Every finding on record at The Legacy at Willow Bend

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure food items were properly stored in the facility's walk-in refrigerator and freezer on 12/02/25. These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 12/2/25 at 9:55 AM in the facility's walk-in refrigerator revealed boiled sweet potatoes covered in a baking tray did not have any date on it. One packet of bacon slices was left open and did not have an open date on it. There were two packets of beef roast that were thawing, covered in plastic wrap, without any date on it. Also, two packets of Swiss cheese slices that were wrapped in a plastic wrap without any date on it. Observation on 12/2/25 at 9:58 AM in the facility's walk-in freezer revealed about 30-40 frozen tater tots were left in an open brown bag, about a pound of frozen sliced carrots were left open in a cardboard box, and 20-30 frozen meat balls were left open in a brown box exposing them to frigid air. In an interview on 12/02/2025 at 12:35 PM with [NAME] D, she stated everyone in the kitchen including dietary aides, cooks, and manager were responsible for appropriate food storage. She stated that the meat was left to thaw by the evening cook and should have a pull date (date it was removed from freezer for thawing) on it. She stated all food items in the kitchen, especially in the refrigerator should be appropriately sealed and dated with either use-by date or open date. She added that items such as cheeses and bacon slices should have open date on it. She added that the risk of not covering or dating food items can lead to cross contamination of foods and food borne illness in residents. In an interview on 12/02/2025 at 2:52 PM with Dietary Aide revealed all food items in the kitchen should be dated and covered appropriately and it was usually the responsibility of the cooks to seal food in the freezer. She stated foods that are out of their original packing should have an open date on them. She added that the risk to residents of not appropriately covering food items was residents could get sick. In an interview on 12/04/2025 at 9:15 AM with the Dietary Manager, he stated that everyone in the kitchen was responsible for food storage, however cooks and himself were ultimately responsible for covering and dating food items. He stated his expectation was that all foods should be appropriately dated, covered, and sealed to prevent any freezer burns and loss of nutritional value. He added that he encouraged all staff to add open dates on items when they are out of the original packaging. He stated that for meats that are pulled from the freezer, his expectation is that the cooks write the date it was pulled-out for thawing and use-by date. He added the risk to residents of improper food storage that included dating, labeling, and covering food items was possibility of food borne illness in residents and cross contamination of food. He stated as the Dietary Manager he conducted daily kitchen rounds and provided in-services to the staff to ensure proper food storage. In an interview on 12/04/2025 at 1:37 PM with the Administrator, she said all food in the kitchen should be dated and labeled. She stated that the cooks and Dietary Manager were mainly responsible for it and her expectation was that all facility and state policies were followed to ensure safe food storage. Record review of the facility policy titled, Stock Dating undated ,reflected, Policy statement: Stock will be routinely dated when received in the facility for the purpose of assuring proper stock rotation . Date stock with date of delivery (per facility policy and state regulations). Record review of the facility policy titled, Preventing Foodborne Illness -Food Handling dated 11/23/22 reflected, It is the policy of this community to store, prepare, handle and serve food so that the risk of foodborne illness is minimized. Review of the Food and Drug Administration Food Code, dated 2022, reflected, . Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents (Resident #48) reviewed for catheter care. The facility failed to ensure CNA A and CNA B maintained Resident #48's foley catheter (foley catheter is a common type of indwelling catheter) drainage bag below the bladder level during transfer from wheelchair to bed on 12/03/25. This failure placed residents at risk for the development and/or worsening of urinary tract infections.Findings include: Record review of Resident #48's admission MDS assessment dated [DATE] reflected, Resident #48 was an [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included hip fracture, obstructive uropathy (condition in which urine cannot drain through the urinary tract), muscle wasting. She was dependent on staff for chair/bed-to-chair transfer. Record review of Resident #48's care plan initiated on 11/24/25 reflected, Focus: [Resident #48] has indwelling catheter (a catheter that drains urine from the bladder by inserting a tube through the abdominal wall and into the bladder) related to obstructive uropathy . Interventions: Catheter: . Position catheter bag and tubing below the level of the bladder and away from entrance room door . Review of Resident #48's Physician's Orders dated 11/16/25, reflected, Foley catheter care every shift every day and night shift for Urinary Retention. Observation on 12/3/25 at 1:41 PM revealed CNA A and CNA B entered Resident #48's room to transfer her from wheelchair to bed. Both the CNAs performed hand hygiene and wore PPE. CNA A adjusted Resident #48's bed to a moderately lower position, still higher than her wheelchair. CNA B unhooked the catheter bag from the wheelchair and put it flat on the bed, above the resident's bladder. CNA A put the gait belt on Resident #48. CNA A and CNA B assisted the resident from the wheelchair to bed. During this procedure, the urine was observed flowing back toward the resident's bladder. CNA A continued to adjust the resident in the bed and then took the gait belt off. Both CNAs disposed of the PPEs, performed hand hygiene, and exited the room. In an interview on 12/03/2025 1:52 PM with CNA A, he stated that Resident 48's catheter bag was put on the bed so that it did not touch the floor. He stated that he observed the urine in the tube go back and forth when CNA B placed the catheter bag on the bed. He then added that he was trained to always keep the catheter drainage bag below the bladder. He stated having it above the bladder could possibility cause the urine to run backwards, which could cause an infection. In an interview on 12/03/25 at 1:58 PM with CNA B, he stated that he should have emptied Resident #48's catheter drainage bag before transferring the resident to avoid any back flow of urine. He stated that he was trained to keep the catheter drainage bag below the bladder. He stated that back flow of urine could cause urinary tract infections. In an interview on 12/03/2025 at 2:10 PM with LVN C stated that it was his expectation that CNAs always kept the catheter drainage bag and catheter tubing below resident's bladder. He stated that failure to do so can cause the urine to retract back to the bladder and increased chances of infection. In an interview on 12/03/2025 2:43 PM with the DON, he stated any resident with a foley catheter should always have the bag and tubing below the bladder, including during transfers. He stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of urinary tract infection and cross contamination. He stated that DON and ADON were ultimately responsible for quality of care provided to residents. He added that the facility conducted skills competency checks for the nursing staff and daily rounding on all residents to watch care and provide re-training as needed. Record review of CNA A's new hire competency check-off for catheter care revealed he was proficient in care as of 10/09/25. Record review of CNA B's annual competency check-off for catheter care revealed he was proficient in care as of 07/15/25. Review of the facility's policy titled, Urinary Catheter Care dated 1/27/24 reflected, . 3.The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of two residents (Residents #8) reviewed for feeding tubes. 1. The facility failed to have orders for Resident #8 for the required amount of water for dilution of crushed medications and the amount of water flushes between each medication given via the G-tube. 2. The facility failed to ensure LVN C diluted crushed medication and liquid medication with 30 ml of water and flushed with 15 ml of water after each medication per facility policy while administering Resident #8's medication via G-tube which resulted in the tube becoming clogged during the medication administration. These failures could place residents at risk of medication incompatibility and tube obstruction. Findings include: 1. Record review of Resident #8's admission MDS assessment, dated 10/23/25, reflected an [AGE] year-old male with an admission date of 10/15/25. Resident #8 had a BIMS score of 13 which indicated he was cognitively intact. Resident #8 had active diagnoses which included cancer of the oropharyngeal region (throat cancer) and dysphagia (difficulty when swallowing food or liquids), and he received 51% or more of total calories through a feeding tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Resident #8's care plan revised on 11/05/25 reflected, The resident requires tube feeding Glucerna 1.5 bolus and Boost as ordered related to dysphagia.Goal.The resident will remain free of side effects or complications related to tube feeding through review date. Record review of Resident #8's Physician Order Summary report dated 12/03/25 reflected, .enteral Feed order every day and night shift Flush tube with 20-30 ml(cc) of water before and after each administration of medication pass. with a start date of 10/15/25. There were no orders for amount of water to dilute medication with, and the amount required between each medication administered. Record review of Resident #8's Medication administration record for December 2025 did not indicate how much water to dilute crushed or liquid medications with or the amount of water flush to use between each medication administered. An observation on 12/03/25 at 06:49 AM of G-Tube medication administration for Resident #8 revealed LVN C prepared medication for Resident #8. LVN C placed 1 tablet Aspirin 81 mg (analgesic), 1 tablet Carbidopa-Levodopa 25-100 mg (treat Parkinson's disease), 1 tablet Vitamin D 25 mcg (supplement), 1 tablet Doxazosin 1 mg (antihypertensive), 1 capsule Duloxetine delayed release 60 mg (antidepressant), 1 tablet Finasteride 5 mg (used to treat enlarge prostrate), Hydrocodone-acetaminophen 7.5-325 mg oral solution 15 ml, 1 tablet Metformin 500 mg (control blood sugar), 1 tablet Metoprolol 25 mg (blood pressure), and 1 capsule Omeprazole delayed released 40 mg (treats reflux) each medication in an individual plastic cup. LVN C opened the Duloxetine and Omeprazole capsules and placed them in a separate plastic cup and then crushed each tablet and placed each of them in separate cups and entered the resident's room. LVN C then filled a plastic cup with water from the bathroom sink and poured approximately 2.5 ccs of water into each medication cup, with the exception of the liquid Hydrocodone-acetaminophen. He then retrieved a 60-cc syringe and checked for residual and flushed the G-tube with 30 ccs of water. LVN C then administered each medication by gravity and did not flush with clear water between each medication. When the Omeprazole and Duloxetine granules were administered the g-tube became sluggish and remained stuck in the tube. LVN C the added 30 cc of water and the medication would not progress. LVN C milked the tube for approximately 15 minutes with the tube going up and down. LVN C then drew medication back out of tube with the syringe twice, and re-instilled with the medication slowly progressing but still had some visible clog in the tube. In the end, LVN C pushed approximately 10 cc of water through the tube to get the medication to progress. In an interview with LVN C on 12/03/25 at 07:12 AM he stated he diluted the medication with 2.5 ccs of water and then would add a little if the medication was still stuck in the cup. He stated he was supposed to flush before and after medication pass with 30 cc of water. He pulled up the physician orders and reviewed and stated it did not indicate how much to dilute medications with or how much to flush in between each medication administered. He stated it was important to flush before and after to prevent the tube from clogging. He stated the omeprazole and duloxetine granules he always gave last because they tended to clog the tube. In an interview with the DON on 12/04/25 9:20 a.m. he stated he had already started an Inservice on ensuring they had physician orders for the dilution of medication and the amount of water flushes in between each medication. He stated the purpose of good dilution of medications and flushes is to ensure all of the medication is administered and to prevent the g-tube from becoming clogged, which could result in the tube needing replaced and inability to give the resident their medications. He stated going forward he and the ADON would be auditing the orders to ensure they had the physician required amount of water for flushes both before, in between and after. In an interview on 12/04/2025 11:34 a.m. with the Facility Pharmacist stated the standard of care is to flush with approximately 5-10 cc between medications and generally dilute meds with 5-10 ml and flush with 20-30 cc of water before and after. He stated the main reason was to prevent clogging the tube. He stated medication was to be given by gravity and not pushed. He reviewed the medications administered to Resident #8 and stated none would have a significant interaction with each other. In an interview with the Administrator on 12/04/25 1:15 p.m. she stated they would be educating the staff on the protocol for medication flushes in between medications and reviewing to ensure everyone knows what batch orders to input on any new g-tube resident. She stated they would be reviewing their standards and guidelines and determining what will be the default flush orders to input, and the physician can add or adjust any of those orders. Record review of LVN C's annual competency checks dated 09/10/25 reflected that he was skilled at medication administration which included flushing the G-tube. Record review of the facility's Standards and Guidelines titled, Administering Medications through an Enteral Tube, dated June 2023, reflected, .Verify that there is a physician's medication order for the procedure.Administer each medication separately and flush between medications.Flush tubing with at least 15 ml warm purified water( or prescribe amount).Dilute medications.Dilute crushed (powdered) medications with at least 30 ml purified water (or prescribed amount).Dilute liquid mediation with 30 ml or more(depending on viscosity) purified water.Administer each medication separately.If administering more than one medication, flush with at least 15 ml warm purified water (or prescribed amount)between medications.When the last of the medication begins to drain from the tubing, flush the tubing with 15 ml of warm purified water (or prescribed amount).

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of five residents (Resident #72 and Resident #73) reviewed for pharmacy services. 1. The facility failed to ensure RN G followed the manufacturer's instructions to prime (means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly) the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of Insulin to be administered to Resident #73. 2. The facility failed to ensure RN F followed the manufacturer's instructions to prime the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of Insulin to be administered to Resident #72. These failures placed residents at risk of not receiving full dosage of medication. Findings included: 1. Record review of Resident #73's, Face sheet, dated 12/04/25 reflected a [AGE] year-old female with an admission date of 11/28/25. Resident #73 had a diagnosis of Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy). Record review of Resident #73's Physician's Order report dated 12/04/25, reflected, Humalog Kwik Pen Subcutaneous Solution 100 UNIT/ML (Insulin Lispro) Inject 5 units subcutaneously before meals.inject as per sliding scale: if.350 - 399 =11 UNITS. with a start date of 11/30/25. An observation on 12/02/25 at 11:34 a.m. revealed RN G performed hand hygiene and put on gloves and gown and entered Resident #73's room to obtain a fingerstick blood sugar. The blood sugar reading was 388. RN G checked the computer to determine the amount of insulin per sliding scale was 5 units of Humalog (Lispro) insulin plus an additional 11 units per sliding scale for a total of 16 units. RN G retrieved the insulin pen from the medication cart and dialed in 16 units without priming the pen first. RN G then entered the resident's room and administered the insulin. In an interview with RN G on 12/02/25 at 11:42 a.m. she stated she was supposed to prime the pen before each dose to ensure the pen was working and to remove the air bubbles. She stated she forgot to prime it. She stated the risk of not priming the pen could result in the pen not working properly and the resident not getting the full amount of insulin required. 2. Record review of Resident #72's, Face sheet, dated 12/04/25 reflected an [AGE] year-old female with an admission date of 11/30/25. Resident #72 had a diagnosis of Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy) Record review of Resident #72's Physician's Order report dated 12/04/25, reflected, Humalog Kwik Pen Subcutaneous Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if.200 - 249 = 2 PLUS ADDITIONAL 2 UNITS =4 UNITS. with a start date of 11/30/25. An observation on 12/02/25 at 11:45 a.m. revealed RN F performed hand hygiene and put on gloves and entered Resident #72's room to obtain a fingerstick blood sugar. The blood sugar reading was 232. RN F checked the computer to determine the amount of insulin per sliding scale was 4 units of Humalog (Lispro) insulin. RN F retrieved the insulin pen from the medication cart and dialed in 4 units without priming the pen first. RN F then entered the resident's room and administered the insulin. In an interview with RN F on 12/02/25 at 11:55 a.m. she stated she was supposed to prime the pen with 2 units before each dose to ensure the pen was working and to remove the air bubbles. She stated she forgot to prime it. She stated the risk of not priming the pen could result in the resident not getting the full amount of insulin required. In an interview with the DON on 12/04/2525 at 09:30 a.m. he stated the insulin pen was to be primed before each injection. He stated failure to do so could result in the resident not receiving the prescribed amount of insulin. He stated all of the nursing staff received competency checks upon hire and annually or more often if an issue was identified. He stated it was the expectation for staff to follow the manufacturer guidelines on administration of insulin pens. He stated he would in-service the nursing staff to ensure they were all aware of the proper procedure. Record review of RN G's annual competency checks dated 09/09/25 reflected that she was skilled at medication administration. Record review of RN F's annual competency checks dated 09/22/25 reflected that she was skilled at medication administration. Record review of the facility's Standards and Guidelines titled, Administering Medications, dated June 2023, reflected, Each nurse's station has a current Physician Deks Reference (PDR) and/or other medication reference, as well as a copy of the surveyor guidance for F755-761 (Pharmacy Services) available. Manufacturer's instructions or user's manual related to any medication administration devices are kept with the devices or at the nurses' station. Review of the manufacture instructions for Lispro obtained from https://www.lillyinsulinlispro.com/ searched on 12/05/25 reflected, .Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food items in the facility freezer were labeled and had use-by dates. 2. The facility failed to ensure Dietary Server G used appropriate hair restraint in the kitchen. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 09/17/24 at 08:02 AM in the facility's walk-in freezer revealed some kind of meat in a gallon size clear plastic storage bag was not labeled or dated. Observation on 09/17/24 at 08:03 AM in the facility's walk-in freezer revealed Brussel sprouts in a gallon sized clear plastic storage bag were not dated. Observation on 09/17/24 at 08:06 AM in the facility's walk-in freezer revealed frozen potato fries in a gallon sized clear plastic storage bag were not dated or labeled. Observation on 09/17/24 at 08:07 AM in the facility's walk-in freezer revealed sweet potato fries in a gallon-sized clear plastc storage bag that was half filled and did not had a use-by date. Observation on 09/17/24 at 08:12 AM revealed Dietary Server G, who was serving breakfast to the residents, was frequently visiting the kitchen prep area and the dining hall did not wear effective hair restraint. Observed Dietary Server G had her bangs outside of the hair restraint and her hair at the back of the head were not secured under the hair restraint. In an interview on 09/17/24 at 08:09 AM with [NAME] F revealed that she did not work the day before, so she was not sure why the food products in the facility freezer were not dated or labeled. She stated that everyone in the kitchen including cooks, dietary aides and Food Service Manager was responsible for dating and labeling all food items in the kitchen. She stated that the risk for residents for not dating and labeling food items was residents could get sick or food borne illness. In an interview 09/18/24 at 01:34 PM with the Dietary Manager stated it was his expectations that all the food items in the kitchen should be dated or labeled. He stated that everyone in the kitchen including the cooks, dietary aides and himself was responsible for labeling and dating food items with Use-by dates. He also stated that it was also his expectation that all dietary staff entering the kitchen area should always wear a hair restraint in a manner that all the hair is restrained appropriately. He stated that he had provided in-services for all kitchen staff in the past that included wearing appropriate hair restraints and dating/labeling food items. He stated that not labeling/dating food items or not wearing adequate hair restraints could cause food borne illness in residents. In an interview on 09/19/24 at 09:08 AM with Dietary Server G revealed that she had worked in the facility for one year as a dietary server. She stated she knew that she had to wear hair restraint such that it covers all the hair before entering the kitchen area. She stated that hair net may have moved and hence her bangs and back of the hair was exposed outside of the hairnet. She stated that the risk to residents if effective hair restraint was not worn would be residents getting hair in their food that could make them sick. Record review of the facility policy titled, Good Hygienic practices for food service employees revised 3/11 revealed, .Hair Restraints: Nutrition Service employees will wear hair restrains such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively control and keep their hair from contacting exposed food, clean equipment, utensils, and linens; and unwrapped single-service and single use articles . Record review of the facility policy titled, Stock Dating revised 3/11, reflected, POLICY STATEMENT: Stock will be routinely dated when received in the facility for the purpose of assuring proper stock rotation Date stock with date of delivery (per facility policy and state regulations). Review of the Food and Drug Administration Food Code, dated 2022, reflected, 2-402.11 Effectiveness. (Hair Restraints) .1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 Residents (Resident #210) reviewed for respiratory care. The facility failed to ensure Oxygen (O2) in use signage was on Resident #210's doorway. This failure could place residents at risk of not receiving appropriate respiratory care. The finding were: Review of Resident #210's face sheet dated 9/17/2024 revealed he was an [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included: Congestive heart failure (heart cannot pump enough blood to meet body's needs), acute respiratory failure (disease that affects breathing), chronic kidney disease (kidneys are damaged and cannot filter blood adequately), Obstructive and reflux uropathy (urine cannot drain through the urinary tract). Record review of Resident #210's Physician Orders dated 9/11/2024 reflected, Oxygen at 2 Liter per minute via nasal cannula as needed to keep O2 Saturation more than 92%. Record review of Resident #210's Baseline care plan dated 09/11/24, reflected Oxygen therapy - while a resident. In an observation and interview on 09/17/24 at 11:06 AM with resident #210 revealed Resident #210 was on Oxygen via nasal cannula. Resident #210 stated he had been on Oxygen since admit to the facility for breathing difficulty. Observed Resident #210's room did not have signage for Oxygen in use outside the door. In an interview on 09/17/24 at 01:10 PM with LVN K revealed that it was her first day working with Resident #210 since he was a new admit to the facility. She stated that he had orders for Oxygen in the electronic health record. She stated that Resident #210 was on Oxygen therapy since admit that was 9/11/24 and there should be a signage on the door for oxygen in use to alert other staff members. She stated that nurses were responsible for putting up the signage. She stated that the risk of not having signage outside Resident's room was decreased quality of care by not meeting resident's care needs. In an interview on 09/19/24 at 11:01 AM with the DON, she stated her expectation was if the resident is on Oxygen therapy, then signage for Oxygen in use should be on the door. She stated floor nurses were responsible for putting the signage on the door. She stated that the facility was a nonsmoking facility. She stated the risk of not having appropriate signage on the door was during emergency or evacuation , the staff may not be aware that resident was dependent on Oxygen therapy and portable oxygen needed to be arranged. She added the risk of inadequate signage was Resident will not receive the care they need, and quality of care will be compromised. Record review of facility policy titled Oxygen Storage dated 05/13/2022 reflected, . 3. Signage will be placed on the doorway of each resident room housing oxygen to notify that oxygen is in use.

47690 48560 Based on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #8, Resident #3, Resident #29, and Resident #13) of 24 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #8 had his fingernails cleaned and trimmed. 2- Resident #3 had his fingernails cleaned and trimmed. 3- Resident #29 had her fingernails cleaned and trimmed. 4- Personal care and skin care was provided for Resident #13 by trimming his fingernails. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Findings included: 1- Review of Resident #8's Admission MDS assessment dated [DATE] reflected Resident #8 was a [AGE] year-old male with initial admitted to the facility on [DATE]. His diagnoses included Hypertension (high blood pressure), Obstructive uropathy (urine cannot drain through the urinary tract), Diabetes mellitus (increased blood glucose levels), Hyperlipidemia (increased blood lipid levels), Cerebrovascular accident (interruption of blood flow to the brain). Resident #8 had a BIMS score of 10 which indicated Resident #8 had moderate cognitive impairment. Resident #8 required moderate assistance with personal hygiene. Review of Resident #8's Comprehensive Care Plan, revised 08/22/24, reflected the following: Focus: [Resident #8] Risk for Self-Care Deficit: Bathing, Dressing, Feeding. Goal: [Resident #8] Will Be Able to Perform Self-Care Needs. Interventions: Provide assistance with ADLs / ADLs as needed. In an observation and interview on 09/17/24 at 09:05 AM with Resident #8 revealed nails on both hands were approximately 1.0 centimeter in length extending from the tip of his fingers and had black areas underneath the nails. Resident #8 stated he would like his nails to be cleaned and trimmed by a staff member but was not offered during his stay at the facility. In an interview on 09/17/24 at 09:17 AM with CNA H revealed that most ADL's such as hair trimming, and nail clipping was completed during shower times. She revealed that since Resident #8 was a Diabetic resident, LVNs or RNs were responsible for clipping his nails. CNA H stated that fingernail clipping should be done weekly or as needed and the risk of not cleaning/ trimming fingernails could be increased risk of infection. In an interview on 09/17/24 at 09:45 AM with RN I revealed that there were no specific days for nailcare, but it should be offered each time during showering. RN I also stated that Nurses were responsible for clipping fingernails for diabetics, after they are notified by the CNAs. He stated that he was not aware that Resident #8 needed fingernail cleaning or trimming. RN I stated that ADLs were monitored daily and the risk to the resident for failure to provide ADL including nail care was increased risk of infection. 2- A record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected Resident #3 was a [AGE] year-old male originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including diabetes mellitus, lack of coordination, and speech and language deficits following cerebral infarction (a serious condition that occurs when blood flow to the brain is reduced or blocked, causing brain tissue to die). Resident #3 had a BIMS score of 3 which indicated Resident #3's cognition was severely impaired. He required partial assistance with personal hygiene. A record review of Resident #3's Comprehensive Care Plan, revised 05/02/24, reflected the following: Focus: [Resident#3] has an ADL self-care performance deficit related to impaired balance .Interventions: . Personal hygiene, nail care: [Resident #3] is totally dependent on 1 staff for personal hygiene and oral care. An observation and interview on 09/17/24 at 10:37 AM revealed Resident #3 was sitting in the recliner in his room. The nails on both hands were long and dirty. The fingernails on both hands were approximately 0.5 inches long and had dirt underneath the nails. The private sitter at the bed side stated since Resident #3 was diabetic she could not trim his fingernails. She stated she did not tell the facility staff about his fingernails needing to be trimmed and cleaned. In an interview with CNA A on 09/17/24 at 10:42 AM, she stated CNAs and LVNs were responsible for nail care. She stated if a resident has diabetes, only nurses were allowed to provide nailcare. She stated the risk for not performing nailcare was an increased risk of infection. She stated Resident #3 was diabetic; she would notify the nurse. 3- A record review of Resident #29's Quarterly MDS assessment dated [DATE] reflected Resident #29 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction (a serious condition that occurs when blood flow to the brain is reduced or blocked, causing brain tissue to die), and hemiplegia (a condition that causes partial or complete paralysis on one side of the body) affecting left side. Resident #29 had a BIMS score of 7 which indicated Resident #29's cognition was severely impaired. She required extensive assistance of two-person physical assistance with personal hygiene. A record review of Resident #29's Comprehensive Care Plan, revised 08/02/24, reflected the following: Focus: [Resident #29] has an ADL self-care performance deficit. Interventions: . Personal hygiene: Resident is totally dependent on staff for personal hygiene. An observation and interview on 09/17/24 at 11:55 AM revealed Resident #29 was laying in her bed. The nails on the right hand were approximately 0.3 centimeter in length extending from the tip of her fingers. The nails were chipped. The nails on the left, contracted, hand were approximately 0.5 centimeter in length extending from the tip of her fingers. Resident #29 stated she did not like her fingernails that long and she stated she did not tell the nurse. In an interview with CNA C on 09/17/24 at 12:01 PM, he stated CNAs and LVNs were responsible for nail care. He stated if a resident has diabetes, only nurses were allowed to provide nailcare. He stated the risk for not performing nailcare was an increased risk of infection and risk to scratch and break the skin. He stated Resident #29 was not diabetic; he would trim her nails. In an interview with the DON on 09/19/24 at 11:37 AM revealed her expectation was that nail care should be provided as needed, especially during shower time. She stated that CNAs were responsible for doing nail care unless the resident had a diagnosis of diabetes. She also stated that as the DON, either herself or her designee were responsible to do routine rounds for monitoring. The DON stated that residents having long, and dirty fingernails could be an infection control issue and cause skin breakdown. 4.Record review of Resident #13's face sheet, dated 09/18/24, reflected Resident #13 was an [AGE] year-old male originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident #13 had diagnoses of hypertension (elevated blood pressure), Diabetes mellitus, kidney transplant status, and muscle wasting and atrophy. Record review of Resident #13's MDS assessment, dated 03/31/24, reflected he had a BIMS score of 13 indicating he was cognitively intact. Resident #13 was dependent on staff to complete ADLs of bed mobility, dressing, and personal hygiene. Record review of Resident #13's Comprehensive Care Plan, dated 09/09/24, reflected the following: Focus: the resident has an ADL self-care performance deficit . Interventions: Personal Hygiene/oral care, nail care: the resident is totally dependent on (1) staff for personal hygiene In an observation/interview on 09/18/24 at 8:13 AM, the nails on both of Resident #13's hands were approximately 0.3 cm in length extending from the tip of his fingers. Resident #13 stated he liked his fingernails trimmed. In an interview/observation on 09/18/24 at 8:15 AM with LVN E revealed she looked at Resident #13's fingernails, and stated Resident #13's fingernails were long, and were supposed to be trimmed, but Resident #13 refused fingernail trimming. Resident #13 stated he liked his fingernails trimmed. LVN E replied that was new to her. LVN E stated it was the responsibility of the nurses to make sure residents' fingernails were trimmed and cleaned. LVN E stated the risk to the residents could be the development of infection and skin tears. In an interview with the DON on 09/19/24 at 11:37 AM revealed her expectation was that nail care should be provided as needed, especially during shower time. She stated that CNAs were responsible for doing nail care unless the resident had a diagnosis of diabetes. She also stated that as the DON, either herself or her designee were responsible to do routine rounds for monitoring. The DON stated that residents having long, and dirty fingernails could be an infection control issue and cause skin breakdown. Record review of the facility policy titled personal Care. Subject: Fingernails, care of dated 05/22/22 reflected: It is the policy of this community to establish procedures to clean the nail bed, to keep nails trimmed, and to prevent infections .1. Nails care includes daily cleaning and regular trimming

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of three residents (Resident #14) reviewed for catheter care. The facility failed to ensure CNA A maintained Resident #14's indwelling urinary catheter (a tube that drains urine from the bladder) drainage bag was below the bladder level during wound care on 09/17/24. This failure placed residents at risk for infection . Findings included: A record review of Resident #14's Quarterly MDS assessment dated [DATE] reflected Resident #14 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder (a condition that causes bladder control issues due to damage to the brain, spinal cord, or nerves), retention of urine, and pressure ulcer of the left buttock. Resident #14 had a BIMS score of 15 which indicated Resident #14's cognition was intact. She required extensive assistance of two-person physical assistance with bed mobility and transfer. Record review of Resident #14's care plan initiated on 12/01/21 reflected, [Resident #14] has indwelling suprapubic catheter (a catheter that drains urine from the bladder by inserting a tube through the abdominal wall and into the bladder) related to neurogenic bladder . Interventions: Catheter: . Position catheter bag and tubing below the level of the bladder and away from entrance room door . Review of Resident #14's Order Summary report dated September 2024, reflected, Suprapubic catheter site: cleanse the wound with normal saline pat dry, apply silver alginate and gauze daily. with a start date of 07/11/24. Observation on 09/17/24 at 10:55 AM revealed RN B entered Resident #14's room to do wound treatment. CNA A entered Resident #14's room to assist RN B. CNA A unhooked the catheter bag from the bed rail and put it flat on the foot of the bed, above the resident's bladder. RN B provided wound care to the left buttock wound. During the procedure urine was observed flowing back toward the resident's bladder. RN B finished the treatment and then CNA A hooked the catheter bag onto the bed rail. In an interview with RN B on 09/17/24 at 11:40 AM she stated she was focused on the treatment; she did not pay attention that the CNA put the urine bag on the bed. She stated the catheter bag and tubing were supposed to be kept below the bladder. She stated failing to do this could cause the urine to back up and might cause an infection. In an interview with CNA A on 09/17/24 at 11:44 AM, she stated she was trained to always keep the catheter drainage bag below the bladder. She stated she did not know why she put the bag on the bed. She stated having it above the bladder could possibility cause the urine to run backwards, which could cause an infection. In an interview with the DON on 09/19/24 at 11:37 AM she stated any resident with a foley catheter should always have the bag and tubing below the bladder. She stated not keeping the foley catheter bag below the resident's bladder, placed them at risk of urinary tract infection and cross contamination. She stated to ensure staff were knowledgeable in the care of indwelling catheters the facility does skills competency checks and she stated the ADON , and Charge Nurses made daily rounds and watched care. She stated when staff needed to be re-trained, she provided the in-service training. Record review of CNA A's competency check off for catheter care revealed she was proficient in care as of 07/03/24. Review of the facility's policy titled, Urinary Catheter Care reflected, . The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two of 12 residents (Resident #23 and Resident #210) observed for infection control. 1. CNA D failed to perform hand hygiene while providing incontinence care to Resident #23. 2. The facility failed to ensure CNA A wore appropriate PPE while providing care to Resident #210 who was on Enhanced Barrier Precaution. These failures placed residents at risk for spread of infection through cross-contamination. Findings include: 1.Record review of Resident #23's face sheet dated 9/18/24 reflected he was an [AGE] year old male. He was originally admitted to the facility on [DATE] and readmitted on [DATE]. He was admitted with diagnoses of hypertension (high blood pressure), dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and depression. Review of Resident #23's care plan initiated 12/09/22 reflected the resident had an ADL self-care performance deficit related to impaired balance and the intervention was the resident required maximum assistance by (1) staff for toileting. Observation on 09/18/24 at 10:36 AM revealed CNA D entered Resident #23's room to provide incontinent care for the resident. CNA D washed his hands in the bathroom, and donned gloves. CNA A cleaned the resident and removed the dirty brief. CNA D then placed the dirty brief in the trash can and cleaned the resident's bottom. After cleaning the resident, without any form of hand hygiene or change of gloves, CNA D put the clean brief underneath the resident, and applied the barrier cream to Resident #23's bottom. CNA D changed gloves without any form of hand hygiene, fastened the resident's brief, and assisted the resident to position in bed. After care, CNA D completed hand hygiene. In an interview on 09/18/24 at 10:45 AM with CNA D, he stated he was supposed to complete hand hygiene before and after caring for a resident. CNA D stated after cleaning the resident he was supposed to clean his hands and change gloves before applying the clean brief. CNA D stated he was supposed to complete hand hygiene to prevent the spread of infection. CNA D stated he had completed a hand hygiene and infection control in-service about two months ago. In an interview on 09/19/24 at 11:00 AM with the DON, she stated infection control was important during care. The DON stated during care the staff were to use the hand sanitizer or wash hands if they were physically soiled. The DON stated the staff were expected to complete hand hygiene before care and after care, she also stated during incontinent care the staff were supposed to change gloves and use hand sanitizer when taking off the dirty brief before applying the clean one. The DON stated hand hygiene was to be completed for infection control. DON said she was the infection preventionist and in-service on infection control was completed within a month ago. Record review of inservices reflected the facility completed an in-service on 07/05/24 for hand hygiene for CNA D. 2. Resident #210 Review of Resident #210's face sheet dated 9/19/2024 revealed he was an [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included: Congestive heart failure (heart cannot pump enough blood to meet body's needs), acute respiratory failure (disease that affects breathing), chronic kidney disease (kidneys are damaged and cannot filter blood adequately), Obstructive and reflux uropathy (urine cannot drain through the urinary tract). Record review of Resident #210's Physician Orders dated 9/13/24 reflected, Continue FOLEY CATHETER, size 20 French every day and night shift. Record review of Resident #210's care plan dated 9/18/2024 reflected, Focus: [Resident #210] have a condition that requires Enhanced Barrier Precautions as related to Foley Catheter and Oxygen. Goal: Infection control intervention to reduce the transmission of Multidrug- resistant organisms. Intervention: Follow Enhanced Barrier Precaution guidelines when providing care and coming in direct contact with potentially infected material or devices that put [Resident #210] at risk. Direct care activities including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting and incontinence care, Device use, Catheter, Trach/Vent, central lines, feeding tubes, wound care and/or skin opening requiring a dressing. Set up isolation per facility protocol. Follow the enhanced barrier guidelines. Observation on 09/18/24 at 10:36 AM revealed Resident #210's room had enhanced barrier precaution (EBP) signage on the door of the room. Resident #210 was on the bed with Oxygen running via Nasal cannula and had a foley catheter. CNA A entered the room, performed hand hygiene, donned gloves, but did not don a gown. CNA A, along with the other CNA present in the room (who had already donned gloves and gown) helped Resident #210 to sit up at the edge of the bed. CNA A then proceeded to attach a gait belt on Resident #210 and checked to see if the gait belt was secured. CNA A and other CNA then helped the resident to slide over from the bed to the weighing scale and then from the weighing scale to the wheelchair in the room while holding on to Resident #210's gait belt. CNA A then proceeded to remove her gloves and performed hand hygiene. In an interview on 09/18/24 at 11:15 AM with CNA A revealed she does not work on Resident #210's hall. She was only tasked to weigh the resident that morning. She stated that she saw the EBP sign on the door but was not familiar with the resident's care. She stated that an Enhanced barrier precaution sign was for residents who had wounds, G-tubes or Foley catheters and PPE including gloves and gowns should be worn during direct care contact with the resident. She stated that since she helped the resident with attaching the gait belt and helped him slide over from the bed, that would be considered as direct contact and she should have donned the gown. She stated that the risk for not wearing adequate PPE that included gown was lapses in infection control and contamination. In an interview on 09/19/24 at 11:04 AM with the DON stated her expectation was nursing staff should wear adequate PPE while providing direct care activities to a resident who has Enhanced Barrier precautions. She stated direct care activities included: bathing, changing, transferring, weighing with assistance, etc. She stated the risk of not donning adequate PPE for EBP residents was increased spread of infections. She stated that as the DON and the Infection preventionist in the facility, she provided education to all nursing staff about adequate PPE, conducted random observation rounds and talked to the residents if they had seen any lapses in infection control to ensure adequate quality of care within the facility. She stated that CNA A had received her latest skill check on 07/03/24 for transfers and PPE. Record review of CNA A Skill checks dated 07/03/24 revealed, CNA A successfully completed annual competency evaluation for PPE and Transfers from bed to chair. Record review of the facility policy titled Infection Control- Subject: Enhanced Barrier Precaution dated 6/24/24 reflected, .A. Used for the following . 2. Indwelling medical devices regardless of MDRO status (Examples: Central line/PICC line, urinary catheter, feeding tube, tracheostomy etc.) . C. Enhanced Barrier Precautions are used when specific, high contact resident care activities are performed (Examples: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use, and wound care etc.) . F. Use of PPE (Personal Protective Equipment) 1. Perform hand hygiene per policy . prior to donning PPE 2. [NAME] gown prior to performing the above listed high-contact resident care activities . Record review of US Center for Disease Control and prevention reflected, . Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. Review of the facility policy dated 10/15/23 and titled Hand washing/Hand Hygiene reflected, 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infection.9. The use of gloves does not replace hand washing/ hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice of preventing healthcare-associated infections. 48560

Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for one of one Resident (Resident #9) and one (Nurses Cart Hall 500) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure RN B, responsible for Nurses Cart Hall 500, removed Resident #9's medications in unsecure containers from the Nurses Cart. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication because of possible diminished effectiveness. The findings include: Observation on 09/17/24 at 10:14 AM of Nurses Cart Hall 500, with RN B revealed the blister pack for Resident #9's diazepam 5 mg tablet (controlled medication used for anxiety) had 6 blister seals broken and the pills still inside the broken blisters were taped over. Interview on 09/17/24 at 10:28 AM, RN B stated the narcotic count was done at shift change and the count was correct. She stated she did not check the blister packs during the count . She stated she was unaware when the blister pack seals were broken, and she was not aware of who might have damaged the blisters and taped them over. She stated the risk would be a potential for drug diversion and we did not know the pills in the taped-over blisters were actually diazepam. She stated the nurses and medication aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated when a broken seal was observed, she would report it to the DON and would discard the pill with another nurse. Interview on 09/19/24 at 11:37 AM, the DON stated she expected if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be potential for drug diversion and infection control issue. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated the ADON, and the DON were supposed to check the carts weekly for monitoring. Record review of the facility's policy titled Storage of Medication, dated 1/27/24, revealed in part .4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on interviews and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for two (CNA D and CNA E) of 10 employees reviewed for employee files. The facility failed to ensure the facility had a copy of criminal background checks conducted prior to hire for CNA D and CNA E. This failure could place residents at risk for abuse and receiving care from unemployable staff. Findings included: Review of facility's policy Abuse Prevention Program undated reflected The facility must develop and implement written policies and procedures that: As part of the resident abuse prevention, the administration will implement the following protocols: .2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . Review of facility's policy Personnel and Staffing Background Screening Investigations undated reflected The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within 2 days of an offer of employment or contract agreement, and completed prior to employment. Review of facility's policy Licensure, Certification and Registration of Personnel effective May 10, 2022 reflected facility conducts employment background screening checks .and criminal conviction investigation checks in accordance with current federal and state laws. Review of CNA D's personnel file reflected the hire date was 03/30/11 with no criminal background check completed in her file. Review of CNA E's personnel file reflected the hire date was 12/29/11 and there was no criminal background check in her file. Interview on 09/14/23 at 3:11 PM with HR Manager revealed that each employee received an offer of employment letter for hire. Interview revealed the employee then gave the facility permission to conduct the criminal background check. The HR Manager stated the facility conducted the background check before the employee worked at the facility. Interview revealed CNAs D and E worked at the facility for over [AGE] years and the records were paper. The HR Manager stated the facility did not have the criminal background checks in their files anymore. The HR Manager stated the criminal background checks were only ran again as needed Interview on 09/14/23 at 3:18 PM with the Administrator revealed that it was the facility's policy to run criminal background checks upon hire for new employees but the facility did not have a copy of it for CNA D and CNA E. She stated the purpose of completing these checks were to protect the residents from harm/persecution at the hands of any staff that we hire. Review of CNA D and CNA E's criminal background checks completed on 09/14/23, after surveyor intervention, reflected both CNA D and CNA E were employable and had no bars to employment.

Based on observation, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the facility's only medication room and 1 (5300 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1- A vial of TB ( Tuberculosis ) serum that was opened and used was dated in the medication room refrigerator. 2- The 5300 Hall medication cart had insulin pen for Resident #13 without an opened date. These failures could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications The findings include: 1-Observation on 09/12/2023 at 2:47 PM of the medication room revealed a vial of TB PPD (purified protein derivative) serum was opened, had been used and was not dated. Interview on 09/12/23 at 2:47 PM, LVN L stated the TB PPD vial was open and the rubber seal breached and was not dated or initialed. He said the risk when given to staff or resident could be the wrong reading. He stated the nurse was responsible to check the vial for the open date before use it. Interview on 09/12/23 at 3:20 PM, the DON said labeling of medications followed manufacturer instructions unless otherwise specifically indicated. She said the staff who opened the vial should have written the open date and the initials. She said all nurses were responsible to check the medication carts and the medication rooms for expiration and labeling of medication. 2- Record review of Resident #13's Comprehensive MDS, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and hyperlipidemia (too many lipids and fats in the blood). He had a BIMS of 15 indicating he was cognitively intact. Record review of Resident #13's physician's orders dated September 2023 revealed an order for insulin glargine solution 100 unit/ml. Inject 10 unit subcutaneously one time a day for diabetes, with an order date of 08/18/23 and no end date. Observation on 09/12/2023 at 3:10 PM revealed the 5300-hall nurse's medication cart had a pen of insulin glargine solution 100 unit/ml for Resident #13. Observation revealed the used insulin pen did not have an opened date. Interview on 09/12/2023 at 3:15 PM, LVN K stated the glargine solution 100 unit/ml belonged to Resident #13 and did not have an opened date. LVN K stated she did not open the pen and she forgot to check if there was an open date on the pen. LVN K stated the purpose for putting an open date was for expiration purposes because the insulin was only good for 28 days. Interview on 09/12/23 at 3:20 PM, the DON stated the insulin flex pens, once opened, needed to be dated because each insulin pen had a 30 or 40-day shelf life and if not thrown out before that time, the insulin could lose its effectiveness. Record review of the facility's policy titled Administering Medications, not dated, revealed in part .12. The expiration /beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Cooks H and I washed hands during lunch meal preparation on 09/13/23. 2.The facility failed to ensure four of six trash cans in the kitchen were covered. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observation on 09/13/23 at 12:09 PM revealed Dietary Cook H touched the metal shelf of steam table with her left open gloved hand. Dietary Cook H did not wash her hands. Dietary Cook H touched inside of the bowl and scooped food into bowl. She started scooping food on plate with utensil and touched the plates. At 12:28 PM Dietary Cook H changed gloves and did not wash hands before putting on new gloves. Observation on 09/13/23 at 12:12 PM revealed Dietary Cook I touched her left hand on her face with gloved hands. She put meat on stove. She changed gloves but did not wash hands between glove change. She took up fries with same gloved hands. At 12:18 PM, Dietary Cook I took gloves off and put new gloves on. She did not wash her hands between glove changes. She grabbed salad from bowl with her gloved hands. Interview on 09/13/23 at 12:35 PM with Dietary Cook H revealed she should have washed her hands when changing her gloves. She stated she should change her gloves and wash hands when her gloves get contaminated or soiled. Interview on 09/13/23 at 12:37 PM with Dietary Cook I stated she should have washed her hands between glove changes before putting on the new gloves. 2. Observations on 09/13/23 at 12:07 PM and 12:30 PM revealed four trash cans were not covered. Two trash cans, when entering kitchen, had no cover and contained used gloves and one of the trash cans had boxes on top. Two trash cans in food prep area revealed the lids were not over the trash can and had about 3/4 full of food debris and used gloves in the food prep area were near the steam table. Interview on 09/13/23 at 12:38 PM with the Dietary Manager stated the dietary staff should have washed hands when changing gloves before putting on new gloves and when gloves were contaminated or soiled. He stated there was a recent in-service on hand hygiene about washing hands. He stated he would initiate an in-service on hand washing for all dietary staff today. Dietary Manager stated he was aware of two of the trash can lids not working to cover the trash can. He stated he needed new lids for these trash cans. He stated the other two trash cans did not have lids but he tried not to keep food debris in it. He stated he was aware the kitchen trash cans need to be covered but he would need to order kitchen trash cans that have a lid to keep the trash covered in the kitchen. Interview on 09/13/23 at 1:55 PM with Dietary Manager stated the risk for dietary staff for not washing their hands place residents at risk for cross contamination and getting sick. He stated he expected dietary staff to wash hands when they become contaminated and when changing gloves to wash hands prior to putting on new gloves. Review of facility's in-service for dietary staff dated 02/24/23 by Dietary Manager reflected Dietary Cook I was in-serviced on hand washing practice. Review of facility's in-service on infection control and handwashing dated 09/07/23 reflected Dietary Cook H and I were in-serviced along with other facility staff. Review of facility's policy Proper/Adequate Hand Washing revised March 2011 reflected 1. Nutrition Services employees will keep their hands and exposed portions of their arms with soap in the handwashing sink. 5. Employees will wash their hands and exposed parts of their arms at the following times: a. After touching bare body parts (such as face, hair, etc.) other than clean hands and clean exposed arms .g. During food preparation, as often as necessary to remove soil and contamination when changing tasks i)After engaging in other activities that contaminate the hands. Review of facility's policy Garbage and Rubbish Disposal revised March 2011 reflected Garbage and rubbish will be disposed of in compliance with state and local regulations .2. All containers will have tight fitting lids or covers and such containers must be kept covered when stored or not in continuous use.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (Resident #24) of 8 residents reviewed for pharmacy services and for 1 (5400 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1- The facility failed to ensure medications were not left unsecured at bedside of Resident #24 2- The facility failed to ensure LVN J and LVN N counted controlled drugs on the 09/12/23 night shift/morning shift change. These failures could place residents at risk of not receiving the intended therapeutic benefit of the medication and the risk of not having the medication available due to possible drug diversion Findings Included: 1- Observation on 09/12/23 at 10:47 AM, of the room [ROOM NUMBER] revealed a pink oval tablet in a medication cup was on the bed side table unattended. Resident #24 was not in the room. Interview on 09/12/23 at 10:55 AM, LVN J stated she did not leave the pill in the resident's room unattended. She stated she did not know who left the medication in the room unattended. She stated that placed everyone at risk of receiving medication not intended for them; could cause serious health problems. Interview on 09/14/23 at 1:30 PM, the DON stated medications should never be left at bedside. The DON stated she was responsible for in-services on medication administration. The DON stated unsecured meds were a risk to everyone with potential to cause serious illness and could also be a choking hazard. 2- During a record review and random count observation of 5400 hall nurses' medication cart with LVN J on 09/12/2023 at 2:26 PM revealed missing signature for 1 tablet of tramadol given to Resident #48. The blister pack count was 22 and the narcotic count sheet was 23. Interview on 09/12/2023 at 2:28 PM, LVN J stated she did not count with the night shift nurse, LVN N, because LVN N was rushing because she had an emergency. LVN J stated she should have counted with LVN N during change of shift. LVN N stated this failure could have potentially caused a drug diversion. An attempted telephone interview on 09/12/2023 at 3:22 p.m. with LVN N, was unsuccessful. Interview on 09/14/2023 at 1:30 PM, the DON stated she expected nurses to count narcotic at the beginning and at the end of their shift with the incoming and off-going nurse. The DON stated this was monitored monthly by the pharmacy consultant. The DON stated she had never really had a problem so monitoring more often was not required. The DON stated the count was important to ensure a drug diversion did not occur. Review of the facility's policy Controlled Substances not dated, reflected the following: .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift 12. At the end of each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together.

Based on observations, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #38) of 19 residents reviewed for comprehensive care plans. 1. The facility failed to develop a care plan for Resident #38's preferences to stay in room and for independent activities in her room. 2. The facility failed to develop a care pan to address Resident #38's pain management. These failures could affect the residents by placing them at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care. Findings included: Review of Resident #38's annual MDS assessment dated [DATE] reflected Resident #38 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart rhythm, coronary artery disease (narrowing of the heart major blood vessels that limit blood flow to the heart)., stress fracture of left fibula ( the long bone in the lower leg) , muscle wasting and atrophy, lack of coordination and abnormalities of gait and mobility. Resident #38 had a BIMS of 13 indicating she was cognitively intact. Resident #28 required limited to extensive assistance with all ADLs. Review of Resident #38's Comprehensive Care Plan last revised on 08/29/23 reflected Resident #38 has an ADL self-care performance deficit [related to] impaired balance. Review revealed it did not reflect her preference to stay in her room. It reflected Resident #38 has little or no activity involvement related to mobility. Interventions included to invite and encourage the resident's family members to attend activities with resident in order to support participation, monitor/document for impact of medical problems on activity level, remind resident may leave activities of any time, and was not required to stay for entire activity, resident needs assistance/escort to activity functions. It did not reflect about Resident #38's preference to do independent activities in her room instead of group activities and what activity preferences Resident #38 liked. The care plan did not address about Resident #38's pain. Observation and interview on 09/12/23 at 10:50 AM revealed Resident #38 was lying in her bed and had a book she was reading in her hands. Resident # 38 stated she liked to read and preferred to stay in her room and not participating in group activities. She stated she liked to read and enjoyed reading books. She stated she had arthritis pain and preferred to stay in her bed due to increased pain. Resident #38 stated she was provided pain medications when needed and they were effective to alleviate her pain. Interview on 09/14/23 at 1:25 PM with the MDS Coordinator revealed she thought Resident #38 came out of her room and was unaware she preferred to stay in bed. She stated Resident #38's pain was not care planned since it was not constant pain and did not cause her a problem. She stated the Lifestyle Coordinator was responsible for care planning about resident's activities. Interview on 09/14/23 at 1:27 PM with Resident Care Coordinator B revealed Resident #38 preferred to stay in her room and in bed. Interview on 09/14/23 at 1:50 PM with DON revealed Resident #38 took Gabapentin for neuropathy and her pain was controlled. She stated Resident #38's pain did not need to be care planed unless it iswas a problem and resident complained of pain. She stated Gabapentin was a minor pain medication compared to narcotic pain medication. She stated the care plan should be resident centered. Interview on 09/14/23 at 2:05 PM with the Lifestyles Coordinator revealed Resident #38 preferred to stay in her room and was independent with her activities like reading books. He stated he visited her in her room regularly and was looking for finding a volunteer who could regularly come visit one-on-one with Resident #38 in her room. He stated he had not updated her care plan to address her preference for staying in the room and reading books. Interview on 09/14/23 at 2:09 PM with RN C revealed Resident #38 preferred to stay in her room and most of the time would be reading a book in her room. He stated Resident #38 took scheduled Gabapentin and would complain of pain or discomfort if getting up in her chair. RN C stated Resident #38 preferred a bed bath. Review of facility's policy Care Plans, Comprehensive Person-centered undated reflected to develop and implement comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs for each resident .7. The care planning process will: b. include an assessment of the resident's strengths and needs; and c. incorporate the resident's personal and cultural preferences in developing the goals of care. 8. The comprehensive, person-centered care plan will: .b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #22, Resident #40) of 5 residents reviewed for infection control. The facility failed to ensure CMA M disinfected the blood pressure cuff in between blood pressure checks for Residents #22 and #40. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #22's Comprehensive MDS assessment, dated 08/13/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including elevated blood pressure, congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), and type 1 diabetes mellitus. She was unable to complete the interview to determine the BIMS due to cognition issues. Record review of Resident #22's physician orders dated 09/14/23 reflected, metoprolol succinate extended release 25 mg tablet, give 0.5 tablet by mouth one time daily - Special instruction: Hold for heart rate less than 60. Record review of Resident #40's Comprehensive MDS, dated [DATE], revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow), elevated blood pressure, and dementia. He had a BIMS of 14 indicating he was cognitively intact. Record review of Resident #40's physician orders dated 09/14/23 reflected, diuretics- monitor for the following: decreased PO (oral intake), acute confusion, agitation, delusions, hypotension and orthostasis (normal response of the body to counteract a fall in blood pressure when a person is laying down and assumes the upright position.) Observation on 09/13/23 at 8:06 AM revealed CMA M performing morning medication pass, during which time she checked the blood pressures on Resident #22. CMA M did not sanitize the blood pressure cuff before or after using it on Resident #22. Observation on 09/13/23 at 8:14 AM revealed CMA M performing morning medication pass, during which time she checked the blood pressure on Resident #40. CMA M used the same blood pressure cuff right after using it on Resident#22. CMA M did not sanitize the blood pressure cuff before using it on Resident #40. Interview on 01/13/23 at 8:28 AM, CMA M stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to wipe the cuff. Interview on 09/14/23 at 1:30 PM, the DON stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She said she was responsible for training staff on infection control. She said that she did routine rounds in the floor to ensure the nurses and med aids were following proper infection control procedures. Record review of facility's policy Cleaning and Disinfection of Resident -Care Items and Equipment, not dated, reflected . d. Reusable items are cleaned and disinfected or sterilized between residents. 3. Durable medical equipment must be cleaned and disinfected before reuse by another resident. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according .

Based on observation, interview, and record review, the facility failed to have physician orders for the resident's immediate care for two (Resident #36 and #160) of four residents reviewed for physician orders. The facility failed to have physician treatment orders for the care of Resident #36's and 160's CVC dressing changes. This failure could place residents at risk for infection. Findings included: Review of Resident # 36's Face Sheet dated 07/15/22 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's care plan originally dated 07/15/22 and updated 08/09/22, revealed the care plan did not address the CVC to his left upper arm There were no goals or interventions identified for the CVC. Review of Resident #36's Consent form dated 07/31/22 for the CVC reflected the date the CVC was inserted into the left upper arm. Review of Resident #36's consolidated physician orders for the month of 07/ 31/22 until 08/09/22 revealed the following order with a start date of 08/01/22: [MEDICATION(S)] HCI Solution (antibiotic) Reconstituted 1 grams intravenously one time a day for infection [CONDITION(S)] until 08/07/2022. No physician orders were noted for dressing changing of the resident's CVC dressing. Observation of Resident # 36's CVC site on 08/09/22 at 10:25 AM revealed the transparent dressing on the left inner arm was undated. The dressing was intact without being compromised and no sign of infection. Interview with Resident #36 revealed he stated his CVC dressing had not been changed since it had been inserted. Observation and interview on 08/09/22 at 11:25 AM revealed the DON checked the date on Resident #36's CVC dressing. She stated the dressing was undated. She stated that the dressing should have been dated at the time it was changed, and it should be changed every seven days (1 day late). Review of Resident #36's Treatment Administration Records from 07/31/22 until 08/09/22, revealed there was no order for a dressing change related to the CVC site. 2. Review of Resident #160's Face Sheet dated 07/29/22 reflected he was admitted to the facility on [DATE] with Urinary Tract Infection and [CONDITION(S)]. Observation on 08/09/22 at 9:50 AM revealed Resident #160's CVC site revealed a date of 07/28/22 on the transparent dressing on the left inner arm. Interview of Resident #160 revealed the dressing of his CVC site was last changed while he was in the hospital, and that it had not been changed since his admission (4 days late). Review of Resident #160's initial care plan dated 07/29/22 revealed the care plan addressed his CVC, including dressing changes, flushes, or monitoring for signs and symptoms of infections and antibiotic therapy. Review of Resident #160's Treatment Administration Record from 07/29/22 through 08/09/22 reflected no documentation related Resident #160's CVC dressing being changed. Review of Resident #160's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation related to his dressing changes or physician orders for Resident #160's CVC. Review of Resident #160's Nurses Progress note from 07/29/22 through 08/09/22 revealed no documentation of his CVC site dressing being changed. An interview on 08/09/22 at 2:22 PM with the DON revealed she was not aware Resident #36's and #160's CVC dressings were not changed every seven days. She stated Resident #36 should have had his dressing changed on 08/08/22, that it was one day past the due date to be changed. She stated Resident #160 should have had his dressing changed on 08/04/22, and that it was four days past the due date to be changed. She was not aware Residents #36, and #160 did not have physician orders for their CVC dressing changes. She stated her expectation were for the RNs to follow the facility's policy for CVC dressing changes every 7 days. She revealed the risk factor for not maintaining and changing the CVC dressing was systemic infection. An interview on 08/10/22 at 12:48 PM with the DON revealed the admitting nurse was responsible for ensuring newly admitted residents or readmitted residents with CVCs had physician orders to monitor and maintain the CVC. The RNs are the only one that can change the CVC line dressings. She stated there must be a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 08/10/22 at 12:22 PM with the NP revealed she was not aware Resident #36, and #160 did not have physician orders for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP stated the dressing should be changed according to the facilities protocol or policy. She stated there were no standing orders for the facility for care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not provide a policy for physician orders related to treatment orders for the care CVC dressing changes at the time of exit.

Based on observation, interview and record review, the facility failed to ensure that residents receiving parental fluids were in accordance with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan and the residents' goals and preferences for two (Resident #36 and #160) of four residents reviewed for quality of care. The facility failed to ensure Resident # 36's and Resident #160's CVC dressings was changed in a timely manner. This failure could place the resident at risk for developing systemic infection. Findings Included: 1. Review of Resident # 36's Face Sheet dated 07/15/22 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's care plan originally dated 07/15/22 and updated 08/09/22, revealed the care plan did not address the CVC to his left upper arm There were no goals or interventions identified for the CVC. Review of Resident #36's Consent form dated 07/31/22 for the CVC reflected the date the CVC was inserted into the left upper arm. Review of Resident #36's consolidated physician orders for the month of July 31, 2022 until August 09, 2022 revealed the following order with a start date of 08/01/22: [MEDICATION(S)] HCI Solution (antibiotic) Reconstituted 1 grams intravenously one time a day for infection [CONDITION(S)] until 08/07/2022. No physician orders were noted for dressing changing of the resident's central venous catheter dressing. Review of Resident #36's Treatment Administration Records from 07/31/22 until 08/09/22, revealed there was no documentation of a dressing change related to the CVC site. Review of Resident #36's nurses note from until 07/31/22 until 08/09/22 revealed no documentation of the dressing being changed. Review of Resident #36's weekly skin assessments from 07/31/22 to 08/09/22 revealed no documentation related to Resident #36's CVC being in place on his left inner arm. Observation of Resident # 36's CVC site on 08/09/22 at 10:25 AM revealed the transparent dressing on the left inner arm was undated. The dressing was intact without being compromised and no sign of infection. Interview with Resident #36 revealed he stated his CVC dressing had not been changed since it had been inserted. Resident #36's CVC dressing change was 1 day late. Observation and Interview on 08/09/22 at 11:25 AM revealed the DON checked the date on Resident #36's CVC dressing. She stated the dressing was undated. She stated that the dressing should have been dated at the time it was changed, and it should be changed every seven days. An interview on 08/10/22 at 8:45 AM with the DON revealed RN A changed Resident #36's CVC dressing on 08/08/22, and that she had documented on the 24-hour report sheet. She presented the 24-hour report form dated 08/08/22 with a handwritten note on the side of the form that read CVC dressing changed She stated she dug the 24 hour report out of the shred box. When asked if this was apart of Resident #36's legal clinical record she replied no. An interview on 08/10/22 at 9:20 AM with RN A revealed she changed the CVC dressing on 08/08/22. She stated she saw it needed to be changed, so she changed the dressing. She later realized there was no physician order to change the CVC dressing but was busy and forgot to write the order for dressing change and she did not document the dressing change in the residents' clinical record. An interview on 8/10/22 at 10:15 AM with the Administrator revealed the 24-hour report was not a part of Resident #36's legal clinical record. An interview on 08/10/22 at 12:48 PM with the DON revealed the admitting nurse was responsible for ensuring newly admitted residents or readmitted residents with CVCs had physician orders to monitor and maintain the CVC. The RNs are the only one that can change the CVC line dressings. She stated there must be a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #160's Face Sheet dated 07/29/22 reflected he was admitted to the facility on [DATE] with Urinary Tract Infection and [CONDITION(S)]. Observation on 08/09/22 at 9:50 AM revealed Resident #160's CVC site revealed a date of 07/28/22on the transparent dressing on the left inner arm. Interview of Resident #160 revealed the dressing of his CVC site was last changed while he was in the hospital, and that it had not been changed since his admission (4 days late). Review of Resident #160's initial care plan dated 07/29/22 revealed the care plan addressed his CVC, including dressing changes, flushes, or monitoring for signs and symptoms of infections and antibiotic therapy. Review of Resident #160's Treatment Administration Record from 07/29/22 through 08/09/22 reflected no documentation related Resident #160's CVC dressing being changed. Review of Resident #160's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation related to his dressing changes. Review of Resident #160's Nurses Progress note from 07/29/22 through 08/09/22 revealed no documentation of his CVC site dressing being changed. An interview on 08/09/22 at 2:22 PM with the DON revealed she was not aware Resident #36's and #160's CVC dressings were not changed every seven days. She stated Resident #36 should have had his dressing changed on 08/08/22, that it was one day past the due date to be changed. She stated Resident #160 should have had his dressing changed on 08/04/22, and that it was four days past the due date to be changed. She was not aware Residents #36, and #160 did not have physician orders for their CVC dressing changes. She stated her expectation were for the RNs to follow the facility's policy for CVC dressing changes every 7 days. She revealed the risk factor for not maintaining and changing the CVC dressing was systemic infection. An interview on 08/10/22 at 12:22 PM with the NP revealed she was not aware Resident #36, and #160 did not have physician orders for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP stated the dressing should be changed according to the facilities protocol or policy. She stated there were no standing orders for the facility care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Center for Disease Control (CDC) a central venous catheter is a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly. These long, flexible catheters empty out in or near the heart, allowing the catheter to give the needed treatment within seconds. (accessed from https://www.cdc.gov/hai/bsi/catheter_faqs.html on 10/25/19) According to the American Nurse Today (journal of the American Nurses Association) article entitled, Providing optimal care for patients with central catheters, dated 05/11/14, care and maintenance of central venous catheters requires vigilance and attention to detail to prevent complications and maintain patency. The article revealed more than 80% of bloodstream infections are linked to vascular access devices and 50% of these infections are preventable. The article indicated dressings at the insertion site help protect the catheter and transparent dressings should be changed every 7 days and gauze dressings every 48 hours. The article also revealed the catheter must be flushed to maintain patency, and failure to maintain patency could lead to occlusion, malfunction, and infection. The article indicated all central catheters should be flushed with normal saline solution before and after medication administration and additional flushing should be based on the facility's guidelines. According to the article competent, confident central-catheter care and maintenance can help prevent dangerous complications that imperil a patient's life. (accessed from https://www.americannursetoday.com/providing-optimal-care-for-patients-with-central-catheters/ on 10/25/19) According to the Center for Disease Control and Prevention's Guidelines for the Prevention of Intravascular Catheter-Related Infections, updated 02/2017, catheter sites should be monitored visually when the dressing is changed and by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. The guidelines also revealed intravascular catheters that are no longer essential should be promptly removed to help prevent infection. The guidelines indicated needleless components should be changed based on the facility's determination or according to the manufactures' recommendations. (accessed from https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html on 10/25/19) Review of the facility's undated policy for Central Venous Catheter Dressing Changes revealed, the Central venous catheter dressing will be changed every seven days or when needed, to prevent catheter-related infection that are associated with contaminated, loosened, soiled, or wet .Change transparent semi-permeable membrane dressing at least every 7 days and PRN, when wet, soiled, or not intact .

Based on observations, interviews and record review, the facility failed to ensure residents had the rights to choose, self determine and participate in activities consistent with their interests, assessments and plan of care for three (Residents #17, #18 and #30) of 24 residents reviewed for resident rights. The facility failed to ensure Residents #17, #18 and #30 were informed and provided the right to eat in the dining room. This deficient practice had the potential to affect residents by placing them at an increased risk of having their rights violated, poor self-esteem and socialization, and a poor quality of life. Findings included: Review of Resident #17's face sheet reflected she was a 92- year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's Significant Change MDS assessment dated [DATE] reflected she had a BIMS of 13 indicating her cognition was intact. She required limited to extensive assistance with ADLs; except eating which she only needed set up help. Interviews on 08/09/22 at 10:15 AM and 08/10/22 at 1:23 PM with Resident #17 revealed she ate in her room for meals since dining room was closed. She stated, in the last week, she had tried to go to dining room for meals but was told by staff she could not go to dining room and had to go back to her room. She stated she was told the dining room was closed for all meals due to a Coronavirus disease outbreak within the last month. She stated she missed socializing and seeing other residents during meal times. She stated she recently had Coronavirus disease but was recovered and not in quarantine. Observation on 08/09/22 at 12:20 to 12:30 PM revealed no residents were in the dining room (Sonoma) for resident room numbers 5101 to 5210 for lunch, and meal trays were taken to resident rooms. There was a sign on dining room door for Sonoma stating residents and facility staff only in dining room but there was no signage that it was closed. Review of Resident #18's face sheet reflected he was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Admission MDS assessment dated [DATE] reflected he had a BIMS of 13 indicating his cognition was intact. He required extensive assistance with most ADLs except eating, which he only needed setup help. He was on antidepressant medication. Observation and interview on 08/10/22 at 9:30 AM revealed Resident #18 was in his room. He stated they have not had group dining for at least three weeks. He had been at the facility for a couple of months now. He stated he missed socializing with other residents in the dining room. He stated the administration had not talked to him or other residents about the dining room closure. He stated he asked nurses and CNAs about the dining room being reopened but he is told it is still closed and do not know when it will be reopened. He stated he liked eating in the dining room and only ate in his room at this time due to not being allowed to be in dining room for meals. He stated he felt like a prisoner having to stay in room and not be allowed to eat in dining room. He further stated prior to dining room closure, he ate in the dining room for his meals and enjoyed conversing with other residents during meal time. He stated he was not in isolation and should be allowed to eat in the dining room if we want to. Review of Resident #30's face sheet dated 08/11/22 reflected she was an 81- year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's Admission MDS assessment dated [DATE] reflected Resident #30 had a BIMS of 15 indicating her cognition was intact. She required limited to extensive assistance with ADLs and only set up help with eating. Observation and Interview on 08/10/22 at 1:21 PM with Resident # 30 revealed she was in her room. She stated she ate her meals in her room, at that time, due to not being allowed to go to the dining room to eat meals. She stated facility staff told her it was shut it down due to positive covid outbreak in July and no one mentioned when it will be reopened. She stated she had gone down to dining room within the last week but was told by staff she had to go back to her room to eat since dining room was closed. She stated she liked to eat in dining room to socialize and see other residents. Interview on 08/10/22 at 12:58 PM with Dietary Manager revealed the facility had three dining rooms and only one dining room (Sierra court) was closed temporarily due to the majority of covid outbreak of residents back in July were on that unit. He stated, the other two dining rooms including Sonoma, were open for residents not on isolation who wanted to eat in dining room for meals. Interview on 08/10/22 at 1:14 PM with CNA D revealed none of the residents are going into dining room for meals at this time for the last 3 weeks. She stated Resident #17 did go to dining room on Sunday but she redirected her back to her room since dining room was closed for meals at this time. She stated Resident #18 asked her to go to dining room for meals and she told him the dining room was still closed. She stated Sonoma dining room was closed when facility had the initial positive covid outbreak and did not know when it would be reopened. She stated none of her residents were currently in isolation at this time. She stated the Sonoma unit had no positive covid-19 residents at this time. Interview on 08/10/22 at 1:17 PM with CNA C revealed the group dining room had been closed for about 3 weeks since the facility had positive COVID-19 residents. She stated only one resident on this unit got COVID-19 and was sent to a facility to be placed on quarantine. She stated Resident #18 liked to eat in dining room when it was open. She stated she did not know when it would reopen but residents did want to go back to group dining room. She stated residents ate in their room for meals at this time but there were no current residents on this unit in isolation for COVID-19. Interview on 08/10/22 at 1:19 PM with LVN B revealed Sonoma dining room was closed at this time and she did not know when it would be reopened. She stated residents asked about eating in dining room for meals but they did not have any update to give to residents when group dining would be allowed again. She stated none of her residents were on isolation at this time. Interview on 08/10/22 at 1:27 PM with RN A revealed there was no group dining at this time due to COVID-19 cases among facility staff. She stated it was closed about 3 weeks ago when facility had positive covid cases and she had not heard an update of restrictions being lifted to allow group dining again. She was aware Residents #17 and #18 on Sonoma wanted to eat in dining room again . She stated she did not currently have any residents on isolation for COVID-19 precautions. She stated there was no current positive residents in the facility that she was aware of. Interview on 08/10/22 at 1:34 PM with LVN E revealed residents on Sierra court unit were currently offered if they wanted to eat in Sierra dining room and able to space out residents for infection control practices. She stated there were residents that ate in dining room for lunch today. Interview on 08/10/22 at 1:36 PM with CNA F revealed residents not in isolation who were on Sierra Court unit were offered the opportunity to eat in dining room if they wanted and they spaced residents out in the dining room at least 6 feet apart. Interview on 08/11/22 at 9:40 AM with ADM revealed Sierra dining room was the only one closed temporarily as a precaution due to the majority of COVID-19 outbreak was on this unit back in July. 2022. She stated Sonoma dining room was open for residents to dine in if they wanted to. She stated she was not aware residents on Sonoma were not allowed to eat in dining room. She stated there must be a miscommunication with facility staff and she would follow-up to ensure residents on this unit were allowed to eat in dining room for meals if they wanted to. She stated as long as residents are not in isolation for COVID-19 monitoring they should be allowed to eat in group dining room. She stated they do not currently have any positive COVID-19 residents in the facility. Record Review of the undated Food Service: Preparing the Resident for a Meal policy reflected the facility was to prepare the resident and the environment in order to help make meal time pleasant for the resident .3. Residents should be encouraged, but not forced, to eat in the dining room. This provides each resident with an opportunity to socialize and make new friends. Record Review of the undated Food Service: Assistance with Meals policy reflected the facility was to assist residents with meals in a manner that meets the individual needs of each resident .Dining Room Residents: 1. All residents will be encouraged to eat in the dining room. Record Review of the COVID-19 Response for Nursing Facilities Version 4.2 dated 06/22/22 reflected While adhering to the core principles of COVID-19 infection prevention and control, communal activities and dining can occur. Book clubs, crafts, movies, exercise and bingo are all activities that can be facilitated with altercations to adhere to the guidelines for preventing transmission. Record Review of CMS QSO-20-39-NH on Nursing Home Visitation - COVID-19 revised 03/10/22 reflected the following under communal dining: While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur . Similar to the guidance for group activities, NFs in areas of low to moderate transmission levels of COVID-19 may consider allowing [residents who are up to date with all recommended COVID-19 vaccine doses including any booster dose] to not use source control when in the communal dining areas of the facility. (Check the level of transmission with the COVID-19 County Check.) However, residents at increased risk for severe disease should still continue to practice physical distancing and use source control, as tolerated. [Residents in isolation and quarantine should not participate in communal dining]. Residents with a positive COVID-19 status require isolation until they meet the criteria to discontinue transmission-based precautions. Residents with an unknown COVID-19 status must quarantine per CDC guidance. Meals can be served in the dining room for residents who require assistance with feeding if physical distancing is practiced.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being one (Resident #36) of 4 residents reviewed for comprehensive care plans. Resident #36's care plan failed to address his CVC line for treatment and care. This failure placed residents at risk for not having individualized care and services to meet their needs. Findings included: Review of Resident # 36's Face Sheet dated 07/15/22 reflected he was an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident # 36's CVC site on 08/09/22 at 10:25 AM revealed the transparent dressing on the left inner arm was undated. The dressing was intact without being compromised and no sign of infection. Review of Resident #36's Care plan dated 07/18/22 did not reflect a care plan to address Resident #36's CVC line placement on 07/31/22. An interview on 08/11/22 at 11:45 with the DON revealed Resident #36's should have had an updated care plan for his CVC line placement. The facility's undated policy Care Plans, Comprehensive Person-Centered reflected .include measurable objective and timeframe; Describe the services that are to be finished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wee-being .include the residents stated goals upon admission and desired outcome; reflect treatment goals; timetable and objectives in measurable outcomes.

Based on observation, interview, and record review the facility failed to ensure each resident was free of any significant medication errors for 2 (Resident #1 and Resident #2) of seven residents reviewed for pharmacy services. The facility failed to administer medications or biologicals in accordance with the prescriber's orders and with accepted professional standards when Resident #1's and Resident #2's identities were switched. Resident #1 and Resident #2 did not receive medications for their first evening and night in the facility. Resident #1 received Resident #2 medications for 2 days and missed receiving his medications for diabetes. An Immediate Jeopardy (IJ) situation was identified on 10/17/20. While the IJ was removed on 10/20/20, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy at a scope of isolated, due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. This failure placed residents at risk of significant medication errors resulting in discomfort and/or jeopardizing resident health and safety. Findings: In an interview on 10/15/20 at 4:08 pm the Administrator stated on 8/18/20 they discovered Resident #1 and Resident #2 were COVID-19 positive. The Administrator stated they were in a rush to move the Resident #1 and Resident #2 because they lived in a memory care unit in an Assisted Living Facility on their campus and given the nature of a memory care unit they were afraid the likelihood of it spreading was even greater. The Administrator stated they were going to place Resident #1 in room [ROOM NUMBER] but it was not ready, so they placed him in room [ROOM NUMBER] and they went back to the memory care unit and brought back Resident #2 and placed him in room [ROOM NUMBER]. The Administrator then went back to print the face sheets, but the internet was down, and around 2:00 pm on 8/18/20 they were finally able to print orders and a copy of those orders were delivered to the COVID-19 unit. (Note: this facility was located on a campus with different levels of care. There was an independent living, assisted living, memory care assisted living, and a nursing care facility. The nursing care facility had a COVID-19 unit that the campus utilized for any COVID-19 positive resident that lived on campus.) In an interview on 10/15/20 at 1:15 pm the director of nursing (DON) stated Resident #1 and Resident #2 on 8/18/20 both moved to their facility from a memory care unit that was on their campus, and around 1:00 am on 8/19/20 Resident #2 had to be sent to the hospital for respiratory decline but was mistakenly sent with the identity of Resident #1. Resident #1 (who stayed in the facility) was believed to be Resident #2 and was provided care in the facility according to Resident #2's orders. The DON stated the mix up in identities was not discovered until the morning of 8/20/20 when the Administrator noticed Resident #1 was in the wrong room. The DON stated the Administrator was familiar with both residents because she has worked on the memory care unit on their campus. In an interview on 10/15/20 at 4:47 pm licensed vocational nurse (LVN) B stated she was working the COVID-19 unit on 8/18/20, her shift began at 6:00 am and she only had one resident on the unit, but her normal position at work was the minimum data set (MDS) nurse. LVN B stated she was helping her one resident with lunch when the DON told her she would be getting residents from the memory care unit on campus because they were COVID-19 positive, and the DON assisted her with getting the beds ready and left. LVN B stated maybe around 1:00 pm the back door opened and the Administrator and the Director to the memory care facility on campus brought in Resident #1 and placed him in room [ROOM NUMBER]. LVN B stated she had to ask for orders and name, and they gave her the name of Resident #1 and told her he had a regular diet. LVN B stated CNA A then arrived on the unit. LVN B stated about 15 minutes later the Administrator and Director of the on-campus memory care facility arrived with Resident #2 and with him they had an oxygen concentrator. LVN B stated she again had to ask for orders and a name, they gave her Resident #2's name and told her that he had pureed diet. LVN B stated CNA A assisted Resident #2 with lunch. LVN B stated the internet was down and she could not access the electronic medical records but someone from the memory care brought her orders on paper; on Resident #1 papers she wrote room [ROOM NUMBER] and on Resident #2 paper work she wrote room [ROOM NUMBER]. (Note according to the Pre-Admission Worksheet Resident #1 was to be placed in room [ROOM NUMBER] and Resident #2 was to be placed in room [ROOM NUMBER]). In an interview on 10/15/20 at 1:53 pm certified nurse aide (CNA) A stated around 12:00 pm on 8/18/20 she was pulled to go work the COVID-19 unit because two new residents were being admitted and they needed more staff. CNA A stated earlier in the day the COVID-19 unit only had one resident and the only staff on the hall was a nurse. CNA A stated when she arrived at the COVID-19 unit she could see the Administrator from her facility (this SNF/NF) and another woman who she thinks was a nurse pushing Resident #2 in a wheelchair outside her building and CNA A was not aware that Resident #1 had already arrived to the unit. CNA A stated the Administrator and nurse wheeled Resident #2 into the room [ROOM NUMBER] and CNA A assisted him into a recliner in the room and the nurse adjusted Resident #2's oxygen concentrator. CNA A stated she assisted Resident #2 with lunch, put him in bed, did peri care, and then left for the day because it was close to 2:00 pm and her shift was over at 2:00 pm. CNA A stated at one point she did look in on Resident #1 and noticed he had eaten 50% of his regular texture meal, but the only resident she provided care for was Resident #2. CNA A stated on 8/19/20 when she returned to work that morning Resident #2 was not there. CNA A stated she feels they may have gotten mixed up because in the past for new admissions they have had the room set up, they have done education with the CNAs on the persons and their needs, and the resident name is on the door before they are admitted , and none of this was done before Resident #1 and Resident #2 arrival. In an interview on 10/16/20 at 2:30 pm LVN D stated he received a call from LVN B and she was upset because the facility had not told her they would be bringing 2 new residents over to the COVID-19 unit and LVN B was only given face sheets, orders, and told they have COVID-19 with no kind of report on either resident. LVN D stated he was working his regular shift as an MDS nurse when he went down to relieve LVN B because she was in a hurry to leave as she had to take her son out of town to college. LVN D stated each resident had a pre-assessment worksheet and it stated Resident #2 was in room [ROOM NUMBER] and earlier that day the receptionist had sent an email stating Resident #2 was in room [ROOM NUMBER]. LVN D stated this was his first time to do an admission in the new electronic medical record system they had. LVN D stated the next day 8/19/20 he came to work at 2:00 pm to relieve the DON and Resident #1 was in room [ROOM NUMBER] and Resident #2 was in room [ROOM NUMBER] but the Administrator had put the residents in the wrong rooms. LVN D stated he did not give any medications the evening of 8/18/20 because they had no medications available due to just being admitted . In an interview on 10/15/20 at 2:25 pm LVN A stated on 8/18/20 she arrived at work at 6:00 pm for the evening shift but not on the COVID-19 unit. LVN A stated she received report about Resident #2 when he started to decline, and she went to the COVID-19 unit because Resident #2 was in respiratory distress. There were electronic charts available for him but there was none of the items that are normally available for a new admission such as a hard chart that included a face sheet, care plan, do not resuscitate (DNR) status, name, room number and a card with their physician's name on it. LVN A stated she cannot remember if they sent out the person in room [ROOM NUMBER] or 5410 but she does know the name that was in the electronic medical record matched the name on the door. She thought she was sending Resident #1 to the hospital ER and that Resident #2 was left behind in room [ROOM NUMBER]. LVN A stated she feels not having a hard chart, a wrist band like when they come from the hospital, name on the door before admission, or a picture in the electronic medical records could have contributed to getting the two gentlemen mixed up. LVN A actually assessed sent Resident #2 to the ER, but with the mixed up identities she thought she sent Resident #1. In an interview on 10/15/20 at 3:20 pm LVN C stated she had nothing to do with the transfer on 8/18/20 other than when Resident #1 and Resident #2 came she entered their orders, because they used to have an admissions nurse but no longer do, and the nurse who received the new admission was responsible for the admission paperwork. LVN C stated the residents did not have a hard chart and under normal circumstances that would be completed before admission. She said they had no transfer papers. LVN C stated she feels factors adding to the mix up on 8/18/20 were the residents came in though a side door, they had no hard chart prepared, they had no transfer papers, and no names on the rooms they were admitting to. In an interview on 10/15/20 at 3:34 pm the DON stated she feels factors that contributed to the mix of Resident #1 and Resident #2 on 8/18/20 were there was no report given from nurse to nurse, the residents coming within a close time frame of each other, internet issues, possibly a breakdown of communication between LVN B and LVN D, and she feels it was rushed due to COVID-19 fears. In an interview on 10/15/20 at 4:08 pm the Administrator stated she feels the failure on 8/18/20 was LVN B knew all the information about Resident #1 and Resident #2 and she passed it on to LVN D and LVN D got the residents mixed up. The Administrator stated even though they had just switched to PointClickCare (PCC) in July of 2020 this was not the first admission from another building on their campus. The Administrator stated she arrived to work early the morning of 8/20/20 and she was talking with the DON and noticed it was not Resident #2 in the bed in room [ROOM NUMBER] but it was Resident #1. They quickly notified the physician, the hospital that Resident #2 was sent to, and the families of the mix of Resident #1 and Resident #2. In an interview on 10/16/20 at 1:35 pm the facility Medical Director stated he was informed the morning of 8/20/20 Resident #1 and Resident #2 had their identities mixed up in the facility. The Medical Director was aware that Resident #1 had received Resident #2 medications but could not answer as to which medications he received because he did not have his records with him. The Medical Director also stated he was aware Resident #1 did not receive his diabetes medications and that Resident #2 was sent to the hospital with the identity of Resident #1. The Medical Director stated he does not believe either resident suffered negative effects of the identity mix up, but he does believe the fear of COVID-19 and both men coming at the same time contributed to this failure. Resident #1 (Resident #1 remained in the facility with the mistaken identity of Resident #2 and received care as if he was Resident #2.) Record review of Resident #1 electronic face sheet accessed on 10/16/20 revealed a [AGE] year-old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #1's responsible party (RP) was documented to be his daughter (Family-A). Record review of Resident #1's Pre-Admission Worksheet/Alert dated 8/18/20 revealed Resident #1 was to admit on 8/18/20 to room [ROOM NUMBER]. Record review of Resident #1's admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was a white male and was admitting from another nursing home or swing bed. Record review of Resident #1's 5-day admission MDS dated [DATE] revealed Resident #1 was a white male admitted on [DATE] from the community/assisted living, had the ability to hear, with clear speech, and could usually be understood and understand others. Resident #1 had a Brief Interview for Mental Status (BIMS) of 3 out of 15 which indicated a severely impaired cognition. Resident #1 required extensive assistance with all activities of daily living (ADL) with the support of 1-2 people for all ADLs and Resident #1 utilized a wheelchair for mobility. Resident #1 was frequently had urinary and bowel incontinence. The MDS revealed Resident #1 had received insulin injections and that he was not prescribed antipsychotics. Resident #1 had also been examined by a physician since admission and had 4 order changes since admission. During Resident #1's assessment and goal setting the MDS indicates Resident #1 participated in this assessment and his wishes was to return to the community/assisted living. This MDS was completed on 8/25/20 and received registered nurse verification on 8/27/20. Record review of Resident #1's Interim Care Plan with an effective date of 8/18/20 and time of 12:30 pm revealed it had been struck out by the Administrator, struck out reason was wrong chart, and the struck-out date was 8/24/20 at 7:37 am. The Interim Care Plan also revealed Resident #1 room number was 5409. The form also revealed the following: cognitively impaired unable to determine (UTD); visual impairment UTD; hearing impairment UTD; communication UTD; understand staff UTD; bed mobility total dependence; transferring total dependence; eating total dependence; toilet use total dependence; bathing total dependence; continent of bowel UTD; Medications/Treatments Resident #1 received oxygen and pain medications; Medical conditions for Resident #1 was diabetes. (Note this Interim Care Plan is based on Resident #2 needs.) Record review of Resident #1 electronic order summary report for active orders as of 8/18/20 accessed on 10/16/20 revealed on 8/18/20 the following orders for Resident #1 had been ordered a Regular diet, regular texture, and thin consistency; Fasting blood sugar once daily; Full code; No allergies [REDACTED]. [MEDICATION NAME] HCl Tablet 1000 MG Give 1 tablet by mouth two times a day for Diabetes Mellitus (DM) [MEDICATION NAME] Tablet 5 MG (linaGLIPtin) Give 1 tablet by mouth one time a day for DM [MEDICATION NAME] Tablet 80 MG Give 1 tablet by mouth two times a day for hypertension (HTN) Hold for systolic blood pressure (SBP) <100 Atorvastatin Calcium Tablet 80 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] Ezetimibe Tablet 10 MG Give 1 tablet by mouth one time a day for cholesterol control [MEDICATION NAME] Tablet 160 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] Aspirin Tablet 325 milligrams (MG) Give 1 tablet by mouth one time a day for [MEDICAL CONDITIONS] [MEDICATION NAME] [MEDICATION NAME] HCl Tablet 100 MG Give 1 tablet by mouth one time a day for depression [MEDICATION NAME] Sodium Tablet 75 MCG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth every 8 hours as needed for cough [MEDICATION NAME] HCl Tablet 1 gram (GM) Give 1 tablet by mouth two times a day every 7 day(s) for diarrhea [MEDICATION NAME] Tablet 1000 MCG Give 1 tablet by mouth one time a day for vitamin deficiency [MEDICATION NAME] Tablet 5 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITIONS] Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth one time a day for [MEDICAL CONDITION] Record review of Resident #1 order recap report electronically accessed on 10/16/20 revealed the following Regular concentrated sweets diet, regular texture, thin consistency order date of 8/21/20 (the day after the identity mix up was discovered and Resident #1 had elevated blood sugars for 3 days post not receiving [MEDICATION NAME] for 2 days), complete blood count (CBC) and comprehensive metabolic panel (CMP) one time only order date of 8/21/20, Check blood sugar twice a day and continue with sliding scale two times a day for Blood sugar order date of 8/23/20; May get midline for iv therapy one time only until 08/23/2020 order date of 8/23/20; and the following medications: [REDACTED] [MEDICATION NAME] HCl Tablet 1 GM Give 1 tablet by mouth STAT for diarrhea order date of 8/24/20 [MEDICATION NAME] Tablet 10 MG Give 1 tablet by mouth one time a day for diabetes discontinued 8/23/20 [MEDICATION NAME] XL Tablet Extended Release 24 Hour 10 MG ([MEDICATION NAME] ER) Give 1 tablet by mouth one time only for Diabetes until 08/22/2020 23:59 order date of 8/22/20 [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 70 - 139 = 0 Do not give insulin; 140 - 180 = 3 units give three units [MEDICATION NAME] R; 181 - 240 = 4 units give four units [MEDICATION NAME] R; 241 - 300 = 6 units give six units [MEDICATION NAME] R; 301 - 350 = 8 units give 8 units [MEDICATION NAME] R; 351 - 400 = 10 units give 10 units [MEDICATION NAME] R and CALL MD, subcutaneously two times a day for DM order date of 8/20/20 Lactobacillus Capsule Give 1 capsule by mouth one time a day for Diarrhea order date of 8/24/20 [MEDICATION NAME] Tablet 500 MG Give 1 tablet by mouth three times a day related to COVID-19 (U07.1) until 08/31/2020 12:36 order date of 8/24/20 [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) Inject 15 unit subcutaneously one time only for DM until 08/20/2020 23:59 with order date of 8/20/20 Sodium Chloride Solution 0.9 % Use 50 millimeter (ml)/hour (hr) intravenously every shift for Nasal agents - Systemic and topical until 08/26/2020 20:44 Give 2 liters Record review of Resident #1 August 2020 medication administration recorded electronically accessed on 10/16/20 revealed Resident #1 did not have any medications signed as given for 8/18/20 or 8/19/20. This information informs you that Resident #2 did not receive any medications while in the facility, since on 8/18/20 and 8/19/20 Resident #2 was thought to be Resident #1 and would have been administered Resident #1's medications. Resident #1's August 2020 Medication Administration Record [REDACTED]. Record review of Resident #1's progress notes revealed no progress notes until 8/20/20 at 9:58 am the note was addressing his elevated blood sugar of 378, not receiving DM medications yesterday, and a new order for regular insulin 15 units a one time dose. On 10/16/20 a request for Resident #1 progress notes from 8/18/20 through 8/20/20 but was given notes from 8/20/20 through 8/24/20. Record review of Residents #1 weights and vitals summary revealed the following: Blood sugar reading did not begin until 8/20/20 with a reading of 378 and they remained above 200 for 3 days on 8/20/20, 8/21/20, and 8/22/20 and on 8/24/20, 8/25/20, 8/26/20, 8/31/20. (Note the normal range for blood sugar reading is 140-200). Resident #1 blood pressures exceeded normal limits of a systolic blood pressure of 139 or greater and diastolic of 89 or higher on 8/20/20, 8/21/20, 8/22/20, 8/23/20, 8/26/20, 8/27/20, 8/28/20, 8/29/20, 8/30/20, and 8/31/20. Resident #1 oxygen saturation, pulse, respiration, and temperature remains with in normal limits. Record review of Resident #1 August 2020 Medication Administration Record [REDACTED] 8/20/20 blood sugar reading of 378 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 15 units. 8/22/20 blood sugar reading of 227 and received [MEDICATION NAME] R 4 units; blood sugar reading of 313 and received [MEDICATION NAME] R 8 units. 8/23/20 blood sugar reading of 182 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 4 units. 8/24/20 blood sugar reading of 231 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 4 units. 8/25/20 blood sugar reading of 174 and received [MEDICATION NAME] R 3 units; blood sugar reading of 249 and received [MEDICATION NAME] R 6 units. 8/26/20 blood sugar reading of 221 and received [MEDICATION NAME] R 4 units; blood sugar reading of 174 and received [MEDICATION NAME] 3 units. 8/27/20 blood sugar reading of 166 and received [MEDICATION NAME] R 3 units. 8/28/20 blood sugar reading of 184 and received [MEDICATION NAME] R 4 units; blood sugar reading of 143 and received [MEDICATION NAME] R 3 units. 8/29/20 blood sugar reading of 184 and received [MEDICATION NAME] R 4 units. 8/30/20 blood sugar reading of 168 and received [MEDICATION NAME] R 3 units. (Note Resident #1 diabetes was well controlled with [MEDICATION NAME] and he had not needed insulin in the past.) Record review of Resident #1 PassPort detailed transaction log dated 8/19/2020 to 8/19/2020 at 5:38 pm provided by the DON on 10/16/20 revealed no medications were dispensed from PassPort until 6:13 pm for Resident #1 as follows: 6:13 pm Levothyroxin, 9:24 pm [MEDICATION NAME], 9:25 pm [MEDICATION NAME] and [MEDICATION NAME], 9:26 pm [MEDICATION NAME]. (Note with the mix up of identity these medications should have been administered to Resident #2, but no medications were signed as given on 8/18/20). Record review of Resident #1 electronic medical record revealed Resident #1 (actually Resident #2) received at least 8 nursing assessments that are required at admission the day of his entry to the facility by LVN D and all have been struck out with a notation indication wrong chart by the Administrator. Record review of an history and physical by Resident #1 physician with an encounter date of 8/20/20 and electronically signed by his physician on 8/24/20 revealed the resident was confused and the physician was unable to get history; he planned to talk with the Resident #1's daughter and family; and No deleterious or untoward side effects were seen by the mix up of patient identities and medication list. I have personally reviewed all meds or both patients. Medications received were [MEDICATION NAME] (Fe), [MEDICATION NAME], Quetiapine, Ropinirole, [MEDICATION NAME], and Terbinafine cream one dose of each medication. Patient showed no side effects by this administration. I have discussed at length with the daughter about the mix up and that we will keep close eye on any new changes. In an interview on 10/15/20 at 1:53 pm CNA A stated although she cannot remember which day it was she does remember Resident #1 receiving pureed foods for breakfast and she sent it back and told them it was wrong, because she remembers him having regular texture foods. CNA A stated she addressed it with the DON who was working the unit and the DON told her it is in his chart to have pureed foods with honey thick liquids. (Note Resident #2 was to be receiving pureed foods). In an interview on 10/15/20 at 7:55 pm Family A stated Resident #1 was tested for COVID-19 on 8/16/20 and on 8/18/20 they were informed he tested positive. On 8/18/20 Family A stated the Administrator called her around lunch to inform her they had moved her father from memory care to the health care building due to him being COVID-19 positive. Around 5:00 pm that day she received a call from the Medical Director of the health care building to discuss the positive COVID-19 test results. On 8/18/20 at 11:54 pm she received a call from a woman whose name she could not recall, to inform her that her father had been transported to a local hospital due to respiratory distress, because his oxygen levels had dropped. Family A stated she asked how her father was asymptomatic 6 hours was earlier was now on oxygen and declining and she knew nothing about it, and LVN A told her she did not know. Family A stated LVN A told her to call the hospital and they would be able to help her. Family A was able to speak with her mother around 3:30 am and inform her of her father being sent to the hospital and her mother was inconsolable. Family A stated around 6:00 am she received a call from the hospital that her father was doing better and did not have to go on a ventilator. At 10:18 am Family A emailed facility nursing staff asking them to please fax her father's medication to the hospital because it does not appear all his medications got reported to the hospital and they were under the impression he was on two liters of oxygen and she mentioned her father was diabetic. Family A stated between 10:20 am - 12:00 pm she received a call from the facility stating they would send the medication list. Family A stated at 12:00 pm she received a call from the hospital stating he was doing well but did not pass a swallow study and his oxygen levels were good, and he may be moving out of intensive care. Family A stated the last communication she had with anyone was on 8/19/20 around 9:00 pm when she spoke with hospital staff they put what she thought was her father on the phone as well so she and him could speak, but she said it did not even sound like her father, the voice was weak and high-pitched. On the morning of 9/20/20 at 9:15 am Family A and her mother conferenced called the hospital to get an update on her father and they were told to call the Administrator at the facility. She said the hospital staff would not answer any questions, and just kept telling her to call the Administrator and gave her the Administrator's phone number. At around 9:30 am she called the number and the Administrator answered telling her she was just about to call her; the Administrator then informed her that her father had never left the building and was still at the facility and was doing well and was still asymptomatic. Family A asked the Administrator how it was possible to mix up the residents and the Administrator told her they were following different protocols by taking them in through the back door and not following the normal procedures for admissions to their facility. The Administrator also informed her that her father had been taking someone else's medications. Family A stated around 12:30 pm her mother got to face time her father and confirm he was in the facility and doing ok. Resident #1 was eventually sent to an area hospital for COVID-19 related issue. Resident #1 was released from the hospital to an intensive rehab unit, and eventually admitted back into the memory care unit. Resident #2 (Resident #2 was sent to the hospital with Resident #1's identity.) Record review of Resident #2 electronic face sheet accessed on 10/16/20 revealed a [AGE] year-old male 8/18/20 with the following Diagnosis: [REDACTED].#2's RP to be his daughter. Record review of Resident #2's Pre-Admission Worksheet/Alert dated 8/18/20 revealed Resident #2 was to admit on 8/18/20 to room [ROOM NUMBER]. Record review of Resident #2's electronic health record did not reveal an MDS. Record review of Resident #2's Interim Care Plan with an effective date of 8/18/20 and time of 12:00 pm revealed it had been struck out by the Administrator, struck out reason was wrong chart, and the struck-out date was 8/24/20 at 7:39 am. The Interim Care Plan also revealed Resident #2 room number was 5409. The form also revealed the following: cognitively impaired yes; visual impairment no; hearing impairment no; communication yes; bed mobility independent; transferring with assistance; eating independent; toilet use with assistance; bathing UTD; continent of bowel yes; Medications/Treatments Resident #2 received pain medications and anti-psychotics/[MEDICAL CONDITION]; Medical conditions for Resident #2 was therapy. This Interim Care Plan is based on Resident #1 needs. Record review of Resident #2 order recap report electronically accessed on 10/16/20 revealed the following: allergies [REDACTED]. [MEDICATION NAME] Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath or Wheezing Aspirin Tablet Chewable 81 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth every 8 hours as needed for cough [MEDICATION NAME] Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 300 MG Give 2 capsule by mouth at bedtime for [MEDICAL CONDITION]/leg pain 2 caps = 600mg [MEDICATION NAME] ER Tablet Extended Release 12 Hour 600 MG Give 1 tablet by mouth every 12 hours as needed for cough/congestion [MEDICATION NAME] Tablet Give 12.5 milligram by mouth two times a day [MEDICAL CONDITION] if SBP is >110 [MEDICATION NAME] Tablet 15 MG Give 1 tablet by mouth one time a day for depression [MEDICATION NAME] HCl Tablet 4 MG Give 1 tablet by mouth every 6 hours as needed for Nausea and Vomiting QUEtiapine [MEDICATION NAME] Tablet 25 MG Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] w/behavioral disturbance rOPINIRole HCl Tablet 0.5 MG Give 2 tablet by mouth every 24 hours as needed for RLS Give 2 tabs = 1mg PO hour of sleep (HS) as needed (PRN) for restless leg syndrome (RLS) rOPINIRole HCl Tablet 5 MG Give 1 tablet by mouth one time a day for RLS Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth one time a day for [MEDICAL CONDITION] Terbinafine HCl Cream 1 % Apply to between toes topically every day shift for Infection [MEDICATION NAME] HCl Tablet 100 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Cream 0.1 % Apply to areas affected by rash topically every 12 hours as needed for rash/pruritus Zinc Tablet 50 MG Give 1 tablet by mouth three times a day for supplement [MEDICATION NAME] Tablet 200 MG Give 200 mg by mouth one time a day for Covid 19 until 08/20/2020 19:00 200mg by mouth (PO) x 1 Dose on 8/20/2020 @ 4PM was ordered 8/19/20 Record review of Resident #2's August 2020 medication administration recorded electronically accessed on 10/16/20 revealed the following medications were signed as administered: Aspirin Tablet Chewable 81 MG on 8/19/20; [MEDICATION NAME] Tablet 325 (65 Fe) MG on 8/19/20; [MEDICATION NAME] Capsule 300 MG Give 2 capsule on 8/18/20 and 8/19/20; QUEtiapine [MEDICATION NAME] Tablet 25 MG on 8/18/20; rOPINIRole HCl Tablet 5 MG on 8/18/20; Tamsulosin HCl Capsule 0.4 MG on 8/18/20; [MEDICATION NAME] Tablet Give 12.5 milligram on 8/19/20; and Terbinafine HCl Cream 1 % Apply to between toes topically on 8/19/20. These medications were administered to Resident #1, since at that time the facility believed he was Resident #2. Record review of Resident #2's PassPort detailed transaction log dated 8/19/2020 to 8/19/2020 provided by the DON on 10/16/20 revealed the following medications had been dispensed: 8/18/20- 5:19 [MEDICATION NAME] and Quetiapine. With the identity mix up Resident #2 did not receive these medications but would have been administered to Resident #1 in error. Record review of Resident #2's progress notes revealed on 8/19/20 at 11:16 am the director of nursing (DON) noted Resident #2 received a pureed diet with honey thicken liquids. On 8/19/20 at 1:34 pm the DON made an entry stating it was reported to her that Resident #2 had received a regular diet with no choking or coughing noted. Resident #2 had a history a prior history of swallowing issues. Currently on a pureed diet with honey thick liquids. Daughter notified of resident receiving regular diet. These notes had been stuck out with notation of wrong chart. Record review of Resident #2's physician notes revealed a note on 8/20/20 at 6:25 Reviewed chart and notes from local hospital. Talked to nurse, medical docto(TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure each resident was free from neglect for 2 (Resident #1 and Resident #2) of seven residents reviewed for freedom from abuse, neglect, and exploitation. The facility failed to provide goods and services to residents that were necessary to avoid physical harm, pain, mental anguish or emotional distress when Resident #1's and Resident #2's identities were switched when the facility did not follow their admission procedures. Resident #1 and Resident #2 did not receive medications for their first evening and night in the facility. Resident #1 received Resident #2 medications for 2 days and missed receiving his medications for diabetes. Resident #2 was sent to the hospital with the identity of Resident #1 and the wrong family was informed of the emergency transfer. Resident #1's family proceeded to make care decisions for the wrong family member when the hospital contacted them about life-saving measures. An Immediate Jeopardy (IJ) situation was identified on 10/17/20. While the IJ was removed on 10/20/20, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy at a scope of isolated, due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. This failure placed residents at risk of having their identity mistaken and neglect. Findings: Record review of the facility policy dated December 2016 revealed the following: Abuse Prevention Program, Policy Statement, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation, As part of the resident abuse prevention, the administration will: 1. Protect our resident from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual .3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect or mistreatment of [REDACTED]. In an interview on 10/15/20 at 4:08 pm the Administrator stated on 8/18/20 they discovered Resident #1 and Resident #2 were COVID-19 positive. The Administrator stated they were in a rush to move the Resident #1 and Resident #2 because they lived in a memory care unit in an Assisted Living Facility on their campus and given the nature of a memory care unit they were afraid the likelihood of it spreading was even greater. The Administrator stated they were going to place Resident #1 in room [ROOM NUMBER] but it was not ready, so they placed him in room [ROOM NUMBER] and they went back to the memory care unit and brought back Resident #2 and placed him in room [ROOM NUMBER]. The Administrator then went back to print the face sheets, but the internet was down, and around 2:00 pm on 8/18/20 they were finally able to print orders and a copy of those orders were delivered to the COVID-19 unit. (Note: this facility was located on a campus with different levels of care. There was an independent living, assisted living, memory care assisted living, and a nursing care facility. The nursing care facility had a COVID-19 unit that the campus utilized for any COVID-19 positive resident that lived on campus.) In an interview on 10/15/20 at 1:15 pm the director of nursing (DON) stated Resident #1 and Resident #2 on 8/18/20 both moved to their facility from a memory care unit that was on their campus, and around 1:00 am on 8/19/20 Resident #2 had to be sent to the hospital for respiratory decline but was mistakenly sent with the identity of Resident #1. Resident #1 (who stayed in the facility) was believed to be Resident #2 and was provided care in the facility according to Resident #2's orders. The DON stated the mix up in identities was not discovered until the morning of 8/20/20 when the Administrator noticed Resident #1 was in the wrong room. The DON stated the Administrator was familiar with both residents because she has worked on the memory care unit on their campus. In an interview on 10/15/20 at 4:47 pm licensed vocational nurse (LVN) B stated she was working the COVID-19 unit on 8/18/20, her shift began at 6:00 am and she only had one resident on the unit, but her normal position at work was the minimum data set (MDS) nurse. LVN B stated she was helping her one resident with lunch when the DON told her she would be getting residents from the memory care unit on campus because they were COVID-19 positive, and the DON assisted her with getting the beds ready and left. LVN B stated maybe around 1:00 pm the back door opened and the Administrator and the Director to the memory care facility on campus brought in Resident #1 and placed him in room [ROOM NUMBER]. LVN B stated she had to ask for orders and name, and they gave her the name of Resident #1 and told her he had a regular diet. LVN B stated CNA A then arrived on the unit. LVN B stated about 15 minutes later the Administrator and Director of the on-campus memory care facility arrived with Resident #2 and with him they had an oxygen concentrator. LVN B stated she again had to ask for orders and a name, they gave her Resident #2's name and told her that he had pureed diet. LVN B stated CNA A assisted Resident #2 with lunch. LVN B stated the internet was down and she could not access the electronic medical records but someone from the memory care brought her orders on paper; on Resident #1 papers she wrote room [ROOM NUMBER] and on Resident #2 paper work she wrote room [ROOM NUMBER]. (Note according to the Pre-Admission Worksheet Resident #1 was to be placed in room [ROOM NUMBER] and Resident #2 was to be placed in room [ROOM NUMBER]). In an interview on 10/15/20 at 1:53 pm certified nurse aide (CNA) A stated around 12:00 pm on 8/18/20 she was pulled to go work the COVID-19 unit because two new residents were being admitted and they needed more staff. CNA A stated earlier in the day the COVID-19 unit only had one resident and the only staff on the hall was a nurse. CNA A stated when she arrived at the COVID-19 unit she could see the Administrator from her facility (this SNF/NF) and another woman who she thinks was a nurse pushing Resident #2 in a wheelchair outside her building and CNA A was not aware that Resident #1 had already arrived to the unit. CNA A stated the Administrator and nurse wheeled Resident #2 into the room [ROOM NUMBER] and CNA A assisted him into a recliner in the room and the nurse adjusted Resident #2's oxygen concentrator. CNA A stated she assisted Resident #2 with lunch, put him in bed, did peri care, and then left for the day because it was close to 2:00 pm and her shift was over at 2:00 pm. CNA A stated at one point she did look in on Resident #1 and noticed he had eaten 50% of his regular texture meal, but the only resident she provided care for was Resident #2. CNA A stated on 8/19/20 when she returned to work that morning Resident #2 was not there. CNA A stated she feels they may have gotten mixed up because in the past for new admissions they have had the room set up, they have done education with the CNAs on the persons and their needs, and the resident name is on the door before they are admitted , and none of this was done before Resident #1 and Resident #2 arrival. In an interview on 10/16/20 at 2:30 pm LVN D stated he received a call from LVN B and she was upset because the facility had not told her they would be bringing 2 new residents over to the COVID-19 unit and LVN B was only given face sheets, orders, and told they have COVID-19 with no kind of report on either resident. LVN D stated he was working his regular shift as an MDS nurse when he went down to relieve LVN B because she was in a hurry to leave as she had to take her son out of town to college. LVN D stated each resident had a pre-assessment worksheet and it stated Resident #2 was in room [ROOM NUMBER] and earlier that day the receptionist had sent an email stating Resident #2 was in room [ROOM NUMBER]. LVN D stated this was his first time to do an admission in the new electronic medical record system they had. LVN D stated the next day 8/19/20 he came to work at 2:00 pm to relieve the DON and Resident #1 was in room [ROOM NUMBER] and Resident #2 was in room [ROOM NUMBER] but the Administrator had put the residents in the wrong rooms. LVN D stated he did not give any medications the evening of 8/18/20 because they had no medications available due to just being admitted . In an interview on 10/15/20 at 2:25 pm LVN A stated on 8/18/20 she arrived at work at 6:00 pm for the evening shift but not on the COVID-19 unit. LVN A stated she received report about Resident #2 when he started to decline, and she went to the COVID-19 unit because Resident #2 was in respiratory distress. There were electronic charts available for him but there was none of the items that are normally available for a new admission such as a hard chart that included a face sheet, care plan, do not resuscitate (DNR) status, name, room number and a card with their physician's name on it. LVN A stated she cannot remember if they sent out the person in room [ROOM NUMBER] or 5410 but she does know the name that was in the electronic medical record matched the name on the door. She thought she was sending out Resident #1 to the hospital ER and that Resident #2 was left behind in room [ROOM NUMBER]. LVN A stated she feels not having a hard chart, a wrist band like when they come from the hospital, name on the door before admission, or a picture in the electronic medical records could have contributed to getting the two gentlemen mixed up. LVN A actually assessed and sent Resident #2 to the ER, but with the mixed up identities she thought she sent Resident #1). In an interview on 10/15/20 at 3:20 pm LVN C stated she had nothing to do with the transfer on 8/18/20 other than when Resident #1 and Resident #2 came she entered their orders, because they used to have an admissions nurse but no longer do, and the nurse who received the new admission was responsible for the admission paperwork. LVN C stated the residents did not have a hard chart and under normal circumstances that would be completed before admission. She said they had no transfer papers. LVN C stated she feels factors adding to the mix up on 8/18/20 were the residents came in though a side door, they had no hard chart prepared, they had no transfer papers, and no names on the rooms they were admitting to. In an interview on 10/15/20 at 3:34 pm the DON stated she feels factors that contributed to the mix of Resident #1 and Resident #2 on 8/18/20 were there was no report given from nurse to nurse, the residents coming within a close time frame of each other, internet issues, possibly a breakdown of communication between LVN B and LVN D, and she feels it was rushed due to COVID-19 fears. In an interview on 10/15/20 at 4:08 pm the Administrator stated she feels the failure on 8/18/20 was LVN B knew all the information about Resident #1 and Resident #2 and she passed it on to LVN D and LVN D got the residents mixed up. The Administrator stated even though they had just switched to PointClickCare (PCC) in July of 2020 this was not the first admission from another building on their campus. The Administrator stated she arrived to work early the morning of 8/20/20 and she was talking with the DON and noticed it was not Resident #2 in the bed in room [ROOM NUMBER] but it was Resident #1. They quickly notified the physician, the hospital that Resident #2 was sent to, and the families of the mix of Resident #1 and Resident #2. In an interview on 10/16/20 at 1:35 pm the facility Medical Director stated he was informed the morning of 8/20/20 Resident #1 and Resident #2 had their identities mixed up in the facility. The Medical Director was aware that Resident #1 had received Resident #2 medications but could not answer as to which medications he received because he did not have his records with him. The Medical Director also stated he was aware Resident #1 did not receive his diabetes medications and that Resident #2 was sent to the hospital with the identity of Resident #1. The Medical Director stated he does not believe either resident suffered negative effects of the identity mix up, but he does believe the fear of COVID-19 and both men coming at the same time contributed to this failure. Resident #1 (Resident #1 remained in the facility with the mistaken identity of Resident #2 and received care as if he was Resident #2.) Record review of Resident #1 electronic face sheet accessed on 10/16/20 revealed a [AGE] year-old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #1's responsible party (RP) was documented to be his daughter (Family-A). Record review of Resident #1's Pre-Admission Worksheet/Alert dated 8/18/20 revealed Resident #1 was to admit on 8/18/20 to room [ROOM NUMBER]. Record review of Resident #1's admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was a white male and was admitting from another nursing home or swing bed. Record review of Resident #1's 5-day admission MDS dated [DATE] revealed Resident #1 was a white male admitted on [DATE] from the community/assisted living, had the ability to hear, with clear speech, and could usually be understood and understand others. Resident #1 had a Brief Interview for Mental Status (BIMS) of 3 out of 15 which indicated a severely impaired cognition. Resident #1 required extensive assistance with all activities of daily living (ADL) with the support of 1-2 people for all ADLs and Resident #1 utilized a wheelchair for mobility. Resident #1 frequently had urinary and bowel incontinence. The MDS revealed Resident #1 had received insulin injections and that he was not prescribed antipsychotics. Resident #1 had also been examined by a physician since admission and had 4 order changes since admission. During Resident #1's assessment and goal setting the MDS indicates Resident #1 participated in this assessment and his wishes was to return to the community/assisted living. This MDS was completed on 8/25/20 and received registered nurse verification on 8/27/20. Record review of Resident #1's Interim Care Plan with an effective date of 8/18/20 and time of 12:30 pm revealed it had been struck out by the Administrator, struck out reason was wrong chart, and the struck-out date was 8/24/20 at 7:37 am. The Interim Care Plan also revealed Resident #1 room number was 5409. The form also revealed the following: cognitively impaired unable to determine (UTD); visual impairment UTD; hearing impairment UTD; communication UTD; understand staff UTD; bed mobility total dependence; transferring total dependence; eating total dependence; toilet use total dependence; bathing total dependence; continent of bowel UTD; Medications/Treatments Resident #1 received oxygen and pain medications; Medical condition for Resident #1 was diabetes. (Note this Interim Care Plan is based on Resident #2 needs.) Record review of Resident #1 electronic order summary report for active orders as of 8/18/20 accessed on 10/16/20 revealed on 8/18/20 the following orders for Resident #1 had been ordered a Regular diet, regular texture, and thin consistency; Fasting blood sugar once daily; Full code; No allergies [REDACTED]. [MEDICATION NAME] HCl Tablet 1000 MG Give 1 tablet by mouth two times a day for Diabetes Mellitus (DM) [MEDICATION NAME] Tablet 5 MG (linaGLIPtin) Give 1 tablet by mouth one time a day for DM [MEDICATION NAME] Tablet 80 MG Give 1 tablet by mouth two times a day for hypertension (HTN) Hold for systolic blood pressure (SBP) <100 Atorvastatin Calcium Tablet 80 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] Ezetimibe Tablet 10 MG Give 1 tablet by mouth one time a day for cholesterol control [MEDICATION NAME] Tablet 160 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] Aspirin Tablet 325 milligrams (MG) Give 1 tablet by mouth one time a day for [MEDICAL CONDITIONS] [MEDICATION NAME] [MEDICATION NAME] HCl Tablet 100 MG Give 1 tablet by mouth one time a day for depression [MEDICATION NAME] Sodium Tablet 75 MCG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth every 8 hours as needed for cough [MEDICATION NAME] HCl Tablet 1 gram (GM) Give 1 tablet by mouth two times a day every 7 day(s) for diarrhea [MEDICATION NAME] Tablet 1000 MCG Give 1 tablet by mouth one time a day for vitamin deficiency [MEDICATION NAME] Tablet 5 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITIONS] Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth one time a day for [MEDICAL CONDITION] Record review of Resident #1 order recap report electronically accessed on 10/16/20 revealed the following Regular concentrated sweets diet, regular texture, thin consistency order date of 8/21/20 (the day after the identity mix up was discovered and Resident #1 had elevated blood sugars for 3 days post not receiving [MEDICATION NAME] for 2 days), complete blood count (CBC) and comprehensive metabolic panel (CMP) one time only order date of 8/21/20, Check blood sugar twice a day and continue with sliding scale two times a day for Blood sugar order date of 8/23/20; May get midline for iv therapy one time only until 08/23/2020 order date of 8/23/20; and the following medications: [REDACTED] [MEDICATION NAME] HCl Tablet 1 GM Give 1 tablet by mouth STAT for diarrhea order date of 8/24/20 [MEDICATION NAME] Tablet 10 MG Give 1 tablet by mouth one time a day for diabetes discontinued 8/23/20 [MEDICATION NAME] XL Tablet Extended Release 24 Hour 10 MG ([MEDICATION NAME] ER) Give 1 tablet by mouth one time only for Diabetes until 08/22/2020 23:59 order date of 8/22/20 [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 70 - 139 = 0 Do not give insulin; 140 - 180 = 3 units give three units [MEDICATION NAME] R; 181 - 240 = 4 units give four units [MEDICATION NAME] R; 241 - 300 = 6 units give six units [MEDICATION NAME] R; 301 - 350 = 8 units give 8 units [MEDICATION NAME] R; 351 - 400 = 10 units give 10 units [MEDICATION NAME] R and CALL MD, subcutaneously two times a day for DM order date of 8/20/20 Lactobacillus Capsule Give 1 capsule by mouth one time a day for Diarrhea order date of 8/24/20 [MEDICATION NAME] Tablet 500 MG Give 1 tablet by mouth three times a day related to COVID-19 (U07.1) until 08/31/2020 12:36 order date of 8/24/20 [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) Inject 15 unit subcutaneously one time only for DM until 08/20/2020 23:59 with order date of 8/20/20 Sodium Chloride Solution 0.9 % Use 50 millimeter (ml)/hour (hr) intravenously every shift for Nasal agents - Systemic and topical until 08/26/2020 20:44 Give 2 liters Record review of Resident #1 August 2020 medication administration recorded electronically accessed on 10/16/20 revealed Resident #1 did not have any medications signed as given for 8/18/20 or 8/19/20. This information informs you that Resident #2 did not receive any medications while in the facility, since on 8/18/20 and 8/19/20 Resident #2 was thought to be Resident #1 and would have been administered Resident #1's medications. Resident #1's August 2020 Medication Administration Record [REDACTED]. (Note this information informs you that Resident #2 did not receive any medications while in the facility). Record review of Resident #1's progress notes revealed no progress notes until 8/20/20 at 9:58 am the note was addressing his elevated blood sugar of 378, not receiving DM medications yesterday, and a new order for regular insulin 15 units a one time dose. On 10/16/20 a request for Resident #1 progress notes from 8/18/20 through 8/20/20 but was given notes from 8/20/20 through 8/24/20. Record review of Residents #1 weights and vitals summary revealed the following: Blood sugar reading did not begin until 8/20/20 with a reading of 378 and they remained above 200 for 3 days on 8/20/20, 8/21/20, and 8/22/20 and on 8/24/20, 8/25/20, 8/26/20, 8/31/20. Resident #1 blood pressures exceeded normal limits of a systolic blood pressure of 139 or greater and diastolic of 89 or higher on 8/20/20, 8/21/20, 8/22/20, 8/23/20, 8/26/20, 8/27/20, 8/28/20, 8/29/20, 8/30/20, and 8/31/20. Resident #1 oxygen saturation, pulse, respiration, and temperature remains with in normal limits. (Note the normal range for blood sugar reading is 140-200). Record review of Resident #1 August 2020 Medication Administration Record [REDACTED] 8/20/20 blood sugar reading of 378 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 15 units. 8/22/20 blood sugar reading of 227 and received [MEDICATION NAME] R 4 units; blood sugar reading of 313 and received [MEDICATION NAME] R 8 units. 8/23/20 blood sugar reading of 182 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 4 units. 8/24/20 blood sugar reading of 231 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 4 units. 8/25/20 blood sugar reading of 174 and received [MEDICATION NAME] R 3 units; blood sugar reading of 249 and received [MEDICATION NAME] R 6 units. 8/26/20 blood sugar reading of 221 and received [MEDICATION NAME] R 4 units; blood sugar reading of 174 and received [MEDICATION NAME] 3 units. 8/27/20 blood sugar reading of 166 and received [MEDICATION NAME] R 3 units. 8/28/20 blood sugar reading of 184 and received [MEDICATION NAME] R 4 units; blood sugar reading of 143 and received [MEDICATION NAME] R 3 units. 8/29/20 blood sugar reading of 184 and received [MEDICATION NAME] R 4 units. 8/30/20 blood sugar reading of 168 and received [MEDICATION NAME] R 3 units. (Note Resident #1 diabetes was well controlled with [MEDICATION NAME] and he had not needed insulin in the past.) Record review of Resident #1 PassPort detailed transaction log dated 8/19/2020 to 8/19/2020 at 5:38 pm provided by the DON on 10/16/20 revealed no medications were dispensed from PassPort until 6:13 pm for Resident #1 as follows: 6:13 pm Levothyroxin, 9:24 pm [MEDICATION NAME], 9:25 pm [MEDICATION NAME] and [MEDICATION NAME], 9:26 pm [MEDICATION NAME]. (Note with the mix up of identity these medications should have been administered to Resident #2, but no medications were signed as given on 8/18/20). Record review of Resident #1 electronic medical record revealed Resident #1 (actually Resident #2) received at least 8 nursing assessments that are required at admission the day of his entry to the facility by LVN D and all have been struck out with a notation indication wrong chart by the Administrator. Record review of an history and physical by Resident #1 physician with an encounter date of 8/20/20 and electronically signed by his physician on 8/24/20 revealed the resident was confused and the physician was unable to get history; he planned to talk with the Resident #1's daughter and family; and No deleterious or untoward side effects were seen by the mix up of patient identities and medication list. I have personally reviewed all meds or both patients. Medications received were [MEDICATION NAME] (Fe), [MEDICATION NAME], Quetiapine, Ropinirole, [MEDICATION NAME], and Terbinafine cream one dose of each medication. Patient showed no side effects by this administration. I have discussed at length with the daughter about the mix up and that we will keep close eye on any new changes. In an interview on 10/15/20 at 1:53 pm CNA A stated although she cannot remember which day it was she does remember Resident #1 receiving pureed foods for breakfast and she sent it back and told them it was wrong, because she remembers him having regular texture foods. CNA A stated she addressed it with the DON who was working the unit and the DON told her it is in his chart to have pureed foods with honey thick liquids. (Note Resident #2 was to be receiving pureed foods). In an interview on 10/15/20 at 7:55 pm Family A stated Resident #1 was tested for COVID-19 on 8/16/20 and on 8/18/20 they were informed he tested positive. On 8/18/20 Family A stated the Administrator called her around lunch to inform her they had moved her father from memory care to the health care building due to him being COVID-19 positive. Around 5:00 pm that day she received a call from the Medical Director of the health care building to discuss the positive COVID-19 test results. On 8/18/20 at 11:54 pm she received a call from a woman whose name she could not recall, to inform her that her father had been transported to a local hospital due to respiratory distress, because his oxygen levels had dropped. Family A stated she asked how her father was asymptomatic 6 hours was earlier was now on oxygen and declining and she knew nothing about it, and LVN A told her she did not know. Family A stated LVN A told her to call the hospital and they would be able to help her. Family A stated around 12:30 am she received a call from the hospital her father had been sent to and they asked if her father had a DNR and Family A informed them she had no document specific to a DNR but she did fax what documents she had such as durable medical power of attorney, HIPAA release, and directive to physicians. Family A received a call around 1:30 am on 8/19/20 and the hospital reported her father had a fever of 102.2 degrees Fahrenheit, difficulty breathing, and a chest x-ray determined he had COVID pneumonia. At this time the person on the phone asked her to confirm if he was on 2 liters of oxygen typically and she let her know her father was not normally on oxygen. She said they discussed if he was a DNR, if they needed to could they place him on a respirator, do chest compressions if needed, and she told her she can't give answers to that at this time, and the nurse told her they would treat him as a full code and they would be moving him to the intensive care unit in a few hours. Family A stated they called her again around 3:00 am asking what life saving measures they could take. Family A was able to speak with her mother around 3:30 am and inform her of her father being sent to the hospital and her mother was inconsolable. Family A stated around 6:00 am she received a call from the hospital that her father was doing better and did not have to go on a ventilator. At 10:18 am Family A emailed facility nursing staff asking them to please fax her father's medication to the hospital because it does not appear all his medications got reported to the hospital and they are under the impression he is on two liters of oxygen and she mentioned her father was diabetic. Family A stated between 10:20 am - 12:00 pm she received a call from the facility stating they would send the medication list. Family A stated at 12:00 pm she received a call from the hospital stating he was doing well but did not pass a swallow study and his oxygen levels were good, and he may be moving out of intensive care. Family A stated the last communication she had with anyone was on 8/19/20 around 9:00 pm when she spoke with hospital staff they put what she thought was her father on the phone as well so she and him could speak, but she said it did not even sound like her father, the voice was weak and high-pitched. On the morning of 9/20/20 at 9:15 am Family A and her mother conferenced called the hospital to get an update on her father and they were told to call the Administrator at the facility. She said the hospital staff would not answer any questions, and just kept telling her to call the Administrator and gave her the Administrator's phone number. At around 9:30 am she called the number and the Administrator answered telling her she was just about to call her; the Administrator then informed her that her father had never left the building and was still at the facility and was doing well and was still asymptomatic. Family A asked the Administrator how it was possible to mix up the residents and the Administrator told her they were following different protocols by taking them in through the back door and not following the normal procedures for admissions to their facility. The Administrator also informed her that her father had been taking someone else's medications. Family A stated around 12:30 pm her mother got to face time her father and confirm he was in the facility and doing ok. Resident #1 was eventually sent to an area hospital for COVID-19 related issue. Resident #1 was released from the hospital to an intensive rehab unit, and eventually admitted back into the memory care unit. Resident #2 (Resident #2 was sent to the hospital with Resident #1's identity.) Record review of Resident #2 electronic face sheet accessed on 10/16/20 revealed a [AGE] year-old male 8/18/20 with the following Diagnosis: [REDACTED].#2's RP to be his daughter. Record review of Resident #2's Pre-Admission Worksheet/Alert dated 8/18/20 revealed Resident #2 was to admit on 8/18/20 to room [ROOM NUMBER]. Record review of Resident #2's electronic health record did not reveal an MDS. Record review of Resident #2's Interim Care Plan with an effective date of 8/18/20 and time of 12:00 pm revealed it had been struck out by the Administrator, struck out reason was wrong chart, and the struck-out date was 8/24/20 at 7:39 am. The Interim Care Plan also revealed Resident #2 room number was 5409. The form also revealed the following: cognitively impaired yes; visual impairment no; hearing impairment no; communication yes; bed mobility independent; transferring with assistance; eating independent; toilet use with assistance; bathing UTD; continent of bowel yes; Medications/Treatments Resident #2 received pain medications and anti-psychotics/[MEDICAL CONDITION]; Medical conditions for Resident #2 was therapy. (Note this Interim Care Plan is based on Resident #1 needs.) Record review of Resident #2 order recap report electronically accessed on 10/16/20 revealed the following: allergies [REDACTED]. [MEDICATION NAME] Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath or Wheezing Aspirin Tablet Chewable 81 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth every 8 hours as needed for cough [MEDICATION NAME] Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 300 MG Give 2 capsule by mouth at bedtime for [MEDICAL CONDITION]/leg pain 2 caps = 600mg [MEDICATION NAME] ER Tablet Extended Release 12 Hour 600 MG Give 1 tablet by mouth every 12 hours as needed for cough/congestion [MEDICATION NAME] Tablet Give 12.5 milligram by mouth two times a day [MEDICAL CONDITION] if SBP is >110 [MEDICATION NAME] Tablet 15 MG Give 1 tablet by mouth one time a day for depression [MEDICATION NAME] HCl Tablet 4 MG Give 1 tablet by mouth every 6 hours as needed for Nausea and Vomiting QUEtiapine [MEDICATION NAME] Tablet 25 MG Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] w/behavioral disturbance rOPINIRole HCl Tablet 0.5 MG Give 2 tablet by mouth every 24 hours as needed for RLS Give 2 tabs = 1mg PO hour of sleep (HS) as needed (PRN) for restless leg syndrome (RLS) rOPINIRole HCl Tablet 5 MG Give 1 tablet by mouth one time a day(TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice allowing them to reach the highest practicable physical, mental, and psychosocial well-being they can achieve for 2 (Resident #1 and Resident #2) of 7 residents reviewed for quality of care. The facility failed to provide needed treatment and care when Resident #1 and Resident #2 identities were switched when the facility did not follow their admission procedures. Resident #1 and Resident #2 did not receive medications for their first evening and night in the facility. Resident #1 received Resident #2 medications for 2 days and missed receiving his routine medications that included medication for diabetes. Resident #2 was sent to the hospital with the identity of Resident #1 and the wrong family was informed of the emergency transfer. Resident #1's family proceeded to make care decisions for the wrong family member when the hospital contacted them about life-saving measures. An Immediate Jeopardy (IJ) situation was identified on 10/17/20. While the IJ was removed on 10/20/20, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy at a scope of isolated, due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. This failure placed residents at risk of not receiving quality care and treatment in accordance with professional standards of practice and could result in serious harm or death. Findings: In an interview on 10/15/20 at 4:08 pm the Administrator stated on 8/18/20 they discovered Resident #1 and Resident #2 were COVID-19 positive. The Administrator stated they were in a rush to move the Resident #1 and Resident #2 because they lived in a memory care unit in an Assisted Living Facility on their campus and given the nature of a memory care unit they were afraid the likelihood of it spreading was even greater. The Administrator stated they were going to place Resident #1 in room [ROOM NUMBER] but it was not ready, so they placed him in room [ROOM NUMBER] and they went back to the memory care unit and brought back Resident #2 and placed him in room [ROOM NUMBER]. The Administrator then went back to print the face sheets, but the internet was down, and around 2:00 pm on 8/18/20 they were finally able to print orders and a copy of those orders were delivered to the COVID-19 unit. (Note: this facility was located on a campus with different levels of care. There was an independent living, assisted living, memory care assisted living, and a nursing care facility. The nursing care facility had a COVID-19 unit that the campus utilized for any COVID-19 positive resident that lived on campus.) In an interview on 10/15/20 at 1:15 pm the director of nursing (DON) stated Resident #1 and Resident #2 on 8/18/20 both moved to their facility from a memory care unit that was on their campus, and around 1:00 am on 8/19/20 Resident #2 had to be sent to the hospital for respiratory decline but was mistakenly sent with the identity of Resident #1. Resident #1 (who stayed in the facility) was believed to be Resident #2 and was provided care in the facility according to Resident #2's orders. The DON stated the mix up in identities was not discovered until the morning of 8/20/20 when the Administrator noticed Resident #1 was in the wrong room. The DON stated the Administrator was familiar with both residents because she has worked on the memory care unit on their campus. In an interview on 10/15/20 at 4:47 pm licensed vocational nurse (LVN) B stated she was working the COVID-19 unit on 8/18/20, her shift began at 6:00 am and she only had one resident on the unit, but her normal position at work was the minimum data set (MDS) nurse. LVN B stated she was helping her one resident with lunch when the DON told her she would be getting residents from the memory care unit on campus because they were COVID-19 positive, and the DON assisted her with getting the beds ready and left. LVN B stated maybe around 1:00 pm the back door opened and the Administrator and the Director to the memory care facility on campus brought in Resident #1 and placed him in room [ROOM NUMBER]. LVN B stated she had to ask for orders and name, and they gave her the name of Resident #1 and told her he had a regular diet. LVN B stated CNA A then arrived on the unit. LVN B stated about 15 minutes later the Administrator and Director of the on-campus memory care facility arrived with Resident #2 and with him they had an oxygen concentrator. LVN B stated she again had to ask for orders and a name, they gave her Resident #2's name and told her that he had pureed diet. LVN B stated CNA A assisted Resident #2 with lunch. LVN B stated the internet was down and she could not access the electronic medical records but someone from the memory care brought her orders on paper; on Resident #1 papers she wrote room [ROOM NUMBER] and on Resident #2 paper work she wrote room [ROOM NUMBER]. According to the Pre-Admission Worksheet Resident #1 was to be placed in room [ROOM NUMBER] and Resident #2 was to be placed in room [ROOM NUMBER]. In an interview on 10/15/20 at 1:53 pm certified nurse aide (CNA) A stated around 12:00 pm on 8/18/20 she was pulled to go work the COVID-19 unit because two new residents were being admitted and they needed more staff. CNA A stated earlier in the day the COVID-19 unit only had one resident and the only staff on the hall was a nurse. CNA A stated when she arrived at the COVID-19 unit she could see the Administrator from her facility (this SNF/NF) and another woman who she thinks was a nurse pushing Resident #2 in a wheelchair outside her building and CNA A was not aware that Resident #1 had already arrived to the unit. CNA A stated the Administrator and nurse wheeled Resident #2 into room [ROOM NUMBER] and CNA A assisted him into a recliner in the room and the nurse adjusted Resident #2's oxygen concentrator. CNA A stated she assisted Resident #2 with lunch, put him in bed, did peri care, and then left for the day because it was close to 2:00 pm and her shift was over at 2:00 pm. CNA A stated at one point she did look in on Resident #1 and noticed he had eaten 50% of his regular texture meal, but the only resident she provided care for was Resident #2. CNA A stated on 8/19/20 when she returned to work that morning Resident #2 was not there. CNA A stated she feels they may have gotten mixed up because in the past for new admissions they have had the room set up, they have done education with the CNAs on the persons and their needs, and the resident name is on the door before they are admitted , and none of this was done before Resident #1 and Resident #2 arrival. In an interview on 10/16/20 at 2:30 pm LVN D stated he received a call from LVN B and she was upset because the facility had not told her they would be bringing 2 new residents over to the COVID-19 unit and LVN B was only given face sheets, orders, and told they have COVID-19 with no kind of report on either resident. LVN D stated he was working his regular shift as an MDS nurse when he went down to relieve LVN B because she was in a hurry to leave as she had to take her son out of town to college. LVN D stated each resident had a pre-assessment worksheet and it stated Resident #2 was in room [ROOM NUMBER] and earlier that day the receptionist had sent an email stating Resident #2 was in room [ROOM NUMBER]. LVN D stated this was his first time to do an admission in the new electronic medical record system they had. LVN D stated the next day 8/19/20 he came to work at 2:00 pm to relieve the DON and Resident #1 was in room [ROOM NUMBER] and Resident #2 was in room [ROOM NUMBER] but the Administrator had put the residents in the wrong rooms. LVN D stated he did not give any medications the evening of 8/18/20 because they had no medications available due to being just admitted . In an interview on 10/15/20 at 2:25 pm LVN A stated on 8/18/20 she arrived at work at 6:00 pm for the evening shift but not on the COVID-19 unit. LVN A stated she received report about Resident #2 when he started to decline, and she went to the COVID-19 unit because Resident #2 was in respiratory distress. There were electronic charts available for him but there was none of the items that are normally available for a new admission such as a hard chart that included a face sheet, care plan, do not resuscitate (DNR) status, name, room number and a card with their physician's name on it. LVN A stated she cannot remember if they sent out the person in room [ROOM NUMBER] or 5410 but she does know the name that was in the electronic medical record matched the name on the door. She thought she was sending Resident #1 to the hospital ER and that Resident #2 was left behind in room [ROOM NUMBER]. LVN A stated she feels not having a hard chart, a wrist band like when they come from the hospital, name on the door before admission, or a picture in the electronic medical records could have contributed to getting the two gentlemen mixed up. LVN A actually assessed sent Resident #2 to the ER, but with the mixed up identities she thought she sent Resident #1. In an interview on 10/15/20 at 3:20 pm LVN C stated she had nothing to do with the transfer on 8/18/20 other than when Resident #1 and Resident #2 came she entered their orders, because they used to have an admissions nurse but no longer do, and the nurse who received the new admission was responsible for the admission paperwork. LVN C stated the residents did not have a hard chart and under normal circumstances that would be completed before admission. She said they had no transfer papers. LVN C stated she feels factors adding to the mix up on 8/18/20 were the residents had no hard chart prepared, they had no transfer papers, and no names on the rooms they were admitting to. In an interview on 10/15/20 at 3:34 pm the DON stated she feels factors that contributed to the mix of Resident #1 and Resident #2 on 8/18/20 were there was no report given from nurse to nurse, the residents coming within a close time frame of each other, internet issues, possibly a breakdown of communication between LVN B and LVN D, and she feels it was rushed due to COVID-19 fears. In an interview on 10/15/20 at 4:08 pm the Administrator stated she feels the failure on 8/18/20 was LVN B knew all the information about Resident #1 and Resident #2 and she passed it on to LVN D and LVN D got the residents mixed up. The Administrator stated even though they had just switched to PointClickCare (PCC) in July of 2020 this was not the first admission from another building on their campus. The Administrator stated she arrived to work early the morning of 8/20/20 and she was talking with the DON and noticed it was not Resident #2 in the bed in room [ROOM NUMBER] but it was Resident #1. They quickly notified the physician, the hospital that Resident #2 was sent to, and the families of the mix of Resident #1 and Resident #2. In an interview on 10/16/20 at 1:35 pm the facility Medical Director stated he was informed the morning of 8/20/20 Resident #1 and Resident #2 had their identities mixed up in the facility. The Medical Director was aware that Resident #1 had received Resident #2 medications but could not answer as to which medications he received because he did not have his records with him. The Medical Director also stated he was aware Resident #1 did not receive his diabetes medications and that Resident #2 was sent to the hospital with the identity of Resident #1. The Medical Director stated he does not believe either resident suffered negative effects of the identity mix up, but he does believe the fear of COVID-19 and both men coming at the same time contributed to this failure. Resident #1 (Resident #1 remained in the facility with the mistaken identity of Resident #2 and received care as if he was Resident #2.) Record review of Resident #1 electronic face sheet accessed on 10/16/20 revealed a [AGE] year-old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #1's responsible party (RP) was documented to be his daughter (Family-A). Record review of Resident #1's Pre-Admission Worksheet/Alert dated 8/18/20 revealed Resident #1 was to admit on 8/18/20 to room [ROOM NUMBER]. Record review of Resident #1's admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was a white male and was admitting from another nursing home or swing bed. Record review of Resident #1's 5-day admission MDS dated [DATE] revealed Resident #1 was a white male admitted on [DATE] from the community/assisted living, had the ability to hear, with clear speech, and could usually be understood and understand others. Resident #1 had a Brief Interview for Mental Status (BIMS) of 3 out of 15 which indicated a severely impaired cognition. Resident #1 required extensive assistance with all activities of daily living (ADL) with the support of 1-2 people for all ADLs and Resident #1 utilized a wheelchair for mobility. Resident #1 was frequently had urinary and bowel incontinence. The MDS revealed Resident #1 had received insulin injections and that he was not prescribed antipsychotics. Resident #1 had also been examined by a physician since admission and had 4 order changes since admission. During Resident #1's assessment and goal setting the MDS indicates Resident #1 participated in this assessment and his wishes was to return to the community/assisted living. This MDS was completed on 8/25/20 and received registered nurse verification on 8/27/20. Record review of Resident #1's Interim Care Plan with an effective date of 8/18/20 and time of 12:30 pm revealed it had been struck out by the Administrator, struck out reason was wrong chart, and the struck-out date was 8/24/20 at 7:37 am. This Interim Care plan was actually based on Resident #2's needs. The Interim Care Plan also revealed Resident #1 room number was 5409. The form also revealed the following: cognitively impaired unable to determine (UTD); visual impairment UTD; hearing impairment UTD; communication UTD; understand staff UTD; bed mobility total dependence; transferring total dependence; eating total dependence; toilet use total dependence; bathing total dependence; continent of bowel UTD; Medications/Treatments Resident #1 received oxygen and pain medications; Medical conditions for Resident #1 was diabetes. Record review of Resident #1 electronic order summary report for active orders as of 8/18/20 accessed on 10/16/20 revealed on 8/18/20 the following orders for Resident #1 had been ordered a Regular diet, regular texture, and thin consistency; Fasting blood sugar once daily; Full code; No allergies [REDACTED]. [MEDICATION NAME] HCl Tablet 1000 MG Give 1 tablet by mouth two times a day for Diabetes Mellitus (DM) [MEDICATION NAME] Tablet 5 MG (linaGLIPtin) Give 1 tablet by mouth one time a day for DM [MEDICATION NAME] Tablet 80 MG Give 1 tablet by mouth two times a day for hypertension (HTN) Hold for systolic blood pressure (SBP) <100 Atorvastatin Calcium Tablet 80 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] Ezetimibe Tablet 10 MG Give 1 tablet by mouth one time a day for cholesterol control [MEDICATION NAME] Tablet 160 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] Aspirin Tablet 325 milligrams (MG) Give 1 tablet by mouth one time a day for [MEDICAL CONDITIONS] [MEDICATION NAME] [MEDICATION NAME] HCl Tablet 100 MG Give 1 tablet by mouth one time a day for depression [MEDICATION NAME] Sodium Tablet 75 MCG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth every 8 hours as needed for cough [MEDICATION NAME] HCl Tablet 1 gram (GM) Give 1 tablet by mouth two times a day every 7 day(s) for diarrhea [MEDICATION NAME] Tablet 1000 MCG Give 1 tablet by mouth one time a day for vitamin deficiency [MEDICATION NAME] Tablet 5 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITIONS] Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth one time a day for [MEDICAL CONDITION] Record review of Resident #1 order recap report electronically accessed on 10/16/20 revealed the following Regular concentrated sweets diet, regular texture, thin consistency order date of 8/21/20 (the day after the identity mix up was discovered and Resident #1 had elevated blood sugars for 3 days post not receiving [MEDICATION NAME] for 2 days), complete blood count (CBC) and comprehensive metabolic panel (CMP) one time only order date of 8/21/20, Check blood sugar twice a day and continue with sliding scale two times a day for Blood sugar order date of 8/23/20; May get midline for iv therapy one time only until 08/23/2020 order date of 8/23/20; and the following medications: [REDACTED] [MEDICATION NAME] HCl Tablet 1 GM Give 1 tablet by mouth STAT for diarrhea order date of 8/24/20 [MEDICATION NAME] Tablet 10 MG Give 1 tablet by mouth one time a day for diabetes discontinued 8/23/20 [MEDICATION NAME] XL Tablet Extended Release 24 Hour 10 MG ([MEDICATION NAME] ER) Give 1 tablet by mouth one time only for Diabetes until 08/22/2020 23:59 order date of 8/22/20 [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 70 - 139 = 0 Do not give insulin; 140 - 180 = 3 units give three units [MEDICATION NAME] R; 181 - 240 = 4 units give four units [MEDICATION NAME] R; 241 - 300 = 6 units give six units [MEDICATION NAME] R; 301 - 350 = 8 units give 8 units [MEDICATION NAME] R; 351 - 400 = 10 units give 10 units [MEDICATION NAME] R and CALL MD, subcutaneously two times a day for DM order date of 8/20/20 Lactobacillus Capsule Give 1 capsule by mouth one time a day for Diarrhea order date of 8/24/20 [MEDICATION NAME] Tablet 500 MG Give 1 tablet by mouth three times a day related to COVID-19 (U07.1) until 08/31/2020 12:36 order date of 8/24/20 [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) Inject 15 unit subcutaneously one time only for DM until 08/20/2020 23:59 with order date of 8/20/20 Sodium Chloride Solution 0.9 % Use 50 millimeter (ml)/hour (hr) intravenously every shift for Nasal agents - Systemic and topical until 08/26/2020 20:44 Give 2 liters Record review of Resident #1 August 2020 medication administration recorded electronically accessed on 10/16/20 revealed Resident #1 did not have any medications signed as given for 8/18/20 or 8/19/20. This information informs you that Resident #2 did not receive any medications while in the facility, since on 8/18/20 and 8/19/20 Resident #2 was thought to be Resident #1 and would have been administered Resident #1's medications. Resident #1's August 2020 Medication Administration Record [REDACTED]. Record review of Resident #1's progress notes revealed no progress notes until 8/20/20 at 9:58 am the note was addressing his elevated blood sugar of 378, not receiving DM medications yesterday, and a new order for regular insulin 15 units a one time dose. On 10/16/20 a request for Resident #1 progress notes from 8/18/20 through 8/20/20 but was given notes from 8/20/20 through 8/24/20. Record review of Residents #1 weights and vitals summary revealed the following: Blood sugar reading did not begin until 8/20/20 with a reading of 378 and they remained above 200 for 3 days on 8/20/20, 8/21/20, and 8/22/20 and on 8/24/20, 8/25/20, 8/26/20, 8/31/20. (Note the normal range for blood sugar reading is 140-200). Resident #1 blood pressures exceeded normal limits of a systolic blood pressure of 139 or greater and diastolic of 89 or higher on 8/20/20, 8/21/20, 8/22/20, 8/23/20, 8/26/20, 8/27/20, 8/28/20, 8/29/20, 8/30/20, and 8/31/20. Resident #1 oxygen saturation, pulse, respiration, and temperature remains with in normal limits. Record review of Resident #1 August 2020 Medication Administration Record [REDACTED] 8/20/20 blood sugar reading of 378 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 15 units. 8/22/20 blood sugar reading of 227 and received [MEDICATION NAME] R 4 units; blood sugar reading of 313 and received [MEDICATION NAME] R 8 units. 8/23/20 blood sugar reading of 182 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 4 units. 8/24/20 blood sugar reading of 231 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 4 units. 8/25/20 blood sugar reading of 174 and received [MEDICATION NAME] R 3 units; blood sugar reading of 249 and received [MEDICATION NAME] R 6 units. 8/26/20 blood sugar reading of 221 and received [MEDICATION NAME] R 4 units; blood sugar reading of 174 and received [MEDICATION NAME] 3 units. 8/27/20 blood sugar reading of 166 and received [MEDICATION NAME] R 3 units. 8/28/20 blood sugar reading of 184 and received [MEDICATION NAME] R 4 units; blood sugar reading of 143 and received [MEDICATION NAME] R 3 units. 8/29/20 blood sugar reading of 184 and received [MEDICATION NAME] R 4 units. 8/30/20 blood sugar reading of 168 and received [MEDICATION NAME] R 3 units. (Note Resident #1 diabetes was well controlled with [MEDICATION NAME] and he had not needed insulin in the past.) Record review of Resident #1 PassPort detailed transaction log dated 8/18/2020 to 8/19/2020 at 5:38 pm provided by the DON on 10/16/20 revealed no medications were dispensed from PassPort until 6:13 pm for Resident #1 as follows: 6:13 pm Levothyroxin, 9:24 pm [MEDICATION NAME], 9:25 pm [MEDICATION NAME] and [MEDICATION NAME], 9:26 pm [MEDICATION NAME]. (Note with the mix up of identity these medications should have been administered to Resident #2, but no medications were signed as given on 8/18/20). Record review of Resident #1 electronic medical record revealed Resident #1 (actually Resident #2) received at least 8 nursing assessments that are required at admission the day of his entry to the facility by LVN D and all have been struck out with a notation indication wrong chart by the Administrator. Record review of an history and physical by Resident #1 physician with an encounter date of 8/20/20 and electronically signed by his physician on 8/24/20 revealed the resident was confused and the physician was unable to get history; he planned to talk with the Resident #1's daughter and family; and No deleterious or untoward side effects were seen by the mix up of patient identities and medication list. I have personally reviewed all meds or both patients. Medications received were [MEDICATION NAME] (Fe), [MEDICATION NAME], Quetiapine, Ropinirole, [MEDICATION NAME], and Terbinafine cream one dose of each medication. Patient showed no side effects by this administration. I have discussed at length with the daughter about the mix up and that we will keep close eye on any new changes. In an interview on 10/15/20 at 1:53 pm CNA A stated although she cannot remember which day it was she does remember Resident #1 receiving pureed foods for breakfast and she sent it back and told them it was wrong, because she remembers him having regular texture foods. CNA A stated she addressed it with the DON who was working the unit and the DON told her it is in his chart to have pureed foods with honey thick liquids. (Note Resident #2 was to be receiving pureed foods). In an interview on 10/15/20 at 7:55 pm Family A stated Resident #1 was tested for COVID-19 on 8/16/20 and on 8/18/20 they were informed he tested positive. On 8/18/20 Family A stated the Administrator called her around lunch to inform her they had moved her father from memory care to the health care building due to him being COVID-19 positive. Around 5:00 pm that day she received a call from the Medical Director of the health care building to discuss the positive COVID-19 test results. On 8/18/20 at 11:54 pm she received a call from a woman whose name she could not recall, to inform her that her father had been transported to a local hospital due to respiratory distress, because his oxygen levels had dropped. Family A stated she asked how her father was asymptomatic 6 hours was earlier was now on oxygen and declining and she knew nothing about it, and LVN A told her she did not know. Family A stated LVN A told her to call the hospital and they would be able to help her. Family A stated around 12:30 am she received a call from the hospital her father had been sent to and they asked if her father had a DNR and Family A informed them she had no document specific to a DNR but she did fax what documents she had such as durable medical power of attorney, HIPAA release, and directive to physicians. Family A received a call around 1:30 am on 8/19/20 and the hospital reported her father had a fever of 102.2 degrees Fahrenheit, difficulty breathing, and a chest x-ray determined he had COVID pneumonia. At this time the person on the phone asked her to confirm if he was on 2 liters of oxygen typically and she let her know her father was not normally on oxygen. She said they discussed if he was a DNR, if they needed to could they place him on a respirator, do chest compressions if needed, and she told her she can't give answers to that at this time, and the nurse told her they would treat him as a full code and they would be moving him to the intensive care unit in a few hours. Family A stated they called her again around 3:00 am asking what life saving measures they could take. Family A was able to speak with her mother around 3:30 am and inform her of her father being sent to the hospital and her mother was inconsolable. Family A stated around 6:00 am she received a call from the hospital that her father was doing better and did not have to go on a ventilator. At 10:18 am Family A emailed facility nursing staff asking them to please fax her father's medication to the hospital because it does not appear all his medications got reported to the hospital and they are under the impression he is on two liters of oxygen and she mentioned her father was diabetic. Family A stated between 10:20 am - 12:00 pm she received a call from the facility stating they would send the medication list. Family A stated at 12:00 pm she received a call from the hospital stating he was doing well but did not pass a swallow study and his oxygen levels were good, and he may be moving out of intensive care. Family A stated the last communication she had with anyone was on 8/19/20 around 9:00 pm when she spoke with hospital staff they put what she thought was her father on the phone as well so she and him could speak, but she said it did not even sound like her father, the voice was weak and high-pitched. On the morning of 9/20/20 at 9:15 am Family A and her mother conferenced called the hospital to get an update on her father and they were told to call the Administrator at the facility. She said the hospital staff would not answer any questions, and just kept telling her to call the Administrator and gave her the Administrator's phone number. At around 9:30 am she called the number and the Administrator answered telling her she was just about to call her; the Administrator then informed her that her father had never left the building and was still at the facility and was doing well and was still asymptomatic. Family A asked the Administrator how it was possible to mix up the residents and the Administrator told her they were following different protocols by taking them in through the back door and not following the normal procedures for admissions to their facility. The Administrator also informed her that her father had been taking someone else's medications. Family A stated around 12:30 pm her mother got to face time her father and confirm he was in the facility and doing ok. Resident #1 was eventually sent to an area hospital for COVID-19 related issue. Resident #1 was released from the hospital to an intensive rehab unit, and eventually admitted back into the memory care unit. Resident #2 (Resident #2 was sent to the hospital with Resident #1's identity.) Record review of Resident #2 electronic face sheet accessed on 10/16/20 revealed a [AGE] year-old male 8/18/20 with the following Diagnosis: [REDACTED].#2's RP to be his daughter. Record review of Resident #2's Pre-Admission Worksheet/Alert dated 8/18/20 revealed Resident #2 was to admit on 8/18/20 to room [ROOM NUMBER]. Record review of Resident #2's electronic health record did not reveal an MDS. Record review of Resident #2's Interim Care Plan with an effective date of 8/18/20 and time of 12:00 pm revealed it had been struck out by the Administrator, struck out reason was wrong chart, and the struck-out date was 8/24/20 at 7:39 am. The Interim Care Plan also revealed Resident #2 room number was 5409. The form also revealed the following: cognitively impaired yes; visual impairment no; hearing impairment no; communication yes; bed mobility independent; transferring with assistance; eating independent; toilet use with assistance; bathing UTD; continent of bowel yes; Medications/Treatments Resident #2 received pain medications and anti-psychotics/[MEDICAL CONDITION]; Medical conditions for Resident #2 was therapy. This Interim Care Plan is based on Resident #1 needs. Record review of Resident #2 order recap report electronically accessed on 10/16/20 revealed the following: allergies [REDACTED]. [MEDICATION NAME] Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath or Wheezing Aspirin Tablet Chewable 81 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth every 8 hours as needed for cough [MEDICATION NAME] Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 300 MG Give 2 capsule by mouth at bedtime for [MEDICAL CONDITION]/leg pain 2 caps = 600mg [MEDICATION NAME] ER Tablet Extended Release 12 Hour 600 MG Give 1 tablet by mouth every 12 hours as needed for cough/congestion [MEDICATION NAME] Tablet Give 12.5 milligram by mouth two times a day [MEDICAL CONDITION] if SBP is >110 [MEDICATION NAME] Tablet 15 MG Give 1 tablet by mouth one time a day for depression [MEDICATION NAME] HCl Tablet 4 MG Give 1 tablet by mouth every 6 hours as needed for Nausea and Vomiting QUEtiapine [MEDICATION NAME] Tablet 25 MG Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] w/behavioral disturbance rOPINIRole HCl Tablet 0.5 MG Give 2 tablet by mouth every 24 hours as needed for RLS Give 2 tabs = 1mg PO hour of sleep (HS) as needed (PRN) for restless leg syndrome (RLS) rOPINIRole HCl Tablet 5 MG Give 1 tablet by mouth one time a day for RLS Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth one time a day for [MEDICAL CONDITION] Terbinafine HCl Cream 1 % Apply to between toes topically every day shift for Infection [MEDICATION NAME] HCl Tablet 100 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Cream 0.1 % Apply to areas affected by rash topically every 12 hours as needed for rash/pruritus Zinc Tablet 50 MG Give 1 tablet by mouth three times a day for supplement [MEDICATION NAME] Tablet 200 MG Give 200 mg by mouth one time a day for Covid 19 until 08/20/2020 19:00 200mg by mouth (PO) x 1 Dose on 8/20/2020 @ 4PM was ordered 8/19/20 Record review of Resident #2's August 2020 medication administration recorded electronically accessed on 10/16/20 revealed the following medications were signed as administered: Aspirin Tablet Chewable 81 MG on 8/19/20; [MEDICATION NAME] Tablet 325 (65 Fe) MG on 8/19/20; [MEDICATION NAME] Ca(TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure medical records were complete, accurately documented, readily accessible, and systematically organized for 3 (Resident #1, Resident #2, and Resident #4) of 7 residents reviewed for resident records - identifiable information. The facility failed to provide accurate records for Resident #1 and Resident #2 when their identities were switched by the facility when they did not follow their admission procedures. Resident #1 and Resident #2 did not receive medications the first evening and night in the facility. Resident #1 received Resident #2 medications for two days and missed receiving his routine medications which included medication for diabetes. Resident #2 was sent to the hospital with the identity of Resident #1 and the wrong family was informed of the emergency transfer. Resident #1's family proceeded to make care decisions for the wrong family member when the hospital contacted them about life-saving measures. An Immediate Jeopardy (IJ) situation was identified on 10/17/20. While the IJ was removed on 10/20/20, the facility remained out of compliance at a severity level of actual harm that is not Immediate Jeopardy at a scope of isolated, due to the facility's need to complete in service training and evaluate the effectiveness of their plan of removal. The facility failed to ensure a complete medical record with sufficient information to identify the resident for the first 3 days of Resident #4 stay at the facility. This failure placed residents at risk of mistaken identity and records not accurately reflecting the plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status. Findings: In an interview on 10/15/20 at 4:08 pm the Administrator stated on 8/18/20 they discovered Resident #1 and Resident #2 were COVID-19 positive. The Administrator stated they were in a rush to move the Resident #1 and Resident #2 because they lived in a memory care unit in an Assisted Living Facility on their campus and given the nature of a memory care unit they were afraid the likelihood of it spreading was even greater. The Administrator stated they were going to place Resident #1 in room [ROOM NUMBER] but it was not ready, so they placed him in room [ROOM NUMBER] and they went back to the memory care unit and brought back Resident #2 and placed him in room [ROOM NUMBER]. The Administrator then went back to print the face sheets, but the internet was down, and around 2:00 pm on 8/18/20 they were finally able to print orders and a copy of those orders were delivered to the COVID-19 unit. (Note: this facility was located on a campus with different levels of care. There was an independent living, assisted living, memory care assisted living, and a nursing care facility. The nursing care facility had a COVID-19 unit that the campus utilized for any COVID-19 positive resident that lived on campus.) In an interview on 10/15/20 at 1:15 pm the director of nursing (DON) stated Resident #1 and Resident #2 on 8/18/20 both moved to their facility from a memory care unit that was on their campus, and around 1:00 am on 8/19/20 Resident #2 had to be sent to the hospital for respiratory decline but was mistakenly sent with the identity of Resident #1. Resident #1 (who stayed in the facility) was believed to be Resident #2 and was provided care in the facility according to Resident #2's orders. The DON stated the mix up in identities was not discovered until the morning of 8/20/20 when the Administrator noticed Resident #1 was in the wrong room. The DON stated the Administrator was familiar with both residents because she has worked on the memory care unit on their campus. In an interview on 10/15/20 at 4:47 pm licensed vocational nurse (LVN) B stated she was working the COVID-19 unit on 8/18/20, her shift began at 6:00 am and she only had one resident on the unit, but her normal position at work was the minimum data set (MDS) nurse. LVN B stated she was helping her one resident with lunch when the DON told her she would be getting residents from the memory care unit on campus because they were COVID-19 positive, and the DON assisted her with getting the beds ready and left. LVN B stated maybe around 1:00 pm the back door opened and the Administrator and the Director to the memory care facility on campus brought in Resident #1 and placed him in room [ROOM NUMBER]. LVN B stated she had to ask for orders and name, and they gave her the name of Resident #1 and told her he had a regular diet. LVN B stated CNA A then arrived on the unit. LVN B stated about 15 minutes later the Administrator and Director of the on-campus memory care facility arrived with Resident #2 and with him they had an oxygen concentrator. LVN B stated she again had to ask for orders and a name, they gave her Resident #2's name and told her that he had pureed diet. LVN B stated CNA A assisted Resident #2 with lunch. LVN B stated the internet was down and she could not access the electronic medical records but someone from the memory care brought her orders on paper; on Resident #1 papers she wrote room [ROOM NUMBER] and on Resident #2 paper work she wrote room [ROOM NUMBER]. (Note according to the Pre-Admission Worksheet Resident #1 was to be placed in room [ROOM NUMBER] and Resident #2 was to be placed in room [ROOM NUMBER]). In an interview on 10/15/20 at 1:53 pm certified nurse aide (CNA) A stated around 12:00 pm on 8/18/20 she was pulled to go work the COVID-19 unit because two new residents were being admitted and they needed more staff. CNA A stated earlier in the day the COVID-19 unit only had one resident and the only staff on the hall was a nurse. CNA A stated when she arrived at the COVID-19 unit she could see the Administrator from her facility (this SNF/NF) and another woman who she thinks was a nurse pushing Resident #2 in a wheelchair outside her building and CNA A was not aware that Resident #1 had already arrived to the unit. CNA A stated the Administrator and nurse wheeled Resident #2 into the room [ROOM NUMBER] and CNA A assisted him into a recliner in the room and the nurse adjusted Resident #2's oxygen concentrator. CNA A stated she assisted Resident #2 with lunch, put him in bed, did peri care, and then left for the day because it was close to 2:00 pm and her shift was over at 2:00 pm. CNA A stated at one point she did look in on Resident #1 and noticed he had eaten 50% of his regular texture meal, but the only resident she provided care for was Resident #2. CNA A stated on 8/19/20 when she returned to work that morning Resident #2 was not there. CNA A stated she feels they may have gotten mixed up because in the past for new admissions they have had the room set up, they have done education with the CNAs on the persons and their needs, and the resident name is on the door before they are admitted , and none of this was done before Resident #1 and Resident #2 arrival. In an interview on 10/16/20 at 2:30 pm LVN D stated he received a call from LVN B and she was upset because the facility had not told her they would be bringing 2 new residents over to the COVID-19 unit and LVN B was only given face sheets, orders, and told they have COVID-19 with no kind of report on either resident. LVN D stated he was working his regular shift as an MDS nurse when he went down to relieve LVN B because she was in a hurry to leave as she had to take her son out of town to college. LVN D stated each resident had a pre-assessment worksheet and it stated Resident #2 was in room [ROOM NUMBER] and earlier that day the receptionist had sent an email stating Resident #2 was in room [ROOM NUMBER]. LVN D stated this was his first time to do an admission in the new electronic medical record system they had. LVN D stated the next day 8/19/20 he came to work at 2:00 pm to relieve the DON and Resident #1 was in room [ROOM NUMBER] and Resident #2 was in room [ROOM NUMBER] but the Administrator had put the residents in the wrong rooms. LVN D stated he did not give any medications the evening of 8/18/20 because they had no medications available due to having just been admitted . In an interview on 10/15/20 at 2:25 pm LVN A stated on 8/18/20 she arrived at work at 6:00 pm for the evening shift but not on the COVID-19 unit. LVN A stated she received report about Resident #2 when he started to decline, and she went to the COVID-19 unit because Resident #2 was in respiratory distress. There were electronic charts available for him but there was none of the items that are normally available for a new admission such as a hard chart that included a face sheet, care plan, do not resuscitate (DNR) status, name, room number and a card with their physician's name on it. LVN A stated she cannot remember if they sent out the person in room [ROOM NUMBER] or 5410 but she does know the name that was in the electronic medical record matched the name on the door. She thought she was sending out Resident #1 to the hospital ER and that Resident #2 was left behind in room [ROOM NUMBER]. LVN A stated she feels not having a hard chart, a wrist band like when they come from the hospital, name on the door before admission, or a picture in the electronic medical records could have contributed to getting the two gentlemen mixed up. LVN A actually assessed and sent Resident #1 to the ER, but with the mixed up identities she thought she sent Resident #2. In an interview on 10/15/20 at 3:20 pm LVN C stated she had nothing to do with the transfer on 8/18/20 other than when Resident #1 and Resident #2 came she entered their orders, because they used to have an admissions nurse but no longer do, and the nurse who received the new admission was responsible for the admission paperwork. LVN C stated the residents did not have a hard chart and under normal circumstances that would be completed before admission. She said they had no transfer papers. LVN C stated she feels factors adding to the mix up on 8/18/20 were the residents came in though a side door, they had no hard chart prepared, they had no transfer papers, and no names on the rooms they were admitting to. In an interview on 10/15/20 at 3:34 pm the DON stated she feels factors that contributed to the mix of Resident #1 and Resident #2 on 8/18/20 were there was no report given from nurse to nurse, the residents coming within a close time frame of each other, internet issues, possibly a breakdown of communication between LVN B and LVN D, and she feels it was rushed due to COVID-19 fears. In an interview on 10/15/20 at 4:08 pm the Administrator stated she feels the failure on 8/18/20 was LVN B knew all the information about Resident #1 and Resident #2 and she passed it on to LVN D and LVN D got the residents mixed up. The Administrator stated even though they had just switched to PointClickCare (PCC) in July of 2020 this was not the first admission from another building on their campus. The Administrator stated she arrived to work early the morning of 8/20/20 and she was talking with the DON and noticed it was not Resident #2 in the bed in room [ROOM NUMBER] but it was Resident #1. They quickly notified the physician, the hospital that Resident #2 was sent to, and the families of the mix of Resident #1 and Resident #2. In an interview on 10/16/20 at 1:35 pm the facility Medical Director stated he was informed the morning of 8/20/20 Resident #1 and Resident #2 had their identities mixed up in the facility. The Medical Director was aware that Resident #1 had received Resident #2 medications but could not answer as to which medications he received because he did not have his records with him. The Medical Director also stated he was aware Resident #1 did not receive his diabetes medications and that Resident #2 was sent to the hospital with the identity of Resident #1. The Medical Director stated he does not believe either resident suffered negative effects of the identity mix up, but he does believe the fear of COVID-19 and both men coming at the same time contributed to this failure. Resident #1 (Resident #1 remained in the facility with the mistaken identity of Resident #2 and received care as if he was Resident #2.) Record review of Resident #1 electronic face sheet accessed on 10/16/20 revealed a [AGE] year-old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Resident #1's responsible party (RP) was documented to be his daughter (Family-A). Record review of Resident #1's Pre-Admission Worksheet/Alert dated 8/18/20 revealed Resident #1 was to admit on 8/18/20 to room [ROOM NUMBER]. Record review of Resident #1's admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was a white male and was admitting from another nursing home or swing bed. Record review of Resident #1's 5-day admission MDS dated [DATE] revealed Resident #1 was a white male admitted on [DATE] from the community/assisted living, had the ability to hear, with clear speech, and could usually be understood and understand others. Resident #1 had a Brief Interview for Mental Status (BIMS) of 3 out of 15 which indicated a severely impaired cognition. Resident #1 required extensive assistance with all activities of daily living (ADL) with the support of 1-2 people for all ADLs and Resident #1 utilized a wheelchair for mobility. Resident #1 was frequently had urinary and bowel incontinence. The MDS revealed Resident #1 had received insulin injections and that he was not prescribed antipsychotics. Resident #1 had also been examined by a physician since admission and had 4 order changes since admission. During Resident #1's assessment and goal setting the MDS indicates Resident #1 participated in this assessment and his wishes was to return to the community/assisted living. This MDS was completed on 8/25/20 and received registered nurse verification on 8/27/20. Record review of Resident #1's Interim Care Plan with an effective date of 8/18/20 and time of 12:30 pm revealed it had been struck out by the Administrator, struck out reason was wrong chart, and the struck-out date was 8/24/20 at 7:37 am. The Interim Care Plan also revealed Resident #1 room number was 5409. The form also revealed the following: cognitively impaired unable to determine (UTD); visual impairment UTD; hearing impairment UTD; communication UTD; understand staff UTD; bed mobility total dependence; transferring total dependence; eating total dependence; toilet use total dependence; bathing total dependence; continent of bowel UTD; Medications/Treatments Resident #1 received oxygen and pain medications; Medical conditions for Resident #1 was diabetes. (Note this Interim Care Plan is based on Resident #2 needs.) Record review of Resident #1 electronic order summary report for active orders as of 8/18/20 accessed on 10/16/20 revealed on 8/18/20 the following orders for Resident #1 had been ordered a Regular diet, regular texture, and thin consistency; Fasting blood sugar once daily; Full code; No allergies [REDACTED]. [MEDICATION NAME] HCl Tablet 1000 MG Give 1 tablet by mouth two times a day for Diabetes Mellitus (DM) [MEDICATION NAME] Tablet 5 MG (linaGLIPtin) Give 1 tablet by mouth one time a day for DM [MEDICATION NAME] Tablet 80 MG Give 1 tablet by mouth two times a day for hypertension (HTN) Hold for systolic blood pressure (SBP) <100 Atorvastatin Calcium Tablet 80 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] Ezetimibe Tablet 10 MG Give 1 tablet by mouth one time a day for cholesterol control [MEDICATION NAME] Tablet 160 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] Aspirin Tablet 325 milligrams (MG) Give 1 tablet by mouth one time a day for [MEDICAL CONDITIONS] [MEDICATION NAME] [MEDICATION NAME] HCl Tablet 100 MG Give 1 tablet by mouth one time a day for depression [MEDICATION NAME] Sodium Tablet 75 MCG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth every 8 hours as needed for cough [MEDICATION NAME] HCl Tablet 1 gram (GM) Give 1 tablet by mouth two times a day every 7 day(s) for diarrhea [MEDICATION NAME] Tablet 1000 MCG Give 1 tablet by mouth one time a day for vitamin deficiency [MEDICATION NAME] Tablet 5 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITIONS] Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth one time a day for [MEDICAL CONDITION] Record review of Resident #1 order recap report electronically accessed on 10/16/20 revealed the following Regular concentrated sweets diet, regular texture, thin consistency order date of 8/21/20 (the day after the identity mix up was discovered and Resident #1 had elevated blood sugars for 3 days post not receiving [MEDICATION NAME] for 2 days), complete blood count (CBC) and comprehensive metabolic panel (CMP) one time only order date of 8/21/20, Check blood sugar twice a day and continue with sliding scale two times a day for Blood sugar order date of 8/23/20; May get midline for iv therapy one time only until 08/23/2020 order date of 8/23/20; and the following medications: [REDACTED] [MEDICATION NAME] HCl Tablet 1 GM Give 1 tablet by mouth STAT for diarrhea order date of 8/24/20 [MEDICATION NAME] Tablet 10 MG Give 1 tablet by mouth one time a day for diabetes discontinued 8/23/20 [MEDICATION NAME] XL Tablet Extended Release 24 Hour 10 MG ([MEDICATION NAME] ER) Give 1 tablet by mouth one time only for Diabetes until 08/22/2020 23:59 order date of 8/22/20 [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 70 - 139 = 0 Do not give insulin; 140 - 180 = 3 units give three units [MEDICATION NAME] R; 181 - 240 = 4 units give four units [MEDICATION NAME] R; 241 - 300 = 6 units give six units [MEDICATION NAME] R; 301 - 350 = 8 units give 8 units [MEDICATION NAME] R; 351 - 400 = 10 units give 10 units [MEDICATION NAME] R and CALL MD, subcutaneously two times a day for DM order date of 8/20/20 Lactobacillus Capsule Give 1 capsule by mouth one time a day for Diarrhea order date of 8/24/20 [MEDICATION NAME] Tablet 500 MG Give 1 tablet by mouth three times a day related to COVID-19 (U07.1) until 08/31/2020 12:36 order date of 8/24/20 [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) Inject 15 unit subcutaneously one time only for DM until 08/20/2020 23:59 with order date of 8/20/20 Sodium Chloride Solution 0.9 % Use 50 millimeter (ml)/hour (hr) intravenously every shift for Nasal agents - Systemic and topical until 08/26/2020 20:44 Give 2 liters Record review of Resident #1 August 2020 medication administration recorded electronically accessed on 10/16/20 revealed Resident #1 did not have any medications signed as given for 8/18/20 or 8/19/20. This information informs you that Resident #2 did not receive any medications while in the facility, since on 8/18/20 and 8/19/20 Resident #2 was thought to be Resident #1 and would have been administered Resident #1's medications. Resident #1's August 2020 Medication Administration Record [REDACTED]. Record review of Resident #1's progress notes revealed no progress notes until 8/20/20 at 9:58 am the note was addressing his elevated blood sugar of 378, not receiving DM medications yesterday, and a new order for regular insulin 15 units a one time dose. On 10/16/20 a request for Resident #1 progress notes from 8/18/20 through 8/20/20 but was given notes from 8/20/20 through 8/24/20. Record review of Residents #1 weights and vitals summary revealed the following: Blood sugar reading did not begin until 8/20/20 with a reading of 378 and they remained above 200 for 3 days on 8/20/20, 8/21/20, and 8/22/20 and on 8/24/20, 8/25/20, 8/26/20, 8/31/20. Resident #1 blood pressures exceeded normal limits of a systolic blood pressure of 139 or greater and diastolic of 89 or higher on 8/20/20, 8/21/20, 8/22/20, 8/23/20, 8/26/20, 8/27/20, 8/28/20, 8/29/20, 8/30/20, and 8/31/20. Resident #1 oxygen saturation, pulse, respiration, and temperature remains with in normal limits. (Note the normal range for blood sugar reading is 140-200). Record review of Resident #1 August 2020 Medication Administration Record [REDACTED] 8/20/20 blood sugar reading of 378 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 15 units. 8/22/20 blood sugar reading of 227 and received [MEDICATION NAME] R 4 units; blood sugar reading of 313 and received [MEDICATION NAME] R 8 units. 8/23/20 blood sugar reading of 182 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 4 units. 8/24/20 blood sugar reading of 231 and received [MEDICATION NAME] R Solution 100 UNIT/ML (Insulin Regular Human) 4 units. 8/25/20 blood sugar reading of 174 and received [MEDICATION NAME] R 3 units; blood sugar reading of 249 and received [MEDICATION NAME] R 6 units. 8/26/20 blood sugar reading of 221 and received [MEDICATION NAME] R 4 units; blood sugar reading of 174 and received [MEDICATION NAME] 3 units. 8/27/20 blood sugar reading of 166 and received [MEDICATION NAME] R 3 units. 8/28/20 blood sugar reading of 184 and received [MEDICATION NAME] R 4 units; blood sugar reading of 143 and received [MEDICATION NAME] R 3 units. 8/29/20 blood sugar reading of 184 and received [MEDICATION NAME] R 4 units. 8/30/20 blood sugar reading of 168 and received [MEDICATION NAME] R 3 units. (Note Resident #1 diabetes was well controlled with [MEDICATION NAME] and he had not needed insulin in the past.) Record review of Resident #1 PassPort detailed transaction log dated 8/19/2020 to 8/19/2020 at 5:38 pm provided by the DON on 10/16/20 revealed no medications were dispensed from PassPort until 6:13 pm for Resident #1 as follows: 6:13 pm Levothyroxin, 9:24 pm [MEDICATION NAME], 9:25 pm [MEDICATION NAME] and [MEDICATION NAME], 9:26 pm [MEDICATION NAME]. (Note with the mix up of identity these medications should have been administered to Resident #2, but no medications were signed as given on 8/18/20). Record review of Resident #1 electronic medical record revealed Resident #1 (actually Resident #2) received at least 8 nursing assessments that are required at admission the day of his entry to the facility by LVN D and all have been struck out with a notation indication wrong chart by the Administrator. Record review of an history and physical by Resident #1 physician with an encounter date of 8/20/20 and electronically signed by his physician on 8/24/20 revealed the resident was confused and the physician was unable to get history; he planned to talk with the Resident #1's daughter and family; and No deleterious or untoward side effects were seen by the mix up of patient identities and medication list. I have personally reviewed all meds or both patients. Medications received were [MEDICATION NAME] (Fe), [MEDICATION NAME], Quetiapine, Ropinirole, [MEDICATION NAME], and Terbinafine cream one dose of each medication. Patient showed no side effects by this administration. I have discussed at length with the daughter about the mix up and that we will keep close eye on any new changes. In an interview on 10/15/20 at 1:53 pm CNA A stated although she cannot remember which day it was she does remember Resident #1 receiving pureed foods for breakfast and she sent it back and told them it was wrong, because she remembers him having regular texture foods. CNA A stated she addressed it with the DON who was working the unit and the DON told her it is in his chart to have pureed foods with honey thick liquids. (Note Resident #2 was to be receiving pureed foods). In an interview on 10/15/20 at 7:55 pm Family A stated Resident #1 was tested for COVID-19 on 8/16/20 and on 8/18/20 they were informed he tested positive. On 8/18/20 Family A stated the Administrator called her around lunch to inform her they had moved her father from memory care to the health care building due to him being COVID-19 positive. Around 5:00 pm that day she received a call from the Medical Director of the health care building to discuss the positive COVID-19 test results. On 8/18/20 at 11:54 pm she received a call from a woman whose name she could not recall, to inform her that her father had been transported to a local hospital due to respiratory distress, because his oxygen levels had dropped. Family A stated she asked how her father was asymptomatic 6 hours was earlier was now on oxygen and declining and she knew nothing about it, and LVN A told her she did not know. Family A stated LVN A told her to call the hospital and they would be able to help her. Family A stated around 12:30 am she received a call from the hospital her father had been sent to and they asked if her father had a DNR and Family A informed them she had no document specific to a DNR but she did fax what documents she had such as durable medical power of attorney, HIPAA release, and directive to physicians. Family A received a call around 1:30 am on 8/19/20 and the hospital reported her father had a fever of 102.2 degrees Fahrenheit, difficulty breathing, and a chest x-ray determined he had COVID pneumonia. At this time the person on the phone asked her to confirm if he was on 2 liters of oxygen typically and she let her know her father was not normally on oxygen. She said they discussed if he was a DNR, if they needed to could they place him on a respirator, do chest compressions if needed, and she told her she can't give answers to that at this time, and the nurse told her they would treat him as a full code and they would be moving him to the intensive care unit in a few hours. Family A stated they called her again around 3:00 am asking what life saving measures they could take. Family A was able to speak with her mother around 3:30 am and inform her of her father being sent to the hospital and her mother was inconsolable. Family A stated around 6:00 am she received a call from the hospital that her father was doing better and did not have to go on a ventilator. At 10:18 am Family A emailed facility nursing staff asking them to please fax her father's medication to the hospital because it does not appear all his medications got reported to the hospital and they are under the impression he is on two liters of oxygen and she mentioned her father was diabetic. Family A stated between 10:20 am - 12:00 pm she received a call from the facility stating they would send the medication list. Family A stated at 12:00 pm she received a call from the hospital stating he was doing well but did not pass a swallow study and his oxygen levels were good, and he may be moving out of intensive care. Family A stated the last communication she had with anyone was on 8/19/20 around 9:00 pm when she spoke with hospital staff they put what she thought was her father on the phone as well so she and him could speak, but she said it did not even sound like her father, the voice was weak and high-pitched. On the morning of 9/20/20 at 9:15 am Family A and her mother conferenced called the hospital to get an update on her father and they were told to call the Administrator at the facility. She said the hospital staff would not answer any questions, and just kept telling her to call the Administrator and gave her the Administrator's phone number. At around 9:30 am she called the number and the Administrator answered telling her she was just about to call her; the Administrator then informed her that her father had never left the building and was still at the facility and was doing well and was still asymptomatic. Family A asked the Administrator how it was possible to mix up the residents and the Administrator told her they were following different protocols by taking them in through the back door and not following the normal procedures for admissions to their facility. The Administrator also informed her that her father had been taking someone else's medications. Family A stated around 12:30 pm her mother got to face time her father and confirm he was in the facility and doing ok. Resident #1 was eventually sent to an area hospital for COVID-19 related issue. Resident #1 was released from the hospital to an intensive rehab unit, and eventually admitted back into the memory care unit. Resident #2 (Resident #2 was sent to the hospital with Resident #1's identity.) Record review of Resident #2 electronic face sheet accessed on 10/16/20 revealed a [AGE] year-old male 8/18/20 with the following Diagnosis: [REDACTED].#2's RP to be his daughter. Record review of Resident #2's Pre-Admission Worksheet/Alert dated 8/18/20 revealed Resident #2 was to admit on 8/18/20 to room [ROOM NUMBER]. Record review of Resident #2's electronic health record did not reveal an MDS. Record review of Resident #2's Interim Care Plan with an effective date of 8/18/20 and time of 12:00 pm revealed it had been struck out by the Administrator, struck out reason was wrong chart, and the struck-out date was 8/24/20 at 7:39 am. The Interim Care Plan also revealed Resident #2 room number was 5409. The form also revealed the following: cognitively impaired yes; visual impairment no; hearing impairment no; communication yes; bed mobility independent; transferring with assistance; eating independent; toilet use with assistance; bathing UTD; continent of bowel yes; Medications/Treatments Resident #2 received pain medications and anti-psychotics/[MEDICAL CONDITION]; Medical conditions for Resident #2 was therapy. (Note this Interim Care Plan is based on Resident #1 needs.) Record review of Resident #2 order recap report electronically accessed on 10/16/20 revealed the following: allergies [REDACTED]. [MEDICATION NAME] Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath or Wheezing Aspirin Tablet Chewable 81 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth every 8 hours as needed for cough [MEDICATION NAME] Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Capsule 300 MG Give 2 capsule by mouth at bedtime for [MEDICAL CONDITION]/leg pain 2 caps = 600mg [MEDICATION NAME] ER Tablet Extended Release 12 Hour 600 MG Give 1 tablet by mouth every 12 hours as needed for cough/congestion [MEDICATION NAME] Tablet Give 12.5 milligram by mouth two times a day [MEDICAL CONDITION] if SBP is >110 [MEDICATION NAME] Tablet 15 MG Give 1 tablet by mouth one time a day for depression [MEDICATION NAME] HCl Tablet 4 MG Give 1 tablet by mouth every 6 hours as needed for Nausea and Vomiting QUEtiapine [MEDICATION NAME] Tablet 25 MG Give 1 tablet by mouth at bedtime for [MEDICAL CONDITION] w/behavioral disturbance rOPINIRole HCl Tablet 0.5 MG Give 2 tablet by mouth every 24 hours as needed for RLS Give 2 tabs = 1mg PO hour of sleep (HS) as needed (PRN) for restless leg syndrome (RLS) rOPINIRole HCl Tablet 5 MG Give 1 tablet by mouth one time a day for RLS Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth one time a day for [MEDICAL CONDITION] Terbinafine HCl Cream 1 % Apply to between toes topically every day shift for Infection [MEDICATION NAME] HCl Tablet 100 MG Give 1 tablet by mouth one time a day for [MEDICAL CONDITION] [MEDICATION NAME] Cream 0.1 % Apply to areas affected by rash topically every 12 hours as needed for rash/pruritus Zinc Tablet 50 MG Give 1 tablet by mouth three times a day for supplement [MEDICATION NAME] Tablet 200 MG Give 200 mg by mouth one time a day for Covid 19 until 08/20/2020 19:00 200mg by mouth (PO) x 1 Dose on 8/20/2020 @ 4PM was ordered 8/19/20 Record review of Resident #2's August 2020 (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure each resident had the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect. CNA A transferred Resident #1, who was care planned for transfers with the assistance of two staff, without assistance on 03/22/17, which resulted in the resident being injured and sustaining a fracture to his right ankle. This failure could affect the facility's 39 residents, who required staff assistance for transfers and placed them at risk for falling, lacerations, fractures and the need for hospitalization . Findings included: Review of Resident #1's Minimum Data Set assessment, dated 02/16/17, revealed he was [AGE] years and was admitted to the facility on [DATE]. The resident was cognitively intact and his [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive care plan, dated 02/16/17, revealed . Requires assistance of 2 staff for transfers Review of Resident #1's radiology report, dated 03/23/17, revealed . Results: There is a fracture involving distal tibia and fibula with minimal displacement. The joint alignment is maintained. There is associated soft tissue swelling. Conclusion: Acute ankle fracture as described above Review of Resident #1's Skilled Care Nurses Note, created 03/22/17 at 11:54 PM and authored by LVN F, revealed . bruising and mild swelling noted to right ankle and right knee Review of Resident #1's Skilled Care Nurses Note, created 03/23/17 at 10:44 PM and authored by LVN M, revealed . C/o (Complains of) RLE (right lower extremity) pain at 2100h (9:00 PM) . acute right ankle fx (fracture). Fx boot in place per order Review of the facility's Provider Investigation Report, dated 03/28/17, revealed . (Resident #1) was being transferred from the bed to the wheelchair. During the transfer the resident got his feet tangled up and the CNA reported that she and another CNA lowered him to the floor. She did not report the incident to the nurse because they lowered him to the floor. The patient later said that his knee, which he had problems with before, was hurting. He was examined and an x-ray was ordered. He complained of no other pain. The x-ray of the knee was negative for any acute issues. The next day his ankle was bruised and swollen. An x-ray showed an acute ankle fracture. He was sent to the hospital for evaluation and treatment . On 3/22/17 at approximately 7:45 am, (CNA A) transferred (Resident #1) from the bed to the wheelchair. At approximately 8:10 am while the resident was in therapy he told his therapist that when transferring from the bed to the wheelchair his right leg got caught under his left leg and he fell to the floor and twisted his knee and his head lightly hit the floor. He told the therapist that now he had knee pain. He also said that the CNA told him not to mention it to anyone. The therapist notified nursing and (LVN B) then did a Head to Toe assessment. She identified that the resident had right knee pain. The resident had no other complaints of pain and no other signs of injury. (LVN B), notified the physician, gave him pain medications and ordered an x-ray of his right knee. The x-ray returned negative for acute injury. The resident was monitored had no other complaints of pain or injury. The DON started an investigation of the fall and why it was not immediately reported. (CNA A) stated that she and another CNA lowered the resident to the floor therefore; she had not considered it a fall. The DON proceeded to educate the CNA on what constituted a fall. The DON also questioned if the CNA talked to (Resident #1) about not saying anything about the fall. She stated that she had not made any such statement to the resident. Later, the DON interviewed (CNA C) who (CNA A) stated helped her transfer (Resident #1). During that interview, (CNA C) indicated that she had not helped (CNA A) transfer the resident to the chair and she stated that when she came in the resident was already on the floor. After reviewing the statements from both CNA's (sic) the DON identified that further investigation was needed because the stories did not match. The CNAs were gone for the day. The next morning before the investigation . could be continued, it was identified that the resident's ankle was bruised and swollen. The family and physician were notified and an x-ray was ordered. While waiting for the x-ray report the resident complained of numbness so the family and physician were notified and the resident was sent to the hospital for further evaluation and treatment. The x-ray report showed an acute ankle fracture. The investigation continued. In a subsequent interview with (CNA A), she admitted that she had transferred the resident by herself. She continued to maintain that she had not told him, not to tell anyone about the fall. The CNA was asked to write a new statement regarding the incident and she was placed on suspension while the investigation was concluded. SAFE Surveys were done with the residents and the (sic) all reported feeling safe, not afraid of anyone and that they could voice any complaints that they had to someone. The investigation showed that (CNA A) transferred the resident without assistance. During that transfer the resident fell to the floor. The CNA did not report the incident to anyone and delayed assessment by not reporting the incident immediately. The CNA initially gave a false statement during the investigation by stating that she had the assistance of another CNA to transfer the resident and that the resident was lowered to the floor. Upon additional questioning, she reported that she did not have assistance during the transfer that should have had 2 persons, but did obtain assistance to move (Resident #1) from the floor to the wheelchair. The CNA was terminated Further review of the facility's investigation regarding Resident #1 revealed an inservice/training record, dated 03/22/17, regarding . Understanding falls and fall prevention, when to notify the nurse prior to moving the resident, gait belt at all times. Preparing the resident for the day/ADL's (Activities of Daily Living)/assist of two was discussed with the nursing staff, including CNAs. An inservice/training record, dated 03/24/17, regarding . Abuse and Neglect/Resident Rights. Identifying abuse/neglect/reporting/prevention was discussed with the nursing staff, including CNAs. An inservice/training record, dated 03/24/17, regarding . Falls/fall prevention, identifying via care guide/care plan resident assistance needs (assist of one or two) use of gait belt. Awareness that an assisted fall is a fall from one plane to another) and must be reported immediately was discussed with the nursing staff, including CNAs. Interview on 04/07/17 at 10:04 AM with the ADM revealed CNA A was assigned to Resident #1 and transferred the resident from his bed to his wheelchair without assistance. The ADM stated the resident required the assistance of two people for transfers. She stated the resident went to the therapy department and mentioned that he had a fall and that his knee was hurting. She stated the resident said that CNA A said not to say anything about the fall. The ADM stated CNA A said that she and CNA C transferred the resident, his feet got tangled up, he was lowered to the floor with no injuries, and then placed in his wheelchair. The ADM stated CNA A denied telling the resident not to say anything. The ADM stated the resident had a history of [REDACTED]. The ADM stated CNA A said there had not been a fall but the resident was lowered to the floor. The ADM stated CNA A was educated on what constituted a fall. The ADM stated a head to toe assessment was completed on the resident and the x-ray was negative. The ADM stated the DON spoke with CNA C who said she had helped get the resident off the floor but there was no mention of initially helping to transfer the resident prior to the fall. The ADM stated the next day the nurse alerted the DON of bruising to the resident's right ankle and another x-ray was ordered STAT (immediately). She stated the swelling continued and the resident was sent to the hospital before the results of the x-ray arrived. The ADM stated she and the DON spoke with CNA A who admitted to transferring the resident without assistance. The ADM stated CNA A said she got CNA C to help get the resident up and denied telling the resident not to say anything. The ADM stated CNA A said that the resident hit his knee when he was lowered to the floor, which the CNA did not consider a fall, but did not have pain. The ADM stated CNA A was suspended and then her employment was terminated. The ADM stated approximately 25 minutes elapsed from the time the resident fell to when the resident mentioned his fall to the therapist. The ADM stated CNA C was also trained on what constituted a fall. The ADM stated CNA C thought the resident had already been assessed and was just helping to get him off the floor. The ADM stated the resident complained of pain with movement of his ankle and was provided with pain medications. The ADM stated the resident confirmed only one person had transferred him prior to his fall. The ADM stated CNAs at the facility received training regarding falls and what constituted a fall. The ADM stated CNA A said she felt like she was able to transfer the resident by herself. The ADM stated the CNAs' training also included abuse and neglect and reporting incidents to the nurses. The ADM stated the facility was scheduled to have therapy conduct a skills checkoff regarding transfers with the staff which would be completed later during April 2017 and on a quarterly/as needed basis. The ADM stated there had been no training regarding return demonstration yet since the incident with Resident #1. The ADM stated the facility had a safety fair after the incident which included transfers. Interview on 04/07/17 at 12:02 PM with OT D revealed Resident #1 told her his right ankle hurt. She stated the resident sometimes had pain and told him they would start off with some light therapy but the resident continued to have pain. She stated the resident told her he had a fall, he said it was his fault and that his nurse did not know. She stated the resident was hesitant but said he had tried to get out of bed when his legs got tangled and he fell . She stated the resident described CNA A as the person who was assisting him at the time of his fall. She stated the resident denied being lowered to the floor and said he had hit his head lightly. She stated the resident told her CNA A had him lie down and she went to get help from an unknown person to help get him up. She stated the resident did not want to get CNA A in trouble and said she asked him not to say anything about it. She stated the resident said his pain was 10 to 12 on a scale of 1 to 10. She stated the resident was taken to the nurse's station and LVN B was notified. She stated the resident returned from the hospital with the boot and was unable to stand. Interview on 04/07/17 at 12:15 PM with the DON revealed OT D informed her of Resident #1's fall and how CNA A asked the resident not to say anything. The DON stated she spoke with CNA A who said the resident was guided to the floor and did not consider it a fall. The DON stated she called the resident's nurse (LVN B) and informed her of the fall who completed a head to toe assessment on the resident. The DON stated the resident complained of knee pain and was alert with no confusion. The DON stated an x-ray was ordered. The DON stated CNA A said, at some point, that CNA C witnessed the resident's fall. The DON stated CNA C denied witnessing the fall and said she was summoned to assist the resident from the floor. The DON stated the resident's x-ray did not indicate a fracture and the staff continued to monitor the resident. The DON stated LVN E said the nurse from the overnight shift reported that the resident had pain and medication was provided. The DON stated she went with LVN E to check on the resident and observed that the resident's right ankle was very swollen and he had a bruise (lilac colored). The DON stated the resident's right foot was turned out and he had complaints of pain. The DON stated an x-ray was ordered STAT and the resident was provided with pain medication. The DON stated it took a while to get the x-ray results (a few hours elapsed) so the resident was transferred to the hospital. The DON stated the hospital confirmed two fractures and a boot was provided to the resident. She stated the resident was transferred back to the facility but was discharged several days later to another facility. The DON stated the facility had been working with the resident and his family for alternate placement prior to the incident. The DON stated she and the administrator interviewed CNA A who was suspended and ultimately terminated. The DON stated the facility had in-services on abuse and neglect, care guide/care plans, gait belts, and what constituted a fall. The DON stated there was an upcoming in-service with therapy which would include a return demonstration. Interview on 04/07/17 at 12:47 PM with CNA C revealed she was in the dining room getting ready for the meal service when CNA A asked for her assistance. CNA C stated she went to Resident #1's room and the resident's bed was all the way to the floor. She stated the resident was lying on his right side on the floor. CNA C stated CNA A said she had to ease the resident to the floor. CNA C stated she asked the resident if he was okay or hurt and the resident had no concerns. CNA C stated she helped CNA A get the resident off the floor and into the wheelchair. CNA C stated the resident was okay during the process of getting him up and the resident denied any pain or problems. CNA C stated the resident and CNA A thanked her and she exited the room. CNA C stated she was not in the room when the resident fell or was lowered to the floor. CNA C stated she assumed the nurse had been notified and was aware that the resident was on the floor. CNA C stated LVN B was not able to lift the residents and figured that was why she had been asked to help. CNA C stated LVN B was down the hall at the medication cart when she went to the room to assist CNA A with the resident. CNA C stated she did not ask the nurse if she was aware the resident was on the floor and CNA A did not say the resident's nurse was aware. Interview on 04/07/17 at 1:03 PM with CNA A revealed Resident #1 was normally able to stand but his legs got tangled up and he had to be lowered to the floor. She stated the resident had no complaints of pain at that time. She stated she knew she should have gotten the nurse to assess the resident after lowering him to the floor but did not consider it a fall. She stated the resident's knee touched the floor first and then his buttocks. She stated she went to get CNA C to help get the resident up. She stated she never tried to mislead the facility in thinking that CNA C had assisted her prior to the resident's fall. She stated the resident required two people to assist him with transfers when he was admitted to the facility and thought he had been changed to a one-person assist with transfers. She stated she last had a second person assist her with the resident's transfers approximately a week prior to the incident. She stated she had transferred the resident without assistance several times prior to the incident. She stated there had been no other occasions where a resident had been transferred outside of their care plan or a resident had fallen without the nurse being notified. Interview on 04/07/17 at 5:36 PM with LVN F revealed she worked with Resident #1 from 6:00 PM to 6:00 AM after his fall. She stated the resident complained of knee pain. She stated the resident's pain was at a six on a scale 1 to 10. She stated the resident's previous x-ray had been negative but there was some swelling with his right knee. She stated there was some bruising and swelling on the resident's right ankle towards the end of her shift that was not severe. She stated she notified LVN B of the concern and the need for a possible ankle x-ray. She stated the resident was given a pain medication during her shift which was effective and the resident was able to rest. Interview on 04/07/17 at 8:43 PM with LVN B revealed CNA A had not asked for assistance with transferring Resident #1 or informed her of the resident's fall. She stated she saw CNA A and CNA C go to Resident #1's room the morning of the incident. She stated the DON notified her of the resident's fall and she then assessed the resident. Review of the facility's Falls - Clinical Protocol policy and procedure, dated April 2013, revealed . Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. *This constitutes a fall. A change in the plane of the resident even when assisted to the floor Review of the facility's Abuse Prevention, Reporting and Investigation policy and procedure, dated 11/16/16, revealed . (Facility) will implement policies and procedures that prevent abuse, neglect, (sic) misappropriation of funds Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Interviews conducted on 04/07/17 from 10:53 AM to 4:49 PM with CNA C, CNA G, RN H, CNA I, LVN J, and CNA L revealed they all knew what constituted a fall and the appropriate steps to take following a resident's fall. Interview on 04/07/17 at 4:35 PM with CNA K, who was in-serviced following the incident, revealed she did not know that staff lowering a resident to the floor constituted a fall. CNA K stated she would still notify the nurse to assess a resident who was lowered to the floor. Review of an undated staff list, provided by the ADM and DON on 04/07/17, revealed 50 nursing staff (CNAs, Medication Aides, LVNs and RNs) had not been in-serviced following the incident with Resident #1. The list reflected 38 of the 50 nursing staff, who had not been in-serviced, were either part-time or worked on an as-needed basis. During a joint interview on 04/07/17 at 5:51 PM with the ADM and DON, the ADM stated the majority of the staff who had not been in-serviced worked on an as-needed basis and it was difficult to get those staff to come in for in-services. Observations on 04/07/17 from 1:25 PM to 2:35 PM of gait belt and mechanical lift transfers for Resident #2, Resident #3, Resident #4 and Resident #5 did not reveal concerns. The ADM provided email documentation on 04/13/17 that reflected 39 residents (on 04/07/17) required staff assistance with transfers.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents for one (Resident #1) of five residents reviewed who required staff assistance with transfers. CNA A failed to transfer Resident #1, who was care planned for transfers with the assistance two staff, with assistance on 03/22/17, which resulted in the resident being injured and sustaining a fracture to his right ankle. This failure could affect the facility's 39 residents, who required staff assistance for transfers and placed them at risk for falling, lacerations, fractures and the need for hospitalization . Findings included: Review of Resident #1's Minimum Data Set assessment, dated 02/16/17, revealed he was [AGE] years and was admitted to the facility on [DATE]. The resident was cognitively intact and his [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive care plan, dated 02/16/17, revealed . Requires assistance of 2 staff for transfers Review of Resident #1's radiology report, dated 03/23/17, revealed . Results: There is a fracture involving distal tibia and fibula with minimal displacement. The joint alignment is maintained. There is associated soft tissue swelling. Conclusion: Acute ankle fracture as described above Review of Resident #1's Skilled Care Nurses Note, created 03/22/17 at 11:54 PM and authored by LVN F, revealed . bruising and mild swelling noted to right ankle and right knee Review of Resident #1's Skilled Care Nurses Note, created 03/23/17 at 10:44 PM and authored by LVN M, revealed . C/o (Complains of) RLE (right lower extremity) pain at 2100h (9:00 PM) . acute right ankle fx (fracture). Fx boot in place per order Review of the facility's Provider Investigation Report, dated 03/28/17, revealed . (Resident #1) was being transferred from the bed to the wheelchair. During the transfer the resident got his feet tangled up and the CNA reported that she and another CNA lowered him to the floor. She did not report the incident to the nurse because they lowered him to the floor. The patient later said that his knee, which he had problems with before, was hurting. He was examined and an x-ray was ordered. He complained of no other pain. The x-ray of the knee was negative for any acute issues. The next day his ankle was bruised and swollen. An x-ray showed an acute ankle fracture. He was sent to the hospital for evaluation and treatment . On 3/22/17 at approximately 7:45 am, (CNA A) transferred (Resident #1) from the bed to the wheelchair. At approximately 8:10 am while the resident was in therapy he told his therapist that when transferring from the bed to the wheelchair his right leg got caught under his left leg and he fell to the floor and twisted his knee and his head lightly hit the floor. He told the therapist that now he had knee pain. He also said that the CNA told him not to mention it to anyone. The therapist notified nursing and (LVN B) then did a Head to Toe assessment. She identified that the resident had right knee pain. The resident had no other complaints of pain and no other signs of injury. (LVN B), notified the physician, gave him pain medications and ordered an x-ray of his right knee. The x-ray returned negative for acute injury. The resident was monitored had no other complaints of pain or injury. The DON started an investigation of the fall and why it was not immediately reported. (CNA A) stated that she and another CNA lowered the resident to the floor therefore; she had not considered it a fall. The DON proceeded to educate the CNA on what constituted a fall. The DON also questioned if the CNA talked to (Resident #1) about not saying anything about the fall. She stated that she had not made any such statement to the resident. Later, the DON interviewed (CNA C) who (CNA A) stated helped her transfer (Resident #1). During that interview, (CNA C) indicated that she had not helped (CNA A) transfer the resident to the chair and she stated that when she came in the resident was already on the floor. After reviewing the statements from both CNA's (sic) the DON identified that further investigation was needed because the stories did not match. The CNAs were gone for the day. The next morning before the investigation . could be continued, it was identified that the resident's ankle was bruised and swollen. The family and physician were notified and an x-ray was ordered. While waiting for the x-ray report the resident complained of numbness so the family and physician were notified and the resident was sent to the hospital for further evaluation and treatment. The x-ray report showed an acute ankle fracture. The investigation continued. In a subsequent interview with (CNA A), she admitted that she had transferred the resident by herself. She continued to maintain that she had not told him, not to tell anyone about the fall. The CNA was asked to write a new statement regarding the incident and she was placed on suspension while the investigation was concluded. SAFE Surveys were done with the residents and the (sic) all reported feeling safe, not afraid of anyone and that they could voice any complaints that they had to someone. The investigation showed that (CNA A) transferred the resident without assistance. During that transfer the resident fell to the floor. The CNA did not report the incident to anyone and delayed assessment by not reporting the incident immediately. The CNA initially gave a false statement during the investigation by stating that she had the assistance of another CNA to transfer the resident and that the resident was lowered to the floor. Upon additional questioning, she reported that she did not have assistance during the transfer that should have had 2 persons, but did obtain assistance to move (Resident #1) from the floor to the wheelchair. The CNA was terminated Further review of the facility's investigation regarding Resident #1 revealed an inservice/training record, dated 03/22/17, regarding . Understanding falls and fall prevention, when to notify the nurse prior to moving the resident, gait belt at all times. Preparing the resident for the day/ADL's (Activities of Daily Living)/assist of two was discussed with the nursing staff, including CNAs. An inservice/training record, dated 03/24/17, regarding . Abuse and Neglect/Resident Rights. Identifying abuse/neglect/reporting/prevention was discussed with the nursing staff, including CNAs. An inservice/training record, dated 03/24/17, regarding . Falls/fall prevention, identifying via care guide/care plan resident assistance needs (assist of one or two) use of gait belt. Awareness that an assisted fall is a fall from one plane to another) and must be reported immediately was discussed with the nursing staff, including CNAs. Interview on 04/07/17 at 10:04 AM with the ADM revealed CNA A was assigned to Resident #1 and transferred the resident from his bed to his wheelchair without assistance. The ADM stated the resident required the assistance of two people for transfers. She stated the resident went to the therapy department and mentioned that he had a fall and that his knee was hurting. She stated the resident said that CNA A said not to say anything about the fall. The ADM stated CNA A said that she and CNA C transferred the resident, his feet got tangled up, he was lowered to the floor with no injuries, and then placed in his wheelchair. The ADM stated CNA A denied telling the resident not to say anything. The ADM stated the resident had a history of [REDACTED]. The ADM stated CNA A said there had not been a fall but the resident was lowered to the floor. The ADM stated CNA A was educated on what constituted a fall. The ADM stated a head to toe assessment was completed on the resident and the x-ray was negative. The ADM stated the DON spoke with CNA C who said she had helped get the resident off the floor but there was no mention of initially helping to transfer the resident prior to the fall. The ADM stated the next day the nurse alerted the DON of bruising to the resident's right ankle and another x-ray was ordered STAT (immediately). She stated the swelling continued and the resident was sent to the hospital before the results of the x-ray arrived. The ADM stated she and the DON spoke with CNA A who admitted to transferring the resident without assistance. The ADM stated CNA A said she got CNA C to help get the resident up and denied telling the resident not to say anything. The ADM stated CNA A said that the resident hit his knee when he was lowered to the floor, which the CNA did not consider a fall, but did not have pain. The ADM stated CNA A was suspended and then her employment was terminated. The ADM stated approximately 25 minutes elapsed from the time the resident fell to when the resident mentioned his fall to the therapist. The ADM stated CNA C was also trained on what constituted a fall. The ADM stated CNA C thought the resident had already been assessed and was just helping to get him off the floor. The ADM stated the resident complained of pain with movement of his ankle and was provided with pain medications. The ADM stated the resident confirmed only one person had transferred him prior to his fall. The ADM stated CNAs at the facility received training regarding falls and what constituted a fall. The ADM stated CNA A said she felt like she was able to transfer the resident by herself. The ADM stated the CNAs' training also included abuse and neglect and reporting incidents to the nurses. The ADM stated the facility was scheduled to have therapy conduct a skills checkoff regarding transfers with the staff which would be completed later during April 2017 and on a quarterly/as needed basis. The ADM stated there had been no training regarding return demonstration yet since the incident with Resident #1. The ADM stated the facility had a safety fair after the incident which included transfers. Interview on 04/07/17 at 12:02 PM with OT D revealed Resident #1 told her his right ankle hurt. She stated the resident sometimes had pain and told him they would start off with some light therapy but the resident continued to have pain. She stated the resident told her he had a fall, he said it was his fault and that his nurse did not know. She stated the resident was hesitant but said he had tried to get out of bed when his legs got tangled and he fell . She stated the resident described CNA A as the person who was assisting him at the time of his fall. She stated the resident denied being lowered to the floor and said he had hit his head lightly. She stated the resident told her CNA A had him lie down and she went to get help from an unknown person to help get him up. She stated the resident did not want to get CNA A in trouble and said she asked him not to say anything about it. She stated the resident said his pain was 10 to 12 on a scale of 1 to 10. She stated the resident was taken to the nurse's station and LVN B was notified. She stated the resident returned from the hospital with the boot and was unable to stand. Interview on 04/07/17 at 12:15 PM with the DON revealed OT D informed her of Resident #1's fall and how CNA A asked the resident not to say anything. The DON stated she spoke with CNA A who said the resident was guided to the floor and did not consider it a fall. The DON stated she called the resident's nurse (LVN B) and informed her of the fall who completed a head to toe assessment on the resident. The DON stated the resident complained of knee pain and was alert with no confusion. The DON stated an x-ray was ordered. The DON stated CNA A said, at some point, that CNA C witnessed the resident's fall. The DON stated CNA C denied witnessing the fall and said she was summoned to assist the resident from the floor. The DON stated the resident's x-ray did not indicate a fracture and the staff continued to monitor the resident. The DON stated LVN E said the nurse from the overnight shift reported that the resident had pain and medication was provided. The DON stated she went with LVN E to check on the resident and observed that the resident's right ankle was very swollen and he had a bruise (lilac colored). The DON stated the resident's right foot was turned out and he had complaints of pain. The DON stated an x-ray was ordered STAT and the resident was provided with pain medication. The DON stated it took a while to get the x-ray results (a few hours elapsed) so the resident was transferred to the hospital. The DON stated the hospital confirmed two fractures and a boot was provided to the resident. She stated the resident was transferred back to the facility but was discharged several days later to another facility. The DON stated the facility had been working with the resident and his family for alternate placement prior to the incident. The DON stated she and the administrator interviewed CNA A who was suspended and ultimately terminated. The DON stated the facility had in-services on abuse and neglect, care guide/care plans, gait belts, and what constituted a fall. The DON stated there was an upcoming in-service with therapy which would include a return demonstration. Interview on 04/07/17 at 12:47 PM with CNA C revealed she was in the dining room getting ready for the meal service when CNA A asked for her assistance. CNA C stated she went to Resident #1's room and the resident's bed was all the way to the floor. She stated the resident was lying on his right side on the floor. CNA C stated CNA A said she had to ease the resident to the floor. CNA C stated she asked the resident if he was okay or hurt and the resident had no concerns. CNA C stated she helped CNA A get the resident off the floor and into the wheelchair. CNA C stated the resident was okay during the process of getting him up and the resident denied any pain or problems. CNA C stated the resident and CNA A thanked her and she exited the room. CNA C stated she was not in the room when the resident fell or was lowered to the floor. CNA C stated she assumed the nurse had been notified and was aware that the resident was on the floor. CNA C stated LVN B was not able to lift the residents and figured that was why she had been asked to help. CNA C stated LVN B was down the hall at the medication cart when she went to the room to assist CNA A with the resident. CNA C stated she did not ask the nurse if she was aware the resident was on the floor and CNA A did not say the resident's nurse was aware. Interview on 04/07/17 at 1:03 PM with CNA A revealed Resident #1 was normally able to stand but his legs got tangled up and he had to be lowered to the floor. She stated the resident had no complaints of pain at that time. She stated she knew she should have gotten the nurse to assess the resident after lowering him to the floor but did not consider it a fall. She stated the resident's knee touched the floor first and then his buttocks. She stated she went to get CNA C to help get the resident up. She stated she never tried to mislead the facility in thinking that CNA C had assisted her prior to the resident's fall. She stated the resident required two people to assist him with transfers when he was admitted to the facility and thought he had been changed to a one-person assist with transfers. She stated she last had a second person assist her with the resident's transfers approximately a week prior to the incident. She stated she had transferred the resident without assistance several times prior to the incident. She stated there had been no other occasions where a resident had been transferred outside of their care plan or a resident had fallen without the nurse being notified. Interview on 04/07/17 at 5:36 PM with LVN F revealed she worked with Resident #1 from 6:00 PM to 6:00 AM after his fall. She stated the resident complained of knee pain. She stated the resident's pain was at a six on a scale 1 to 10. She stated the resident's previous x-ray had been negative but there was some swelling with his right knee. She stated there was some bruising and swelling on the resident's right ankle towards the end of her shift that was not severe. She stated she notified LVN B of the concern and the need for a possible ankle x-ray. She stated the resident was given a pain medication during her shift which was effective and the resident was able to rest. Interview on 04/07/17 at 8:43 PM with LVN B revealed CNA A had not asked for assistance with transferring Resident #1 or informed her of the resident's fall. She stated she saw CNA A and CNA C go to Resident #1's room the morning of the incident. She stated the DON notified her of the resident's fall and she then assessed the resident. Review of the facility's Falls - Clinical Protocol policy and procedure, dated April 2013, revealed . Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. *This constitutes a fall. A change in the plane of the resident even when assisted to the floor Interviews conducted on 04/07/17 from 10:53 AM to 4:49 PM with CNA C, CNA G, RN H, CNA I, LVN J, and CNA L revealed they all knew what constituted a fall and the appropriate steps to take following a resident's fall. Interview on 04/07/17 at 4:35 PM with CNA K, who was in-serviced following the incident, revealed she did not know that staff lowering a resident to the floor constituted a fall. CNA K stated she would still notify the nurse to assess a resident who was lowered to the floor. Review of an undated staff list, provided by the ADM and DON on 04/07/17, revealed 50 nursing staff (CNAs, Medication Aides, LVNs and RNs) had not been in-serviced following the incident with Resident #1. The list reflected 38 of the 50 nursing staff, who had not been in-serviced, were either part-time or worked on an as-needed basis. During a joint interview on 04/07/17 at 5:51 PM with the ADM and DON, the ADM stated the majority of the staff who had not been in-serviced worked on an as-needed basis and it was difficult to get those staff to come in for in-services. Observations on 04/07/17 from 1:25 PM to 2:35 PM of gait belt and mechanical lift transfers for Resident #2, Resident #3, Resident #4 and Resident #5 did not reveal concerns. The ADM provided email documentation on 04/13/17 that reflected 39 residents (on 04/07/17) required staff assistance with transfers.

Based on observation, interview and record review, the facility failed to implement written policies and procedures, which prohibit neglect for one (Resident #1) of five residents reviewed for neglect. CNA A transferred Resident #1, who was care planned for transfers with the assistance two staff, without assistance on 03/22/17, which resulted in the resident being injured and sustaining a fracture to his right ankle. This failure could affect the facility's 39 residents, who required staff assistance for transfers and placed them at risk for falling, lacerations, fractures and the need for hospitalization . Findings included: Review of the facility's Abuse Prevention, Reporting and Investigation policy and procedure, dated 11/16/16, revealed . (Facility) will implement policies and procedures that prevent abuse, neglect, (sic) misappropriation of funds Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress Review of the facility's Falls - Clinical Protocol policy and procedure, dated April 2013, revealed . Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. *This constitutes a fall. A change in the plane of the resident even when assisted to the floor Review of Resident #1's Minimum Data Set assessment, dated 02/16/17, revealed he was [AGE] years and was admitted to the facility on [DATE]. The resident was cognitively intact and his [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive care plan, dated 02/16/17, revealed . Requires assistance of 2 staff for transfers Review of Resident #1's radiology report, dated 03/23/17, revealed . Results: There is a fracture involving distal tibia and fibula with minimal displacement. The joint alignment is maintained. There is associated soft tissue swelling. Conclusion: Acute ankle fracture as described above Review of Resident #1's Skilled Care Nurses Note, created 03/22/17 at 11:54 PM and authored by LVN F, revealed . bruising and mild swelling noted to right ankle and right knee Review of Resident #1's Skilled Care Nurses Note, created 03/23/17 at 10:44 PM and authored by LVN M, revealed . C/o (Complains of) RLE (right lower extremity) pain at 2100h (9:00 PM) . acute right ankle fx (fracture). Fx boot in place per order Review of the facility's Provider Investigation Report, dated 03/28/17, revealed . (Resident #1) was being transferred from the bed to the wheelchair. During the transfer the resident got his feet tangled up and the CNA reported that she and another CNA lowered him to the floor. She did not report the incident to the nurse because they lowered him to the floor. The patient later said that his knee, which he had problems with before, was hurting. He was examined and an x-ray was ordered. He complained of no other pain. The x-ray of the knee was negative for any acute issues. The next day his ankle was bruised and swollen. An x-ray showed an acute ankle fracture. He was sent to the hospital for evaluation and treatment . On 3/22/17 at approximately 7:45 am, (CNA A) transferred (Resident #1) from the bed to the wheelchair. At approximately 8:10 am while the resident was in therapy he told his therapist that when transferring from the bed to the wheelchair his right leg got caught under his left leg and he fell to the floor and twisted his knee and his head lightly hit the floor. He told the therapist that now he had knee pain. He also said that the CNA told him not to mention it to anyone. The therapist notified nursing and (LVN B) then did a Head to Toe assessment. She identified that the resident had right knee pain. The resident had no other complaints of pain and no other signs of injury. (LVN B), notified the physician, gave him pain medications and ordered an x-ray of his right knee. The x-ray returned negative for acute injury. The resident was monitored had no other complaints of pain or injury. The DON started an investigation of the fall and why it was not immediately reported. (CNA A) stated that she and another CNA lowered the resident to the floor therefore; she had not considered it a fall. The DON proceeded to educate the CNA on what constituted a fall. The DON also questioned if the CNA talked to (Resident #1) about not saying anything about the fall. She stated that she had not made any such statement to the resident. Later, the DON interviewed (CNA C) who (CNA A) stated helped her transfer (Resident #1). During that interview, (CNA C) indicated that she had not helped (CNA A) transfer the resident to the chair and she stated that when she came in the resident was already on the floor. After reviewing the statements from both CNA's (sic) the DON identified that further investigation was needed because the stories did not match. The CNAs were gone for the day. The next morning before the investigation . could be continued, it was identified that the resident's ankle was bruised and swollen. The family and physician were notified and an x-ray was ordered. While waiting for the x-ray report the resident complained of numbness so the family and physician were notified and the resident was sent to the hospital for further evaluation and treatment. The x-ray report showed an acute ankle fracture. The investigation continued. In a subsequent interview with (CNA A), she admitted that she had transferred the resident by herself. She continued to maintain that she had not told him, not to tell anyone about the fall. The CNA was asked to write a new statement regarding the incident and she was placed on suspension while the investigation was concluded. SAFE Surveys were done with the residents and the (sic) all reported feeling safe, not afraid of anyone and that they could voice any complaints that they had to someone. The investigation showed that (CNA A) transferred the resident without assistance. During that transfer the resident fell to the floor. The CNA did not report the incident to anyone and delayed assessment by not reporting the incident immediately. The CNA initially gave a false statement during the investigation by stating that she had the assistance of another CNA to transfer the resident and that the resident was lowered to the floor. Upon additional questioning, she reported that she did not have assistance during the transfer that should have had 2 persons, but did obtain assistance to move (Resident #1) from the floor to the wheelchair. The CNA was terminated Further review of the facility's investigation regarding Resident #1 revealed an inservice/training record, dated 03/22/17, regarding . Understanding falls and fall prevention, when to notify the nurse prior to moving the resident, gait belt at all times. Preparing the resident for the day/ADL's (Activities of Daily Living)/assist of two was discussed with the nursing staff, including CNAs. An inservice/training record, dated 03/24/17, regarding . Abuse and Neglect/Resident Rights. Identifying abuse/neglect/reporting/prevention was discussed with the nursing staff, including CNAs. An inservice/training record, dated 03/24/17, regarding . Falls/fall prevention, identifying via care guide/care plan resident assistance needs (assist of one or two) use of gait belt. Awareness that an assisted fall is a fall from one plane to another) and must be reported immediately was discussed with the nursing staff, including CNAs. Interview on 04/07/17 at 10:04 AM with the ADM revealed CNA A was assigned to Resident #1 and transferred the resident from his bed to his wheelchair without assistance. The ADM stated the resident required the assistance of two people for transfers. She stated the resident went to the therapy department and mentioned that he had a fall and that his knee was hurting. She stated the resident said that CNA A said not to say anything about the fall. The ADM stated CNA A said that she and CNA C transferred the resident, his feet got tangled up, he was lowered to the floor with no injuries, and then placed in his wheelchair. The ADM stated CNA A denied telling the resident not to say anything. The ADM stated the resident had a history of [REDACTED]. The ADM stated CNA A said there had not been a fall but the resident was lowered to the floor. The ADM stated CNA A was educated on what constituted a fall. The ADM stated a head to toe assessment was completed on the resident and the x-ray was negative. The ADM stated the DON spoke with CNA C who said she had helped get the resident off the floor but there was no mention of initially helping to transfer the resident prior to the fall. The ADM stated the next day the nurse alerted the DON of bruising to the resident's right ankle and another x-ray was ordered STAT (immediately). She stated the swelling continued and the resident was sent to the hospital before the results of the x-ray arrived. The ADM stated she and the DON spoke with CNA A who admitted to transferring the resident without assistance. The ADM stated CNA A said she got CNA C to help get the resident up and denied telling the resident not to say anything. The ADM stated CNA A said that the resident hit his knee when he was lowered to the floor, which the CNA did not consider a fall, but did not have pain. The ADM stated CNA A was suspended and then her employment was terminated. The ADM stated approximately 25 minutes elapsed from the time the resident fell to when the resident mentioned his fall to the therapist. The ADM stated CNA C was also trained on what constituted a fall. The ADM stated CNA C thought the resident had already been assessed and was just helping to get him off the floor. The ADM stated the resident complained of pain with movement of his ankle and was provided with pain medications. The ADM stated the resident confirmed only one person had transferred him prior to his fall. The ADM stated CNAs at the facility received training regarding falls and what constituted a fall. The ADM stated CNA A said she felt like she was able to transfer the resident by herself. The ADM stated the CNAs' training also included abuse and neglect and reporting incidents to the nurses. The ADM stated the facility was scheduled to have therapy conduct a skills checkoff regarding transfers with the staff which would be completed later during April 2017 and on a quarterly/as needed basis. The ADM stated there had been no training regarding return demonstration yet since the incident with Resident #1. The ADM stated the facility had a safety fair after the incident which included transfers. Interview on 04/07/17 at 12:02 PM with OT D revealed Resident #1 told her his right ankle hurt. She stated the resident sometimes had pain and told him they would start off with some light therapy but the resident continued to have pain. She stated the resident told her he had a fall, he said it was his fault and that his nurse did not know. She stated the resident was hesitant but said he had tried to get out of bed when his legs got tangled and he fell . She stated the resident described CNA A as the person who was assisting him at the time of his fall. She stated the resident denied being lowered to the floor and said he had hit his head lightly. She stated the resident told her CNA A had him lie down and she went to get help from an unknown person to help get him up. She stated the resident did not want to get CNA A in trouble and said she asked him not to say anything about it. She stated the resident said his pain was 10 to 12 on a scale of 1 to 10. She stated the resident was taken to the nurse's station and LVN B was notified. She stated the resident returned from the hospital with the boot and was unable to stand. Interview on 04/07/17 at 12:15 PM with the DON revealed OT D informed her of Resident #1's fall and how CNA A asked the resident not to say anything. The DON stated she spoke with CNA A who said the resident was guided to the floor and did not consider it a fall. The DON stated she called the resident's nurse (LVN B) and informed her of the fall who completed a head to toe assessment on the resident. The DON stated the resident complained of knee pain and was alert with no confusion. The DON stated an x-ray was ordered. The DON stated CNA A said, at some point, that CNA C witnessed the resident's fall. The DON stated CNA C denied witnessing the fall and said she was summoned to assist the resident from the floor. The DON stated the resident's x-ray did not indicate a fracture and the staff continued to monitor the resident. The DON stated LVN E said the nurse from the overnight shift reported that the resident had pain and medication was provided. The DON stated she went with LVN E to check on the resident and observed that the resident's right ankle was very swollen and he had a bruise (lilac colored). The DON stated the resident's right foot was turned out and he had complaints of pain. The DON stated an x-ray was ordered STAT and the resident was provided with pain medication. The DON stated it took a while to get the x-ray results (a few hours elapsed) so the resident was transferred to the hospital. The DON stated the hospital confirmed two fractures and a boot was provided to the resident. She stated the resident was transferred back to the facility but was discharged several days later to another facility. The DON stated the facility had been working with the resident and his family for alternate placement prior to the incident. The DON stated she and the administrator interviewed CNA A who was suspended and ultimately terminated. The DON stated the facility had in-services on abuse and neglect, care guide/care plans, gait belts, and what constituted a fall. The DON stated there was an upcoming in-service with therapy which would include a return demonstration. Interview on 04/07/17 at 12:47 PM with CNA C revealed she was in the dining room getting ready for the meal service when CNA A asked for her assistance. CNA C stated she went to Resident #1's room and the resident's bed was all the way to the floor. She stated the resident was lying on his right side on the floor. CNA C stated CNA A said she had to ease the resident to the floor. CNA C stated she asked the resident if he was okay or hurt and the resident had no concerns. CNA C stated she helped CNA A get the resident off the floor and into the wheelchair. CNA C stated the resident was okay during the process of getting him up and the resident denied any pain or problems. CNA C stated the resident and CNA A thanked her and she exited the room. CNA C stated she was not in the room when the resident fell or was lowered to the floor. CNA C stated she assumed the nurse had been notified and was aware that the resident was on the floor. CNA C stated LVN B was not able to lift the residents and figured that was why she had been asked to help. CNA C stated LVN B was down the hall at the medication cart when she went to the room to assist CNA A with the resident. CNA C stated she did not ask the nurse if she was aware the resident was on the floor and CNA A did not say the resident's nurse was aware. Interview on 04/07/17 at 1:03 PM with CNA A revealed Resident #1 was normally able to stand but his legs got tangled up and he had to be lowered to the floor. She stated the resident had no complaints of pain at that time. She stated she knew she should have gotten the nurse to assess the resident after lowering him to the floor but did not consider it a fall. She stated the resident's knee touched the floor first and then his buttocks. She stated she went to get CNA C to help get the resident up. She stated she never tried to mislead the facility in thinking that CNA C had assisted her prior to the resident's fall. She stated the resident required two people to assist him with transfers when he was admitted to the facility and thought he had been changed to a one-person assist with transfers. She stated she last had a second person assist her with the resident's transfers approximately a week prior to the incident. She stated she had transferred the resident without assistance several times prior to the incident. She stated there had been no other occasions where a resident had been transferred outside of their care plan or a resident had fallen without the nurse being notified. Interview on 04/07/17 at 5:36 PM with LVN F revealed she worked with Resident #1 from 6:00 PM to 6:00 AM after his fall. She stated the resident complained of knee pain. She stated the resident's pain was at a six on a scale 1 to 10. She stated the resident's previous x-ray had been negative but there was some swelling with his right knee. She stated there was some bruising and swelling on the resident's right ankle towards the end of her shift that was not severe. She stated she notified LVN B of the concern and the need for a possible ankle x-ray. She stated the resident was given a pain medication during her shift which was effective and the resident was able to rest. Interview on 04/07/17 at 8:43 PM with LVN B revealed CNA A had not asked for assistance with transferring Resident #1 or informed her of the resident's fall. She stated she saw CNA A and CNA C go to Resident #1's room the morning of the incident. She stated the DON notified her of the resident's fall and she then assessed the resident. Interviews conducted on 04/07/17 from 10:53 AM to 4:49 PM with CNA C, CNA G, RN H, CNA I, LVN J, and CNA L revealed they all knew what constituted a fall and the appropriate steps to take following a resident's fall. Interview on 04/07/17 at 4:35 PM with CNA K, who was in-serviced following the incident, revealed she did not know that staff lowering a resident to the floor constituted a fall. CNA K stated she would still notify the nurse to assess a resident who was lowered to the floor. Review of an undated staff list, provided by the ADM and DON on 04/07/17, revealed 50 nursing staff (CNAs, Medication Aides, LVNs and RNs) had not been in-serviced following the incident with Resident #1. The list reflected 38 of the 50 nursing staff, who had not been in-serviced, were either part-time or worked on an as-needed basis. During a joint interview on 04/07/17 at 5:51 PM with the ADM and DON, the ADM stated the majority of the staff who had not been in-serviced worked on an as-needed basis and it was difficult to get those staff to come in for in-services. Observations on 04/07/17 from 1:25 PM to 2:35 PM of gait belt and mechanical lift transfers for Resident #2, Resident #3, Resident #4 and Resident #5 did not reveal concerns. The ADM provided email documentation on 04/13/17 that reflected 39 residents (on 04/07/17) required staff assistance with transfers.

Based on observation, interview and record review, it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent injury for one (Resident #1) of five residents reviewed for accidents. Resident #1 was assessed on admission (03/17/12) and was determined to be a fall risk who required maximum assist with ADLs. At that time staff implemented a personal alarm and ensured the bed was in a low position. An individualized care plan was not generated following the resident's fall risk assessment to ensure implementation of interventions to potentially prevent falls/injury. On 03/20/12, the resident was found sitting on the edge of her recliner with the foot rest extended and her legs in front of her. The resident did not know what happened. A personal alarm was not present and the bed was not in the low position. Resident #1 sustained a 16 cm by 13 cm laceration behind the left knee. She was sent to the ER, admitted to the hospital and a plastic surgeon was required to suture the laceration. These failures could affect the 49 residents who required assistance with transfers and/or the 11 residents who were identified as having sustained falls, and placed them at risk for falls. A fall had the potential to result in a painful injury, which required medical treatment and/or a hospital stay. Findings included: 1) The MDS assessment dated [DATE] reflected Resident #1, a [AGE] year-old female, was admitted on [DATE] and required extensive assistance with ADLs, used a wheelchair for mobility and was not steady when moving: on and off the toilet, from a seated to standing position and during surface to surface transfers. The [DIAGNOSES REDACTED]. Resident #1 was observed on 04/04/12 at 1: 20 PM to be a large lady. Resident #1 was in bed, and the bed was in the low position with the foot of the bed elevated, and a personal alarm was in place (usually placed beneath the resident and alarms to warn staff when the resident attempted to get up without assistance). A mat, approximately two inches thick, 18 inches wide and the full length of the bed, was on the floor next to the bed. Observation of the resident's injury behind her left knee and calf revealed a sutured area approximately six inches by four inches in a T shape. When trying to interview Resident #1, the resident did not respond to the surveyor's questions, but complained about generalized pain. Resident #1's Fall Risk Evaluation dated 03/17/12 reflected the resident was at high risk for falls, was chairbound, had balance problems while standing, required assistive devices to ambulate, took medication with side effect of lethargy and confusion, and had diagnoses, which could contribute to a fall. The facility's current Fall Prevention and Management Program Policy dated 09/01/2005 reflected a Fall Risk Assessment was to be completed within 24 hours of admission. An Interim Care Plan was to be initiated for residents determined to be at risk. Individualized care plan interventions were to be implemented for those residents found to be at high risk for falls. Interventions included: Assess environment and make appropriate changes such as bed in low position; and/or personal alarms attached to chair or bed. A review of Resident #1's Interdisciplinary Care Plan, dated 03/17/12, revealed the resident would be provided ADL assistance in a safe manner according to the resident's individual needs. There was nothing specific in regard to the resident having been identified as a high fall risk and no interventions were listed. The Care Plan was not individualized as reflected in the facility's policy for fall prevention. A review of a Skilled Daily Nurses Note, dated 03/17/12, revealed Resident #1 was unable to stand and required the assistance of two persons. The resident was alert x 2 (person and place)and was receiving oxygen at 2 lpm per nasal cannula. There was nothing documented about interventions being implemented for safety. In an interview on 04/04/12 at 5:00 PM with LVN C, she stated she was the nurse for Resident #1 on 03/19/12. LVN C stated Resident #1 had a personal alarm and low bed. When queried about the personal alarm and low bed, LVN C said she believed the resident was at risk for falls. She added Resident #1's cognition was poor, but the resident had not attempted to stand up (without assistance). In an interview with CNA B on 04/04/12 at 5:05 PM, she stated she had provided care to Resident #1 on 03/19/12. CNA B stated the resident was confused, had a personal alarm in place, her bed was in the low position and the call light was in reach on 03/19/12. In an interview with CNA A on 04/04/12 at 9:55 AM, she stated on the morning of 03/20/12 she went to answer Resident #1's call light. She stated she opened the resident's door and Resident #1 was sitting on the front of the recliner with the foot rest extended with blood on the floor beneath her and on the foot rest. She stated she immediately notified the nurse, who came and provided treatment to the resident. She stated Resident #1's bed was not in the low position, but on a level with recliner, and there was no personal alarm on the resident's bed. When queried, CNA A said she did not know if the resident was at risk for falls. In an interview on 04/04/12 at 10:20 AM with LVN E, she stated she was called to Resident #1's room by the aide. She entered the room and observed resident sitting on the front edge of the recliner with her leg extended out in front of her. The foot rest was extended out and the chair was tipped forward. LVN E stated she observed blood and urine on the floor beneath the foot rest, and there was blood on the foot rest of the chair. When queried whether the resident had a bed alarm, LVN E said the resident did not have a bed alarm, but her call light was still activated. She stated she assessed Resident #1, who had a large laceration on the back of her left knee. LVN E stated Resident #1 was transferred to the hospital for evaluation and treatment, where she was admitted . She stated the resident was in the hospital four to five days and a plastic surgeon sutured the laceration for the resident. She added there were several sutures required to close the laceration. In an interview with the Therapy Director on 04/04/12 at 12:10 PM, she stated Resident #1 was living in the Assisted Living area of the facility prior to being admitted to the skilled nursing unit. She stated Resident #1 was previously independent and used a walker to ambulate. The Therapy Director stated when the resident was admitted to the unit, the resident had a functional decline and required maximum assistance with transfers. On 04/04/12 at 2:45 PM, LVN F was interviewed per telephone. She confirmed working the 6:00 AM - 6:00 PM shift on 03/17/12. LVN F stated Resident #1 was forgetful at times, but remembered to use the call light. LVN F stated Resident #1 scored a 10 on the Fall Risk Assessment (indicating the resident was a High Risk for falls) and she was weak. LVN F stated the resident was provided a bed alarm, call light, her bed was to be in the lowest position and the aides were to provide mats on the floor next to the beds. On 04/05/12 at 12:30 PM in an interview with CNA D, she stated on 03/20/12 at 5:30 AM, she had provided care to Resident #1. At that time, the resident was in bed with the bed in the low position and a personal alarm was in place. A Physical Therapy Initial Assessment, dated 03/19/12, reflected Resident #1 required maximum assistance with transfers and maximum assistance to maintain balance while standing. In an interview with the Physical Therapist on 04/04/12 at 1:45 PM, she stated she completed Resident #1's initial therapy evaluation on 03/19/12. She said she had provided therapy for resident when she lived in the assisted living unit for several weeks, which was prior to her admisstion to the facility. The resident had developed Pneumonia and was admitted to the hospital. When she was discharged from the hospital, she was admitted to the facility. She stated Resident #1 was independent with most of her ADLs when she lived in the assisted living unit. She said when the resident was admitted to the skilled nursing unit, the resident required maximum assistance (the resident was unable to do much for herself due to being weak) with all her ADLs and was unable to move her legs to the edge of the bed without assistance. Because of that, the Registered Physical Therapist did not believe Resident #1 would even attempt to get out of bed, did not consider her a fall risk and did not recommend fall prevention interventions. She said Resident #1's last fall was approximately two years prior. She added Resident #1 was very fatigued when she ambulated at the time of the evaluation. A review of the Occupational Therapy Initial assessment dated [DATE] revealed Resident #1 was a maximum assist with transfers and other ADLs. A Speech Therapy Initial assessment dated [DATE] reflected Resident #1 had a severe cognitive deficit. A review of the facility's accident incident report dated 03/20/12 revealed on 03/20/12 at approximately 7:05 AM, Resident #1 was found sitting on the front edge of her recliner, which was tipped forward and had the foot rest extended. The resident had activated the call system, staff responded, and found the resident on her recliner. Assessment revealed the resident sustained [REDACTED]. The facility's Investigation Report dated 03/20/12 reflected Resident #1 sustained a serious injury on 03/20/12 at 7:00 AM. The Report reflected Resident #1 required the extensive assistance of two people, was not independently ambulatory, did not have the capacity to make informed decisions and had periods of confusion. The injury was described a an approximate 16 cm x 13 cm jagged laceration to the back of the left knee. Assessment at 7:20 AM reflected the resident was able to move her extremities and there was a medium amount of fresh blood on the floor with some clots and pieces of skin. A summary of the facility's investigation findings was a repeat of the CNA and LVN finding the resident with an injury. The CNA and the LVN provided witness statements. There was no mention made of the use of a personal alarm or the bed being in the lowest position. The Investigation Report reflected the facility's action taken post-investigation included: a) The family had just brought in the recliner on 03/19/12 and the facility was going to ask for its removal. b) Bed and chair alarm at all times. c) Reinforce the resident's use of the call light for assistance. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 04/04/12, reflected 49 residents required assistance with transfers. The facility's Form CMS-802, Roster/Sample Matrix, dated 04/04/12 reflected 11 residents were identified with falls.