to a dining room table. Observation revealed the resident sat in a black wheelchair instead of the Broda chair per the plan of care. On 11/18/13 at 8:44 A.M., 9:00 A.M. 9:20 A.M., 9:32 A.M., 9:50 A.M., 9:53 A.M. the resident sat in the black wheelchair. At 9:53 A.M. direct care staff U took the resident to the bathroom. At 10:10 A.M., 10:25 A.M., 12:10 P.M., 12:26 P.M., 12:40 P.M., 1:15 P.M., and 1:26 P.M. the resident sat in the black wheelchair. On 11/18/13 the resident laid in bed on his/her back at 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M., 3:00 P.M., 3:15 P.M., 3:30 P.M., 3:45 P.M., 4:00 P.M., 4:15 P.M. and 4:30 P.M. (duration of 2 hours and 25 minutes). Observation revealed a pressure relieving mattress on the resident's bed. On 11/19/13 at 7:45 A.M. direct care staff U entered the resident's room. Observation revealed the resident in bed on his/her back. Observation revealed the black wheelchair in the resident's room without a pressure relieving device. During interview with direct care staff T at that time, he/she stated the resident only used the black wheelchair when he/she went to to the beauty shop on Mondays. Direct care staff T stated the resident sat in the black wheelc

The facility identified a census of 171 residents. The sample included 29 residents. Based on observation, interview and record review the facility failed to utilize fall interventions as planned for 1 (#160) of 4 residents sampled for falls resulting in a fracture of the hip and failed to ensure a safe bathing environment in 4 of 6 showers for 2 of 4 days onsite of the survey. Findings included: - Resident #160's Quarterly Minimum Data Set (MDS) 3.0 dated 5/24/12 documented the resident with a Brief Interview for Mental Status Score of 0, which indicated the resident with severe cognitive impairment. He/She required extensive assistance with bed mobility, transfers and toileting. The resident had no falls in the last month, or the last 2-6 months and no fractures related to falls in the last 6 months prior to admission. The Care Area Assessment (CAA) for falls dated 12/14/11 recorded the resident fell in October resulting in an overnight hospital admission with a concussion and clavicular fracture from which he/she had fully recovered. He/She was on the falling star program and had a new lower highback chair that could be move about easier as well as bed and chair pad alarms. The care plan for falls initiated 6/09/10 and last reviewed 7/21/12 directed the staff to have the resident sit in an arm chair during meals or broda chair, do quarterly fall assessments and as warranted. On 7/22/11 staff added the resident to the falling star program. Staff were to anticipate and meet the resident's needs and ensure the resident had a bed alarm and chair alarm. Staff were to check the alarms for proper placement and functioning every shift. The Fall Risk Evaluation dated 5/18/12 indicated the resident at risk for falls. Progress Note dated 7/21/12 at 10:59 P.M. documented staff heard the resident yelling. Staff observed the resident who laid on his/her back on the floor behind the resident's broda chair at about 3:15 P.M. The resident was assessed on the floor and no obvious injuries were found. Two direct care staff and the nurse assisted the resident to a chair then got the lift and put the resident back in the broda chair. The resident complained of left hip pain when staff rotated his/her leg from side to side. The resident rated his/her pain at an 8 on a scale of 1-10 with 10 as the worst pain. Staff notified the physician and family and the resident was transported to the hospital by ambulance. The resident admitted to the hospital with [REDACTED]. The clinical record contained an X-ray dated 7/21/12 which recorded findings compatible with a mildly displaced right femoral neck fracture with the appearance of a linear fracture fragment which appeared to include a portion of a lesser trochanter. The osseous structures were normally mineralized. A Consultation Report dated 7/21/12 from the physician recorded the resident fell off a chair and that caused a fracture. Further review of the clinical record revealed the resident returned to the facility on [DATE] from the hospital and later passed away. Review of the facility fall investigation dated 7/21/12 documented the resident fell at 3:10 P.M. in the day room and licensed nursing staff M heard the resident and ran to the resident. The resident laid on the floor beside the broda chair. The resident had been folding clothing prior to the fall. Staff sent the resident to the hospital where the resident underwent [REDACTED]. The facility investigation showed prior to the fall, the night shift nurse reported the resident's pad alarm did not function and the nurse attempted to repair the alarm, but failed. Staff placed the box portion of the wireless pad alarm that did not function at the nurse's station and left the pad under the resident. Staff reported they did not have a functioning alarm under the resident since the resident laid in bed. Staff reported toileting the resident at 1:30 P.M. and the alarm did not function at that time. The day shift nurse documented the alarm was checked, but during an interview with facility staff he/she admitted the staff did not check the resident's alarm for placement and function. During interview on 8/6/12 at 4:51 P.M. licensed nursing staff S reported he/she made rounds often and checked on residents to make sure they are safe and have the appropriate interventions in place and to ensure staff are following the resident's care plan. During interview on 8/7/12 at 10:01 A.M. licensed nursing staff P reported the facility's fall precautions included having the resident use a low bed, keeping the call light in reach, prompt answering of resident's call lights, frequent observation and providing activity of daily living assistance. During interview on 8/7/12 at 4:47 P.M. licensed nursing staff L reported licensed nurse U, the nurse on duty at the time of the fall, falsified records when he/she charted the resident's alarm was checked for functioning and placement. When the resident fell out of the Broda chair staff did not have a functioning alarm under the resident to alert staff that the resident tried to get up out of the chair. The resident had a history of [REDACTED]. The fall happened at shift change and the nurse going off shift failed to ensure the resident had a functioning alarm to assist with the resident's safety and the oncoming nurse failed to check the resident to ensure the resident's alarm was in place and functioning. Staff L reported the facility was responsible for this resident's fall and staff should check at the beginning of the shift to ensure resident fall interventions were in place and that fall alarms were in place and functioning. He/She acknowledged the facility failed to keep the resident safe and some facility licensed staff were terminated from their positions. The facility provided a notarized statement written by licensed nurse L who wrote on 7/23/12 he/she interviewed licensed nurse U regarding the incident of 7/21/12 who reported he/she checked the bed alarm, but did not check the chair alarm. Upon reviewing the information, licensed nurse L stated licensed nurse U signed off documenting he/she checked the chair alarm, when he/she had not. The facility provided a policy entitled Personal Alarms revised 6/13/12 which directed it was the responsibility of all staff on each shift caring for a resident with a personal alarm to perform testing of the alarm. Each individual should immediately report any alarm that is not functioning correctly to the charge nurse. Malfunctioning alarms would be replaced immediately if the replacement of the battery does not resolve the problem. The facility failed to utilize fall interventions as planned for this resident with a history of falls which resulted in a fall with injury. Observation during an environmental tour on 8/7/12 from 9:00 A.M. to 11:00 A.M. revealed the shower rooms on Lincoln, Eastminster, Westminster, Mulvane Square, and Norwich Plaza lacked non-skid surfaces. Staff interview on 8/7/12 at 9:30 A.M. with environmental staff LL stated shower rooms on all the units should have bath mats in the shower/bath areas. Staff interview on 8/7/12 at 10:10 A.M. with nursing staff L stated nursing staff used bath/shower mats when giving a resident a bath/shower when a resident needed to stand during the shower; and the shower mat was not needed if the resident sat in a shower chair. Staff interview on 8/7/12 at 3:00 P.M. with administrative staff A and administrative nursing staff D stated staff used shower mats in the bath/shower rooms per facility policy. The undated Policy and Procedure for shower/tub bath revealed staff placed a non-skid bath mat on the floor where the resident would step in/out of the tub or shower. The facility failed to provide non-skid surfaces in 5 of the 7 unit shower/bathing rooms.

The facility reported a census of 170 residents. The sample included 3 residents. Based on observation, record review, and staff interview the facility failed to provide a safe environment and monitor the function of resident safety alarms for 2 residents (#1, #2) of the sample and failed to implement interventions for 1 (#2) of the sampled residents which resulted in a fall with fractures. Findings included: - The physician's orders [REDACTED]. The telephone order form dated 11/21/11 revealed to transfer resident to the emergency room (ER) regarding a fall; left hip and thigh pain. The Significant Change Minimum Data Set (MDS) 3.0 with a Assessment Reference Date (ARD) of 11/29/11 revealed the resident had long/short term memory problems; was unable to recall current season, location of room, and staff names/faces, and that she/he was in a nursing home; was severely impaired with making decisions regarding tasks of daily living; required extensive assistance with two plus persons physically assisting for bed mobility, transfer, dressing, eating, and personal hygiene; total dependence with one person physically assisting with locomotion on/off the unit; total dependence with two plus person physically assisting with toileting and bathing; used a wheelchair for mobility; had a fall since admission or prior assessment; and had 1 non-injury and 1 major injury fall since admission/prior assessment. The Care Area Assessment (CAA) dated 12/2/11 for falls revealed staff obtained information from a fall risk assessment dated ,[DATE]; a POS of 11/11,and the History/Physical dated 11/26/11. The care plan dated 12/2/11 for falls revealed a significant decline in mobility with fractures secondary to falls, confusion, poor safety awareness, restlessness, a history of falls/injury, and multiple risk factor: the resident was on the falling star program; when restless or having increased anxiety/confusion provide 1 to 1 assistance, visual supervision, and visit and calm resident in her/his room; 2 to 1 for positioning; reposition every (Q)1 to 2 hours; check and change with perineal care Q 2 hours; bed placed in lowest position; gray full length fall-floor mat by both sides of the bed; bed bolster secured on both sides of the bed; anticipate and meet resident needs such as toileting, snacks, fluids, etc.; respond promptly to requests for assistance; in the event of a fall, complete a post fall assessment; begin orthostatic blood pressures (BPs) and/or neuro checks as indicated; treat skin tears or wounds; make necessary notifications; analyze previous resident falls to determine pattern trend to be addressed; perimeter mattress to bed; personal pull away alarm to bed, and chair alarm used in the wheelchair. The discharge summary dated 11/23/11 revealed the resident had a computed tomography (CT) to the chest, abdomen, and pelvis which revealed a fracture of the left iliac and acetabulum involving the central anterior column of the acetabulum without disarticulation. Fracturing of the 9th, 10th, 11th, and 12th ribs. An X-ray of the pelvis showed a left femoral neck acetabular and portable left superior pubic ramus fracture. The Physician's Progress noted dated 11/26/11 revealed the resident had a recent fall and hospitalized from 11/22 - 11/23/11. She/he was found to have a left-sided rib fractures, left hip fracture, and left pelvic fracture. surgery for [REDACTED]. Provider recommended non-weight bearing on the left leg and follow-up in 4 weeks. The October, November, and December 2011 Treatment Administration Record (TAR) lacked documentation staff checked the personal/chair alarms every shift. The Comprehensive Fall Risk assessment dated [DATE] revealed a score of 22 for high risk and had a history of [REDACTED]. The Quarterly Fall Risk assessment dated [DATE] revealed a score of 13 for moderate risk of falls and had a history of [REDACTED]. The Comprehensive Fall Risk assessment dated [DATE] revealed a score of 17 for high risk and had a history of [REDACTED]. The Admission Fall Risk assessment dated [DATE] revealed a score of 20 for high risk and had a history of [REDACTED]. The policy and procedure for Personal Alarms dated 2/17/2011 revealed testing of personal alarm monitors was the responsibility of the staff on each shift caring for a resident with a personal alarm. The Nurses' Notes (NN) dated 11/21/11 at 1:00 A.M. revealed a bed alarm sounded. The nurse hurried into the resident's room and the resident sat on the edge of the bed with her/his wet brief on the floor and her/his foam boots thrown across the room. The resident stated she/he needed to go to the bathroom; staff assisted the resident into the bathroom with 2 to 1 assist; bed in low position, bolsters in place, and call light within reach. The NN dated 11/21/11 at 10:29 A.M. revealed the resident up in a wheelchair in her/his room. Transferred with a gait belt with 2 to 1 assist.; mobility per wheelchair; bed/chair alarms functioning due to the resident would not use a call light. The NN dated 11/21/11 at 6:00 P.M. the resident's bed alarm sounded at 4:30 P.M.; writer went to alarm and found the resident on the floor lying on the left side with her/his head against the wheelchair. The resident's left ear lacerated and bleeding. Had range of motion (ROM) with the upper/lower extremities without complaints of pain or signs of injury. The resident had stated "I'm ok, just get me up". The resident complained of pain in the hip and left thigh. Staff contacted the doctor at 4:45 P.M. regarding fall and new complaint of hip and thigh pain. Doctor returned call at 4:50 P.M. with orders for transportation via personal vehicle (per family's request) or non-emergency transport; staff contacted the family at 4:55 P.M. with update of left hip and thigh pain and advised resident be transported via non-emergency transport instead of personal vehicle; to ER at 5:10 P.M. The NN dated 11/23/11 at 11:05 A.M. admission note revealed resident returned to the facility at 11:03 A.M. by gurney from the hospital and put into bed; bed bolsters fastened in place; floor mats put into place; call light within reach; bed placed to a low position; and family at bedside. Observation on 12/7/11 at 10:45 A.M. revealed resident laid on right side in bed on perimeter mattress with bolster on both sides; fall mats on floor by right/left side of bed; and bed in low position. Staff interview on 12/7/11 at 10:55 A.M. with Licensed Nursing Staff H stated staff found the resident was found on the floor and had a cut to the left ear and did not complain of pain until later. Post fall interventions consisted of bed bolsters, bed alarm, bed placed in low position, and fall mats bilaterally. Family interview on 12/7/11 at 1:13 P.M. stated the resident fell getting out of bed to use the restroom. Preventive interventions consisted of a personal alarm, a bed alarm, and family asked for floor mats to be in place. Staff interview on 12/7/11 at 4:14 P.M. with Direct Care Staff Q stated the resident fell by rolling out of bed and there was not a landing pad on the floor on the left side of the bed as care planned. Fall measures that should have been in place were fall mats on both sides of the bed; a cordless bed alarm; a personal pull alarm; bed in low position; and bed bolsters on both sides of the bed. Central supply checked the alarms. Staff interview on 12/7/11 at 4:26 P.M. with Licensed Nursing Staff I stated the nurse checked bed/personal alarms every shift and documented on the TAR. Resident had a personal pull alarm and chair alarm prior to fall. The resident was known for taking off the personal alarm which was why a chair alarm was put in placed. The unit manager was responsible for reviewing the Medication Administration Record (MAR)/TAR to ensure everything was in order. Staff interview on 12/8/11 at 9:30 A.M. with Administration Nursing Staff D stated Licensed Nursing Staff J had just walked past the resident's room and appeared to be asleep; the bed alarm sounded and she/he found the resident on the floor on the left side of the bed; a wheelchair was by the bed; no bed bolster was in place on the left side at that time; a floor mat was on right side of the bed; the floor mat for the left side of the bed leaned against the wall; the left ear was bleeding; bed bolster was on the right side of bed; the left sided bolster was found under the left side of the bed; staff assessed the resident while on the ground; resident denied pain and placed into a wheelchair and wheeled to the nurses' station to attend the ear; resident then complained of left leg pain; the doctor/family was called; family member took resident to the ER; the resident had a history of [REDACTED]. When alarms were implemented staff checked them every shift documented on the TAR. Staff interview on 12/8/11 at 9:47 A.M. with Direct Care Staff O stated she/he put the resident to bed at 2:45 P.M.; placed the floor mats down on both sides of the bed and placed the wheelchair against the wall. She/he had glanced into the room while walking back and forth and did not notice whether the floor mats were in place. The resident fell about 4:00 P.M. Fall interventions since fall consisted of bed placed in low position; bolsters in place to keep resident from falling out of bed and asked for by the family; resident checked every 1 to 2 hours; sat in the room with the resident when she/he ate; to make sure the wheelchair was out of the way; and floor mats on the floor. Family interview on 12/8/11 at 11:15 A.M. stated before the fall she/he requested the bolsters and floor mats as the resident had fallen before. Telephone staff interview on 12/8/11 at 1: 54 P.M. Licensed Nursing Staff J stated she/he was in the next door room when she/he heard the resident's alarm and found her/him on the floor. The floor mat was propped up against the wall; the bolster fell down when the resident got out of the bed; the resident hit her/his ear somewhere on the wheelchair and first aide applied; family/provider was called. The resident's assessment was within normal limits (WNL); ROM was normal for the resident and had no signs of injury and within 15 to 30 minutes up in the wheelchair the resident complained of pain in the left side and had a history of [REDACTED]. Staff checked the alarms by activating them to make sure they alarmed. Staff checked the alarm each shift and documented on the TAR. Telephone staff interview on 12/8/11 at 12:55 P.M. with Licensed Nursing Staff stated she/he heard a CNA state the resident fell and went into the resident's room and resident was in a wheelchair; the resident had hurt her/his ear and looked like it was torn. Staff wheeled the resident to the nurses' station where she/he cleaned the left ear with a gauze and normal saline. The wheelchair by the bed at that time faced the foot of bed. The floor mat looked like it was folded in half and leaned against the wall. Was not sure if the bolster was on the left side of the bed. The facility failed to provide a safe environment for this dependent resident with a history of falls resulting in fractures and hospitalization and failed to document and monitor the personal/chair alarms every shift. - The physician's orders [REDACTED]., epilepsy, upper respiratory infection, chronic urinary tract infection, and congestive heart failure. The Annual Minimum Data Set (MDS) 3.0 with a Assessment Reference Date (ARD) of 10/20/11 revealed a brief interview for mental status (BIMS) score of 9 for moderately cognitive impairment; a mood score of 11 for moderate depression; required extensive assistance with two plus physical assist for bed mobility, and transfer; extensive assistance with one person physically assist for locomotion on unit, dressing, and bathing; limited assistance with one person physically assist for toilet use, and personal hygiene; resident was not steady, only able to stabilize with human assistance with moving from seated to standing position, moving on/off toilet, and surface to surface transfer; impairment on one side of upper extremity; used a wheelchair for mobility; had a fall since admission/prior assessment; and one fall with injury. The Care Area assessment dated [DATE] for falls revealed the resident had a fall on 10/13/11 which resulted in an emergency room (ER) visit due to complaints of back pain which she/he returned later that day with negative findings of any serious injury. The resident had acquire some bruising and complained of being sore for a few days. She/he was at risk for future falls due to impaired cognition with short and long term memory problems probably due to progression of Alzheimer's dementia, impulsive, and continued to transfer self due to impaired balance; she/he was encouraged to ask for staff assistance as that was the cause of her/his last fall; she/he was trying to transfer self from a wheelchair to the toilet. She/he utilized a wheelchair for mobility - self-propelled and staff assisted. The CP dated 2/7/11 and revised 10/13/11 directed staff to assist with all transfers; provide extensive assist with transfers; use a gait belt, and sit to stand lift when fatigued (10/24/11); place the call light within reach while in her/his room and cue to use call light when the resident needed help; provide a safe environment and adequate lighting; keep frequently used items within reach; teach resident safety factors for [DIAGNOSES REDACTED]. call for assistance; and transfer training with the restorative aide (RA). The Fall Risk Evaluation dated 10/7/11 revealed a score of 18 indicating a high risk for falls and had a history of [REDACTED]. The Fall Risk Evaluation dated 11/16/11 revealed a score of 19 indicating a high risk for falls and had a history of [REDACTED]. The October, November, and December 2011 Treatment Administration Record (TAR) lacked documentation staff checked the chair alarm every shift for function and placement. The Nurses' Note dated 11/15/11 at 11:15 P.M. revealed the resident was lying on the floor in between bed and wheelchair on the left side with her/his back to the bathroom. The policy and procedure for Personal Alarms dated 2/17/2011 revealed testing of personal alarm monitors was the responsibility of the staff on each shift caring for a resident with a personal alarm. Observation on 12/7/11 at 11:42 A.M. revealed resident sat in the dining room in a wheelchair. A chair alarm was present on the chair. Staff interview on 12/7/11 at 4:39 P.M. with Licensed Nursing Staff F stated resident fell in the bathroom while helped on to the toilet by a CNA. Preventive measures put into place consisted of a chair alarm; assisted with transfers; the wheelchair placed out of reach and resident encouraged to call for assistance to the wheelchair. On 11/15/11 the resident fell when she/he tried to transfer her/himself from the toilet. Staff checked the chair alarm every shift and documented on the TAR; the new nurse checked the TARs. Resident interview on 12/8/11 at 7:20 A.M. stated staff reminded her/him to make sure the resident's shoes were on and tied; to use the call bell and wait for assistance; and to wear her/his glasses to prevent falls. Staff interview on 12/8/11 at 1:10 P.M. with Administrative Nursing Staff C stated the nurses checked the alarms each shift and documented on the TAR. Staff interview on 12/8/11 at 1:30 P.M. with Direct Care Staff G stated the resident could be impulsive. Staff reminded the resident to call for help. Fall interventions consisted of a chair alarm, the falling star program, park the wheelchair away from the resident so she/he could not get to it; place the call bell within reach and remind the resident to call for assistance; staff checked the chair alarm every shift to make sure it was working and documented on the TAR. Staff interview on 12/8/11 at 1:44 P.M. with Direct Care Staff N stated the resident had a chair and bed alarm. The alarms sounded when the resident got up. Staff triggered the alarms to see if they were functioning. The facility failed to monitor a chair alarm for function every shift per facility policy.

The facility reported a census of 179, and the sample was 11. Based on observation, record review, and staff interview the facility failed to have preventive measures in place for the prevention of falls for 1 (#1010) who sustained a fracture, and failed to have a functioning bed alarm in place for 1 (#1002) of 3 residents reviewed for falls. Findings included: - Review of resident 's #1010 physician's orders [REDACTED]. The resident's significant change MDS 2.0 with a completion date of 9/15/10 documented the resident had modified independence of cognitive skills for daily decision making skills, short and long term memory impairment, required extensive staff assistance with bed mobility, transferring, dressing and toilet use and did not ambulate in the room or corridor. The assessment also identified the resident had fallen in the past 31-180 days. The resident's fall resident assessment protocol (RAP) dated 9/15/10 documented the resident was at risk for falls due to a history of falls and left sided [DIAGNOSES REDACTED] from a massive CVA. The resident's quarterly Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 4/14/11 identified the resident scored 12 (a score of 12 indicated the resident had moderately impaired cognitive skills for daily decision making) on the Brief Interview for Mental Status, did not exhibit any behaviors, required extensive staff assistance with two person physical assistance with bed mobility, transferring, dressing and toilet use, did not walk in the room or corridor and required extensive staff assistance with locomotion on and off the unit. The assessment coded the resident's balance unsteady, the resident was only able to stabilize with human assistance when moved from seated to standing position, when transferred on and off toilet and during surface to surface transfers. The assessment identified the resident had not fallen since the prior assessment. The resident's fall risk assessment dated [DATE] identified the resident scored 17. According to the legend a score of 10 or higher indicated the resident at risk for falls. Documentation on the form read: the resident had fallen 1-2 times during the last 90 days, the resident confined to the chair and the resident was not able to attempt the balance test without physical help. The resident's fall risk evaluation dated 6/14/11 identified the resident scored a 20. According to the legend a score of 10 or higher indicated the resident was at risk for falls. The resident's care plan dated 6/14/11 documented the resident was at risk for falls and fall prevention measures included the resident would not be alone when in the chair, remind resident to activate the call light, provide hazard free environment and to teach the resident safety factors. An entry made to the care plan on 6/7/11 included " Intervention for fall not left in room alone." An entry to the care plan dated 4/12/11 documented fall interventions included: low boy bed and fall mat to prevent injury or decrease risk of injury. According to the care plan the resident utilized a bed alarm from 3/15/11 until 4/8/11. The care plan lacked evidence the facility had interventions in place to minimize the resident ' s falls from the wheelchair until 6/7/11. A nurse's note dated 1/8/11 timed 10:04 P.M. documented staff found the resident sitting on the floor with his/her feet out in front of him/her and the resident stated that he/she slid out of the chair. A nurse's note dated 3/15/11 timed 6:00 AM documented staff found the resident in his/her room sitting on the side of the bed, and the resident stated he/she was trying to get to the children. The note also documented the facility placed a bed alarm on the resident ' s bed. A nurse's note dated 4/12/11 timed 5:17 A.M. documented the staff found the resident lying on the floor beside his/her bed at 4:00 A.M., the resident lay on his/her back with his/her feet straight out in front of him/her, and his/her arms at his/her side. The note read the resident stated that he/she heard the bell and was going downstairs to prepare dinner for his/her family. The note suggested interventions that included: place a fall mat beside the resident ' s bed and place the resident in a " Low boy bed. " A nurse's note dated 6/7/11 and timed 11:27 P.M. documented that at 8:33 P.M. staff heard the resident calling for help and the staff found the resident in his/her room on the floor face down on his/her left side. The resident ' s left hip and leg was completely under the resident, the resident had hit his/her head on the footrest of the bed, and rated his/her pain level at an 8. The resident transferred to a local hospital via ambulance. The facility investigation of the 6/7/11 fall included a written statement from direct care staff B that noted the staff placed the resident, who sat in the wheel chair, into the resident's room at about 7:30 P.M. and clipped the call light onto the arm rest of the chair. Review of a local hospital's Discharge/Transfer Referral dated 6/14/11 documented the resident had a left supracondylar femur fracture and the surgical procedure included an ORIF (open reduction internal fixation) performed on 6/10/11. A nurse's note dated 6/19/11 and timed 2:49 P.M. documented the resident insisted that he/she get up and walk, and the staff was unable to reason with the resident. The resident kept dropping his/her right leg off the wheelchair in attempts to get up and staff reminded the resident he/she broke his/her leg in a previous attempt to stand and walk. Observation on 7/5/11 at 9:10 A.M. revealed the resident lay in bed, an x-ray machine beside the resident's bed, fall mat at the foot of the resident's bed ( not properly placed), and no staff in the resident's room. At 9:12 A.M. direct care staff A entered the resident's room, stated the resident just had an x-ray of his/her left leg and confirmed the fall mat was not in place. During interview with licensed nurse A on 7/6/11 at 9:50 A.M. the staff reported the resident should not be in the room unattended when he/she sat in the wheelchair and staff placed the fall mat beside the resident's bed when the resident was in bed to minimize the resident's risk for falls and injury. On 7/6/11 at 12:03 P.M. observation revealed the resident sat in the wheelchair in his/her room with no staff in attendance. At this time this writer spoke with licensed nurse B (who was in the entrance to the dining room) regarding the above observation and the licensed nurse confirmed the resident was not to be in the wheelchair in his/her room unattended. During interview with licensed nurse A on 7/6/11 at 12:45 P.M. the nurse reported the resident had impaired cognition, utilized a chair alarm until 4/11, the facility discontinued the chair alarm at that time and provided education to the resident regarding not ambulating without staff assistance. The facility failed to develop a care plan to minimize the resident's falls from the wheelchair from 4/11 until 6/7/11 (on that date the resident fell from the wheelchair and received a fracture of the left femur). The facility also failed to follow the resident's care plan regarding leaving the resident unattended when the resident sat in the wheelchair in his/her room. - Resident # 1002 had [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) dated 2/16/11 for cognition recorded the resident had advanced cognitive impairment due to Parkinson's disease and dementia. The resident had poor safety awareness as evidenced by attempts to self transfer, wander, and eat too quickly. The resident had severe self-care deficits evidenced by being dependent on staff for cares and decision making. The resident was oriented to self and family. The CAA for falls recorded the resident had a history of [REDACTED]. The quarterly Minimum Data Set (MDS) dated 4/20/11 recorded the resident sometimes understands/was understood, had memory problems, had severely impaired cognitive skills for daily decision making, needed extensive assistance with activities of daily living except eating, did not walk, was incontinent, and had 2 or more falls since admission. The care plan dated 4/23/11 recorded the resident was a fall risk characterized by history of falls/injury, had multiple risk factors related to history of falls, such as unsteady gait, cognitive deficit, and poor safety judgement and for the staff to offer magazine/activities to keep him/her busy. The care plan noted the resident attempted to stand up if he/she was bored/restless, and for the staff to place the bed in the lowest position, to never leave the resident alone while awake (in room or bathroom), to monitor for anxiety, to do a quarterly fall assessment, to engage the resident in diversional activity if restless, to anticipate and meet needs such as toileting, snacks, fruits, etc, to respond promptly to request for assistance, place alarms to the bed and the chair and to check for proper placement and functioning every shift. The care plan noted for the staff to make sure the resident could not reach and turn off the alarm, to check the resident every 30 minutes to 1 hour to ensure safety. On 4/23/11 the care plan noted for the staff to place the resident in a recliner for rest periods during day (by nurses station), on 4/26/11 to place a motion alarm and floor mats in room, on 5/15/11 to place the resident at the nurses station, and to offer a sport channel or similar TV show. On 5/16/11 the care plan noted for the staff to remind the spouse to notify them when he/she departed after the daily visit, on 6/5/11 for the staff to do 30 minute checks (ongoing), to not leave resident unattended in the wheel chair, and to keep the bed in the lowest position. On 6/24/11 the care plan noted for the staff to involve the resident in activity after the spouse left. Review of the nurses progress notes revealed the resident had 6 falls since 4/11. The nurses notes dated 6/4/11 at 10:48 P.M. noted that about 4:15 P.M. the resident was on the floor in the middle of his/her room, on his/her right side, attempting to get to his/her feet. The staff immediately assessed the resident for pain, (the resident denied pain), the resident had full range of motion of his/her extremities, he/she sustained 2 abrasions, one on the right hip approximately 1 inch in length and ? inch in diameter, the second abrasion on the right mid-abdomen/flank that was approximately 2 centimeter in diameter. The staff cleansed both wounds with normal saline and left open to air. The resident denied hitting the head and there was no evidence of head trauma noted. Vital signs were within normal limits, and the staff instituted neurological checks, and 30 minute checks. The staff toileted the resident and placed him/her in the wheel chair in direct view of the staff. Additional interventions included not leaving the resident unattended in the dining room, bathroom or wheel chair. The nurses notes dated 6/5/11 at 10:00 P.M. bed alarm in place and working, and the bed in the lowest position. The facility investigation dated 6/7/11 recorded the resident fell on [DATE] at 4:15 P.M. The charge nurse walked by the resident's room and saw him/her on the floor. The facility noted the resident had a bed alarm but that it did not sound, and the resident had a small abrasion to the right hip and mid back. Review of the treatment record for 6/11 called for the staff to check the bed alarm for proper placement and for functioning every shift with a start date of 2/11. The staff initialed they had checked this on 6/4/11 for all three shifts. An observation 7/5/11 at 11:35 A.M. the resident sat in a Broda chair at the nurses station with a book on the desk in front of him/her. The resident had a personal safety alarm attached to the chair but the staff had not fastened it to the resident. Shortly thereafter licensed nursing staff D fastened the alarm to the resident's shirt. The staff said the resident should have the alarm clipped on. The staff said the resident also had another alarm, which was underneath the resident. An observation on 7/5/11 at 3:30 P.M. the resident attempted to get out of bed, he/she had his/her legs hanging over the mattress and tried to get up in a sitting position. The surveyor encouraged the resident to use the call light to alert the staff that he/she wanted to get out of bed, which he/she eventually did. An interview on 7/6/11 at 10:20 A.M. with licensed nursing staff E said the resident had repeated falls. The staff said when the resident was awake they don't leave him/her alone in the room. The staff said if the resident watched TV in the lounge and he/she got agitated the staff brought the resident to the nurses station and do 1 on 1 with him/her, and gave him/her ice cream. An interview on 7/6/11 at 11:00 A.M. with licensed nursing staff C said the resident fell from the bed on 6/4/11. The resident's bed alarm did not sound. The facility failed to have a working bed alarm in place as care planned for this resident with frequent falls.

The facility had a census of 179. The sample included 16 residents. Based upon observation, record review and staff interview the facility failed to provide adequate supervision to prevent accidents for 3 (#168, #114, #83) of 6 residents sampled for accidents. Findings Included: - Review of resident #168's Physician order [REDACTED]. The resident's quarterly Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 1/26/11 identified the resident had long and short term memory problems, moderately impaired cognition and did not exhibit any behaviors. The MDS also identified the resident was independent with all activities of daily living (ADLs) except dressing (required staff supervision). The assessment also identified the resident balance steady at all times during transitions and walking and had not fallen since admission or the prior assessment. The resident's care plan dated 2/3/11 identified the resident at risk for falls related to the aging process, and would have reduced risk for falls thru the next review date. The care plan fall risk interventions included that staff would ensure commonly used articles were within easy reach, would ensure resident's pathways was free of furniture, clutter, and that staff would ensure the resident had adequate lighting when he/she ambulated. The care plan also included documentation that the resident fell on [DATE], 3/13/11 and 3/14/11. Notations to the care plan included staff added a bed alarm on 3/8/11 and discontinued it on 3/9/11 (after the low bed in place). On 3/14/11, staff placed a bed alarm and personal alarm and also implemented 1 to 1 standby assist with a gait belt during toilet use, transfers and ambulation. The staff also requested that physical therapy and occupational therapy evaluate the resident. The resident's care plan did not address that the resident utilized a perimeter mattress ( a foam wedged shaped mattress that prevented falls from the bed). A nurse's note dated 2/24/11 timed 5:17 PM documented the resident's physician reviewed the resident's medications and decreased the resident's Paxil to 20 milligrams (mg) daily for 7 days, then 20 mg every other day (QOD) for 7 days. The physician also gave an order for [REDACTED]. A nurse's note dated 3/9/11 timed 1:51 A.M. documented that at 11:45 P. M. staff found the resident in his/her room, sitting on the floor, the resident complained of left hip pain and staff noted bruising to the resident's left and right elbows and left outer calf. The note also documented the resident stated that he/she slipped off the bed and staff placed a bed alarm on the resident's bed. A nurses's note dated 3/9/11 and timed 12:11 PM documented the staff placed the low boy bed in the resident's room and removed the bed alarm. The clinical record lacked evidence that the facility thoroughly assessed the causal factor of the resident's fall on 3/9/11. The clinical record also lacked evidence as to how staff would know the resident had exited from the bed after removal of the bed alarm. A nurse's note dated 3/13/11 timed 7:51 P.M. documented that at 6:15 P.M. the resident stood up to exit out of the dining room, the resident fell and staff observed a laceration about 2 inches long on the left side of the resident's head, 2 lacerated areas on the resident's ear, 5 inch skin tear on the resident's left forearm, the resident complained of left hip pain and an ambulance service transported the resident to a local hospital emergency room (ER) due to the head bleed and the resident's complaints of left hip and mid back pain. A nurse's note dated 3/13/11 and timed 10:32 P.M. documented the resident returned from the ER and a family member stated the resident received 15 stitches to the scalp and 3 stitches to ear. The note also documented staff noted a bruise to the left side of the resident's face from the temple to the lower cheek area, and received an order to apply Triple Antibiotic Ointment three times a day, and to use APAP (Acetaminophen) or Motrin for the resident's pain. The note documented the family member expressed concern that the recent medication changes was "causing problems" for his/her family member. A nurse's noted dated 3/14/11 and timed 6:43 A.M. documented that at 4:05 A.M. staff found the resident on the floor next to his/her bed, the mattress was also on the floor leaning against the resident. The note documented that staff requested a physical therapy order and an evaluation of the resident's medications and staff placed the bed alarm on the resident's bed. A nurse's note dated 3/14/11 and timed 6:57 P.M. documented staff had bed and chair alarms in place for safety and the resident received stand by assist when ambulating. A nurse's note dated 3/15/11 and timed 6:30 A.M. documented that at 4:55 A.M. the resident's alarm sounded, staff heard the resident hollering and staff found the resident on the floor beside his/her bed on the backside of the bed laying on the right side. The note also documented the resident stated he/she rolled off the bed, no new injuries noted and that staff would recommend a scoop mattress. A nurse's note dated 3/16/11 and timed 1:57 P.M. documented that on 3/15/11 at approximately 11:30 A.M. staff placed a large blue gait belt on the resident, the staff were aware of the need to use the gait belt when transferring and walking the resident to the dining room. The note documented the resident was cooperative with the gait belt, the resident gait was steady but faltered slightly during turns and the resident was unsteady when he/she attempted to sit at the table. The staff placed a personal alarm on the resident at that time (3/15/11). A physician's orders [REDACTED]. to 2.5 mg daily, hold if blood pressure was less than 110/60 and to perform a urinalysis (UA) per standing order for frequency and/or urgency. Observation on 5/10/11 at 2:30 P. M. revealed the resident sat in a recliner in the television room and had no alarm in place. Observation at 2:40 P. M. revealed the resident ambulated from the television room to his/her room independently. Observation on 5/11/11 at 7:25 A.M. revealed the resident lay in bed on his/her right side with the perimeter mattress and bed alarm in place. On 5/11/11 at 8:00 A.M. observation revealed the resident sat in a chair in the TV room and had no personal alarm in place. On 5/11/11 observation at 8:15 A.M. revealed the resident ambulated independently without staff assistance from the TV room to the dining room. During interview with licensed nurse D on 5/10/11 at 2:55 P.M. the staff reported the facility utilized the perimeter mattress on residents identified at risk for falls. During interview with licensed nurse on 5/12/11 at 12:45 P.M. the staff confirmed that the facility did not thoroughly assess the causal factors of the resident's falls in a timely manner during the month of March 2011. The staff also reported that the resident now ambulated independently and did not require the 1:1 stand by assist or the chair alarm as care planned. The facility failed to assess the causal factors of the resident's falls in a timely manner, failed to implement assistive devices to minimize the resident's falls in a timely manner and failed to utilize the gait belt and 1:1 stand by assist as care planned. - Review of resident #114's Physician order [REDACTED]. allergies [REDACTED]. Review of the resident's face sheet identified the facility admitted the resident to the facility on [DATE]. Review of the resident's discharge/transfer referral with an admitted 12/17/10 and a discharge date of [DATE] identified the resident had a principal [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) 3.0 with an assessment reference date (ARD) of 1/10/11 identified the resident scored 12 on the Brief Interview for Mental Status (a score of 12 indicated the resident had mildly impaired cognition), did not exhibit behaviors, required extensive staff assistance with bed mobility, walking in the room, required limited staff assistance with transferring and hygiene, required extensive staff assistance with dressing and toilet use and utilized a walker and wheelchair. The assessment identified the resident fell during the last month prior to his/her admission to the facility and had sustained a fracture related to a fall in the 6 months prior to admission and had not experienced any falls since admission to the facility or the prior assessment. The resident's care plan with an initial date of 1/4/11 and reviewed 3/10/11 documented staff assisted the resident with all transfers and monitored the resident's bed mobility. The care plan documented the resident utilized a low bed in the lowest position, mats beside his/her bed and a bed and chair alarm that staff checked every shift to ensure that they functioned and were in place. A notation on 4/11/11 documented that staff ensured the resident's floor was clear when staff transferred the resident and that the resident's call light would be within reach. A nurse's note dated 2/27/11 and timed 11:55 P.M. documented the resident laying on the floor next to his/her bed and complained of head and left hip pain. The note also documented a bed alarm was in place on the resident's bed but "did not go off when the resident got out of bed." A nurse's note dated 2/28/11 and timed 3:25 P.M. documented the resident came back from the emergency room and that the x ray and fluoroscopy showed that a pin at the previous injury site was no longer in place but that this was not a new issue and the physician felt that it had been out of place for at least 2 months, the resident was weight bearing as tolerated with walker and 1 to 1 staff assistance. A nurse's note dated 3/3/11 and timed 3:55 A. M. documented the resident's bed alarm triggered, staff went to the resident's room and the resident had rolled himself/herself out of the bed and was on the floor. The note documented staff observed two areas of swelling on the superior aspect of the resident's head, one approximately the size of a nickel and the other one approximately the size of a quarter. The note also documented the resident complained of left hip pain and staff transferred the resident to the emergency room for an x-ray of his/her left hip. A nurse's note dated 3/3/11 and timed 9:05 A.M. documented the hospital admitted the resident with a [DIAGNOSES REDACTED]. A nurse's note dated 4/8/11 and timed 11:45 P.M. documented a late entry that read that at approximately 10:50 P.M. the resident rung his/her call light and staff found the resident laying on his/her back on the floor with a laceration to left forearm that measured approximately 11 centimeters (cm) long and 3 cm wide, the blood already clotting, hematoma present and complained of left hip pain and staff transferred the resident to a local emergency room (ER). A nurse's note dated 4/9/11 timed 3:45 A.M. documented the resident returned from the ER with orders that included wound care per facility protocol and for staff to continue current orders and fall precautions. According to a History and Physical (H & P) with an admission date of [DATE] documented the resident transferred from the nursing home due to increased confusion, left hip pain and agitation. The H&P also documented the resident had recently had left hip surgery (left hip hemiarthroplasty) was wheelchair bound and had experienced a recent fall and bruised his/her left forearm. A Discharge/Transfer Referral from a local hospital with an admission date of [DATE] and discharge date of [DATE] documented the principal [DIAGNOSES REDACTED]." The resident's current care plan (no date recorded) documented fall interventions that included the resident utilized a low bed,floor mats and transfer bars (care plan in place after resident returned from hospital on [DATE]). Observation on 5/10/11 at 3:30 P.M. revealed the resident lay in bed and had no floor mat in place. Observation on 5/11/11 at 8:00 A.M. revealed the resident lay in bed on his/her back with no floor mat in place. Observation on 5/11/11 at 2:05 P.M. 3:30 P.M. and 4:00 P.M. revealed the resident lay in bed on his/her back with no floor mat in place. Observation on 5/12/11 at 7:00 A.M. and 8:30 A.M. revealed the resident lay in bed on his/her back with no floor mat in place. During interview with direct care staff on 5/12/11 at 8:30 A.M. the staff reported the resident did not have floor mats in place and also reported the 3 strips they did not consider floor mats. During interview with licensed nurse on 5/12/11 at 12:45 P.M. the staff reported the floor strips in the resident's room they did not consider a fall mat and also reported the resident did not utilize the alarms anymore. The staff reported they discontinued the alarms after the resident readmission to the facility on [DATE]. The staff reported the resident's fall interventions included the floor mat and low bed. The facility failed to implement the floor mat as care planned and also failed to ensure the effectiveness of the alarms in this resident with a prior history of falls and left hip fracture. - The April 2011 physician's orders [REDACTED]. The 1-27-11 Quarterly Minimum Data Set (MDS) noted the resident sometimes understood; the Brief Interview for Mental Status (BIMS) score of 3 indicated severe cognitive impairment; he/she had symptoms of delirium (inattention and disorganized thinking), exhibited verbal behavior symptoms towards others, and had other behavior symptoms; was totally dependent on 2 or more staff for bed mobility, dressing, and bathing; was totally dependent on one staff for locomotion on/off unit and personal hygiene; required the extensive assistance of one staff with eating and the extensive assistance of 2 staff for transfers and toilet use; did not walk and balance was not steady with moving on/off toilet, surface to surface transfer and moving from standing to seated position; had limitation of functional Range of Motion (ROM) to the upper extremity on one side and bilaterally to the lower extremities; used a wheelchair; the fall history indicated the resident had no falls since admission/prior assessment; had a pressure reducing mattress and pad in chair; and received antianxiety and antidepressant medications. The 4-21-11 Quarterly MDS noted 1 no injury fall. The 8-16-10 Significant Change Resident Assessment Protocol (RAP) for Dementia noted the resident was alert and oriented upon readmission from a hospital diagnostic unit, but was confused and disoriented to place and time; exhibited delusions and hallucinations, and there was a change to his/her medications made during the hospital stay. The 8-16-10 Significant Change Resident Assessment Protocol (RAP) for Functional/Rehabilitation noted the resident had multiple diagnoses/conditions including an old CVA with left sided hemiparesis, cognitive loss, impairments, behavioral symptoms, and continued to require extensive to total assistance from 1-2 staff for completion of Activity of Daily Living (ADL); the resident was able to feed him/herself on most occasions but needed occasional assistance from one staff if unable to complete on his/her own; required the use of sit-to-stand lift with 2 staff for transfers; used a wheelchair for mobility and required the total assistance of staff since return from the hospital. The resident received Physical Therapy upon return from the hospitalization in August. The 8-16-10 Significant Change Resident Assessment Protocol (RAP) for Falls noted the resident was at risk for falls due to decreased mobility and weakness because of a left sided hemiparesis resulting from an old CVA that placed him/her at risk for falls. had multiple chronic conditions that included mood problems that played a role in the risk for falls; had some delusional thinking that he/she could ambulate even though he/she could not since the CVA; had no recent falls; call light placed within reach; and planned to continue to monitor for falls. The resident received Physical Therapy post hospitalization in August 2010 to assist in improving overall strength and to assist with transfers. The 4-29-11 Fall risk assessment noted the resident received antihypertensives, narcotics, sedative, and psychotropic medications; fell ,[DATE] times in the last 6 months; had no recall, was totally incontinent, confined to a chair, oriented, and unable to independently come to a standing position. The resident was a moderate fall risk with a score of 15. The 8-16-10 Care Plan for Cognition reviewed 4-28-11 noted... - staff re-direct the resident with inappropriate behavior - stimulate brain activity with small groups, trivia, reminese, word games, group discussions, and memory enhancer medications - BIMS quarterly to monitor for change in cognitive status - break activities into manageable subtasks, one instruction at a time - repeat communication using more than words - provide cuing/prompting to ensure the resident made attempts at his/her own care - modify the environment to prevent situations that may trigger inappropriate behavior - remove the resident to his/her room to lower stimuli The 8-23-10 Care Plan for Injury Risk/Falls initiated 8-23-10 and reviewed 4-29-11 noted... - call light within reach and show the resident where the call light was located (handwritten and not dated) - assess for safety needs and level of alertness and document improvement or deterioration related to medications/drugs - monitor cognitive deficits - monitor compliance with safety, document improvement or deterioration status - Intervention on 3-21-11 broda chair with the goal to provide comfort in an attempt to decrease anxiety because of an attempt by the resident to get out of his/her wheelchair. The 3-17-11 at 3:30 P.M. Nurses Notes (NN) revealed the resident was very anxious yelling and screaming, "help help." The resident stated he/she was nailed to the chair and trying to find someone. Staff called the physician at 3:50 P.M. about the resident's mental status, increased anxiety, and behaviors. The NN on 3-17-11 at 4:15 P.M. staff called the nurse to the resident's room. The resident was on the floor and had vomited. Staff was unable to get a blood pressure and the resident's face was red. Staff assisted the resident to a sitting position where he/she vomited twice. Then staff assisted the resident to a wheelchair and called the physician and receivied an order to send the resident to the emergency room for evaluation. The NN on 3-17-11 at 11:30 P.M. the resident returned to the facility with an order for [REDACTED]. The NN on 4-28-11 at 2:06 P.M. the resident was upset again, yelling out, pinching staff, swinging out, and hallucinating. The NN on 4-29-11 at 4:40 P.M. staff called the nurse to the resident's room where the resident was on the floor on his/her side facing the bed frame. The resident had emesis around his/her head and he/she was continued to vomit. The resident said he/she hurt all over, then he/she stated he/she did not hurt. Vital signs were 187/101 respirations of 22, oxygen saturation of 80 % and a pulse of 140. The nurse was in the room trying to tell the resident he/she could not get out of his/her chair and walk just before the fall. The resident was very agitated. Staff called the physician and received an order to transport to the emergency room . The resident continued to vomit at 3:15 P.M. as the ambulance staff left the facility with him/her. The hospital emergency room Triage note of 3-17-11 revealed the resident admitted with a possible fall, hitting head, and screaming. The resident did not scream at triage, had confusion, and denied pain. It was difficult to understand the resident's speech. He/she had no neurological deficits nor facial droop per hospital physician A. Physician A's progress note of 5-7-11 revealed, the resident was in the emergency room (ER) because of agitation and he/she eventually tipped his/her wheelchair hitting his/her head. The hospital staff evaluated the resident and discovered Methicillin-resistant Staphylococcus aureus (MRSA) in the resident's urine. During an observation on 5-11-11 at 9:30 A..M. direct care staff returned the resident to his/her room and left him/her in a wheelchair/broda chair with a call light in his/her right hand. The call light was on at 9:30 A.M. The resident stated to this writer he/she wanted to go to bed. At 9:40 A.M. facility staff walked past the ringing call light and failed to check with the resident. Two licensed administrative staff walked by, looked at the light and failed to inquire/check. At 9:44 A.M., direct care staff H arrived from the other hall to answer the light. Staff H spoke with the resident said he/she did not feel well. Staff H said he/she would tell the nurse and left the room after turning the call light off. The resident remained in his/her chair. At 9:47 A.M. the resident put his/her light on again. Direct care staff I answered the light and spoke with the resident. The resident told staff I he/she wanted to get into bed. Staff I turned off the call light and left the room stating he/she would find some additional staff to assist. At 9:50 A.M. licensed nursing staff J entered the resident's room and informed the resident that he/she gave the resident a pain pill and to give it a little longer to work and left the room. At 9:55 A.M. the resident put his/her call light on again and became agitated calling out and moving about in his/her chair so that the sound of bumping was audible outside the resident's room. Administrative staff B passing by, went to check on the resident. The resident said he/she wanted to get back into bed. Staff B found two direct care staff assistance into his/her bed. Approximately 30 minutes following the first call light, the resident received assistance into his/her bed. On 5-12-11 at 7:58 A.M., licensed nursing staff K stated he/she remembered the 4-29-11 fall. Staff K stated when the resident got agitated, he/she moved in his/her chair and the resident was agitated in his/her chair in his/her room before the fall. Staff K stated direct care staff found the resident on the floor. The resident was using the Broda chair at this point per licensed nursing staff K.. On 5-12-11 at 8:25 A.M., licensed nursing staff O stated the resident used a regular wheelchair when he/she fell on [DATE] and then was using a Broda chair during the fall in April. Staff O stated he/she heard the resident threw him/herself out of the chair. The resident got very agitated at times per licensed nursing staff O. On 5-12-11 at 8:28 A.M. licensed nursing staff M stated per the Nurses Notes, the change in wheelchair to a Broda Chair was the intervention for the 3-17-11 fall. He/she thought the intervention for the 4-29-11 fall was a change in medications but stated the documentation in the Nurses Notes did not clarify his/her assumption and noted the Care Plan for Falls did not list interventions. During an interview on 5-12-11 at 9:20 A.M., direct care staff J stated the resident got agitated when in his/her chair as the resident felt he/she could walk. When the resident fell [DATE], he/she fell out of the chair. On 5-12-11 at 9:25 A.M., licensed nursing staff L stated he/she added some interventions this morning to the resident's Care Plan. Staff L stated he/she was aware of the resident's observed agitation and rocking of the wheelchair/broda chair on 5-11-11 and stated the staff put the resident back into his/her room because of the agitation. Licensed nursing staff L stated that the staff should make sure that they assisted the resident to bed instead of leaving him/her in the wheelchair when he/she was agitated as the resident had two previous falls from the wheelchair when agitated. The facility Policy for High Risk Fall Protocol dated 2/2011 noted... - If an assessment indicated that a resident was at risk for falls, the resident will have risk factors identified with interventions implemented. Each time nursing staff leaves the room of a resident who was at high risk for falling, ask the resident if they were in need of assistance to the bathroom, a drink of water or had another need. - When the resident expressed a need, the staff should assist the resident promptly. The facility failed to timely assess this dependent resident and provide effective interventions for the prevention of falls.

The facility had a census of 187 residents and the sample was 8. Based on observation, record review, and staff interview, the facility failed to follow the care plan interventions for the prevention of falls and injury for two (#1, and #2) residents in the sample reviewed for falls. Findings included: - Resident #1 had [DIAGNOSES REDACTED]., atrial fibrillation, cardiomegaly, diabetes type 2, esophageal reflux, and peripheral neuropathy as listed on the 12/10/10 Physician order [REDACTED]. The Care Area Assessment (CAA) dated 10/28/10 recorded for activities of daily living that the resident needed 2 person assist and stand up lift with transfer/toileting. The 1/6/11 Minimum Data Set recorded a BIMS (Brief Interview for Mental Status) of 8 (mildly impaired), needed extensive assistance of 2 staff with bed mobility, transfer, toileting, and dressing, needed extensive assistance of 1 staff with personal hygiene, ate independently with set up help, and had no falls. The Fall Risk assessment dated [DATE] recorded the resident was at risk for falls. The care plan dated 10/29/09 at risk for falls characterized by history of falls/injury, multiple risk factors related to limited mobility and inability to stand alone and for the staff to transfer the resident with 2 assist and standing lift. On 1/10/11 the fall intervention was: "staff gave the direct care staff (CNA) the CNA sheet to the new orient CNA." The nurses notes (NN) dated 1/10/11 times 5:10 P.M. recorded the direct care staff placed a gait belt around the resident and the resident leaned forward too far and slid from a sitting position in the recliner onto the floor landing on their bilateral knees and came to rest on the staff's feet. Two direct care staff lifted the resident off the floor back into the recliner and took the resident's vitals. The staff then notified the nurse. The resident reported knee pain, and worse pain in the left knee. There was no apparent swelling, injury, redness or bruising. The staff administered pain medication to the resident. At this time the resident declined treatment. Approximately an hour later the nurse assessed the resident again with no change in appearance of the knees, but the resident grimaced and withdrew from light touch. The nurse notified the physician and received an order to send the resident to the emergency room (ER) for evaluation/treatment. The facility investigation into the 1/10/11 fall recorded that the facility was orientating direct care staff under the guidance of the facility senior mentor, who answered the resident's call light on 1/10/11 at 5:10 P.M. The resident requested to transfer from his/her recliner into the wheel chair. As the resident leaned forward to have the staff apply the gait belt, the resident leaned too far forward resulting in the resident sliding from the edge of the recliner, landing in the kneeling position on top of the staff's feet. The direct care staff called out for assistance and 2 direct care staff transferred the resident back into the recliner, after which they obtained nursing assessment. The ambulance transferred the resident to the ER, the hospital admitted the resident with [DIAGNOSES REDACTED]. The facility included a statement from the facility physician who reviewed the X-ray taken 1/10/11 of the left leg after the initial fall which noted there was a small joint effusion but no bony pathology. The physician stated they knew there was a crack in the knee from this finding in the X-ray, stating the small joint effusion with a joint prosthesis indicated this. The diagnostic radiology report dated 1/10/11 of the right knee recorded: "Comminuted spiral fracture of the right distal femoral diaphysis extending into the femoral component of the prosthesis. The prosthesis is in alignment, There is bony demineralization. Small joint effusion is seen." The diagnostic radiology report dated 1/10/11 of the left knee recorded: "There is bony demineralization. Knee prosthesis are in alignment. A small joint effusion is seen. No acute bony pathology is seen." The facility correction action was: 1) the CNA received written reprimand, 2) all staff meeting to discuss proper guidance of orienting staff, 3) verbal counseling provided to CNA on CNA cheat sheet, 4) all orienting staff will sign acknowledgement and understanding of CNA "cheat sheets"which inform staff of appropriate care/transfers during the New Orientation education class, 5) staff involved received counseling regarding transferring residents after a fall. The facility readmitted the resident on 1/14/11 after having suffered a comminuted spiral fracture of the right distal femoral diaphysis extending into the femoral component of the prosthesis and surgically repaired the fracture. The nursing admission assessment dated [DATE] recorded the facility admitted the resident from the hospital with the [DIAGNOSES REDACTED]. The staff noted the resident was totally dependent for bed mobility/transfer. Nurses notes (NN) dated 1/16/11 at 3:37 A.M. noted the resident slept well through out the night, and that the staff checked the resident every 2 hours, on scheduled rounds, and re-positioned the resident. The staff noted the right leg was in an immobilizer, and elevated on pillows. NN 1/17/11 at 8:18 A.M. physical therapy in working with resident the resident had incontinent loose stool, and they cleaned/repositioned the resident. The resident complained of pain at a level 10 in the left leg to thigh area. The facility notified the physician and received an order for [REDACTED]. At 1:38 P.M. mobile X-ray of the left leg and at 5:53 P.M. the facility transferred the resident to the emergency room with left oblique distal femur fracture. Review of the record revealed the resident had no falls since the 1/10/11 fall. The hospital history and physical dated 1/18/11 recorded the hospital admitted the resident on 1/17/11 with an apparent femur fracture. "A week ago he/she went to the hospital, was admitted with right distal femur fracture sustained in nursing facility, and had it surgically repaired. Went back to the nursing facility and now complained of left leg pain. Outpatient X-ray today revealed a positive femur fracture of the left leg with lower extremity swelling, has immobilizer in place on both legs now. From ER appeared to have left femur fracture distal into the prosthesis. Had previous total knee prosthesis with involvement of the fracture to the junction of the femoral component of the total knee." Plan: "Will treat non operatively in a fracture brace from Hangar-to be worn at all times." On 1/19/11 the facility readmitted the resident from the hospital after having suffered an oblique fracture of the left distal femur extending down to the prosthesis. The hospital treated the resident non operatively in a fracture brace. An interview on 2/8/11 at 5:12 P.M. with licensed nursing staff E reported that on 1/10/11 a direct care staff called him/her into the resident's room and had the resident up in the recliner. This nurse assessed the resident. This staff said the resident who was very alert/oriented looked visibly shaken, and was in pain, did not want an X-ray and he/she administered a pain medication. "This staff said that after 1 hour, the pain had gotten worse, and at this time the resident wanted to be seen by the doctor, so they began the process of getting the resident out." This staff said that typically he/she wanted to assess a person where they fell , but that this CNA D was new. An interview on 2/8/11 at 5:20 P.M. with direct care staff D said they had been on the unit a couple of days before 1/11/11, and that another direct care staff oriented them. The staff said they did not know about the CNA cheat sheets until after the fall happened, then the unit staff showed him/her where they were. This staff said they use them now. CNA D said they answered the resident's call light, used a gait belt for the transfer and did not know the resident was a lift transfer. The staff said they slid the resident forward to put the gait belt on, and then the resident slid out, landed on the staff's feet, not on the floor. The staff said they called for assistance. The staff said the resident was not in visible pain when he/she fell , not until they moved him/her into the chair. This staff said once the resident was in the chair they got the floor nurse. An interview 2/9/11 at 11:45 A.M. with administrative staff B said the facility had no policy per se on the orientation of new staff but that the facility scheduled direct care staff D for 2 weeks of orientation and that he/she was assigned with another aide to work the unit. This staff said the staff should have been with the senior mentor at the time they helped the resident transfer. The facility failed to follow the care plan, to transfer the resident with a stand up lift, which resulted in a fall/fracture. The facility failed to provide adequate orientation to a new direct care staff to follow each resident's care plan for transfers. This resulted in a fall that fractured the leg and required surgery. - Resident #2 had [DIAGNOSES REDACTED]. The 1/10/11 Minimum Data Set recorded the resident had a BIMS (Brief Interview for Mental Status) with a score of 12 (mildly impaired), needed extensive assistance of 2 with transfer/toileting, did not walk, used a wheel chair, and had no falls since admission. The fall assessment dated [DATE] recorded the resident was a moderate risk for falls. The care plan for at risk for falls dated 2/18/09 recorded for the resident to have bed/chair alarms. The nurses notes dated 1/19/11 at 3:48 P.M. recorded that the resident was up and out of bed for hospice to place a new mattress on his/her bed, and that the resident wanted to stay in the room until the was bed ready. The staff found the resident on the floor in his/her doorway, and had hit his/her head causing a hematoma on the right forehead. Three staff removed the resident using a Hoyer lift to bed after the nurse assessed the resident. The facility investigation date 1/20/11 recorded the resident fell on [DATE] at 11:05 A.M. in their room, and that the direct care staff instructor saw the resident lying on the floor with no chair alarm on. The instructor heard a loud noise and saw the resident lying on the floor in the doorway to the bathroom with the wheel chair behind him/her. The nurse assessed the resident and noted a hematoma on the right forehead with a tiny open area at the site. The nurse started neurological checks (within normal limits), and the doctor who was on site assessed the resident also. The hospice mattress was changed out by the durable medical equipment provider, the resident sat in the room, and the staff gave him/her a call light to use. The resident tried to get up and fell . The investigation noted that the wheel chair had an alarm on now. An observation on 2/4/11 at 3:00 P.M. the resident sat up in the wheel chair while staff made the bed. The resident said they took a fall about 2 weeks ago, was going to pick something up from the floor and fell out. The resident said they would never do that again except if it was a 100 dollar bill, and laughed. The resident pointed to his/her right forehead area and said that they got when from the fall. The resident had a small bruise visible on the forehead. The resident had an alarm on while in the chair. An interview on 2/9/11 at 9:45 A.M. with licensed nursing staff B said he/she was the nurse the day the resident fell and was in the common area at the time. This staff said "students were here, someone hollered the resident was on the floor." This staff went to the room and saw the resident laid on the floor with the wheel chair back a little. The staff th resident had a big knot on the forehead that was bleeding, a skin tear, and did not have an alarm on his/her wheel chair, but had one on bed. The facility failed to follow fall prevention interventions as planned that resulted in a fall with injury.