Every finding on record at Trinity Healthcare Center

Based on observation, staff interview, and facility policy review, the facility failed to ensure clean linens were transported in a manner to prevent contamination for one (1) of three (3) days of survey. Findings Include: Review of facility policy, Infection Prevention and Control Program with an implementation date of 10/2022, the policy stated, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. On 4/28/2026 at 11:34 AM, an unidentified staff member was observed transporting clean linens in a cart without a cover in the resident hallway. During an interview with the Administrator, she stated and confirmed, Staff members were educated on the safe transportation of resident's linens, and they are to be covered to prevent contamination.

Based on staff interviews, record review, and facility policy review, the facility failed to accurately complete and submit a Minimum Data Set (MDS) assessment for a resident not receiving hospice services for one (1) of 17 assessments reviewed. Resident #38 Findings include: Record review of facility policy titled, Conducting an Accurate Resident assessment dated 10/25, revealed, Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Resident #38 During the record review of Resident #38's Significant Change Minimum Data Set (MDS) Section O - Special Treatments, Procedures, and Programs dated 3/25/26, the data revealed the resident received hospice care while a resident at the facility. Record review of Resident #38's Clinical Physician Orders since his admission to facility on 12/23/25, revealed that hospice services had not been ordered. An interview with the MDS Registered Nurse (RN) Coordinator on 4/30/26 at 8:45 AM, revealed she was responsible for completing and submitting the MDS assessments. She acknowledged that the staff, resident, and family had discussed hospice services for Resident #38, but the family chose to not place the resident on hospice but to provide comfort measures for the resident. She acknowledged that she mistakenly submitted a significant change MDS for hospice care which led to an inaccurate assessment. During an interview on 4/30/26 at 9:00 AM, the Director of Nursing (DON) acknowledged the MDS assessment was information on a resident's status at the time of the assessment and should be entered and submitted accurately. She confirmed Resident #38 did not receive hospice services during his admission to the facility. She confirmed the facility failed to accurately complete and submit the MDS assessment for Resident #38. Record review of Resident #38's admission Record revealed the facility admitted the resident on 12/23/25 with diagnoses that included Malignant Neoplasm of Pancreas. Record review of Resident #38's MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated the resident had a moderate cognitive impairment.

Based on observations, staff and resident representative interviews, record review and facility policy review, the facility failed to ensure a resident was free from pain after exhibiting nonverbal signs of excruciating pain for one (1) or 16 residents sampled. Resident #29 Findings Include: Review of the facility policy titled, Pain Management with no revision date revealed under the Policy .The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences This review revealed under Policy Explanation and Compliance Guidelines .The facility utilizes a systematic approach for recognition, assessment, treatment and monitoring of pain .k. Sighing, groaning, crying, breathing heavily; under Pain Assessment: e. Determining factors that make the pain better or worse; and under Monitoring: 1. Reassess patients with pain regularly based on the facility's established intervals. On 05/28/24 at 11:03 AM, an observation revealed two staff members were leaving Resident #29's room with a bag of garbage and the resident was moaning loud enough that it could be heard from the hallway outside of her room. Upon entering the resident's room, the resident was sitting up in her wheelchair, dressed in personal clothes and continued making loud moaning noises with her mouth open at all times, her eyebrows were furrowed, and a single tear fell from her right eye. The resident was unable to be interviewed and could not answer questions. On 5/28/24 at 11:20 AM, an interview with Licensed Practical Nurse (LPN) #2 revealed the aides were just in there getting Resident #29 up out of bed and the LPN stated that they were observed leaving the room around 11:00 AM. Record review of Resident #29's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnosis that included Multiple Myeloma not having achieved remission and Secondary Malignant Neoplasm of Bone. An observation on 5/28/24 at 1:00 PM, revealed the resident sitting up in her wheelchair in the resident's room with continuous moaning that could be heard in the hallway and continued to have furrowed brows and facial grimacing. Record review of Resident #29's physicians orders revealed an order dated 3/15/24 for Hydrocodone-Acetaminophen tablet 5-325 milligrams (mg) by (via) PEG (Percutaneous Endoscopic Gastrostomy Tube) every 4 (four) hours as needed for pain. Record review of Resident #29's May 2024 Electronic Medication Administration Record (EMAR) revealed the resident has received 9 (nine) Hydrocodone pills as needed in the last 29 days with the last administration being 5/27/24 at 1:47 AM. An interview on 5/29/24 at 10:20 AM, with Resident #29's husband who is her representative revealed it is hard to tell when she is hurting so they just give her pain medicine sometimes. He stated she has Multiple Myeloma that deteriorates the resident's bones, so it hurts her when they have to move her. An interview on 5/29/24 at 10:45 AM, with Certified Nurse Assistant (CNA) #2 confirmed that Resident #29 moans most of the time, but when they get her up or move her, she moans even louder. She stated that she has told the nurses before that she thinks the resident is hurting, but she has not told them that every time they get her up or move her that she moans out like this. An interview on 5/29/24 at 11:00 AM, with LPN #2 and Registered Nurse (RN) #1 confirmed that Resident #29 moaned all of the time, but they give her pain medicine when her moaning increased or has gotten louder because that was how they could tell when she was hurting. They confirmed that the resident had a cancer that affected her bones, so it probably did hurt when she was moved or transferred. They revealed that the resident did not get pain medicine with transfers but could see how that would be a good idea. An interview on 5/29/24 at 11:15 AM, with CNA #3 confirmed that Resident #29's moaning would increase when they got her up or moved her and she was sure it was because of pain. An interview on 5/29/24 at 12:00 PM, with RN/Minimum Data Set (MDS) Nurse confirmed that Resident #29 had a diagnosis of Multiple Myeloma and movement probably increased the resident's pain. She revealed she did the pain assessment for Resident #29's Minimum Data Set (MDS) assessments and confirmed that the resident moans a lot. She stated that the only way to know for sure the resident is in pain is if her moaning increased, but there would be no way to tell what the pain level was on a scale of 1-10, because the resident is unable to verbalize that information. She stated that receiving a pain pill 9 times in the last 29 days was probably not enough for this resident. She stated that she feels like the resident is to a point where she could use a more continuous type of pain medication. An interview on 5/29/24 at 1:55 PM, with Nurse Practitioner (NP) confirmed that Resident #29 had Multiple Myeloma that more than likely caused pain with movement. She revealed that on the resident's initial assessment in 3/2024, she discovered the resident had spasticity in her right posterior neck with pain and she started her on a muscle relaxer. She confirmed that the resident had PRN pain pills ordered, but it was hard to tell with this resident if she was in pain except that her moaning would change. She stated that maybe they should consider changing her order of PRN pain pills to be given before transfer or scheduled. An interview on 5/29/24 at 3:30 PM, with the Director of Nurses (DON) confirmed that Resident #29 probably needs something scheduled for pain with a diagnosis of Multiple Myeloma. She confirmed that the resident moans almost all of the time, but her moaning does get a different pitch to it when they think she is in pain. She confirmed that it would be impossible for the resident to give them a pain scale of 1-10 or let them know if she is relieved from the pain medication. She stated that a resident with Multiple Myeloma probably needs more than 9 pain pills in 29 days for pain control. Review of Resident #29's MDS with an Assessment Reference Date (ARD) of 3/18/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident is severely cognitively impaired and in Section J that the resident had pain that is indicated with nonverbal sounds.

Based on observation, staff interview, record review and facility policy review, the facility failed to implement a comprehensive care plan for a resident exhibiting nonverbal signs of pain and a care plan to address ADL (activities of daily living) of a resident for two (2) of 19 resident care plans reviewed. Resident #29 and Resident #17. Findings Include: Review of the facility policy titled, Comprehensive Care Plans with no revision date revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #29 Record review of Resident #29's care plans revealed a care plan regarding Elder is at risk for pain with a goal of; The elder will verbalize pain reduction or relief with each intervention. Interventions included administer pain medications as ordered and monitor for effectiveness, observe for need for pain medications prior to any care and observe for verbal/nonverbal indications of discomfort. An observation on 05/28/24 at 11:03 AM revealed that two staff members were leaving Resident #29's room with a bag of garbage and the resident was moaning loud enough to be heard in the hallway. Upon entry into the resident's room, the resident was sitting up in her wheelchair, dressed in personal clothes and continued making loud moaning noises with her mouth open at all times, her eyebrows were furrowed, and a single tear fell from her right eye. The resident was unable to be interviewed and could not answer questions at this time. An interview on 5/28/24 at 11:20 AM with Licensed Practical Nurse (LPN) #2 revealed the aides were getting Resident #29 up out of bed when they were observed leaving the room around 11:00 AM. During an interview on 5/29/24 at 10:45 AM, with Certified Nurse Assistant (CNA) #2 confirmed that Resident #29 moans most of the time, but when they get her up or move her, she moans loader. She stated that the resident's care plans are to let the staff know what care the resident needs and we should have let her nurse know she was moaning out and they could give her pain medication. During an interview on 5/29/24 at 12:00 PM with Registered Nurse (RN)/Minimum Data Set (MDS) Nurse confirmed that Resident #29 had a diagnosis of Multiple Myeloma and movement probably increases the resident's pain. She stated that the only way to know for sure that the resident is in pain is if her moaning increased, but there would be no way to tell what the pain level was on a scale of 1-10, because the resident is unable to verbalize that information. She revealed that the residents care plan provides the care needed for the residents. She confirmed that she put in the resident's pain care plan and the care plan goal of the resident verbalizing pain relief would be difficult to for her to achieve. On 5/29/24 at 3:30 PM, an interview with the Director of Nurses (DON) confirmed that it would be impossible for Resident #29 to give them a pain scale of 1-10 or let them know if she is relieved from the pain medication. She confirmed that the care plan needed some changing to apply more to this resident and was not being implemented to the best of its ability due to not providing as needed (PRN) pain medication or offering every 4 hours as ordered. Record review of Resident #29's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnosis that included Multiple Myeloma not having achieved remission and Secondary Malignant Neoplasm of Bone. Record review of Resident #29's physicians orders revealed an order dated 3/15/24 for Hydrocodone-Acetaminophen tablet 5-325 milligrams (mg) by (via) PEG (Percutaneous Endoscopic Gastrostomy Tube) every 4 hours as needed for pain. Record review of Resident #29's Electronic Medication Administration Record (EMAR) revealed the resident has received nine (9) PRN (as needed) Hydrocodone pills in the last 29 days with the last administration being 5/27/24 at 1:47 AM. 47874 Resident #17 Record review of the ADL care plan for Resident #17 revealed the resident had an ADL self-care performance deficit related to activity intolerance, dementia, impaired balance, and stroke. Interventions included the resident requires substantial assistance by two (2) staff with personal hygiene. On 5/28/2024 at 11:06 AM, an observation revealed Resident #17 sitting in a wheelchair in the day room with one-fourth (1/4) inch of gray facial hair observed to the sides of his face and above his lip. On 5/29/2024 at 1:44 PM, an observation and interview with the Director of Nursing (DON) confirmed Resident #17 had long facial hair. An interview with the Director of Nursing (DON) on 5/30/2024 at 10:25 AM revealed the purpose of the care plan was to have a guide to follow for resident care and confirmed the care plan for personal hygiene was not followed. Record review of the Admission Record revealed the facility admitted Resident #17 on 11/14/2023 with a medical diagnosis of unspecified dementia.

Based on staff interview, record review, and facility policy review, the facility failed to ensure that a resident's personal property was safeguarded, and that staff did not misappropriate property for one (1) of 56 residents residing in the facility. Resident #23. Based on actions taken by the facility on 5/23/24, this was determined to be Past Non-Compliance. Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation with a revision date of 3/15/204 revealed under, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Record review of the internal investigation conducted by the Administrator (ADM) dated 5/22/2024 for Resident #23 revealed, On May 21, 2024, at 3:30 PM, Director of Nursing (DON) reported to me that she suspected Certified Nurse Assistant (CNA) #1, had taken a bottle of lotion from an elder (Resident). The DON reported that today around 2:55 PM, CNA #1 was in her office. She was speaking with her, and proper name of employee and picked up a pair of jogging pants out of a bag in the office to show them something. The DON happened to notice a bottle of lotion in the bag that was the same kind she had purchased and put into a gift basket for two of our elders for their birthday on Sunday. The DON went on to say that CNA #1 made the comment that the bag was hers . At this time, CNA #1 picked up the bag and exited the building towards the parking lot. The DON reported that she then went to the rooms of the elder that she had made birthday baskets for on Sunday and noticed that she did not see the lotion in the basket she had given Elder #23 . Upon review of camera footage, CNA #1 was seen at 2:40 PM exiting Elder #23's room and placing the bottle of lotion into the right leg scrub pocket of her scrubs. This is a large bottle of lotion, and the top portion of the bottle can be seen in the pocket as CNA #1 walks up the hall and enters the DON's office at 2:41 PM. Abuse by means of misappropriation can be substantiated related to this incident . An observation of Resident #23 on 5/28/2024 at 10:26 AM, revealed she was alert to name only. An interview with Resident #23's daughter on 5/28/2024 at 2:32 PM, revealed her mother was not cognizant and would not be aware of any missing personal items. She explained that the facility called and notified her sister about the missing bottle of lotion after it happened. She revealed they did not buy the lotion; it came in a gift basket the facility provided for her mother's birthday. The daughter stated both she and her sister came to the facility and looked through her mother's personal items, but were unable to find the lotion. On 5/29/2024 at 2:20 PM, review of the camera footage captured on 5/21/2024 at 2:38 PM revealed, CNA #1 entered Resident #23's room with no lotion visible in her pant pockets and later exits the room while placing a white bottle into her right scrub pant pocket. She was then seen walking down the hallway with the upper portion of the white bottle visible in her right pocket, and entered an office. An interview with the DON on 5/29/2024 at 2:40 PM, revealed CNA #1 had a bag in her office the day of the incident because she had bought her a jogging suit. The DON explained that she observed a bottle of lotion in CNA #1's bag that looked identical to the bottle that she had purchased and given out to Elder #23 in a gift basket over the weekend. She revealed after CNA #1 picked up the bag and left for the day, she went down to Elder #23's room and was unable to locate the lotion in the gift basket. She revealed she spoke with the Administrator (ADM) and notified her. The DON explained that they reviewed the camera footage, which confirmed that CNA #1 went into the resident's room and came out with the lotion bottle and placed it in her pocket. She revealed they called and notified CNA #1 that she was suspended pending the investigation. The DON revealed CNA #1 denied the allegation and revealed that she had brought the lotion to work with her to use on the Elders. An interview with the ADM on 5/29/2024 at 3:26 PM, confirmed through investigation of the camera footage and witness statements the misappropriation of Resident #23's property was substantiated and CNA #1 was terminated. A telephone interview with CNA #1 on 5/30/2024 at 10:32 AM, revealed she was called by the ADM and told that she was caught on a camera recording taking some lotion out of Resident #23's room. She revealed that she did not take the lotion and explained that she brought her lotion to work to use because she had sensitive skin. CNA #1 stated she kept her lotion in her pocket all day, which was what the camera caught. The SA validated through record review that an in-service was conducted on Abuse/Neglect on 5/21/24 with all staff with sign in sheets. The SA validated through interview with the Administrator and record review of the facility investigation that an investigation was conducted, CNA #1 was suspended and terminated on 5/23/24. The SA determined this to be Past Non-Compliance. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/13/2024 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6, which indicated that Resident #23 is severely cognitively impaired. Record review of the Admission Record revealed the facility admitted Resident #23 on 6/21/2022 with a medical diagnosis of unspecified dementia.

Based on observation, interview and facility policy review, the facility failed to safely store narcotics in the medication room refrigerator for one (1) of two (2) medication rooms in the facility. (100 hall medication room) Findings include: Review of the facility policy titled, Controlled Substance Administration and Accountability, with an implementation dated of 10/2022, revealed it is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. An observation of the 100-hall medication room on 05/29/24 at 4:20 PM, with Licensed Practical Nurse (LPN) #1 revealed one vial of Ativan two (2) milligrams/one (1) milliliter in a clear plastic box in the refrigerator. The Ativan was not in a compartment secured to the refrigerator. This was confirmed by LPN #1. An observation and interview, on 05/30/24 at 9:10 AM, with the Director of Nursing (DON) confirmed the injectable Ativan was not in a separately locked permanently affixed compartment in the refrigerator. She stated that she understands that the box could easily be removed from the refrigerator. She stated she could see how it could get mixed up in all the things in the refrigerator and not be noticed if it was missing. A telephone interview, on 5/30/24 at 10:00 AM, with the Pharmacy Consultant revealed that they had discussed this in the past and he thought they had put what needed to be done in place.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs) for a resident dependent on staff for shaving for one (1) of sixteen sampled residents. Resident #17 Findings Include: Record review of the facility policy titled Grooming a Resident's Facial Hair undated, revealed under, Policy: It is the practice of this facility to assist residents with grooming facial hair to meet their preference. An observation of Resident #17, on 5/28/2024 at 11:06 AM, revealed he was sitting in a wheelchair in the day room. Gray facial hair observed on the sides of his face and above his lip, measuring approximately one-fourth (1/4) inch in length. An interview with Certified Nurse Aide (CNA) #2 on 5/29/2024 at 10:50 AM, revealed Resident #17 gets a shower on Tuesday, Thursday, and Saturday during the 3-11 shift. She confirmed the resident was unshaven, and reveled the resident should have been shaved yesterday, which would have been his scheduled shower day. An interview with Resident #17 on 5/29/2024 at 1:38 PM, revealed he preferred to be clean-shaven and voiced that he wanted to be shaved every other day. An observation and interview with the Director of Nursing (DON) on 5/29/2024 at 1:44 PM, confirmed Resident #17 had long facial hair. She revealed her expectation was for the aides to shave the male residents on their shower days. Record review of the Admission Record revealed the facility admitted Resident #17 on 11/14/2023 with a medical diagnosis of unspecified dementia.

Based on observation, staff interview, record review, and facility policy review, the facility failed to store a respiratory suctioning device in a manner that prevented the possibility of the spread of infection for one (1) of two (2) residents with suction devices. Resident #23 Findings Include: Review of the facility policy titled Infection Prevention and Control Program undated, revealed under, Policy: This facility has established and maintains an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. An observation of Resident #23 on 5/28/2024 at 10:26 AM and 2:29 PM, revealed a suction machine with the attached tubing was placed on the floor beside the resident's bed, with an unbagged yankauer suction tool lying on the floor. Record review of the Order Summary Report for Resident #23 revealed an order dated 1/27/2024, Bedside suction with yankauer as needed for increased secretions. An interview with Licensed Practical Nurse (LPN) #1 on 5/29/2024 at 10:24 AM, confirmed the suction device being on the floor and unbagged was an infection control concern and the suction device must be replaced with a new one. She revealed when respiratory equipment was not in use, it should be bagged to keep the device clean and prevent the spread of infection. An interview with the Director of Nursing (DON) on 5/29/2024 at 10:31 AM, revealed the purpose of keeping respiratory equipment in a bag when not in use was to keep the items clean to prevent the spread of infection. Record review of the Admission Record revealed the facility admitted Resident #23 on 6/21/2022 with a medical diagnosis of unspecified dementia.

Based on staff interview, record review and facility policy review, the facility failed to send a written notice to the resident representative regarding a resident being transferred to the hospital for one (1) of three (3) residents reviewed for hospitalization s. Resident #8 Findings Include: Review of the facility policy titled, Transfer and discharge date d 10/2022, revealed under, Policy Explanation and Compliance Guidelines .#4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand . Record review of Resident #8's hospital discharge summary dated 1/21/24 revealed the resident was hospitalized for a possible head injury due to a fall. An interview on 5/29/24 at 11:05 AM, with the Licensed Practical Nurse (LPN)/Medical Records revealed she does not mail a transfer/discharge notice to the resident representative when the resident is discharged . She stated that there is a form in the facilities electronic record system that they complete and send with the resident when they go to the hospital, but that form is not mailed or saved, and the computer system deletes it after 30 days. She admitted that she was not aware of the regulation to send a written notice when a resident is transferred or discharged . An interview on 5/29/24 at 4:40 PM, with the Administrator confirmed the facility was not sending written notices to the representative for transfer/discharges and was unaware of the regulation to do so and stated they would work on developing something and get started doing that. Review of Resident #8's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia, mild with other behavioral disturbances.

Based on staff interview, record review, and facility policy review, the facility failed to provide the Notice of Medicare Non-Coverage to two (2) of three (3) residents discharged from Medicare Part A services with service times remaining. Resident #27 and Resident #49 Findings include: Review of facility policy titled, Advanced Beneficiary Notices, with revision date of October 2022, revealed, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Review of facility policy also revealed, 5. The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). The contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice, . c. A Notice of Medicare Non-Coverage . shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization. i. This notice is used when all covered services end for coverage reasons. ii. An exhaustion of benefits is not considered a termination for 'coverage' reasons. An interview with the Licensed Social Worker (LSW) on 03/08/23 at 11:55 AM, revealed she was the person responsible for completing the Skilled Nursing Facility (SNF) Beneficiary Protection Notifications for residents that were discharged from skilled services with time remaining on their Part A services. She stated she was unaware that a Notice of Medicare Non-Coverage form had to be provided to each resident or the resident's representative when they were discharged from skilled services with time remaining. She stated she thought that this form was only needed when the resident had a Medicare Advantage Plan and she confirmed that she had not provided this form to the residents as required and it was due to being unaware of the requirement. An interview with the Administrator on 3/8/23 at 3:15 PM, revealed she was aware of the requirement for the Notice of Medicare Non-Coverage to be provided to the resident or to the resident representative and she had even done these at another facility, but she was unaware this was not being done at this facility. She confirmed the facility failed to complete the Notice of Medicare Non-Coverage for the residents who were discharged with time remaining on their Part A coverage. Record review of Resident #27's Admission Record revealed she was admitted to the facility on [DATE] with diagnosis of Surgical Amputation of left leg below knee. Record review of Resident #27's Beneficiary Protection Notification Review revealed resident's Medicare Part A skilled services episode start date of 9/2/22 and last covered day of Part A service was 9/30/22. This form revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review of this form revealed the Notice of Medicare Non-Coverage form was not provided to the resident. Record review of Resident #49's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses of Displaced Spiral Fracture of Shaft of Left Femur. Record review of Resident #49's Beneficiary Protection Notification Review revealed resident's Medicare Part A skilled services episode start date of 1/30/23 and last covered day of Part A service was 2/28/23. This form revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Review of this form revealed the Notice of Medicare Non-Coverage form was not provided to the resident.

Based on observation, staff interview and facility policy review, the facility failed to provide a safe and clean dietary environment for the storage and service of foods to the residents for two (2) of two (2) dietary tours. Findings include: Review of the facility policy #40[AGE], titled, Dining Services - Cleaning Ovens dated 02/01/2020, revealed the objective was to ensure equipment is cleaned and in good working condition and ovens will be cleaned and sanitized weekly. This is the responsibility of the dining service cooks/utilities. During initial tour of the Dietary Department, on 2/18/2020 at 10:30 AM, an observation revealed in the walk-in refrigerator with these undated and unlabeled food items: A container of eight (8) boiled eggs, one bowl of chopped meat, three (3) containers of pureed foods, a bowl of scrambled eggs, approximately one-half of a nine (9) to 11 pound turkey breast and ham. These items were removed by the Director of Dining Services (DDS) at this time. An observation, on 2/18/2020 at 10:45 AM, of the stand-alone refrigerator near the serving line, revealed trays containing two (2) glasses of water, one (1) glass of tea, two (2) bowls of pureed bread, two (2) bowls of pudding, two (2) glasses of buttermilk, six (6) glasses of tomato juice, one (1) glass of strawberry Ensure, four (4) glasses of nectar thick sweetened tea, and four (4) glasses of nectar thickened water without a date or label. On the bottom shelf there was eight (8) cups of mandarin oranges and one (1) cup of sliced peaches not covered or dated. One of the cups of oranges had a piece of grated cheese in it that fallen out of a salad that was on the shelf above it. The Registered Dietician (RD) removed the cup of mardarin oranges containing the cheese from the refrigerator. There was a two quart pitcher of tea and a two quart pitcher with a small amount of tomato juice barely covering the bottom of the pitcher on the top shelf. Neither of these was labeled or dated. The RD removed the pitcher of tomato juice from the refrigerator. An interview, on 2/18/2020 at 10:50 AM, with the RD, confirmed that all food and drinks should be labeled and dated. She stated she guessed they weren't because they usually throw away everything left over after the meal. She confirmed the cheese should not have been in the bowl of mandarin oranges. She stated that she didn't know why the pitcher of tomato juice was in the refrigerator because it was empty. An interview, on 2/18/2020 at 10:55 AM, with the DDS, confirmed that containers of food put in the refrigerators should be labeled and dated. He stated some of the things like the scrambled eggs should not have been in the refrigerator, they should have been thrown away. An observation, on [DATE]20 at 11:45 AM, revealed the entire inside of the convection oven was covered with a dark brown coating. The oven racks were coated with a black charred material and the door ledge was covered with black flakes and brownish food particles. During an interview, on [DATE]20 at 12:30 PM, with the Director of Dining Services (DDS), he stated the convection oven needed to be taken care of immediately. He stated the carbon build-up and charred food could cause a fire. The DDS stated the kitchen staff should do daily cleaning and he thought deep cleaning was done by maintenance because they did not have the chemicals in the kitchen needed for deep cleaning. An interview, with the RD, on [DATE]20 at 12:35 PM, revealed no prior cleaning schedules were available because the new company people had come in and thrown everything away last night. An interview, on 2/20/20 at 12;20 PM, with the Administrator (ADM), revealed the ovens had been cleaned last night. The ADM stated he had a smoker at his house that was cleaner than the oven. He stated that he eats in the kitchen and he did not want to get sick and he did not want his residents to get sick. He stated the DDS is responsible for looking at and monitoring these kitchen problems. The ADM stated the new company had cleaned out all their previous papers, schedules and policies.

Based on staff interview, record review, and facility policy review, the facility failed to submit an accurate Minimum Data Set (MDS) assessment regarding medication administration for one (1) of 15 MDSs reviewed. Resident #27. Findings include: Review of facility policy titled, Resident Assessment - RAI, dated 10/2016, revealed, this facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by C[CONDITION]. Record review of Resident #27's Minimum Data Set (MDS) Section N, dated 12/23/2019, revealed Resident #27 received an anticoagulant medication for seven of the seven (7 of 7) look back day period. Review of Resident #27's medical record revealed Resident #27 did not have a physician's orders [REDACTED]. The medical records did not reveal Resident #27 had received an anticoagulant medication. On [DATE]20 at 10:00 AM, the facility's Minimum Data Set (MDS) Coordinator, stated she was responsible for entering Resident #27's information into the MDS system. The MDS Coordinator stated during the 12/23/2019 MDS assessment, the resident was not receiving an anticoagulant medication, but she was receiving an antibiotic. The MDS Coordinator stated she failed to accurately enter the medication as an antibiotic, as ordered, instead of an anticoagulant. On 02/20/20 at 1:39 PM, during an interview, the facility's Director of Nursing (DON) confirmed Resident #27's MDS was inaccurately completed and submitted. She stated accurate completion of the MDS information is important for proper documentation of the resident's needs and care areas.

Based on record review, staff interview and facility policy review, the facility failed to ensure Resident #1 was free from abuse and/or neglect, for one of five residents reviewed for abuse and neglect. Findings include: Review of facility's policy titled, Abuse, Neglect and Exploitation - 2019, revealed: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect is defined as 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 written report and investigation, dated 12/2/19, revealed Registered Nurse (RN) #2 entered Resident #1's room, on 11/28/19 at 1:00 PM, to administer medications. The report indicated RN #2 was informed at that time by Resident #1 that she had been trying to call for help. The investigative report indicated RN #2 found the call light within the resident's reach but found that the end that plugs into the wall was on the floor and a drinking straw was inserted into the call box. The facility initiated an investigation at this time and determined by review of the camera log and that call light log that Licensed Practical Nurse (LPN) #3 was the last employee seen entering the room while the call light was functioning. The findings of the report revealed there was enough evidence to substantiate that LPN #3 was willfully neglectful of the resident. LPN #3's employment was terminated because of the incident on 12/5/19. Review of the facility's Call Light investigation for the video camera revealed there was a staff person in Resident #1's room at least every 30 minutes to an hour at the time the resident was in her room. There were times the resident was out of her to the lobby, dining room, and hallways. There were times when staff would go in, and leave out within a minute or two to get supplies or a lift. Review of the Call Log and Video Log Summary revealed a call from Resident #1, on 11/28/19 at 3:23 AM, that lasted 12 seconds. The video log showed LPN #3 entered Resident #1's room at 3:24 AM. The call light was turned off and 18 seconds after LPN #3 entered the resident's room the call light came back on for 12 seconds and at 3:26 AM, LPN #3 was seen leaving the room. There was no further recorded call light activations on the summary log until 1:03 PM on 11/28/19. The video log revealed staff entering and exiting the room during the hours of 3:23 AM and 1:03 PM. An interview with the Administrator, on 1/2/2020 at 11:30 AM, revealed an investigation was initiated as soon as the disabled call light was found. Resident #1's daughter was notified, and she requested that her mother not be informed of the intentional disabling of her call light. The Administrator stated the request was honored. The Administrator stated that initially LPN #3 denied any knowledge of the disabled call light, but during their second conversation (by phone with a witness) she admitted she had done wrong and was ashamed of what she had done. Upon reviewing all the information, LPN #3 was terminated. Review of the facility's Corrective Action Form, dated 12/4/19, revealed LPN #3 was discharge, and the Nature of the Incident was for neglect. Review of an email, dated 1/2/20 at 3:36 PM, revealed the Administrator notified the Mississippi Board of Nursing regarding the incident involving LPN #3 and Resident #1's call light disablement. A phone interview with LPN #3, on 1/2/2020 at 1:55 PM, revealed she stated she did not have any knowledge of how the straw ended up in the call light system. LPN #3 stated she did not put it there and she does not know who did. She stated she informed the Administrator of that during their first interview. LPN #3 stated she also spoke with the Administrator by phone and informed him she was having a bad night that night due to having her finger crushed in her car door and other personal problems concerning her son. LPN #3 stated she never admitted to disabling Resident #1's call light. Review of the Hours Worked Simplified Report, dated 11/28/19, revealed LPN #3 worked the 11 PM to 7 AM shift. An interview with Registered Nurse (RN) #2, on 1/3/2020 at 2:45 PM, revealed she found the disabled call light when she went in to give medications. RN #2 stated the call light was within reach, but she noticed the call light was unplugged and laying on the floor. She stated a drinking straw was in the call box. RN #2 stated the curtain was blocking the call light system from view. Review of the facility's in-service records revealed an in-service was provided to the staff, on 3/26/19, on Abuse and Neglect. Review of the sign in sheet revealed LPN #3's signature was on the sheet. The facility also provided an in-service to the staff, on 2/2/20, regarding Abuse and Neglect. Review of Resident #1's Face Sheet revealed Resident #1 was admitted by the facility, on 3/19/2015 with [DIAGNOSES REDACTED]. Review of the Intake Information form revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact.

Based on observation, staff interview, resident interview, and professional standards documentation, the facility failed to properly administer a metered dose inhaler, for one (1) of seven (7) resident medication administration observations, Resident #26. Findings include: Review of Mosby's Pocket Guide to Nursing Skills and Procedures, Perry and Potter, 8th edition, revealed instructions for using the Symbicor Inhaler. Instructions revealed to have the resident to take a deep breath and exhale completely to prepare the airway to receive the medication. Once medication inhaled, hold breath for approximately 10 seconds to allow the medication to reach deeper branches of the airway. About two (2) minutes after the dose, instruct the resident to rinse the mouth with warm water and spit it out to remove the residual medication to reduce transmission of microorganisms. During on observation of medication administration, on 12/18/17 at 4:44 PM, Licensed Practical Nurse (LPN) #1 administered [MEDICATION NAME] metered dose inhaler to Resident #26. LPN #1 did not instruct the resident to breath out fully and breath in slowly when the medication was administered or to hold her breath for 10 seconds after her deep breath. Resident #26 immediately started talking after administration of medication, did not take a breath or hold for 10 seconds. LPN handed the resident a cup of water and told the resident to drink and the resident drank the water. The resident did not spit the water out. During an interview, on 12/19/17 at 04:57 PM, LPN #1 confirmed she did not instruct the resident to exhale, and inhale when the [MEDICATION NAME] medication was administered through the metered dose inhaler. LPN #1 confirmed that she did not instruct the resident to rinse her mouth and spit the water out. LPN #1 revealed she was nervous and just messed up, she knew better and usually had her inhale after the medication was administered and to rinse and spit. She had been in-serviced and knew the proper technique. Interview with Resident #26, on 12/20/17 at 11:30 AM, revealed she usually did follow directions and rinse and spit after the inhaler, but did not during observation because the nurse did not give her a cup to spit in. Resident #26 revealed she did not and had not had any sores in her mouth. During an interview, on 12/21/17 at 10:43 AM, the Director of Nursing (DON) revealed she was informed of the error during the medication pass with the metered dose inhaler and had already in-serviced the LPN on administration of metered dose inhalers. The DON confirmed the metered dose inhaler should be given after the instructions are told to the resident and then with the [MEDICATION NAME], the resident should rinse and spit after the administration. The DON revealed she would in-service all nursing staff. On 12/21/17 at 11:00 AM, interview with the Pharmacy Consultant confirmed that before administering a metered dose inhaler the nurse should instruct the resident on the required instructions. The Pharmacy Consultant revealed he had reviewed the proper procedure with nursing.

Based on observation, staff interview, and facility policy review, the facility failed to ensure incontinent care was provided in a manner to prevent possible cross contamination for two (2) of four (4) incontinent care out of a total of six (6) care observations, Resident #7 and Resident #8; and the facility further failed to prevent the possible spread of infection during medication pass for one (1) of three (3) nurses observed during med pass. Findings included: A facility policy titled Standard Precautions Infection Control , dated 06/12/14, revealed the facility assumed all residents were potentially infected and organisms could be transmitted during the course of providing patient care services. An observation on 10/04/16 at 9:25 AM Certified Nursing Assistant (CNA) #2 failed to change soiled gloves after incontinent care for Resident #8 then touched a clean brief, the linens and positioned the resident in bed. CNA #2 handed the soiled washcloths to CNA #1 during incontinent care to place in the garbage bag. CNA #1 did not change her gloves after assisting CNA #2 and touched Resident #8's linen, clean brief and call light with her dirty gloves. An observation on 10/4/16 at 9:40 AM revealed CNA #1 used the gloves she had placed in her pocket during the incontinent care for Resident #7. CNA #1 failed to change her gloves after incontinent care and with those soiled gloves opened Resident #7's bedside dresser, pulled out a tube of skin protectant, and applied to Resident #7's buttocks. CNA #1 then placed the skin protectant back in the dresser and closed the drawer with the same pair of soiled gloves. An interview on 10/04/16 at 9:55 AM revealed CNA #2 confirmed she failed to change gloves during care and positioning of Resident #8. CNA #2 said, I really meant to change gloves. I just forgot. An interview on 10/04/16 at 9:55 AM revealed CNA #1 confirmed she used gloves she had placed in her scrub pockets and said, We shouldn't do that. CNA #1 confirmed she touched items in the room and dresser without removing dirty gloves. An observation on 10/04/16 at 8:30 AM revealed Licensed Practical Nurse (LPN) #1 placed two (2) eye drop medication boxes on a resident's dresser without a barrier during administration of medications. LPN #1 then placed both boxes in her scrub top pocket before placing back in the top of the medication cart. An interview on 10/04/16 at 8:40 AM revealed LPN #1 confirmed she did not place a barrier for the eye drop boxes on resident's dresser and placed both in her scrub pocket. LPN #1 said, I was looking for my keys, and I just dropped the boxes (in pocket) by accident. A review of the facility's face sheet revealed the facility admitted Resident #8 on 09/16/09. Resident #8's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/16 revealed Resident 8's Brief Interview for Mental Status (BIMS) was conducted by staff and staff assessment indicated severe cognitive impairment. A review of the facility's face sheet revealed the facility admitted Resident #7 on 01/30/04. Resident #7's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/14/16 revealed Resident 7's Brief Interview for Mental Status (BIMS) was conducted by staff and staff assessment indicated severe cognitive impairment.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure peri-care was provided in a manner to prevent a possible Urinary Tract Infection for one (1) of four (4) incontinent care observed, Resident #8. A facility policy titled Incontinence Care, dated 03/05/2014, revealed that it was the policy of the facility to provide perineal care to incontinent residents in order to promote cleanliness, comfort and prevent infection to the extent possible. A review of Resident #8's Minimum Data Set ((MDS) dated [DATE] revealed in Section H0300 that resident was assessed to be always incontinent. A review of the Care Plan for Resident #8 revealed an intervention to provide peri-care every two (2) hours and as needed. An observation on 10/04/16 at 9:25 AM revealed Certified Nursing Assistant (CNA) #2 wiped from back to front on sides of the perineal area. CNA #2 changed the washcloths and then wiped from back to front over the urinary meatus but did not change the area of the washcloth with each wipe over the urinary meatus. Resident #8 was turned to her left side and CNA #2 then washed each buttock with a circular motion. CNA #2 changed the washcloth then wiped down between the buttocks and over the anus toward the urinary meatus. An observation on 10/04/16 at 9:25 AM revealed that neither CNA #2, nor CNA #1 notified Resident #8's nurse to stop tube feeding during care. Resident #8's tube feeding of Glucerna 1.2 was running continuously at 60cc/hr per pump during the entire course of care. Resident #8's head of the bed was elevated about 20 degrees during the incontinent care, then the resident was laid flat while the CNA's were positioning Resident #8 in the bed. An interview on 10/04/16 at 9:55 AM CNA #2 confirmed she did wipe from back to front over the perineal area on Resident #8. CNA #2 said the concern was the resident getting a urinary tract infection [MEDICAL CONDITION]. CNA #2 and CNA #1 both confirmed they should have let the nurse know about the care so the nurse could stop the tube feeding before starting care. An interview on 10/04/16 at 4:20 PM Director of Nursing (DON) said Resident #8's Care plan did list peri-care every (two) 2 hours and that would imply correct peri-care. DON stated, The aides know better. We covered all this (peri-care) during the training. DON also said she expected the aides to notify the nurse to stop a tube feeding before performing incontinent care on a resident. A review of the facility's face sheet revealed the facility admitted Resident #8 on 09/16/09. Resident #8's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/16 revealed Resident 8's Brief Interview for Mental Status (BIMS) was not conducted and staff assessment indicated severe cognitive impairment.

Based on observation, staff interview, record review and facility policy review, the facility failed to follow Resident #8's plan of care for incontinent/Peri-care for one (1) of four (4) residents care planned for incontinence care. Findings included: A facility policy titled Care Plans, dated 06/12/14, revealed each care plan was to incorporate problem areas regarding care and treatment goals. A review of Resident #8's Care Plan revealed an intervention to provide peri-care every two (2) hours for her incontinence of the bladder. An observation on 10/04/16 at 9:25 AM revealed Certified Nursing Assistant (CNA) #2 wiped from back to front on each side of the front perineal area, changed washcloths, and then wiped over the urinary meatus from back to front. CNA #2 did not change the area of the washcloth when she wiped over the urinary meatus. CNA #2 then washed and rinsed the area between the buttocks and over the anus downward toward the urinary meatus. An observation on 10/04/16 at 9:25 AM revealed CNA #2 and CNA #1, who was assisting, did not notify Resident #8's nurse to stop tube feeding during peri-care. Resident #8's had a feeding of Glucerna 1.2 that ran continuously at 60cc/hr per pump during the entire course of care. Resident #8's head of the bed was left elevated around 20 degrees during the incontinent care, then the resident was laid flat while the CNA's were positioning Resident #8 in the bed. An interview conducted on 10/04/16 at 9:55 AM with CNA #2 confirmed she did wipe from back to front over the perineal area on Resident #8. CNA #2 said she had a check off training recently and all the steps for peri-care were covered during that training. CNA #2 said the concern was the resident getting a urinary tract infection [MEDICAL CONDITION]. CNA #2 and CNA #1 both confirmed they should have let the nurse know about the care so the nurse could stop the tube feeding before starting care. An interview on 10/04/16 at 4:20 PM Director of Nursing (DON) said the care plan would not list the steps for incontinent care but the training would cover each step. She said Resident #8's Careplan did list peri-care every (two) 2 hours and that would imply correct peri-care. DON stated, The aides know better. We covered all this (peri-care) during the training. DON also said she expected the aides to notify the nurse to stop a tube feeding before performing incontinent care on a resident. A review of CNA #2's Incontinent Care Checklist, dated 09/10/16, revealed the step to wipe front to the back was checked off yes. The check list did not cover what to do for a resident with a feeding tube. A review of the facility's face sheet revealed the facility admitted Resident #8 on 09/16/09. Resident #8's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/16 revealed Resident 8's Brief Interview for Mental Status (BIMS) was not conducted and staff assessment indicated severe cognitive impairment.

Based on record review, staff interview and policy review, the facility failed to complete a Significant Change Minimum Data Set (MDS) in a timely manner for Resident # 2 (number two). Although Resident # 2 had declines/changes in health status in two or more areas since the comprehensive MDS of 04/05/16, the facility had not completed a Significant Change MDS as of 10/05/16. This affected Resident # 2, for one of thirteen sampled residents reviewed for completion of MDS Assessments. Findings include: The CMS (Centers for Medicare/Medicaid Services) RAI (Resident Assessment Instrument) identified the MDS as a core set of screening, clinical, and functional status elements, including common definitions and coding categories which forms the foundation of a comprehensive assessment for all residents. A Significant Change in Status Assessment is appropriate when: there is a determination that a significant change in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments. A review of MDS Assessments for Resident # 2 included the following: 1. Significant Change MDS (Comprehensive) with an Assessment Reference Date (ARD) of 04/05/16, 2. Quarterly Assessment, with an ARD of 06/29/16 and 3. Quarterly Assessment, with an ARD of 09/20/16. A comparison of the Comprehensive MDS, with an ARD of 04/05/16 with the Quarterly assessment dated [DATE] revealed the resident had declines in the area of cognition (Section C), functional status (Section G), Bowel and Bladder Incontinence (Section H), Weight Loss (Section K), Development of a Pressure Ulcer with an onset date of 06/17/16 (Section M). A comparison of the Comprehensive MDS, with an ARD of 04/05/16, and the Quarterly assessment dated [DATE] revealed Resident # 2 had declines in the area of cognition (Section C), functional status (Section G), Bowel and Bladder Incontinence (Section H), Stage 4 (four) pressure ulcer (Section M). During an interview on 10/05/16 at 12:15 PM the Registered Nurse (RN) responsible for MDS Assessments acknowledged that a Significant Change MDS should have been completed on 06/29/16 and on 09/20/16 instead of Quarterly Assessments for Resident # 2. The RN said the Significant Change was indicated because there were two or more declines in the resident's status from the comprehensive Assessment MDS with an ARD of 04/05/16. The RN affirmed that Resident # 2's had declines in areas of cognition, functional status (eating), incontinence, weight loss and developed a pressure ulcer (06/17/16). The RN said because a Significant Change had been completed for 04/05/16 and the resident's condition was expected to decline, she had only completed a Quarterly Assessment. The RN said if a Significant Change had been completed, the MDS would have had Care Area Triggers and Care Area Assessments which do not trigger on a Quarterly Assessment. Although facility staff recognized a decline in Resident # 2's status in two or more areas on the 06/29/16 and 09/20/16 Quarterly MDS Assessments compared to the Comprehensive MDS of 04/05/16, the facility failed to complete a Significant Change in Status MDS as of 10/05/16.

Based on observation, staff interview and facility policy review the facility failed to remove expired medications from the 200 Hall Medication Room, for one (1) of two (2) medication rooms checked. Findings Include: Review of the facility's policy entitled, Storage of Medication, dated 02/24/14 revealed, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from inventory, disposed of according to procedures for medication disposal and reordered from pharmacy. Observation of the 200 Hall Medication Room on 11/11/15 at 3:10 PM, revealed a box containing 45 individual vials of Ipratropium Bromide and Albuterol Sulfate inhalation solution with an expiration date of November 2014. Interview, on 11/11/15 at 3:10 PM with Registered Nurse (RN) #1 revealed all nurses are responsible for checking the medication room on a daily basis and discarding any expired meds. RN #1 stated the medication room was checked today and the nurse must have thought the expiration date was 11/15, only paying attention to the month and not the year. Interview, on 11/11/15 at 3:30 PM, with the Director of Nursing (DON) revealed nurses are inserviced to monitor medications daily for expired meds and to properly dispose any expired medications.

Based on observation, staff interview and facility policy review, the facility failed to store supplements according to manufacturers expiration date for one (1) of two (2) dietary tours. Findings Include: Review of facility policy entitled, Food and Supply Storage Procedures, dated 01/15, stated, Remove from storage any items for which the expiration date has expired. Observation on 11/10/15 at 10:05 AM of the dry storage area in the dietary department revealed 3 cases of Very Vanilla Boost with expiration of 10/29/15 and also 21 Thick and Easy Thickened Reduced Fat 8 ounce Milk boxes with an expiration date of 08/21/15. Interview with the Dietary Manager at the time of the observation confirmed these products were past their expiration dates and stated, That's not something we use a lot, and we had purchased those for residents who are no longer here at the facility. I should have sent them back for credit when those residents discharged . I would be the one that would check for expiration dates and I'm normally in here (dry storage room) every Monday and Thursday checking for expirations.

Based on record review, interviews and facility policy review, the facility failed to implement new or appropriate approaches/interventions for Resident #5 after falls for one (1) of seven (7) residents reviewed for falls. Resident #5 Review of the facility's policy entitled, "Fall Prevention and Risk Reduction", dated 03/05/14, revealed, "Elders found at risk for falls will be careplanned accordingly. Incident reports from falls will be followed by QA (Quality Assurance) and the interdisciplinary team, therapy will screen elder for falls as indicated by the team". Record review revealed the following falls for Resident #5: 1. Review of the 01/15/14 at 2:15 AM "Resident Incident Report" revealed a fall occurred on in which the resident was found sitting upright on the floor in his/her room. Neuro (Neurological) checks were initiated. Review of the Multi-Disciplinary Fall Screen, dated 01/15/14 revealed "Presently on PT (Physical Therapy) caseload". 2. Review of the "Resident Incident Report" dated 02/10/14 at 7:40 PM revealed a fall occurred in which the resident was found lying on the floor on his/her back in front of the wheelchair. Neuro checks were begun. A Therapy screen was initiated, but the Resident was currently on PT caseload per Multidisciplinary Fall Screen dated 02/11/14. 3. Review of the 05/28/14 at 6:20 PM "Resident Incident Report" revealed a fall occurred in which the resident was found on floor lying on his/her back after staff heard the alarm signal. A Therapy screen was recommended. The Multi-Disciplinary Fall Screen, dated 05/29/14, revealed, "The patient may benefit from a new w/c (wheelchair). Further evaluation requested to further evaluate the need of the pt (Resident/Patient)". There was no documented evidence of an evaluation for a new wheelchair. 4. Review of the "Resident Incident Report" dated 06/27/14 at 7:31 PM revealed the resident was found sitting on the floor, neuro checks were initiated and a Certified Nursing Assistant (CNA) recommendation was made to ensure the alarms were working and in place. The Multi-Disciplinary Fall Screen, dated 06/30/14, revealed, "The patient had no memory of falling. The patient was educated to utilize the call light and wait for assistance before getting up. Bed and body alarm interventions are currently in place". 5. Review of the "Resident Incident Report" revealed a fall occurred on 07/08/14 at 2:04 PM in which the resident reached for a chair and fell . A Therapy screen was recommended. The Multi-Disciplinary Fall Screen, dated 07/09/14 revealed, "The patient appeared agitated before time of fall. Alarms were in place, and no other recommendations are given. No skilled services (therapy) are recommended at this time". 6. Review of the "Resident Incident Report" revealed a fall occurred on 07/17/14 at 9:48 PM in which the resident was found on the floor after staff heard the alarm sound. Review of the video revealed the Resident struck his/her head on the floor. Neuro checks were initiated. A Multi-Disciplinary Fall Screen was completed on 07/18/14, which revealed, "The patient did not recall the fall. No other recommendations for skilled services are given. The patient was educated to call for help". 7. Review of the "Resident Incident Report" revealed a fall occurred on 09/16/14 at 7:00 PM in which the resident was found on the floor with a laceration about his/her left ear in his/her room. The resident required transport to the hospital and required 5 (five) staples to close the laceration. A Multi-Disciplinary Fall Screen was performed on 09/17/14 which revealed "Due to cognition inconsistency and behaviors, this resident remains a 2 (two) person assist. Resident has had alarm and body alarm. Educated the resident of call light and not to get up without assistance". Interview, on 12/23/14 at 8:10 AM, with the Director of Nursing (DON) confirmed approaches to educate the Resident for fall precautions were not effective due to Resident #5's cognitive deficit. Review of the Face Sheet revealed the facility admitted Resident #5 on 01/13/14 with diagnoses, which included Rheumatoid Arthritis. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/14, revealed the Resident had short and long-term memory problems and moderately impaired decision making abilities.

Based on record review, staff interview and facility policy review, the facility failed to update care plans following falls for Resident #5 and failed to address a Gradual Dose Reduction (GDR) for Resident #1 and Resident #3, for three (3) of 15 residents reviewed. Findings Include: Review of the facility's policy entitled "Care Plans", dated 06/12/14, revealed, "The Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each elder" and, "Assessments of elders are ongoing and care plans are revised as the information about the resident's condition changes". Resident #5 Review of Resident #5's Care Plans revealed there were no interventions implemented in the Care Plan for a fall dated 05/28/14 at 6:20 PM in which the resident was found on floor lying on his/her back after staff heard alarm signal. A Therapy screen was recommended. Review of the Resident #5's fall report for 06/27/14 at 7:31 PM revealed the resident was found sitting on the floor, neuro (neurological) checks were initiated, and a Certified Nursing Assistant (CNA) recommendation was made to ensure the alarms are working and in place. The Care Plan was dated 06/27/14 and read "Staff educated". The Care Plan did not include the specifics as to the staff education and "Neuro checks". On 07/08/14, there was an entry in the Care Plan to continue to remind the resident to ask for assistance for a fall that occurred on 07/08/14 at 2:04 PM in which the resident reached for a chair and fell . Review of the significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/15/14, revealed a staff assessment of mental status that recognized Resident #5 had short and long term memory problems and moderately impaired decision-making abilities. There was no documentation in the Care Plan for interventions for a fall that occurred on 10/01/14 at 7:56 PM. A Therapy screen was recommended; however, Resident #5 received Occupational and Speech Therapy already at the time of the fall. The Care Plan did not include the fall or any interventions for a fall on 10/07/14 at 12:35 AM in which Resident #5 was found on the floor in the day room after the staff heard an alarm. Neuro checks were initiated and a Therapy screen was recommended. Interview, on 12/22/14 at 4:15 PM, with Registered Nurse (RN) #1 confirmed there were no interventions and no change in interventions in the Care Plan after each of the falls. Interview, on 12/23/14 at 8:10 AM, with the Director of Nursing (DON) confirmed the facility did not update the Care Plan for Resident #5 and stated the Care Plan was not updated at the time of the fall with new interventions. The DON stated interventions were added to the Care Plan by the RN responsible for updating all Care Plans. Review of the Face Sheet revealed the facility admitted Resident #5 on 01/13/14 with [DIAGNOSES REDACTED]. Resident #1 Review of Resident #1's Care Plan revealed no approach to attempt a GDR documented for [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (antipsychotic), or Klonopin (benzodiazepine). Review of the facility's document, "Tranmittal 22 Excerpt GDR", dated "[DATE]", revealed the facility addressed quarterly or annual Gradual Dose Reduction (GDR) attempts of antipsychotics, sedatives/hypnotics, and medication other than antipsychotics and sedative/hypnotics. Interview, on 12/29/14 at 10:30 AM, with Registered Nurse (RN) #1, confirmed the need for a GDR was not documented in the Care Plan for Resident #1. Review of the Cumulative Physician Orders, for December 2014, revealed the following MEDICATION ORDERS FOR [REDACTED] 1. An order, dated 01/21/10, for the antidepressant "[MEDICATION NAME] 5 MG (milligrams) Tablet give one (1) tablet PO QD (by mouth daily)". 2. An order, dated 09/11/13, for the antipsychotic "[MEDICATION NAME] 25 MG tablet PO Q 6 PM (by mouth every day at 6:00 PM)". 3. An order, dated 04/03/12, for the benzodiazepine/antianxiety, "Klonopin 0.125 MG 1 (one) PO (by mouth) daily". Review of the Face Sheet for Resident #1 revealed the facility admitted the resident on 12/11/08 with diagnoses, which included Anxiety and Dementia. Resident #3 Review of Resident #3's cumulative Physician Orders, for December 2014, revealed an order dated 07/16/13 for "Ambien (sedative/hypnotic) 5 MG tablet PO Q HS (by mouth every night)". Review of Resident #3's Care Plan revealed the facility did not include the need for a GDR in the resident's Care Plan [MEDICATION NAME](sedative/hypnotic). Interview, on 12/29/14 at 10:30 AM, with RN #1 confirmed the need for a GDR [MEDICATION NAME] not documented in the Care Plan for Resident #3. Review of the Face Sheet revealed the facility admitted Resident #3 on 01/11/12 with diagnoses, which included Dementia, [MEDICAL CONDITION] and Anxiety.

CI MS # Based on observation, interview, record review and facility policy review, the facility failed to ensure that one (1) of four (4) residents, Resident #1, was provided assistance to prevent falls during perineal/toileting care. Resident #1 was assessed and care planned for two (2) person assist with toileting and Certified Nurse Aide (CNA) #1 provided care by herself and allowed Resident #1 to roll of the bed when she was turned on the right side. This resulted in a hematoma to Resident #1's head which was evaluated in the emergency room . The hematoma resolved without adverse effects. Findings include: Observation on 6/18/13 at 10:30 a.m. revealed that Resident #1 was in the bed with bilateral splints to the upper extremities. Resident #1 was alert and non-verbal. The bed had half side rails which were padded and the bed was in the low position. There was a concave air mattress on the bed. Resident #1 had no redness or bruising to the forehead or head area. Licensed Practical Nurse (LPN) #1 was present and stated that Resident #1's hematoma was resolved and no further bruising present. LPN #1 stated that Resident #1 required two (2) people for assistance with all activities of daily living (ADL) except for feeding, which required one (1) person. LPN #1 stated that the care required and the amount of assistance needed for each resident could be found in the computer Kiosk system or at the desk in a folder where all resident's were listed and the amount of care assistance required for each resident. Record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/13, revealed that Resident #1 had severe cognitive impairment and required total assistance of two (2) + persons for bed mobility, transfer, dressing, toileting, personal hygiene and bathing. Resident #1 had bilateral impairment range of motion. Review of Resident #1's care plan dated 4/29/13 revealed that two (2) person total assistance was required with activities of daily living functioning related to End Stage Dementia, Immobility, Impaired Cognition, and incontinent of bowel and bladder. Interventions included two (2) person total assist for toileting and bathing as of 2/22/12. Record review revealed Resident #1's care plan was updated 6/2/13 for falling out of bed. Interventions included therapy screen for proper positioning techniques and in-service floor staff, bed to have concave air mattress, observe hematoma for worsening and neuro checks for 24 hours. Review of the "Assigned Tasks List" for Resident #1, which is the in the computer Kiosk for the Certified Nurse Aides (CNA) to document care for each resident, revealed activities of daily living assist level: two (2) person total assist for transfers with Hoyer lift only and two (2) person total assist for toileting and bathing with a start date of 2/22/12. Review of the activities of daily living documentation for Resident #1 from 5/26/13 through 6/2/13 revealed that two-four (2-4) persons was used to perform toileting or peri-care for Resident #1. On 6/2/13 Certified Nurse Aide #1 documented that two (2) people provide the peri-care for Resident #1. Review of an incident report dated 6/2/13 at 10:11 p.m. revealed Certified Nurse Aide #1 called the nurse to resident's room. Nurse noted resident's lying supine on floor next to window. CNA stated while performing perineal care on resident she rolled out of the bed when she rolled her to the right side. Nurse noted resident eyes were rolled back in her head and snoring. Hematoma on resident's head. CNA and nurse assisted resident back to bed. Once resident was in bed nurse noted resident began yawning. Eyes no longer rolled. Nurse notified MD (name of physician). Neuro checks initiated. (Name of Physician notified.) Order given to send to (Name of hospital) ER (emergency room ) for evaluation and tx (treatment). Vitals Signs: Temp 98.6, Pulse 59, Resp 22, Blood pressure 109/44, Pain scale 0. Resident was sent to the emergency room (ER) for evaluation." Review of the ER Report dated 6/2/13 revealed that Resident #1 had a hematoma to the left parietal back of head, no laceration or bleeding. CT scan was obtained and was negative for fracture and no acute intracranial findings. Resident #1 was sent back to the facility with no new care orders. Review of nurse's notes revealed that Resident #1 was monitored and Neuro checks performed as ordered with no lasting effects or further consequences related to the fall. There was no change in Resident #1's physical or mental status after the fall from her baseline prior to the fall. Interview with the Administrator on 6/18/13 at 9:30 a.m. revealed that CNA #1 had provided care to Resident #1 without assistance of another staff as required per care plan and gave no real reason as to why she had done the care by herself. CNA #1 admitted that she was aware that Resident #1 required two (2) people assist for care. The Administrator stated that CNA #1 was suspended pending the investigation and then terminated for not following the care plan for Resident #1. Resident #1 went to the ER (emergency room ) with a hematoma, the CT (computed tomography) was negative and resident had no lasting adverse effects and was back to pre-fall level of services. Interview with Certified Nurse Aide (CNA) #1 on 6/18/13 at 12:45 p.m. revealed that she had worked 3-11 on 6/2/13 and was doing peri-care on Resident #1 and had turned her over on the right side and apparently the resident was too far over and rolled over the rail and off the bed onto the floor CNA #1 stated that the half rails were up and the head of the bed was up some as well, not flat. CNA #1 stated that Resident #1 landed between the bed and the air conditioner unit (floor carpeted) and there was no bleeding or hollering from the resident. CNA #1 went and got the nurse who came in and checked the resident and we put her back in the bed then sent her out to the emergency room . CNA #1 stated that she had worked at the facility approximately [AGE] years and had been trained on abuse and neglect and following the care plans. CNA #1 stated that the computer tells us the basic plan of care as well as information at the nurse's station. CNA #1 stated that Resident #1 required two (2) person assist with ADLs (activities of daily living), had not intended to change the resident at the time, was going to do oral care, but the resident was dirty and just went ahead to clean her up because she was a little person and thought she could be done by herself. CNA #1 stated that usually there were two (2) people to provide the care for Resident #1. CNA #1 stated that she was aware that Resident #1 required two people assist, but that was a chance that she risked. CNA #1 stated that she was contacted by the Administrator who suspended her the next day and then terminated her for not following the care plan for Resident #1. CNA #1 acknowledged that she was aware that not following the care plan could be considered neglect and that she had not followed Resident #1's care plan when she provided care by herself. CNA #1 admitted to being trained by the Attorney General's office and the facility on abuse/neglect and following the care plan. Interview with the Director of Nursing (DON) on 6/18/13 at 2:10 p.m. revealed that Resident #1 was assessed and care planned for two (2) person assist with all ADLs except eating and that CNA #1 had attempted to provide perineal care to Resident #1 and during the turn, resident rolled off the bed onto the floor and sustained a hematoma and was sent to the ER for evaluation. The DON stated that Resident #1 returned to the facility a few hours later with no significant injury, no fracture and CT (computed tomography) was negative for bleeding. The Hematoma was monitored without concerns and there was no change in her medications or level of care. The DON stated that CNA #1 was terminated for not following Resident #1's care plan and the resident could have been seriously harmed and considered the CNAs actions as neglect for not providing the care that was assessed and care planned for her safety. The DON stated that in-services were provided to 100% of the staff on abuse/neglect and following the care plan after the incident. Review of an in-service dated 2/7/12 revealed the topic of Toileting, Showering and ADL (Activity of Daily Living) assistance levels ....Make sure you have appropriate assist level. This was signed by Certified Nurse Aide (CNA) #1 along with many other CNAs. Review of an in-service dated 2/1/13 revealed that Certified Nurse Aide #1 had signed the training on abuse, neglect, and exploitation in Senior Care Settings. Review of an acknowledgement, dated 4/4/02 by CNA #1, revealed: "... 6. I understand if a resident is listed extensive assist for transfers or extensive assist for ambulation that I am always supposed to have another person help me with this procedure. I understand if I fail to get help with the resident that I am negligent and could be reported to abuse register as such and could be terminated as an employee of (Name of facility)." This was signed by Certified Nurse Aide #1. Review of in-service 6/4/13 with Topic: Providing adequate supervision/assist to residents. Revealed that all CNA staff was in-serviced about the level of assistance for each resident in the computer and on the care plan and that elders cannot be left with less supervision than is listed. Review of the facility's "Abuse Neglect Reporting - Resident" policy, not dated, noted, "Each resident had the right to be free from verbal, sexual, mental, physical abuse, including corporal punishment, involuntary seclusion, and/or misappropriation of property." Review of the facility's "Using the Care Plan" policy, not dated, noted, "The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident ... Procedure: ... Documentation must be consistent with the resident's care plan ..."

Based on observation, record review, staff interview, and facility policy and procedure review the facility failed to provide adequate supervision to prevent accidents for two (2) of seven (7) residents reviewed for falls/fractures, Resident #9 and Resident #10. Resident #9 was left unattended in the shower and Resident #10 was left unattended in the bathroom. Both Resident's sustained injuries and were sent to the hospital for evaluation and treatment. Findings include: Resident #9 Record review revealed that Resident # 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/11 revealed that Resident #9 was moderately impaired in cognitive skills for daily decision making. Resident's functional status reflected limited and extensive assistance in all areas. A review of the most recent MDS with an ARD of 1/4/12, revealed that Resident #9 had a decline and was severely impaired in cognitive skills for daily decision making. Review of the physician's orders [REDACTED]." On 12/12/08, an order was written for "body alarm to clothing while in w/c (wheelchair)." Review of the Incident Log revealed that on 3/28/11 at 8:46 a.m. Resident #9 sustained a fall with a deep laceration to the head. Resident #9 was sent to ER for evaluation and treatment. Review of Departmental Notes, dated 3/28/11 at 9:30 a.m., revealed, "CNA giving resident a shower, CNA turned around to help another CNA with a resident by the time CNA turned back around resident fell out of shower chair on floor, nurse notified and RN supervisor assessed resident, laceration to left forehead area skin tear to top of left and right hand. Tx (treatment) started. Resident assisted x 3 assist to bed. Neuro check continued @ 8:50 a.m." Review of "Facts of the Incident", dated 3/28/11 on 7/3 shift revealed "CNA #3 was in shower room giving Resident bath. Resident was in shower chair. Another staff member in shower room toileting a resident asked for assist with her resident. CNA #3 left her resident alone in shower chair to step across the room. Before she could get back to her resident, she (Resident #9) fell out of the chair onto floor, resulting in laceration to head. Resident has history of leaning in wheelchair and is care planned as a two (2) person assist. Resident had to be transferred to ER for evaluation. Received sutures to forehead, resident also obtained skin tear to top of both right and left hands. "The effects of incident on employee's work or other employees or residents" stated: "Leaving resident's side resulted in fall in which resident received injury." "What specific actions are to be accomplished to improve the behavior/performance" stated "Do not leave a leaning/2 person assist resident at any time in shower room. (Even if only to step to the other side of the room). Do not bring more residents into shower room that can be safely assisted at one time. Bath schedule to be modified on hall." Review of Hospital ER visit dated 3/28/11 revealed that there were three (3) centimeter laceration to forehead, treatment of [REDACTED]. An interview on 2/1/12 at 5:00 p.m. by phone with CNA #3 regarding Resident #9's fall on 3/28/11 in the shower room revealed: "CNA #3 and CNA #2 was in the shower room and CNA #2 asked me for help. I went to help and then Resident #9 fell out of the chair (shower chair). I got the nurses. She (Resident #9) had busted her head and had a skin tear on her hand. I can't remember which hand. I was in-serviced on making sure that someone was there (during shower) at all times. CNA #3 stated that Resident #9 was a two (2) person assist." Interview on 2/2/12 at 9:10 a.m. with CNA #2 regarding Resident #9's fall (on 3/28/11 in the shower room) stated "I vaguely remember it. I know she fell when I asked for help. Resident #9 leaned forward and kept going and fell . I got the nurses and called the RN Supervisor. She (Resident #9) had a gash on her head and two (2) skin tears. I don't remember if the chair (shower chair) had straps on it. We got a new chair now. This one has a seatbelt. Resident #9 was a two (2) person assist and with the Hoyer lift." An interview on 2/2/12 at 10:10 a.m. with the Director of Nursing (DON) regarding the fall sustained by Resident #9 on 3/28/11 revealed: "There were two (2) CNAs' in the room (shower room), but there were two (2) residents in there also. One of them (CNA #3) went to get help and the other CNA (#2) stayed with the Resident #9. There was an in-service done the same day. All new hires watched a video on care. I don't know if there is a safety strap on that shower chair or not. There are two (2) chairs in the room (shower). We have a new tilt chair for the shower room. The CNA's were educated on not to take two (2) residents' that is a two (2) person assist in there (shower room) at the same time unless there is enough help." Observation on 2/2/12 at 10:12 a.m. with the DON of the shower room revealed two (2) shower chairs without straps and a tilt shower chair. The DON acknowledged the shower chairs were the same as the chair Resident #9 fell from on 3/28/2011. An interview on 2/2/12 at 11:50 a.m. with Licensed Practical Nurse (LPN) #2 (MDS Nurse) regarding Resident #9 revealed; "Resident #9 was a one (1) person assist with bath, a two (2) person lift and transfer. The care plan did not reflect how many staff members should be there for her (Resident #2) Activities for Daily Living (ADL). We have a scheduled care monitor on the computer that the CNA's use. The DON stated that it could be viewed on the computer, however, it would not print out. The DON stated, "Sorry it (computer) won't go back to the time you want (3/18/11). The computer tells them (CNA's) how many people it takes for care based on the MDS assessment which is updated and changed as needed (prn)." The DON stated that Resident #9 was a two (2) person assist. Interview on 2/2/12 at 2:15 p.m. with the Administrator regarding Resident #9 fall on 3/28/11. The Administrator stated, "There were four (4) people in there (shower room) not two (2) people. There were four (4) CNAs' in there. I can get their names for you. Will that help? She (Resident #9) was not left unsupervised." Interview on 2/2/12 at 3:00 p.m. with CNA #1 revealed that she was in the bathroom during the event (fall of Resident #9). CNA #1 stated that she was showering her resident and heard CNA #2 yell, and when she turned around, Resident #9 was on the floor. CNA #1 stated: " I think the shower chairs are the same. They didn't have straps. The recliner chair is much better than the regular shower chairs because it has a strap and it reclines to secure the resident. Each person showering is one (1) to one (1)." Review of Resident #8's care plan revealed a problem stating: "At risk for falls r/t (related to) weakness; poor trunk control and history of falls". The onset date was 11/27/2006. Some of the measures included: "*4 Up in wheelchair qd (every day). Bed alarm to bed for safety. Check functioning q (every) 2 hours and prn (as needed). Body alarm to clothing while up in wheelchair. Falling star program: star near door and monitor location Q (every) hour. 11/10/10: Res (resident) had a fall. Care plan reviewed and updated: Therapy Screen, adjusted height of wheelchair." 11/15/10: Res (resident) rolled OOB (out of bed). Care plan reviewed and updated - ordered concave mattress. 11/16/10; moved bed to rest along wall, ensure that mat is on other side of bed on floor." "Chair alarm to chair for safety; check functioning Q 2 hrs." On 3/28/11, an intervention stated: "Res is to use reclining shower chair for showers R/T (related to) poor trunk control." "Resident had fall in shower room. Res (Resident) has poor trunk control and fell out of shower chair. Rec'd head injury, sent to ER (emergency room ) for eval and treatment as indicated." There was another notation on the care plan stating: "On 5/5/11 "Res rolled out of bed onto mat beside bed on floor. No injury. Ordered concave mattress for bed to help prevent rolling out of bed. Elder has an elec (electric) low bed." Review of Activities of Daily Living policy (not dated revealed): Upon admission, with each careplan and prn, the ADL assistance levels will be reviewed and assigned to the staff via the Computerized Care Guide. Review of the care plan dated 11/27/06 revealed: - At risk for falls related to weakness, poor truck control and history of falls. Resident #9 has poor truck control and fell out of shower chair. Received head injury and was sent to emergency room (ER) for Evaluation and Treatment. Resident #10 Review of a closed record revealed that Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) Tranischemic Attack (TIA)/Stroke. Review of the MDS with an ARD of 12/10/10 revealed that Resident #10 was moderately impaired in cognitive skills for daily decision making. Resident #10 required extensive assistance of two (2) or more persons for transfers, bed mobility and toileting. Review of a significant change MDS with an ARD of 3/9/11, revealed that Resident #10 was severely impaired in cognitive skills for daily decision making. Resident #10 was totally dependent on two (2) or more staff for bed mobility and toilet use. Further review of Resident #10's clinical record revealed that she experienced a fall on 2/27/11 at 12:00 a.m. which resulted in multiple pelvic fractures. Resident #10 was assisted from her bed to the wheelchair, and then transferred onto the toilet in the bathroom by Certified Nursing Assistant (CNA) #7. CNA #7 left Resident #10 sitting on the toilet to go answer another call light. Resident #10 attempted to get up without assistance and fell to the floor. Resident #10 was sent out to the emergency room for evaluation of Right Hip pain. The CT of the Pelvis revealed multiple fractures. A review of Resident #10's Resident Incident Report dated 12:00 a.m. 2/27/11, revealed the following: " Narrative of incident and description of injuries" "Nurse heard resident yelling for help. Nurse walked in resident's bathroom and noted resident lying in supine position in front of toilet with head under towel rack in front of toilet. Resident trying to sit up. Resident able to move all 4 extremities on command however resident c/o (complain of) RT (right) hip and buttock pain. PERRL (pupil equal and reactive to light). Strong bilateral hand grip. Resident c/o RT buttock and hip pain. 2 (two) inch red scratch noted to RT buttocks. Immediate Actions Taken: Neuro check and observation. Resident given pain med and MD notified. Vital Signs: Temp 97.0 Pulse 74 Respirations 20 B/P 114/76 Pain Scale 7. Physician (name) notified 2/27/11 at 12:10 a.m. Family notified (name) 2/27/11 at 07:10 a.m. " A review of the Statement of Incident for Certified Nursing Assistant (CNA) #7 revealed the following: "Please write below where you were located in facility and what activity engaged in when incident occurred. Name (CNA #7) Name of Resident involved: (Name of Resident #10). Activity/Where Located": "I was in the bathroom of (name of resident) placing her on the toilet when incident occurred; prior to the incident I placed (Resident #10) on the toilet, she proceeded in having a bowel movement; (Name of other resident) light was ringing, I then told (Resident #10) to pull the light if she finishes before I come back." Review of Nurse's Notes (NNs) 2/27/11 12:00 a.m. revealed the following: "Role: Charge Nurse. 114/76 74 20 97 94%. (vital signs and oxygen saturation (O2 sat) While standing @ (at) Med Cart Nurse heard resident yelling "Someone please help me". Nurse and CNA walk in bathroom and saw resident lying in supine position in front of toilet. CNA (name) was the 1st (first) one in the restroom after incident occurred. Resident trying to raise up in sitting position. Resident able to move all 4 extremities. Bilateral hand grip strong. PERRL. Once CNA stood resident up after nurse completed assessment, Nurse ask resident what happened. Resident stated "She told me to pull the light, but I thought I could do it myself. Resident assist X2 to W/C (wheelchair) and place in bed. Once resident was in the bed, 2 (two) inch red scratch noted to RT buttocks. Resident c/o RT hip and buttocks pain Nurse administered Tylenol for RT hip and buttocks pain. No bruises noted @ present time. Cold compress applied to RT buttocks area. In case bruising occurred. 12:20 a.m. Dr. (name) notified about resident's fall and c/o RT hip and buttock pain. Nurse asked if MD would like resident to be sent out to ER (emergency room ). MD stated cont (continue) to observe resident and call her in morning if resident cont. to c/o pain and discomfort. Nurse called RP (Responsible Person) (name) no results. Review of Resident #10's February Medication Administration Record(MAR) revealed that Resident #10 was given Tylenol 325 milligrams (mgs.) tablets X 2 (two) at 12:17 a.m. for a pain level of seven (7) on a scale of 10, and then again at 4:34 a.m. for a pain level of seven (7) on a scale of 10. Further review of the NNs revealed the following: "2/27/11 at 12:17 a.m. (BP) 99/61 (Pulse) 100 (Resp) 20 (temp) 96.7 (oxygen sats) 92%. Resident lying in bed with HOB (head of bed) elevated. O2 (oxygen) intact. PERRL. Bilateral hand grip strong. Resident able to move all 4 (four) extremities on command; however cont. to c/o pain to RT buttocks whenever she moves her RT leg." "2/27/11 at 3:30 a.m. Resident asked to get up, Resident sitting in recliner. 2/27/11 6:31 a.m. Nurse made 2nd. Attempt to notify RP, (name), again no result. Nurse also phone second contact (name) no result. Resident in dayroom in recliner asking if she can have coffee. Resident assisted to dining room for morning meal. Will relay to next shift to cont. to contact RP. 2/27/11 7:10 a.m. (name) return call and Registered Nurse (R.N.) (name) informed him about Resident #10's fall. 2/27/11 8:01 a.m. @ 8:00 a.m. after Resident #10 had eaten breakfast she said "I fell last night and broke my hip". I reassured Resident #10. Checked skin of body for bruising, scrapes or excessive redness. None apparent. I observed Resident #10 had her right hand under her right buttock. When questioned if she had pain in the area she pointed to the hip joint area I placed a call to Dr. (Name), left voice mail. Also placed a call to RP, son of resident, RP (name). Again left a voice mail for a call back. 2/27/11 9:30 a.m. Awaiting return call from Dr. (name) and RP (name). Voice mail left at 8:00 a.m., 8:30 a.m. and 9:00 a.m. Resident #10 is lying on her back continues to place her right hand under her right buttock. 2/27/11 10:16 a.m. 110/59 88 20 97.9 93% on RA (room air) ...After morning meal resident started to complain of right pelvic pain and hip pain and holds hand under right buttock. Dr. (name) notified and new order to send resident to ER for further evaluation to rule out fracture hip. Son notified and states we will be on his way to the hospital this afternoon. 2/27/11 10:17 a.m. Dr. (name) returned call @ 10:05 a.m. authorized transport to (name of hospital). Placed 911 call for transport. Resident #10 placed on gurney for transport to (name of hospital). Records sent with her. 2/27/11 12:22 p.m. received call from (name of hospital) Resident #10 has multiple (5) fractures of her pelvis to be admitted to rm." Record review revealed a physician's orders [REDACTED].#10 to the ER for care, X-ray post fall 2/27/11 12:30 a.m. c/o pain right hip area. A review of the Hospital ER History and Physical dated 2/27/11 at 15:23 p.m. revealed the following: "Chief Complaint: Pelvic Fracture. History of present illness: This is a 95 y/o white woman who resides at (name of facility). She has multiple medical problems including previous CVA (stroke/Cardiovascular Accident), previous pelvic fractures, prolapsed bladder, chronic Atrial Fibrillation, Osteoporosis, CHF and severe [DIAGNOSES REDACTED]. Apparently the patient was up last night going to the bathroom. She fell but was placed back in bed. Apparently she had no acute problem at that time. There is really no way to know if she had any syncope or other complaints, which led to her falling. This morning she complained to the nurse about some pain in her hips. She was sent to the ER and, according to the report given by the ER physician, she had multiple areas of fractures but no hip fracture." A review of the CT Pelvis w/o (without) contrast 2/27/11 revealed the following: "Indication: Fall with pelvic pain. Impression: Multiple pelvic fractures." A review of Resident #10's Quarterly Minimum Data Set (MDS) 12/15/10 revealed her cognitive status was coded an eight (8) or moderately impaired for decision making. Further review of the MDS revealed Resident #10 required extensive assistance with two (2) persons to physically assist with toileting, and balance during transition and walking. Resident #10 was not steady, only able to stabilize with human assistance moving on and off toilet. Review of Resident #10's Care Plan with admitted [DATE] revealed the Problem/Need on 8/3/09 stating: "Requires assist with ADL (Activities of Daily Living) Functioning R/T weakness and Pelvic Fracture. Risk for Falls R/t Pelvic Fracture, Unsteady Gait and the following included Approaches: 5. Assist to transfer; watch for poor balance and unsteady gait. 9. Assist with toileting q (every) two (2) hours and PRN (as needed). Review of Resident #10's ADL Documentation for February 1 through February 26, 2011 revealed 147 entries. For the column "How did you have to help the elder go to the bathroom or have peri care performed? (Toileting)" 32 of the 147 entries checked "I had to move an arm, leg, or other body part (Extensive). Sixty six (66) of the 147 entries are checked in the column" I have to help the elder get on and off the toilet. (Extensive)." Review of Resident #10's ADL Documentation for February 1 through February 26, 2011 revealed 137 entries. For the column "How did you have to help the elder get in and out of bed or chair? (Transfers) 51 of the 137 entries checked the "I had to move an arm, leg, or other body part. (Extensive)." Fifty two (52) of the 137 entries checked the "The elder had to lean on me. (Extensive)." On 2/2/12 at 11:20 a.m. an interview with CNA #7 revealed she has been employed with the facility one (1) year and four (4) months. CNA #7 stated that she was working the 11:00 p.m. to 7:00 a.m. shift at the time of Resident #10's fall on 2/27/11. CNA #7 reported that she transferred to 7 a.m. to 3 p.m. shift in October 2011. CNA #7 reported that Resident #10 was a one (1) person assist for transfers from the bed to the chair, and to the toilet in the bathroom at the time of the fall on 2/27/11. CNA #7 reported that she knew Resident #10's transfer needs by her Care Plan which was on the facility's computer system. CNA #7 stated, "I check the computer for charting every one (1) to two (2) hours during my shift, it pulls up her picture and level of care." CNA #7 reported the following regarding the incident on 2/27/11 at 12:00 a.m. " I was at the desk. The light came on, I went down there. She said she had to go to the bathroom. I helped her transfer to the wheelchair, then to the bathroom. She had to have a bowel movement. While she was in the bathroom another light went off, it was Mrs. (name) directly across the hall from (Name of Resident #10). I told (Name of Resident #10) I had to go across the hall and for (Name) (Resident #10) to pull the call light in the bathroom. I was in room with Mrs. (name), she is a two (2) person assist for transfers. I pulled the light to call for the other CNA to come help me with Mrs. (name) to take her to the bathroom. (Name) CNA, the other CNA on the hall came to help me with (the other resident). We got (that resident) to the bathroom, then we heard (Resident #10). We went in, she was sitting on the floor. We told her we could not get her up until the nurse came and checked her. We had to get the nurse to come and check her. The nurse came down. (Resident #10) reported she was sorry she did not use the light. The nurse did an assessment and we checked her vital signs (v/s). After the assessment and v/s, we transferred her back up to the wheelchair. She said she was alright, just her butt was hurting. (Name of the nurse) told us to put (Resident #10) in the bed. After the incident the facility Administrator and Director of Nurses (DON) did an in-service with us to not leave residents in the bathroom unattended and make sure we transfer residents with the level of assistance they need. CNA #7 reported that she probably should not have left Resident #10 unattended on the toilet in the bathroom to go answer the other light. CNA #7 stated that she probably should have waited, or maybe got another staff member to answer the light." Interview on 2/2/12 at 12:00 p.m. with Licensed Practical Nurse (LPN) #2/MDS Nurse revealed that they cannot print an ADL care plan. The ADL Care Plan and care level for the CNA's are in the computer system which included transfer assistance. When the CNA logs into the resident's care, the transfer needs pop up on the side of the screen. The transfer needs are identified by numbers. A three (3) equals two (2) person assist, two (2) equals one (1) person assist. We can't print any of the ADL Care Plan. The transfer level is based on the MDS assessment. LPN #2/MDS Nurse reported that she entered the transfer care level into the computer system for the CNA's to know the level of care needed. If I see the numbers one (1) , two (2) and three (3) are being documented inconsistently on the ADLs, I go talk to the CNA's to find out what is going on with the resident to see if the transfer level needs to be changed. If we identify a change in the care level, we make a change in the computer ADLs. Interview on 2/2/12 at 2:00 p.m. with the DON revealed that she remembered the fall incident on 2/27/11 on 11:00 p.m. to 7:00 a.m. shift. The DON reported that Resident #10 had fallen in the bathroom resulting in a fractured pelvis. The DON reported after the fall, the facility started an investigation to determine what had happened. They reviewed the facility hall surveillance camera and determined the time frames did coincide with what the interviews with the staff revealed. The 11:00 p.m. to 7:00 a.m. shift supervisor did an immediate in-service with the CNA's that same night about not leaving resident unattended in the bathroom. The DON stated that they also followed up with disciplinary actions with the staff involved. A sign was placed over the call light in the bathroom to remind the resident not to get up without calling for assistance. The DON reported that she understands that this is a concern due to Resident #10 being left unattended in the bathroom, getting up without assistance resulting in a fractured pelvis. Interview on 2/27/12 at 2:20 p.m. with the facility's Administrator revealed that they had also reviewed the facility's surveillance films on the night of 2/27/11, and what they saw on the film correlated with the staff interviews.