Every finding on record at Uintah Basin Rehabilitation and Senior Villa

Based on interview and record review, it was determined that the facility did ensure a written notification of discharge was provided to a resident. Specifically, a resident who was transported to the hospital, and subsequently discharged from the facility, did not receive a written notice of discharge.On April 15, 2026, the surveyor reviewed Resident 2's electronic medical record and confirmed she was sent to the emergency room and discharged from the facility on September 26, 2026. No notice of discharge was present in the record. Hospital documentation from that date indicated the patient could not return to the facility, as the facility could not ensure her safety.The surveyor reviewed the facility's discharge policy and confirmed the policy required written notification to the resident and their representative, including the reason for discharge, the effective date, the discharge location, appeal rights, and contact information for the Ombudsman, and relevant advocacy agencies.On April 15, 2026, the surveyor interviewed the facility Administrator, who acknowledged that while the resident and family were informed verbally, no written notice of discharge was provided.

Based on observation and interview, it was determined the facility did not store, distribute and serve food in accordance with professional standards for food service safety. Specifically, meal tray items were uncovered when delivered by staff and uncovered meal tray items were placed at nurses' stations for extended periods; snacks with packaging that read Keep Refrigerated were stored at room temperature; food within the kitchen fridge and freezer were observed unlabeled and left open to air; food was stored at ground level in the walk-in refrigerator; and kitchen staff were unable to demonstrate an ability to check the concentration of sanitizer within sanitation buckets and the dish washing machine. Findings included: 1. Meal trays, which included, uncovered desserts and cups of canned fruit were transported through halls or placed at nurses' stations. On [DATE] at 11:31 AM, Kitchen Aide 1 carried a lunch tray, which included uncovered cake, from the tray line in the main dining room to the nurses' station. The tray was placed at the nurses' station. The lunch tray sat at the nurses' station until 11:34 AM, at which time a Certified Nursing Assistant (CNA) delivered the tray by walking to the far end of the 300 hall. On [DATE] at 11:31 AM, staff carried two lunch trays, which included uncovered cake and peaches, from the tray line in the main dining room to the nurses' station. The trays were placed at the nurses' station. The lunch tray with the uncovered peaches sat at the nurses' station until 11:39 AM, at which time a CNA delivered the tray to resident room 602. The lunch tray with the uncovered cake sat at the nurses' station until 11:42 AM, at which time a CNA delivered the tray to resident room 610. On [DATE] at 12:13 PM, the hall lunch tray cart was delivered to the 300 hall. A CNA was observed to deliver lunch trays to resident rooms 309 and 312. The cake was observed to be uncovered and the lunch trays were walked through the 300 hall. On [DATE] at 12:22 PM, the hall lunch tray cart was moved to the 600 hall. A CNA was observed to deliver lunch trays to resident rooms 306, 501, and 614. The cake and peaches were observed to be uncovered and the lunch trays were walked through the halls from the 600 hall. On [DATE] at 8:22 AM, a breakfast meal tray was placed at the nurses' station with an uncovered cup of canned fruit. The meal tray had been transported by a Kitchen Aide from the main dining room to the nurses' station. At 8:25 AM, the breakfast tray, with an uncovered cup of fruit, was transported by a CNA to the far end of the 300 hall. On [DATE] at 7:29 AM, a breakfast meal tray, with an uncovered cup of canned fruit, was observed at the nurses' station. At 7:31 AM, a CNA transported the breakfast meal tray to the far end of the 600 hall; the cup of fruit remained uncovered. On [DATE] at 7:38 AM, a breakfast meal tray with an uncovered cup of canned fruit was observed sitting at the nurses' station. At 7:41 AM, a CNA transported the breakfast meal tray to the far end of the 300 hall; the cup of fruit remained uncovered. On [DATE] at 8:07 AM, the Charge Nurse collected a breakfast tray from the tray cart. The breakfast tray included an uncovered cup of fruit. The charge nurse then walked with the tray from the beginning of the 500 hall to the far end of the hall. On [DATE] at 9:12 AM, the Dietary Manager (DM) was interviewed. The DM reported her kitchen staff should know to cover all tray items when the trays were placed at the nurses' station. The DM stated she had thought tray items which were delivered within a covered tray cart could be uncovered. The DM was not aware, that during delivery, the tray cart would be parked at one end of the resident hall, and then nursing staff would be walking through the unit to deliver trays. The DM had thought staff were pushing the meal tray cart from doorway to doorway when delivering trays. 2. Snacks with packaging that indicated Keep Refrigerated were observed stored at room temperature. On [DATE] at 1:47 PM, the snack cart was observed to be parked near the nurses' station. On the second shelf of the cart was an assortment of cookies, chips, and string cheese. The string cheese packaging read, Keep Refrigerated. On [DATE] at 9:12 AM, the DM was interviewed. The DM reported her staff should have placed the Keep Refrigerated snacks on ice when delivering them to the nursing units. 3. On [DATE], an initial tour of the kitchen was completed, and a follow-up tour was concluded on [DATE]. During the initial and follow-up kitchen tours, food items were found not stored in accordance with professional standards for food service safety. On [DATE] at 11:09 AM, a package of frozen pancakes and a package of a frozen fried item were found within the walk-in freezer. The packages were observed to not be labeled with a date or description. An open package of frozen, cubed chicken and frozen edamame were not labeled with a date. On [DATE] at 11:13 AM, the walk-in fridge was observed. In the walk-in refrigerator, small service bowls filled with canned peaches were stored uncovered and unlabeled. Also, cartons of milk were stored in crates on the floor of the walk-in fridge. A container of unlabeled, condiment squeeze bottles were identified in the walk-in fridge. The condiment bottles were not labeled with a description or date. On [DATE] at 8:21 AM, the refrigerator located near tray line in the main dining room was observed. Within the fridge was a magic cup frozen dessert. The packaging of the magic cup frozen dessert read, Consume within 5 days of thawing, under refrigeration. The magic cup within the fridge was not labeled with the date it had been thawed. Kitchen Aide 1 was interviewed and asked why the magic cup frozen dessert was not labeled. Kitchen Aide 1 stated, That should not be in there. On [DATE] at 8:34 AM, the walk-in fridge contained a pan of diced potatoes submerged in water unlabeled with a date or description. The milk cartons continued to be stored on the floor of the walk-in fridge. On [DATE] at 10:38 AM, the refrigerator at the nurses' station was observed. Within the nurses' station refrigerator, 2 yogurts were identified with use by date of [DATE]. On [DATE] at 9:12 AM, the DM was interviewed. The DM stated staff should have known to place the milk cartons on the shelving unit and should have labeled items that enter the fridge or freezer with a date and description. The DM stated the kitchen staff clean the resident refrigerator located at the nurses' station, and the kitchen staff discard any expired items. 4. When kitchen aide staff were asked to demonstrate how they check the sanitizer concentration of the dish washing machine and sanitizer buckets, the staff were unable to locate working test strips. On [DATE] at 8:48 AM, Kitchen Aide 1 ran the dishwasher to demonstrate functionality. Kitchen Aide 1 attempted to check the amount of sanitizer through utilizing a sanitizer test strip. The test strip did not change in coloration. Kitchen Aide 1 reported being in charge of washing dishes today, and Kitchen Aide 1 reported being unaware of what to do if the sanitizer strips were not working. Kitchen Aide 1 reported having just started recently, and Kitchen Aide 1 reported needing more training on how to use the dishwasher. On [DATE] at 9:11 AM, the DM was interviewed. The DM reported being unaware of any trouble with the dishwasher. The DM attempted to test the sanitizer concentration of the dish washing machine and reported, These are not the right test strips. We do not have the right ones. The DM stated she typically relied on staff to inform her when more sanitizer test strips were needed, and the DM reported, I will have to re-educate the staff.

Based on observation, interview, and record review it was determined, for 5 of 27 sampled residents, the facility assessment did not accurately reflect the resident's status. Specifically, the facility did not ensure that all participants in the assessment process had the requisite knowledge to complete an accurate assessment for resident's documented with limited range of motion, a resident documented with nutritional concerns, and a resident documented with wandering behaviors. Resident identifiers: 3, 13, 15, 23, and 30. Findings include: 1. Resident 3 was admitted to the facility on [DATE] and readmitted in 10/26/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/14/21, resident 3's medical record was reviewed. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed in Section G - Functional Status: Functional Limitation in Range of Motion (ROM): a. Upper extremity (shoulder, elbow, wrist, hand): 1. Impairment on one side b. Lower extremity (hip, knee, ankle, foot): 0. No impairment The Centers for Medicare & Medicaid Service's Resident Assessment Instrument (RAI) Version 3.0 Manual's definition of Functional Limitation in Range of Motion was, Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk for injury. The Hospital Emergency Department (ED) Medical Doctor Note dated 3/12/21, revealed on the Physical Exam Extremities Upper extremities exhibit normal ROM. Review of the nurses' Patient Driven Payment Model (PDPM) Assessment during the look back period 3/14/21 to 3/20/21 for resident 3 revealed the following: a. On 3/14/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment b. On 3/15/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment c. On 3/16/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment d. On 3/17/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment e. On 3/18/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment f. On 3/19/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment g. On 3/20/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment On 7/14/21 at approximately 4:06 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated she had coded resident 3 as having limited ROM due to resident 3 had gone to the Hospital's ED on 3/12/21, and was diagnosed with right upper arm [CONDITION(S)], which the MDS Coordinator thought restricted resident 3's right arm ROM. 2. Resident 13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/15/21, resident 13's medical record was reviewed. A Quarterly MDS assessment dated [DATE], revealed in Section G - Functional Status: Functional Limitation in ROM: a. Upper extremity (shoulder, elbow, wrist, hand): 2. Impairment on both sides b. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides Review of the nurses' PDPM Assessment during the look back period 4/12/21 to 4/18/21 for resident 13 revealed the following: a. On 4/12/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides b. On 4/13/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides c. On 4/14/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides d. On 4/15/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides e. On 4/16/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides f. On 4/17/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides g. On 4/18/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides [Note: The nurses' PDPM Assessments were inconsistent. Upper extremities were assessed as 0. No impairment for three days and 2. Impairment on both sides for four days during the look back period.] 3. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/15/21, resident 15's medical record was reviewed. An Admission MDS assessment dated [DATE], revealed in Section K - Swallowing/Nutritional Status: Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in the last 6 months: 2. Yes, not on prescribed weight-loss regimen. Resident 15's Admission weight on 4/13/21, was documented as 78.2 pounds (lbs). Resident 15's Admission MDS assessment weight on 4/25/21, was documented as 79.6 lbs. [Note: Resident 15 had a weight gain of 1.4 lbs.] On 7/15/21 at approximately 10:53 AM, an interview was conducted with the MDS Coordinator. Resident 15's weights were reviewed with the MDS Coordinator. The MDS Coordinator stated she would have to research why she had coded resident 15 as losing weight on the Admission MDS assessment. On 7/15/21 at approximately 11:08 AM, the MDS Coordinator emailed a Physician's Clinic Note dated 4/8/21. The Physician's Clinic Note revealed in the History of Present Illness section of the note, Patient has been losing weight. In the Assessment/Plan section, the note revealed, Patient's kids have had a hard time finding things that the patient will eat. She is losing a lot of weight and getting weaker. In the Exam section, the note revealed a weight of 49.9 kilograms (kg) [109.8 lbs]. The MDS Coordinator stated resident 15's weight during the clinic visit on 4/8/21, was 109.8 lbs. The MDS Coordinator stated resident 15's Admission MDS assessment weight on 4/25/21, was 79.6 lbs. The MDS Coordinator stated resident 15 had a weight loss of 30.2 lbs [-27.5%]. [Note: The 4/8/21 Physician's Clinic Note dated 4/8/21, included a History and Physical exam dated 9/2/20. Resident 15's weight 49.9 kg was from the H&P exam performed on 9/2/20. Resident 15's weight from the H&P exam was not within the 6 month look back period.] 4. Resident 23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/15/21, resident 23's medical record was reviewed. A Quarterly MDS assessment dated [DATE], revealed in Section E Wandering - Presence & Frequency: Has the resident wandered? 2. Behavior of this type occurred 4 to 6 days, but less than daily. Review of the nurses' PDPM Assessment during the look back period 5/20/21 to 5/26/21 for resident 23 revealed the following: a. On 5/20/21, PDPM Assessment: Section E - Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No b. On 5/21/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No c. On 5/22/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No d. On 5/23/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No e. On 5/24/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No f. On 5/25/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No g. On 5/26/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No 5. Resident 30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/15/21, resident 30's medical record was reviewed. An Annual MDS assessment dated [DATE], revealed in Section G - Functional Status: Functional Limitation in ROM: a. Upper extremity (shoulder, elbow, wrist, hand): 2. Impairment on both sides b. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides Review of the nurses' PDPM Assessment during the look back period 2/21/21 to 2/28/21 for resident 30 revealed the following: a. On 2/21/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides b. On 2/22/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides c. On 2/23/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides d. On 2/24/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides e. On 2/25/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides f. On 2/26/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides g. On 2/27/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides [Note: The nurses' PDPM Assessments were inconsistent. Upper extremities were assessed as 0. No impairment for three days and 2. Impairment on both sides for four days during the look back period.] On 7/15/21 at approximately 12:18 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated she used the PDPM assessment that the facility nurses' complete during the MDS Assessment look back period to determine how to code a resident's MDS Assessment. The MDS Coordinator stated the look back period was seven days prior to the assessment. The MDS Coordinator stated she had not trained the nursing staff on the specific RAI definition for ROM and she needed to do more training to ensure accurate coding of the assessments. The MDS Coordinator further stated that she was confident the nursing staff knew how to assess ROM and wandering. The MDS Coordinator stated she also included her own observations of the residents when coding the MDS assessments.

Based on observation, interview, and record review, it was determined the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, for 4 of 27 sampled residents, following witnessed and unwitnessed falls the facility did not maintain and update the comprehensive care plan to include the services that were to be furnished. Resident identifiers: 1, 3, 13, and 23. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/21 at 1:25 PM, resident 1 was interviewed. Resident 1 stated, I fell last week. Tripped over my feet going around my wheelchair. I was alone in my room. On 7/14/21, a review of resident 1's medical record was completed. Resident 1 had a care plan that revealed, [Resident 1] is a high risk for falls with an actual fall related to generalized weakness, acquired absence of left leg below knee and difficulty walking. Date Initiated: 09/06/2017, Revision on: 04/01/2020. Interventions included; a. Anticipate and meet needs. Bed in lowest position. Date Initiated: 09/06/2017, Revision on: 01/15/2020 b. Be sure call light is within reach and encourage use as needed for assistance. Keep personal items within reach. Date Initiated: 09/06/2017, Revision on: 12/20/2019 c. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 12/20/2019 d. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: Physical Therapy (PT), Occupational Therapy (OT), Restorative Program, and/or Recreation Therapy with physical activity. Date Initiated: 12/20/2019 e. Ensure proper footwear is worn (such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Date Initiated: 12/20/2019 f. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN (as needed). Date Initiated: 12/20/2019, Revision on: 01/15/2020 g. Follow facility fall protocol. Date Initiated: 09/06/2017 h. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; and rails on walls, personal items within reach. Date Initiated: 12/20/2019, Revision on: 01/15/2020 i. PT and/or OT evaluate and treat as ordered or PRN. Date Initiated: 12/20/2019, Revision on: 01/15/2020 The facility incident report dated 6/26/21, revealed CNA (Certified Nursing Assistant) . found resident in his room on the floor. Resident was transferring himself from his electric wheelchair to his push wheelchair. Resident fell backwards onto his bottom. Resident had proper foot wear (shoes) on, prosthesis was on his left leg, call light was not in reach due to him being on the floor up against the wall . Resident states that he was just trying to get from his electric w/c (wheelchair) to his manual w/c and tripped and then fell backward onto his bottom. Once he hit the ground his head bumped the wall. [Note: no interventions were initiated or revised following fall on 6/26/21.] On 7/14/21 at 2:21 PM, CNA 6 was interviewed. CNA 6 reported she was not at work the day resident 1 fell . CNA 6 reported being unaware of any new interventions put in place following resident 1's fall to help prevent future falls. CNA 6 reported new interventions were placed in the fall intervention book at the nurses' station, and that was typically where she gathered instructions on how to work with residents for fall prevention. On 7/14/21 at 2:23 PM, the fall intervention book was reviewed. Regarding resident 1, the fall prevention book read, Actual Fall intervention: 1. Re-educate [Resident 1] to call for assistance when transferring. 2. PT will continue with wheelchair safety training. On 7/14/21 at 2:28 PM, the Physical Therapy Assistant (PTA) was interviewed. The PTA reported resident 1 was on therapy caseload for occupational and restorative therapy, but not physical therapy at that time. On 7/14/21 at 2:32 PM, the Physical Therapy (PT) Director was interviewed. The PT Director reported, No, [resident 1] is not on physical therapy for wheelchair training. He completed that already. I did not receive a referral after he fell recently because he doesn't fall often. 2. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/13/21 at approximately 8:29 AM, resident 3 was observed sitting in the recliner in his room. Resident 3 was dressed and well groomed. The call light button was within reach. Resident 3 stated that staff had responded well when he had pushed the call light button for help. Resident 3 stated he had used his walker when he needed to get up and walk. Resident 3 stated that he had fallen recently. On 7/13/21, resident 3's medical record was reviewed. Resident 3's current Care Plan was reviewed and revealed a Focus Area, [Resident 3] is a high risk for falls with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Initiated: 09/23/2019 Revision on: 04/29/2021 Fall Prevention interventions on the Care Plan included: a. Anticipate and meet needs. Bed in lowest position. Date Initiated: 9/23/19 Revision on: 1/15/20 b. Be sure call light is within reach and encourage use as needed for assistance. Keep personal items within reach. Date Initiated: 9/23/19 Revision on: 12/20/19 c. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 12/20/19 d. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: Physical Therapy, Occupational Therapy, Restorative Program, and/or Recreation Therapy with physical activity. Date Initiated: 12/20/19 e. Ensure proper footwear is worn (such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Date Initiated: 12/20/19 f. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Date Initiated: 12/20/19 Revision on: 1/15/20 g. Follow facility fall protocol. Date Initiated: 09/23/2019 h. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. Date Initiated: 12/20/19 Revision on: 01/15/20 i. PT and/or OT evaluate and treat as ordered or PRN. Date Initiated: 09/23/2019 Revision on: 1/15/20 Review of resident 3's 2021 Progress Notes revealed that resident 3 had a fall on 4/27/21 and another fall on 6/5/21. [Note: There were no new fall prevention interventions initiated or revised following resident 3's falls.] On 7/13/21 at approximately 10:28 AM an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she would fill out an incident report and included fall prevention interventions to prevent future falls. LPN 1 stated she was aware that resident 3 had fallen in the past. LPN 1 stated she had reminded resident 1 to ask for help when getting up but that he was not complaint and continues to get up on his own. On 7/14/21 at approximately 9:58 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurse completed an Incident Report after a resident fall and the report would include new fall prevention interventions. The DON stated that she or the Minimum Data Set (MDS) Coordinator reviewed the Fall Incident Reports to determine if the fall prevention interventions noted by nursing staff were appropriate or not and then update the resident's Care Plan. When asked why resident 3's Care Plan had no new interventions following his fall on 4/27/21, the DON stated that OT completed an Activities of Daily Living evaluation. When asked if OT made any fall prevention recommendations, the DON said there were no new interventions recommended after the OT evaluation. When asked why there were no new fall prevention interventions following resident 3's fall on 6/5/21, the DON stated they had a meeting with resident 3 and a family member to reinforce following safety measures. The DON stated there were no new fall prevention interventions that came from that meeting. The DON was asked how fall prevention interventions were communicated to staff. The DON stated there was a Fall Intervention Book at the Nurses' Station that included fall prevention interventions specific to each resident, which was updated every 90 days. The DON stated that new fall prevention interventions were also discussed daily as needed with clinical staff at the beginning of every shift in their group huddles. 3. Resident 23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 23's medical record was reviewed on 7/13/21. A Care Plan Problem initiated on 5/14/21 and revised on 7/13/21, documented (Resident 23) is high risk for falls with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Goals initiated on 5/17/21 with a review date 8/25/21, documented To be free of falls through the review date. To not sustain serious injury from a fall through the review date. Side effects of medications contributing to gait disturbance, balance disturbance, [CONDITION(S)], movement disorders and increasing fall risk will be reduced by the reviewed in [CONDITION(S)] meeting with a GDR (Gradual Dose Reduction) if appropriate. The Interventions initiated on 5/14/21, included the following: a. Anticipate and meet needs. b. Bed in lowest position. c. Be sure call light was within reach and encourage use as needed for assistance. d. Keep personal items within reach. e. Electronic Motion Sensor in use. Ensure the device was in place and working. Initiated on 5/14/21 and revision on 5/17/21. f. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. g. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT, OT, Restorative Program, and/or Recreation Therapy with physical activity. h. Ensure proper footwear was worn such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. i. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. j. Follow facility fall protocol. k. Keep personal items within reach. l. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. m. PT and/or OT evaluate and treat as ordered or PRN. Resident 23's fall interventions were located in the Fall Intervention book at the nurses' station. The form documented Actual Fall Intervention: 1- Q (every) 1 (hour) Resident Current Status checks. 2-Electronic Motion Sensor in use. Ensure the device is in place and working. Standard Fall Interventions: Anticipate and meet needs. Bed in the lowest position. Be sure call light is within reach and encourage use as needed for assistance. Keep personal items within reach. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: Physical Therapy, Occupational Therapy, Restorative Program, and/or Recreation Therapy with physical activity. Ensure proper footwear is worn (such (sic) as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Follow facility fall protocol. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. PT and/or OT evaluate and treat as ordered or PRN. On 5/29/21 at 8:20 AM, an Incident Description documented, Resident was found by [name removed] CNA sitting on the floor in front of her recliner next to her bed, she was in her night gown and brief, was continent. Was last checked on 20 minutes before at 0600 (6:00 AM). Call light was not on. Resident was self transferring from bed to recliner, became weak and sat on floor. Her statement 'I was trying to get to my recliner and sat down on the floor'. The Notes section of the report documented, 5/29/2021 Interventions 1. Every hour toileting. 5/31/2021 Resident placed on every hour toileting. No injuries noted. [Resident 23] is confused and frequently attempts to get up unassisted. [Note: The care plan was not updated with the fall intervention.] On 6/28/21 at 7:25 PM, an Incident Description documented, I was called to room [ROOM NUMBER] at 1925 (7:25 PM), resident was sitting upright in front of her recliner. Resident had non-skid socks on. her call light was attached to her recliner within reach and not on, motion sensor in place and working. Resident was last check (sic) on at 1910 (7:10 PM). When asked what happened, resident stated 'I was trying to get from my chair to my bed'. The Notes section of the report documented, 6/29/21 Intervention: Staff education initiated to encourage resident to be in the lobby doing activities/watching tv until she is ready for bed. [Note: The care plan was not updated with the fall intervention.] On 7/13/21 at 1:41 PM, an interview was conducted with CNA 1. CNA 1 stated she also worked as the Medical Records Manager at the facility. CNA 1 stated fall interventions were listed in the electronic medical record under the Individualized Support Plan (ISP) tab. CNA 1 stated interventions in place for resident 23 were a low bed, non skid socks, motion sensor, and one hour checks. CNA 1 stated she would chart on the tablet if a resident was a one hour check. CNA 1 showed this surveyor in the electronic medical record that resident 23 was a one hour check. CNA 1 further stated that resident 23 required 2 people for a transfer. 4. Resident 13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 13's medical record was reviewed on 7/14/21. A Care Plan Problem initiated on 10/26/17 and revised on 5/22/21, documented [Resident 13] is a High risk for falls with an actual fall) (sic) with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interventions initiated on 10/26/17, included the following: a. Bed in lowest position. Revision date 1/15/20. Be sure call light is within reach and encourage use as needed for assistance. b. Keep personal items within reach. Revision date 12/20/19. c. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT, OT, Restorative Program, and/or Recreation Therapy with physical activity. Revision date 12/20/19. d. Ensure proper footwear was worn (such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Revision date 12/20/19. e. Follow facility fall protocol. f. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. Revision date 1/15/20. g. Actual Fall Interventions: 1- Every hour Resident Status checks 2-Encourage resident to get into bed at bed time. Date initiated 2/3/20 and revision on 6/22/21. Anticipate and meet needs. h. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Date initiated 12/20/19. i. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Date initiated 12/20/19 and revision on 1/15/20. j. PT and/or OT evaluate and treat as ordered or PRN. Date initiated 12/20/19 and revision on 1/15/20. On 4/3/21 at 7:40 PM, an Incident Description documented, Resident found by [name removed] RN (Registered Nurse) sitting on the floor at the nurses station with her legs extended in front of her with her brief wet. No injuries noted. Resident does not c/o (complain of) pain. Resident last toileted at 1847 (6:47 PM). Wheelchair next to resident and there was a stool next to resident. Resident said she sat down. The Notes section of the report documented, 4/12/2021 1.Rolling stool locked in Charge nurse office. 2.Staff education that resident to be in site of staff when in common area. 4/16/2021 No injuries noted from incident. Staff encouraged to toilet resident if restless and monitor in common area. [Note: The care plan was not updated with the fall intervention.] On 6/20/21 at 2:31 PM, an Incident Description documented, Resident was in her room on the floor laying on her left side next to her recliner that was up in the highest position. Resident had non skid socks on and call light was hooked on recliner. Resident was last checked on 10 minutes earlier at 1420 (2:20 PM). Resident did not have any injuries after assessment. Started neuros. Resident Unable to give Description. The Notes section of the report documented, Recliner removed from room for safety. [Note: The care plan was not updated with the fall intervention.] On 7/13/21 at 2:02 PM, an interview was conducted with RN 2. RN 2 stated fall interventions were communicated to staff in the fall intervention book that was located at the nurses' station, huddles at shift change, and the meetings where interventions were discussed. RN 2 stated the MDS Coordinator, DON, and Assistant Director of Nursing (ADON) updated care plans with interventions. On 7/13/21 at 2:31 PM, an interview was conducted CNA 7. CNA 7 stated the fall intervention book at the nurses' station had the fall interventions for all residents. CNA 7 stated the residents were alphabetical in the fall book and had their own individualized plan. CNA 7 also stated the brains paper she carried in her pocket had resident interventions listed. On 7/13/21 at 2:33 PM, an interview was conducted with CNA 8. CNA 8 stated resident fall interventions were on the resident care plans. CNA 8 stated she able to access the resident care plans on her Tablet. CNA 8 showed this surveyor her Tablet and how she was able to access the resident care plans. On 7/14/21 at 11:11 AM, an interview was conducted with the Charge Nurse. The Charge Nurse stated the DON would update the care plans with interventions. The Charge Nurse stated the DON would print the care plan interventions and she would update the fall intervention books with the printed interventions. On 7/14/21 at 2:04 PM, an interview was conducted the Administrator. The Administrator stated Resident 13 had standard fall interventions in place. On 7/14/21 at 2:24 PM, an interview was conducted with CNA 6. CNA 6 stated resident 13 required assistance with all activities of daily living. CNA 6 stated resident 13 was very confused. CNA 6 stated she was unsure what fall interventions were in place for resident 13. CNA 6 showed this surveyor the Fall Interventions book at the nurses station and resident 13 did not have a sheet in the book indicating fall interventions implemented. On 7/15/21 at 8:56 AM, an interview was conducted with the DON and ADON. The DON stated that herself or the MDS coordinator would update the care plans with interventions. The DON stated at the time of the fall the nurse would come up with the interventions. The DON stated if an intervention was not monitored the intervention was not added to the care plan. On 7/15/21 at 10:39 AM, an interview was conducted with the DON and ADON. The DON stated staff were educated about resident fall interventions during clinical stand up with the nursing staff and at shift change group huddle with nursing staff and CNA's. The DON stated the CNA on the resident hall that had a fall would know right away the fall interventions. The DON stated the CNA's get initial training snap shots of the resident. The DON stated ongoing interventions were on the resident care plan and in the Fall Interventions book at the nurses station.

Based on observation, interview, and record review it was determined, for 3 of 27 sampled residents, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, residents that had multiple falls were not provided interventions or adequate supervision to prevent falls from occurring. Resident identifiers: 3, 13, and 23. Findings include: 1. Resident 23 was admitted to the facility on [DATE] with diagnoses which included but not limited to [CONDITION(S)], weakness, dementia without behavioral disturbance, anxiety disorders, essential hypertension, spinal stenosis, pulmonary heart disease, low back pain, history of falling, unsteadiness on feet, dysphagia, [CONDITION(S)], and type 2 diabetes mellitus with diabetic [CONDITION(S)]. On 7/12/21 at 12:25 PM, a staff member was observed in resident 23's room and the staff member was heard asking resident 23 about falling out of her chair that morning. On 7/12/21 at 2:58 PM, resident 23 was observed in the day room. Resident 23 was observed to have a large hematoma on the left side of her forehead that appeared to be bruising. The hematoma was covered with a bandage. Resident 23's medical record was reviewed on 7/13/21. An Admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 23 required extensive assistance of one person for bed mobility, transfers, walk in room and corridor, locomotion on and off the unit, dressing, and personal hygiene. Resident 23 required extensive assistance of two persons for toilet use. Resident 23 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking with assistive devices, moving off and on toilet, surface to surface transfer, and turning around to face the opposite direction while walking. An Admission MDS assessment dated [DATE], documented that resident 23 had a Brief Interview for Mental Status (BIMS) score of a 2. A BIMS score of 0 to 7 indicates a severe cognitive impairment. A Care Plan Problem initiated on 5/14/21 and revised on 7/13/21, documented (Resident 23) is high risk for falls with the diagnoses of [CONDITION(S)], low back pain, weakness and a recent fall. The Goals initiated on 5/17/21 with a review date 8/25/21, documented To be free of falls through the review date. To not sustain serious injury from a fall through the review date. Side effects of medications contributing to gait disturbance, balance disturbance, [CONDITION(S)], movement disorders and increasing fall risk will be reduced by the reviewed in [CONDITION(S)] meeting with a GDR (Gradual Dose Reduction) if appropriate. The Interventions initiated on 5/14/21, included the following: a. Anticipate and meet needs. b. Bed in lowest position. c. Be sure call light was within reach and encourage use as needed for assistance. d. Keep personal items within reach. e. Electronic Motion Sensor in use. Ensure the device was in place and working. Initiated on 5/14/21 and revision on 5/17/21. f. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. g. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: Physical Therapy (PT), Occupational Therapy (OT), Restorative Program, and/or Recreation Therapy with physical activity. h. Ensure proper footwear was worn such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. i. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety as needed (PRN). j. Follow facility fall protocol. k. Keep personal items within reach. l. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. m. PT and/or OT evaluate and treat as ordered or PRN. Resident 23's fall interventions were located in the Fall Intervention book at the nurses' station. The form documented Actual Fall Intervention: 1- Q (every) 1 (hour) Resident Current Status checks. 2-Electronic Motion Sensor in use. Ensure the device is in place and working. Standard Fall Interventions: Anticipate and meet needs. Bed in the lowest position. Be sure call light is within reach and encourage use as needed for assistance. Keep personal items within reach. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: Physical Therapy, Occupational Therapy, Restorative Program, and/or Recreation Therapy with physical activity. Ensure proper footwear is worn (such (sic) as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Follow facility fall protocol. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. PT and/or OT evaluate and treat as ordered or PRN. On 5/14/21, resident 23 was categorized high risk for falling with a score of 105 on the Morse Fall Scale form. A Morse Fall Scoring 45 and higher was categorized high risk. On 5/17/21 at 10:00 PM, an Incident Description documented, Nurse observed resident on the floor in front of her room with her legs extended in front of her. Foot wear in place resident in street clothes Walker in front of patient. Nurses aide at resident's side. Nurses aide stated that resident was leaning to the left side and was losing her balance so she assisted resident to the floor CNA (Certified Nursing Assistant) reacted urgently to prevent injury which did not provide time for gait belt use. Resident was up trying to ambulate on her own. Nurses aide had motion sensor and was behind resident at the time of incident. No injuries noted. Resident denies pain or discomfort. The Notes section of the report documented, 5/18/2021 PT to evaluate for restorative program. 5/27/2021 Evaluated by physical therapy and will receive physical therapy for strengthening. [Note: Intervention was implemented on the care plan on 5/14/21, prior to resident 23's fall. No new fall interventions were implemented.] On 5/29/21 at 8:20 AM, an Incident Description documented, Resident was found by [name removed] CNA sitting on the floor in front of her recliner next to her bed, she was in her night gown and brief, was continent. Was last checked on 20 minutes before at 0600 (6:00 AM). Call light was not on. Resident was self transferring from bed to recliner, became weak and sat on floor. Her statement 'I was trying to get to my recliner and sat down on the floor'. The Notes section of the report documented, 5/29/2021 Interventions 1. Every hour toileting. 5/31/2021 Resident placed on every hour toileting. No injuries noted. [Resident 23] is confused and frequently attempts to get up unassisted. [Note: The care plan was not updated with the fall intervention.] On 6/17/21 at 7:40 AM, an Incident Description documented, Called to the resident room by [name removed] CNA. I arrived to find the resident sitting on the floor between her recliner and walker with legs stretched out in front of her. Resident stated she was trying to go to breakfast. Resident was wearing street clothes with non slip socks. Resident was dry with no incontinence noted. Last checked on at 0655 (6:55 AM). Resident stated 'I was going to breakfast'. The Notes section of the report documented, 6/17/2021 intervention 1 - social work to contact family in order to obtain resident hobbies/likes. Recreational therapy to encourage participation in activities and or hobbies of choice to decrease restless impulsive behaviors. [Note: Intervention was implemented on the care plan on 5/14/21, prior to resident 23's fall. No new fall interventions were implemented.] On 6/28/21 at 7:25 PM, an Incident Description documented, I was called to room 306 at 1925 (7:25 PM), resident was sitting upright in front of her recliner. Resident had non-skid socks on. her call light was attached to her recliner within reach and not on, motion sensor in place and working. Resident was last check (sic) on at 1910 (7:10 PM). When asked what happened, resident stated 'I was trying to get from my chair to my bed'. The Notes section of the report documented, 6/29/21 Intervention: Staff education initiated to encourage resident to be in the lobby doing activities/watching tv until she is ready for bed. [Note: The care plan and Fall Intervention book was not updated with the fall intervention. Intervention Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. was implemented on the care plan on 5/14/21.] On 7/12/21 at 11:10 AM, an Incident Description documented, . I looked down the hall to see [resident 23] on the floor with [name removed] RN (Registered Nurse) and [name removed] next to her. Resident was outside her doorway in prone position slightly tilted to her left facing the wall with wheelchair at her feet. Resident wearing day clothes and nonskid socks. Resident with no incontinence noted. Resident last checked at 1102 (11:02 AM) watching television. AAOx3 (awake, alert, and oriented to person, place, or time) unable to state name but was able to state her birthday. Resident states, 'I have a bump on my head. I don't know what happened'. Mental Status section of the form documented, . Resident at baseline LOC (Level of consciousness). 2.8cm (centimeters) x 2.2.cm abrasion to left knee without bleeding. 0.5 bruise and abrasion to right thumb knuckle without bleeding. 0.8cm in length skin tear to left side of forehead. 4.2cm hematoma to left side of forehead moderate bleeding. Cleaned with gauze, spot dressing applied. resident reported head pain, ICE was attempted per resident tolerance. PRN [MEDICATION(S)] 50mg administered. The Notes section of the report documented, 7/12/2021 Intervention #1: Switched out wheelchair for a smaller and taller wheelchair with PT recommendation. On 7/13/21 at 1:38 PM, Resident 23 was observed in bed sleeping. Resident 23 had a bandage on the hematoma located on the left side of her forehead. Resident 23's left eye was bruised. On 7/13/21 at 1:41 PM, an interview was conducted with CNA 1. CNA 1 stated she also worked as the Medical Records Manager at the facility. CNA 1 stated fall interventions were listed in the electronic medical record under the Individualized Support Plan tab. CNA 1 stated fall interventions in place for resident 23 were a low bed, non skid socks, motion sensor, and one hour checks. CNA 1 stated she would chart on the tablet if a resident was a one hour check. CNA 1 showed this surveyor in the electronic medical record that resident 23 was a one hour check. CNA 1 further stated that resident 23 required 2 people for a transfer. On 7/13/21 at 1:56 PM, an interview was conducted with the PT Director. The PT Director stated resident 23 was in a wider wheelchair and resident 23 fidgets. The PT Director stated resident 23 was evaluated for a smaller wheelchair yesterday and one was provided for her. The PT Director stated he had been working with resident 23 on balance to help prevent falls. On 7/13/21 at 2:02 PM, an interview was conducted with RN 2. RN 2 stated fall interventions were communicated to staff in the Fall Intervention book that was located at the nurses' station, huddles at shift change, and in the meetings where interventions were discussed. RN 2 stated the MDS Coordinator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) updated care plans with interventions. RN 2 stated after a resident had a fall the nurse would check the resident and assess for injury, after the resident was assessed the resident would be moved with the Hoyer lift, the resident would be treated for pain if necessary, and if needed the resident would be further assessed at the hospital. RN 2 stated she would inform the Medical Director (MD), DON, and the resident's family of the fall. RN 2 stated at first she was concerned that resident 23 was not further assessed by the MD after the fall yesterday. RN 2 stated resident 23 was confused to begin with and at her baseline prior to the fall. RN 2 stated after resident 23 fell yesterday the staff provided one to one monitoring and resident 23 was monitored and further assessed throughout the day. RN 2 stated resident 23 had a face time visit with family that was familiar with resident 23's baseline. On 7/13/21 at 2:19 PM, an interview was conducted with the Social Worker (SW) and the Recreational Therapy staff member. The SW stated she spoke to resident 23's daughter in law but had not made a progress note of the conversation. The SW stated resident 23 enjoyed reading but Recreational Therapy was already reading to resident 23. The Recreational Therapy staff member stated resident 23 liked to visit, fold items, and ball yarn. The Recreational Therapy staff member stated resident 23 needed to be kept busy. On 7/13/21 at 2:31 PM, an interview was conducted CNA 7. CNA 7 stated the Fall Intervention book at the nurses' station had the fall interventions for all residents. CNA 7 stated the residents were alphabetical in the Fall Intervention book and residents had their own individualized plan. CNA 7 also stated the brains paper she carried in her pocket had resident interventions listed. On 7/13/21 at 2:33 PM, an interview was conducted with CNA 8. CNA 8 stated resident fall interventions were on the resident care plans. CNA 8 stated she was able to access the resident care plans on her Tablet. CNA 8 showed this surveyor her Tablet and how she was able to access the resident care plans. On 7/13/21 at 2:39 PM, Resident 23 was observed in bed sleeping. Resident 23 had a bandage on the hematoma located on the left side of her forehead. Resident 23's left eye and cheek were bruised. On 7/13/21 at 3:03 PM, an interview was conducted with the Physical Therapy Assistant (PTA). The PTA stated that she had assessed resident 23 for a different wheelchair after the fall yesterday. The PTA stated the new wheelchair was a little narrower for resident 23 and was a better fit. The PTA stated she tried to work with resident 23 on balance yesterday but resident 23 was busy all day and today resident 23 had been in bed all day. On 7/14/21 at 11:11 AM, an interview was conducted with the Charge Nurse. The Charge Nurse stated the DON would update the care plans with interventions. The Charge Nurse stated the DON would print the care plan interventions and she would update the Fall Intervention books with the printed interventions. The Charge Nurse stated there was a Fall Intervention book at each nurses' station. On 7/15/21 at 8:56 AM, an interview was conducted with the DON and ADON. The DON stated that herself or the MDS Coordinator would update the care plans with interventions. The DON stated at the time of the fall the nurse would come up with the interventions. The DON stated they had tried to call resident 23's family regarding additional interventions and there were no additional helpful things offered. The ADON stated she had asked Recreational Therapy to increase their time with resident 23. The DON stated if an intervention was not monitored the intervention was not added to the care plan. 2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included but not limited to type 2 diabetes mellitus with diabetic [CONDITION(S)], dementia with behavioral disturbance, major depressive disorder, essential hypertension, muscle weakness, chronic pain syndrome, [CONDITION(S)], other reduced mobility, difficulty in walking, and need for assistance with personal care. Resident 13's medical record was reviewed on 7/14/21. A Quarterly MDS assessment dated [DATE], documented that resident 13 required extensive assistance of one person for bed mobility, transfers, walk in room and corridor, dressing, toilet use, and personal hygiene. Resident 13 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking with assistive devices, moving off and on toilet, surface to surface transfer, and turning around to face the opposite direction while walking. A Quarterly MDS assessment dated [DATE], documented that resident 13 did not have a BIMS conducted due to resident 13 rarely or never understood. A Care Plan Problem initiated on 10/26/17 and revised on 5/22/21, documented [Resident 13] is a High risk for falls with an actual fall) (sic) with the diagnosis of dementia with behavioral disturbance. The Goal initiated on 12/20/19 and revised on 2/25/21, documented To not sustain serious injury from a fall through the review date. The Interventions initiated on 10/26/17, included the following: a. Bed in lowest position. Revision date 1/15/20. Be sure call light is within reach and encourage use as needed for assistance. b. Keep personal items within reach. Revision date 12/20/19. c. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT, OT, Restorative Program, and/or Recreation Therapy with physical activity. Revision date 12/20/19. d. Ensure proper footwear was worn such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Revision date 12/20/19. e. Follow facility fall protocol. f. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. Revision date 1/15/20. g. Actual Fall Interventions: 1- Every hour Resident Status checks 2-Encourage resident to get into bed at bed time (HS). Date initiated 2/3/20 and revision on 6/22/21. Anticipate and meet needs. h. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Date initiated 12/20/19. i. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Date initiated 12/20/19 and revision on 1/15/20. j. PT and/or OT evaluate and treat as ordered or PRN. Date initiated 12/20/19 and revision on 1/15/20. On 12/11/20 at 12:22 AM, an Incident Description documented, I was called to come to room 303 at 0022 (12:22 AM), when I entered the room [resident 13] was sitting straight up on the floor in the front of her recliner. There was a maroon blanket under her and she did have on non-skid socks and she was in her nightgown. Call light was clipped to the chair and was not used for assistance. Last checked on and offered toileting at midnight. Resident stated she wanted us to help her up. Resident unable to verbalize why she was on the ground or what she was attempting to do. The Notes section of the report documented, 12/11/2020 Interventions: Encourage resident to get into bed and not the recliner at HS. [Note: Intervention was implemented on the care plan on 2/3/20, prior to resident 13's fall. No new fall interventions were implemented.] On 4/3/21 at 7:40 PM, an Incident Description documented, Resident found by [name removed] RN sitting on the floor at the nurses station with her legs extended in front of her with her brief wet. No injuries noted. Resident does not c/o (complain of) pain. Resident last toileted at 1847 (6:47 PM). Wheelchair next to resident and there was a stool next to resident. Resident said she sat down. The Notes section of the report documented, 4/12/2021 1.Rolling stool locked in Charge nurse office. 2.Staff education that resident to be in site of staff when in common area. 4/16/2021 No injuries noted from incident. Staff encouraged to toilet resident if restless and monitor in common area. [Note: The care plan and Fall Intervention book was not updated with the fall intervention.] On 5/7/21 at 8:10 PM, an Incident Description documented, I was called to room 303 at 2010 (8:10 PM). Resident's chair was slightly tipped forward, resident's bottom was on the floor, her back was on the foot rest of the recliner and her head was where her bottom was suppose to be. Resident stated 'let's go'. Resident had her call light clipped to her bed, she had non-skid were in place, resident was incontinent. Last checked on at 2003 (8:03 PM) by me, resident was in her chair and I provided a blanket to her. Resident stated 'Lets go. When ask (sic) what happened, resident stated 'I need to get up'. [Note: No new fall interventions were implemented.] On 6/20/21 at 2:31 PM, an Incident Description documented, Resident was in her room on the floor laying on her left side next to her recliner that was up in the highest position. Resident had non skid socks on and call light was hooked on recliner. Resident was last checked on 10 minutes earlier at 1420 (2:20 PM). Resident did not have any injuries after assessment. Started neuros. Resident Unable to give Description. The Notes section of the report documented, Recliner removed from room for safety. [Note: The care plan and Fall Intervention book was not updated with the fall intervention.] On 7/14/21 at 2:04 PM, an interview was conducted the Administrator. The Administrator stated Resident 13 had standard fall interventions in place. On 7/14/21 at 2:24 PM, an interview was conducted with CNA 6. CNA 6 stated resident 13 required assistance with all activities of daily living (ADL). CNA 6 stated resident 13 was very confused. CNA 6 stated she was unsure what fall interventions were in place for resident 13. CNA 6 showed this surveyor the Fall Interventions book at the nurses station and resident 13 did not have a sheet in the book indicating what fall interventions were implemented. On 7/15/21 at 10:08 AM, an observation was made of a rolling stool chair at the nurses station near the 500 and 600 resident hallways. The rolling stool chair was unattended by staff and accessible to residents. An additional observation was made of a rolling stool chair in the resident day room. The rolling stool chair was unattended by staff and accessible to residents. On 7/15/21 at 10:39 AM, an interview was conducted with the DON and ADON. The DON stated staff were educated about resident fall interventions during clinical stand up with the nursing staff and at shift change group huddle with nursing staff and CNA's. The DON stated the CNA on the resident hall that had a fall would know right away the fall interventions implemented. The DON stated the CNA's get initial training snap shots of the resident. The DON stated ongoing interventions were on the resident care plan and in the Fall Interventions book at the nurses' station. The ADON stated the rolling stool chair location changed with Covid because residents were in their rooms. The ADON stated the rolling stool chair was not always locked up in the Charge Nurse office but the rolling stool chair was locked up when not in use. 3. Resident 3 was admitted to the facility on [DATE] and readmitted in 10/26/2020 with diagnoses that included but not limited to type 2 diabetes mellitus with diabetic [CONDITION(S)], end stage renal disease, [CONDITION(S)] in chronic kidney disease, repeated falls, weakness, and dependence on renal [CONDITION(S)]. On 7/13/21 at approximately 8:29 AM, resident 3 was observed sitting in the recliner in his room. Resident 3 was dressed and well groomed. The call light button was within reach. Resident 3 stated that staff have responded well when he has pushed the call light button for help. Resident 3 stated he has used his walker when he needed to get up and walk. Resident 3 stated that he had fallen recently. On 7/13/21, resident 3's medical record was reviewed and revealed the following: Review of the resident's 2021 Progress Notes revealed that resident 3 had fallen twice. Resident 3 had one fall on 4/27/21 and another fall on 6/5/21. Resident 3' current Care Plan was reviewed and revealed a Focus Area, [Resident 3] is a high risk for falls with diagnoses of weakness, a history of repeated falls and unsteadiness on feet and a recent fall. Date Initiated: 09/23/2019 Revision on: 04/29/2021 Fall Prevention interventions on the Care Plan included: a. Anticipate and meet needs. Bed in lowest position. Date Initiated: 9/23/19 Revision on: 1/15/20 b. Be sure call light is within reach and encourage use as needed for assistance. Keep personal items within reach. Date Initiated: 9/23/19 Revision on: 12/20/19 c. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 12/20/19 d. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT, OT, Restorative Program, and/or Recreation Therapy with physical activity. Date Initiated: 12/20/19 e. Ensure proper footwear is worn (such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Date Initiated: 12/20/19 f. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Date Initiated: 12/20/19 Revision on: 1/15/20 g. Follow facility fall protocol. Date Initiated: 09/23/19 h. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. Date Initiated: 12/20/19 Revision on: 01/15/20 i. PT and/or OT evaluate and treat as ordered or PRN. Date Initiated: 09/23/19 Revision on: 1/15/20 Review of resident 3's 2021 Progress Notes revealed that resident 3 had a fall on 4/27/21 and another fall on 6/5/21. [Note: There were no new fall prevention interventions initiated or revised following resident 3's falls.] The Incident Reports completed following resident 3's fall on 4/27/21 and 6/5/21 were reviewed and revealed the following: a. On 4/27/21, Nursing Description: Resident found by RN 3 lying on his left side in front of his recliner. 2 skin tears noted to left elbow. Call light within reach but not in use. No footwear in use. Resident was last checked on by CNA 3 at 12:18 AM. Resident Description: I was trying to put my pajama pants back on to go sit back in my chair and got my feet stuck in the same pant leg. Resident denies hitting head states he just hit his elbow and side. Immediate Action Taken: Head to toe assessment completed by RN 3. Three person assist by Hoyer lift to chair by RN 3, CNA 3, and CNA 4. Skin tears to left elbow cleansed with normal saline [MEDICATION(S)] and protective dressing applied. [NAME] checks started, DON, family and Physician notified. Injury: Left elbow skin tear. Resident 3 oriented to person, place, time and situation. DON Note: Resident resistant to assistance with cares. Resident 3 was educated on the risk of falls and asking for assistance. The fall interventions implemented on 4/27/21, revealed the following. Resident educated to ask for assistance with ADL's and to wear provided non skid footwear. OT to evaluate for ADL dependence. [Note: Fall intervention to wear non skid footwear was initiated on the care plan on 12/20/19. Fall intervention to have OT evaluate was initiated on the care plan on 9/23/19 and revised on 1/15/20. The care plan was not updated with additional fall interventions.] b. On 6/5/21, Nursing Description: Resident was found on floor next to the side of his bed on his bottom with back against bed by CNA 5. Non slip socks were on feet, pants on with no shirt, call light was not on when he fell resident turned call light on after he fell . Was last checked on by CNA at 12:13 PM was sitting in recliner watching television (TV). Checked by nurse at approximately 2:00 PM and was sitting in recliner watching TV. Resident Description: Resident said he was putting some clothes away getting ready to take a shower and his foot slipped out from under him and he fell down. Resident hit his back against the bed but did not hit his head. Immediate Action Taken: Vital Signs Blood Pressure 144/72, Heart Rate 77, Respirations 20, Temperature 97.3, Oxygen Saturation 95. Licensed Practical Nurse (LPN 2) did assessment. LPN 2 and CNA 5 used lift to get resident off of the floor and into his recliner. Injury: Bruising. Resident 3 oriented to person, place, time and situation. DON Note: Plan made to discuss resident falls and resistance to safety measures with family and resident for possible solution. Resident was encouraged to ask for assistance. The fall interventions implemented on 6/5/21, revealed the following. Encouraged resident to ask for assistance. [Note: Fall intervention was implemented after resident 3 fell on [DATE]]. Staff to discuss with resident and family during Interdisciplinary meeting to reduce increased falls and resistance to safety precautions. On 7/13/21 at approximately 10:17 AM, an interview was conducted with CNA 1. CNA 1 was asked to describe the process when a resident had a fall. CNA 1 stated that when a resident fell , she would quickly check to see if the resident was okay and then immediately notified the nurse. CNA 1 stated the resident was not moved until the nurse came and assessed the resident for injury. CNA 1 stated after the nurse had assessed the resident and the resident was okay, she would assist the nurse with helping the resident up off the floor. CNA 1 further stated she would get the resident's vital signs and start neuro checks for the next 72 hours. CNA 1 stated she was aware that resident 3 had fallen in the past and she had reminded resident 3 to ask for help when getting up to go to the bathroom. On 7/13/21 at approximately 10:26 AM, resident 3 was observed sleeping in the recliner in his room. Resident 3's feet were elevated in the recliner. The call light button was within reach. Resident 3 had non-skid socks on both feet. On 7/13/21 at approximately 10:31 AM, an interview was conducted with LPN 1. LPN 1 was asked to describe the process when a resident had a fall. LPN 1 stated when a CNA notified her that a resident had fallen, she would immediately assess the resident, checking for fractures, and neurological signs and symptoms. LPN 1 stated that neuro checks were done for 72 hours. LPN 1 stated she would notify the DON, MD, and the resident's family. LPN 1 stated that she would fill out an incident report and would include fall prevention interventions to prevent future falls. LPN 1 stated that fall prevention strategies could include; checking on the resident hourly for toileting, asking the resident to call for help when getting up to walk, having the resident wear non-skid socks, and sometimes using a motion detector which would alert the CNA if the resident was trying to get out of bed. LPN 1 stated she was aware that resident 3 had fallen in the past. LPN 1 stated she had reminded resident 3 to ask for help when getting up but resident 3 was not complaint and continued to get up on his own. On 7/14/21 at approximately 8:31 AM, resident 3 was observed sleeping in his recliner in his room. Resident 3's feet were elevated but he had no non skid socks on his feet. Resident 3's call light button was within reach. On 7/14/21 at approximately 9:58 AM, an interview was conducted with the DON. The DO [TRUNCATED]

Based on observation, interview, and record review, it was determined the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, for 1 of 27 sampled residents, the facility did not ensure the resident's physician was contacted timely regarding side effects of a medication change, and the facility did not ensure the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident 28 was admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/21 at 3:35 PM, resident 28 was interviewed and exhibited a delayed response in speech when asked questions. Certified Nursing Assistant (CNA) 2 reported resident 28 began having more seizures and tremors a couple months ago. CNA 2 reported, since that time, resident 28 had a decline in her ability to communicate and resident 28 never fully recovered. On 7/14/21, a review of resident 28's medical record was completed. On 3/26/21, resident 28 had a visit with the neurologist; at which time a change was made to the medication [MEDICATION(S)]. A nursing progress note dated 3/26/21, written by Registered Nurse (RN) 1 read, Note Text: telehealth visit with [neurologist] due to COVID-19 (coronavirus disease 2019) restrictions. labs (sic) and drug therapeutic levels reviewed. New orders to decrease [MEDICATION(S)] to 1 capsule for 2 weeks and then discontinue [MEDICATION(S)] after 2 weeks and monitor increase in tremors. [Note: The neurologist's visit note dated 3/26/21 was unable to be located within resident 28's medical record.] Resident 28's medication regimen regarding an anti-[CONDITION(S)] medication, [MEDICATION(S)], was reviewed. The following was included; a. Prior to 3/26/21, resident 28's order for [MEDICATION(S)] medication read, [MEDICATION(S)] Capsule 100 MG (milligrams) Give 2 capsule by mouth in the evening related to OTHER GENERALIZED [CONDITION(S)] AND EPILEPTIC SYNDROMES. b. As of 3/26/21, the medication order read, [MEDICATION(S)] Capsule 100 MG Give 1 capsule by mouth in the evening related to OTHER GENERALIZED [CONDITION(S)] AND EPILEPTIC SYNDROMES; Start date: 03/26/2021. End Date: 04/09/2021. c. Other orders included, Complete Progress Note Every Shift about resident condition, and monitor for tremors due to decrease in [MEDICATION(S)]. every shift related to OTHER GENERALIZED [CONDITION(S)]. every shift for 3 Days -Start Date- 03/26/2021, and, Complete Progress Note Every Shift about resident condition, and monitor for tremors due to discontinuation of [MEDICATION(S)]. every shift for 3 Days -Start Date- 04/09/2021. [Note: No progress notes about resident 28's condition and monitor for tremors were found within resident 28's medical record from the time period of 3/27/21 through 3/30/21 or from the time period of 4/9/21 to 4/13/21.] Within resident 28's progress notes the following occurrences were documented regarding resident 28's tremor and medication change side effects; a. 4/6/21: Note Text: Reported that resident had some difficulty in fully swallowing some food at breakfast. After a few sips of water resident was able to swallow food with out difficulty. Lungs clear bilaterally. No other concerns noted at this time. Will continue to monitor. b. 4/6/21: Body tremors have seemed to have increased. Did leave message with [neurologist's] office concerning recent medication change possibly contributing to tremors. Will continue to monitor and f/u (follow up) with [neurologist's] office. c. 4/16/21: Note Text: Left message with [neurologist's] office concerning resident's increase in tremors and correlation with recent medication change of Zonisomide (sic). Will continue to monitor and f/u with [neurologist's] office or house MD (Medical Director) if tremors increase. d. 4/17/21: Note Text: Resident has had an increase in tremors to the point that she is having a hard time eating and drinking. Unable to reach [in-house doctor], notified [other in-house doctor], he ordered the [MEDICATION(S)] to be resumed at 100mg and tapered for now until [neurologist] can be notified on Monday. [Note: no progress notes regarding staff having attempted to reach resident 28's neurologist were documented from 4/6/21 to 4/16/21. Per resident's progress notes resident was noticed with increased tremors as of 4/6/21; when current medication dose of [MEDICATION(S)] was at 100 mg rather than 200 mg daily. The zonesamide medication was then discontinued on 4/9/21, per RN 1's telephone order.] Per resident 28's weight history, resident 28 experienced a 4.4% weight reduction between the time period of 3/30/21 through 4/27/21. On 3/30/21, resident 28 had a documented weight of 158.6 pounds. On 4/27/21, resident 28 had a documented weight of 151.7 pounds. A physician's note from resident 28's neurologist dated 4/29/21, documented the following; a. Telephone note, 04/12/2021. The patient did worse after her [MEDICATION(S)] was decreased from 200mg nightly to 100mg. Because of the tremor it was difficult to swallow. I changed the dose back to 200mg once daily. Refill sent [Note: No progress note was found within resident 28's medical record indicating neurologist's change in medication dose on 4/12/21, and no documentation of a telephone encounter was noted from 4/12/21.] b. We have tried to reduce polypharmacy with [resident 28], and lately I tried to reduce the [MEDICATION(S)], and had given instructions to restart the medicine if [resident 28] had tremor [sic] or [CONDITION(S)] or seizures. However that masses (sic) [message] did not get through .I talked with staff to make it clear that my notes do indicate what should be done in case there are problems with medication changes that I make. In addition I am happy to receive calls and make adjustments. The issue with the last set of phone calls was that I was asked to refill prescriptions following instructions that I did not know about. In the future, a phone call to the office or just looking back at my last clinic note would be the best course of action, and could potentially avoid a lot of confusion. On 7/14/21 at 4:06 PM, the Charge Nurse was interviewed. The Charge Nurse reported the neurologist visit note dated 3/26/21 was not within resident 28's chart, and the Charge Nurse would have to contact the physician's office to locate documentation. When the Charge Nurse was asked about the [MEDICATION(S)] medication, the Charge Nurse reported being unsure why staff would discontinue the anti-[CONDITION(S)] medication on 4/9/21 if resident 28 had been experiencing increased tremors as of 4/6/21. On 7/15/21 at 11:02 PM, RN 1 was interviewed. RN 1 reported, I was in the visit with [resident 28] and the neurologist. The doctor said to monitor for tremors, and call if [resident 28] had any tremors. [The neurologist] did not say [resident 28] could be restarted on the medication. On 7/15/21, the neurologist's visit note dated 3/26/21 was now available for review. The physician's visit note included orders for resident 28's medication change, which read, decrease [MEDICATION(S)] to 1 capsule in the evening for 2 weeks, then stop. If there are seizures, or more [CONDITION(S)] (twitching) then okay to . restart [MEDICATION(S)]. On 7/15/21 at 10:35 AM, the Director of Nursing (DON) was interviewed. The DON reported, [Physician visit notes] can come late because it takes a while for the doctor to transcribe the note. It should not take 4 months to get a note. The visit note should have been in [resident 28's] chart.

Based on interview and record review, it was determined the facility did not maintain medical records on each resident that were complete and readily accessible. Specifically, for 1 of 27 sampled residents, the facility did not have a complete and accessible record of a resident's physician visits with the neurologist. Resident identifier: 28. Findings included: Resident 28 was admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/14/21, resident 28's medical record was reviewed. Prior to 3/26/21, resident 28's order for [MEDICATION(S)] medication read, [MEDICATION(S)] Capsule 100 MG (milligrams) Give 2 capsule by mouth in the evening related to OTHER GENERALIZED [CONDITION(S)] AND EPILEPTIC SYNDROMES. Following resident 28's neurologist visit on 3/26/21, this medication order was adjusted. On 3/26/21, resident 28 had a visit with the neurologist; at which time a change was made to the medication [MEDICATION(S)]. A nursing progress note dated 3/26/21, written by Registered Nurse (RN) 1 read, Note Text: telehealth visit with [neurologist] due to COVID-19 (coronavirus disease 2019) restrictions. labs (sic) and drug therapeutic levels reviewed. New orders to decrease [MEDICATION(S)] to 1 capsule for 2 weeks and then discontinue [MEDICATION(S)] after 2 weeks and monitor increase in tremors. [Note: The neurologist visit note dated 3/26/21 was unable to be located within resident 28's medical record.] Resident 28's medication regimen regarding an anti-[CONDITION(S)] medication, [MEDICATION(S)], was reviewed. The orders placed on 3/26/21, by RN 1 for changes in [MEDICATION(S)] medication included the following: a. [MEDICATION(S)] Capsule 100 MG Give 1 capsule by mouth in the evening related to OTHER GENERALIZED [CONDITION(S)] AND EPILEPTIC SYNDROMES, Start date: 03/26/2021, and, End Date: 04/09/2021. b. Complete Progress Note Every Shift about resident condition, and monitor for tremors due to decrease in [MEDICATION(S)]. every shift related to OTHER GENERALIZED [CONDITION(S)] . for 3 Days -Start Date- 03/26/2021. c. Complete Progress Note Every Shift about resident condition, and monitor for tremors due to discontinuation of [MEDICATION(S)]. every shift for 3 Days -Start Date- 04/09/2021 A physician's note from resident 28's neurologist dated 4/29/21, was reviewed. Documentation read; a. Telephone note, 04/21/2021. The patient did worse after her [MEDICATION(S)] was decreased from 200 mg nightly to 100 mg. Because of the tremor it was difficult to swallow. I changed the dose back to 200 mg once daily. Refill sent [Note: No progress note was found within resident 28's medical record indicating neurologist change in medication dose on 4/21/21, and no documentation of a telephone encounter was noted from 4/21/21.] b. We have tried to reduce polypharmacy with [resident 28], and lately I tried to reduce the [MEDICATION(S)], and had given instructions to restart the medicine if [resident 28] had tremor [sic] or [CONDITION(S)] or seizures. However that masses (sic) [message] did not get through .I talked with staff to make it clear that my notes do indicate what should be done in case there are problems with medication changes that I make. In addition I am happy to receive calls and make adjustments. The issue with the last set of phone calls was that I was asked to refill prescriptions following instructions that I did not know about. In the future, a phone call to the office or just looking back at my last clinic note would be the best course of action, and could potentially avoid a lot of confusion. [Note: Within resident 28's medical record there was no documentation of the neurologist's conditional restart of anti-[CONDITION(S)] medication if resident 28 had tremors or [CONDITION(S)] or seizures]. On 7/14/21 at 4:06 PM, the Charge Nurse was interviewed regarding the location of resident 28's neurologist visit from 3/26/21. The Charge Nurse reported the visit note was not within resident 28's chart, and the Charge Nurse would have to contact the physician's office to locate documentation. On 7/15/21, the 3/26/21 neurologist visit note was now available. The neurologist visit note included orders for resident 28's medication change, which read, decrease [MEDICATION(S)] to 1 capsule in the evening for 2 weeks, then stop. If there are seizures, or more [CONDITION(S)] (twitching) then okay to . restart [MEDICATION(S)]. On 7/15/21 at 10:35 AM, the Director of Nursing (DON) was interviewed. The DON stated, [Physician visit notes] can come late because it takes a while for the doctor to transcribe the note. It should not take 4 months to get a note. The visit note should have been in [resident 28's] chart.

Based on observation, interview and medical record review, it was determined for 3 of 4 sample residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, one resident who had not been checked on and had sustained a fall trying to reach the bathroom and fractured her femur. Two residents who had multiple falls, had duplicate interventions added to the care plan. Resident identifiers: 1, 2 and 3. Findings include: 1. Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 1's medical record was reviewed. Nursing progress notes revealed the following entries: a. [DATE] 12:43 (PM) Health Status Note Note Text: MD (Medical Director) notified of fall and new order obtained to send resident to ER (emergency room ), and give tylenol standing order (tylenol 325mg 1 tab q(every)6 (hours) PRN (as needed)). EMS (Emergency medical services) notified at 1207, Called (Name of Hospital) ER and gave report to (Name of ER nurse) at 1213. EMS arrived at 1220, EMS completed assessment, did vitals, and packaged resident for transport in room. EMS left facility with resident at 1238. b. [DATE] 12:53 (PM) Health Status Note Incomplete Documentation - Note Text: MD notified of fall and new order obtained to send resident to ER. c. [DATE] 13:09 (1:09 PM) Incident Note Note Text: Un-witnessed fall occurred .Notified DON,family,MD. d. [DATE] 16:08 (4:08 PM) Health Status Note Note Text: Spoke with the emergency room resient (sic) is being admitted to the hospital with [REDACTED]. e. [DATE] 08:46 Physical Therapy Late Entry: Note Text: Late entry. Note given as a follow up as to why the patient was need seen by rehab. Patient was moved to the rehab side of the building to be able to better assess if she would be a good rehab candidate. She became non responsive at the hospital before coming back to (Name of Facility). She did become a little more responsive at (Name of Facility) and so the question was asked could she participate with rehabilitation services. She never to become responsive enough to justify her working with rehab. Consulted with family and their wish was for the patient to remain on comfort care. f. [DATE] 20:42 (8:42 PM) Health Status Note Note Text: Resident expired at 7:12pm. Family was in room with resident, DON notified at 8:44pm and Physician notified at 8:02pm. Resident was on Hospice care during for comfort care. Postmortem care provide by CNA. A facility incident report dated [DATE] at 11:45 AM, revealed the following: Incident Description: Another residents family alert staff to resident being on floor in her room. Upon entering resident room resident sitting on buttocks in floor on left side between wall and bed. She was wearing street clothes with shoes on, brief was wet, denied hitting head. Floor clear without clutter. Evaluated resident, alert with confusion which is her baseline. Was last toileted at 10:00 AM, last check was 10:40 AM. Physical assessment completed, stated right hip pain rating pain level as a 5 on a ,[DATE] pain scale. MD notified with orders to send to ER for eval (evaluation). VS (vital signs)obtained. BP (blood pressure) ,[DATE]. All others WNL (within normal limits). Determination made to transfer resident from floor to bed due to resident positioning, resident continued attempts to stand by rocking back and forth, and desire for increased comfort. Resident Description: Resident stated she was attempting to go to BR (bathroom) and lost balance and fell . Immediate Action Taken: Physical assessment completed, vs obtained. MD notified with arrangements for ER eval. Resident assisted off floor via hoyer. (Name of Certified Nursing Assistant's (CNAs)) and placed in bed for increased comfort while awaiting ER transfer. Notes: Administered PNR (sic) (as needed) tylenol per order at 1205. Baseline confusion, no increased confusion noted post fall. Follow up pain assessment while being packaged by EMS was stated at ,[DATE]. Pain rating given while resident was being transferred onto gurney and strapped to gurney. No increase of pain noted following initial pain medication dosing until EMS moved resident. A final investigation report dated [DATE] revealed the following: Investigation: Staff interviews conducted with all staff members involved . Expanding the investigation: [DATE] 1230 (PM) interview (CNA 5) (Certified Nursing Assistant assigned to resident) (CNA 5) stated resident had been toileted last at 10:02 AM and was last visualized by her at 11:40 AM when resident was seen sitting in her chair next to her bed. At 11:45 AM (CNA 5) was notified, via radio, that resident was found on the floor. (CNA 5) was in the restroom at the time of the incident. (CNA 5) stated 'I usually toileted her right before lunch but I was using the bathroom.' Other staff were unable to locate (CNA 5) during initial attempts of notification. (Documentation review showed (CNA 5) had last documented toileting resident at 0928 (AM). Due to lack of documentation, we were unable to determine validity of claim (CNA 5) had visualized resident in bedside chair 5 minutes prior to unwitnessed fall. Due to reasonable cause of neglect, and resident being found in soiled clothing, (CNA 5) was suspended immediately following interview.) All other staff interviews conducted. It was determined that another residents family member noticed resident on the floor and notified (CNA 6) at the nurses station who went to residents room and then radioed for additional assistance. Residents assigned aide, (CNA 5), was in the restroom and not immediately available. Resident was then assessed by (Licensed Practical Nurse (LPN) 1) and (Registered Nurse (RN) 2) where she gave an initial pain rating of a 5. Resident stated she was attempting to ambulate to the bathroom. Due to position of resident on the floor, sitting at an angle with feet outstretched, and requiring pillows be placed behind her by (CNA 6) in an attempt to get her comfortable, resident was transferred via hoyer lift to bed by (CNA 5) and (CNA 7) and positioned for increased comfort while EMS was notified and ER transfer was arranged. Resident did not have any orders for pain medication. Physical (sic) gave verbal order for tylenol 325 mg (milligrams) to be administered. Physician did not want stronger medication given in the event that resident required surgical intervention. When DON (Director of Nursing) arrived in resident room, resident was lying in bed with eyes closed and covered with her blankets. She did not appear in immediate distress although she stated her hip was sore when asked if she was in pain. Resident could not give numerical pain rating at that time. Resident does have cognitive impairment. Resident was noted to have soiled brief. Due to the possibility of potential fracture, emergency staff advised (facility) staff to not change residents brief until x-ray could be obtained and medication administered for increased comfort prior to moving hip area for brief change. When EMS arrived and resident was transferred to gurney, resident pain increased ,[DATE]. Resident was transferred to the emergency room where x-ray showed fracture of right femur. As of this writing, family and physicians are still determining if surgical intervention will be implemented. Conclusion: Per CMS (Centers for Medicare/Medicaid) definition of neglect, 'the failure of the facility, it's 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,' neglect will be substantiated in this case due to resident not being provided the ADL (activities of daily living) assistance necessary to have prevented her from attempted unsafe ambulation on her own resulting in an unassisted fall. Resident was found with a soiled brief and stated she was attempted (sic) to ambulate to the restroom. Employee (CNA 5's) accounting of last toileting time and documentation were not consistent and do not show that employee protected resident by providing ADL care to meet optimal needs of resident. At this time, aide (CNA 5) will be terminated due to safety risk of continued employment The Corrective Disciplinary Action Form dated [DATE] revealed the following: Termination. On [DATE] - an unwitnessed fall investigation was opened for resident who (CNA 5) had been assigned to. During investigation, neglect was substantiated due to resident attempting to ambulate to bathroom unassisted and falling. When resident was found, her brief, clothing, and chair pad were soiled in urine. The last time (CNA 5) had documented toileting resident had been nearly 2.5 (2 ,[DATE]) hours earlier. (CNA 5 had stated that she had toileted resident less than two hours prior and checked on her 5 minutes prior to the incident but no documentation was present to verify claim. Due to neglect, resident suffered a fractured femur requiring ER transfer and possible surgical intervention. On [DATE] at 11:20 AM, an interview was conducted with CNA 6. CNA 6 stated that she was the first CNA to the room after a resident family member reported that resident 1 was on the floor. CNA 6 stated that CNA 6 who was assigned to care for resident 1 could not be found the day that resident 1 was on the floor. CNA 6 stated that resident 1 was so wet that the floor and the resident was a huge mess. CNA 6 stated that she sat by resident 1 on the floor waiting for the nursing staff and placed a pillow behind her head. CNA 6 stated that when CNA 5 came into the room, she was in a hurry to get the resident up on the bed and get her changed. CNA 6 stated that CNA 5 had told her that they needed to get her changed. CNA 6 stated that CNA 5 was in a hurry to get resident 1 up on the bed and changed because she knew she was in trouble because she had not toileted her resident. CNA 6 stated that CNA 5 would often hide and not take care of her residents. CNA 6 stated that CNA 5 would go to the dining room at 7:00 in the morning and leave herself (CNA 6) and the other CNAs to get her people up. CNA 6 stated that she had been called into the DONs office to talk about goals for the year and a possible raise, and that she had informed the DON that one goal was to be patient with coworkers and told the DON that specifically, CNA 5 and informed her of the issues pertaining to CNA 5. CNA 6 stated that she had informed the DON a couple of months prior to resident 1's fall. On [DATE] at 12:32 PM, an interview was conducted with CNA 8. CNA 8 stated that she had heard on the walkie that resident 1 had fallen and went to see if she could help. CNA 8 stated that there were plenty of people there so she went back to her hall. CNA 8 stated that CNA 5 had informed people that she (CNA 8) had been responsible for her (CNA 5) termination. CNA 8 stated that resident 1 had a censor and that CNA 5 had informed staff that the censor was not working. CNA 8 stated that she had informed administrative staff that the censor was working because she had it in her pocket prior to giving it to CNA 5. CNA 8 stated that CNA 5 had a lot of personal things going on and that it interfered with her job because she was always on the phone texting with her boyfriend. CNA 8 stated that CNA 5's focus was on her boyfriend problems, not her job and that it always interfered with patient care. On [DATE] at 12:45 PM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that CNA 5 had a time management problem and would not get residents to the dining room on time and would then make everyone else late. The CNA Coordinator stated that there were times when he call lights would be going off and other CNAs would have to answer the lights and would have to find CNA 5 and that she would be at the end of the hall and just charting instead of attending to her residents. The CNA Coordinator stated that had to do education with CNA 5 quite often. On [DATE] at 1:00 PM, and interview was conducted with CNA 9. CNA 9 stated that she had issues with CNA 5 and that they had butted heads. CNA 9 stated that the issues were always because CNA 5's call lights would be going off and she (CNA 9) would have to go to CNA 5's hall to answer the call lights and that a lot of us CNAs had to do that. CNA 9 stated that CNA 5 would be nowhere to be found and that a lot of patient care would be left undone. On [DATE] at 1:23 PM, an interview was conducted with the facility DON. The facility DON stated that with any fall from the residents, they would place the fall assessment scores in the care plan as a low, medium or high risk. The facility DON stated that they would talk about falls and interventions in the stand up and stand down meetings. The facility DON stated that the CNAs would round more often after talking with the nurses about residents who were high risk or who had had a recent fall. The facility DON stated that interventions were put in place after a resident fall by the nurses on duty for the resident that day. The facility DON stated that the administrative staff would then go through the interventions to make sure that there were no duplicate interventions. The facility DON stated that all staff members had access to the care plan to know what interventions were in place including CNAs who should be looking for a change but should be getting those changes in interventions from the nursing staff. The Facility DON stated that if a resident continued to have falls, that that meant that interventions were not working. The facility DON stated that the day resident 1 fell , that the nurse had been in to assess resident 1 and that the thought process was to get her off the floor for increased comfort. The facility DON stated that CNA 5 was terminated because we substantiated that she had not toileted resident 1 and determined that she had been neglected. The facility DON stated that they had given CNA 5 the opportunity to document particulars about resident 1 prior to termination that that CNA 5 did not document the things that she had told administrative staff regarding resident 1's care. The facility DON stated that they had to look at the cameras, or charting or just trust that the CNAs were telling the truth that a resident was looked at appropriately. The facility DON stated that she had not looked at the cameras but had looked at the documentation and that it did not match what CNA 5 had told them. The facility DON stated that she had heard murmurings of CNA 5 not performing her duties and that they had come to light a week prior to the fall. The facility DON stated that she had talked with CNA 5 a couple of times and that she had tried to tell her of her issues and that she (DON) had more of a casual conversation to give guidance. The facility DON stated that there were no verbal or written warnings by herself. 2. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 3's medical record was reviewed. Nursing progress notes revealed the following entries: a. [DATE] 08:45 Health Status Note Note Text: (physician) notified of residents fall and pain in R wrist, and resident refusing to be evaluated in the emergency room , new orders obtained for R wrist X-Ray. b. [DATE] 09:05 Health Status Note Note Text: Resident sent to radiology for X-Ray via (Name of Facility) transport. c. [DATE] 09:35 Health Status Note Note Text: PRN pain medication administered. resident rating pain in R wrist 6 out of 10. d. [DATE] 10:46 Health Status Note Note Text: (physician) called to notified of radiology report showing a fracture in R wrist, no answer, a text message was sent. Wound nurse placed splint on R wrist, using ABD pads and ice pack resident states pain level in at a 3 out of 10. Two more attempts to get a hold of (physician). e. [DATE] 11:15 Health Status Note Note Text: DON reported that (physician) has given orders to contact (orthopedic physician) office. (Orthopedic physician) office contacted and stated that a cast would not be able to be placed for 7 day's once the [MEDICAL CONDITION] has subsided, and new orders obtained to sent to ER for triage. 1125 Dispatch notified 1130 report given to emergency room . 1135 EMS arrived for transport. Facility Incident Reports revealed that resident 3 had falls on the following dates: a. [DATE] 22:20 (10:20 PM) Nurse and CNA heard loud noise from residents room followed by the resident yelling for help. Resident description: I was just going to the bathroom. I was outside the bathroom door and opened it and my walker moved a little and tipped over and I went with it. I hit by (sic) back on the chair behind me. Injuries: bruise. Interventions put in place: Resident educated to utilize call light for assistance to the bathroom. Resident educated to utilize wheelchair breaks in order to ensure walker does not move away from resident. Resident educated to ensure that her walker is far enough from door that the door will not hit the walker and tip it over. b. [DATE] 1300 (1:00 PM) Upon entering room, resident was on the floor. Resident was sitting up with back leaning against recliner chair. Resident description: I was trying to get the red book on the bottom shelve and I was pulling on it and I fell . I hit my head on the bookcase. Injuries: Hematoma on top of scalp. Interventions put in place: Removed books from bottom shelve. Educated resident on importance of calling for assistance. Encourage resident to organize and clear out some of the cluttered (sic) and to place items on upper shelves. c. [DATE] 9:56 AM Resident found sitting on floor in doorway in room, resident stated she was putting bible on her wheelchair when she lost her balance and fell back landing on her buttocks and hitting head on Rt (right) shoulder, resident was transferred from floor via hoyer. Injuries: Small laceration noted to back of Rt head. Interventions put in place: Educate residents on importance of asking for assistance while ambulating in room. Housekeeping did deep clean of room again to remove as much clutter as possible. Interventions put in place: Educated resident on importance of asking for assistance while ambulating in room. Housekeeping did deep clean of room again to remove as much clutter as possible. d. [DATE] 8:40 Another resident began yelling in the hallway that someone is on the floor. Ran into the hallway to find resident laying on her back with her head in the hallway and the rest of her body in her room, her walker was upright at her feet, resident was clean and dry. Resident description: Resident stated she was walking to the restroom with the use of her walker when she lost her balance and fell backward on to the floor. Injuries: Pain in right wrist, swelling noted, resident refused to be evaluated in the emergency room and was taken directly to radiology. Interventions put in place: Resident was educated on importance of using she (sic) call light to request assistance when ambulating for safety. Residents room is cluttered with repeated attempts by social work and housekeeping to declutter resident space. Resident educated on importance of de[DIAGNOSES REDACTED] room for safety. Physical therapy eval (evaluation) for unsteadiness of her feet. e. [DATE] 9:21 Resident call light went off. Upon entering room, resident noted to be on floor next to bed. Resident description: Resident stated she was adjusting her pillow and fixing her massager when she lost her balance and slid to the floor. Injuries: None. Interventions put in place: Educated resident on use of call light for assistance. Consult with therapy for balance program. On [DATE] at 2:15 PM, an interview was conducted with the facility DON. The facility DON stated that she was unaware of the intervention being duplicates and that this case must have slipped through my hands. The facility DON stated that we could add a motion sensor. The facility DON stated that resident 3 was trying to maintain her independence and we encourage her to let us help. On [DATE] at 4:30 PM, an interview was conducted with resident 3. Resident 3 stated that she never used the call light for assistance to the restroom because she can do it herself. Resident 3 stated that she was wearing gripper socks the day she fell and fractured her wrist but somehow her feet slipped out from under her. Resident 3 stated that she had never been informed by facility staff that she was to have assistance with ambulation. Resident 3 stated that she had always done that herself and that facility staff informed her that she needed assistance to ambulate after I fractured my wrist. 3. Resident 2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on [DATE]. Resident 2's care plan was reviewed. A problem area for falls was identified and initiated on [DATE] and documented as The resident is High risk for falls with a history of falls and an actual fall in facility. the goal documented The resident will not sustain serious injury from a fall. The following interventions were initiated: a. On [DATE] Anticipate and meet The resident's needs. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Assess for proper footwear. Assess for type of walker for safety. Education to visitors to notify staff in case of a resident fall as staff is professionally trained for transfers in care of resident injury. Follow facility fall protocol. Pt (Physical therapy) to evaluate and treat as ordered or PRN (as needed). b. On [DATE] PT (physical therapy) notified of need for walker assessment. A Medicare Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented under section C that resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severely impaired cognition. Another Medicare Quarterly MDS assessment dated [DATE] documented under section C that resident 2 had a BIMS score of 5, which indicated continued severe impaired cognition. A review of resident 2's physician orders [REDACTED]. Post-Fall Head to Toe assessments revealed that resident 2 sustained falls on [DATE], [DATE], and [DATE]. Facility incident reports were obtained for resident 2's most recent falls on [DATE] and [DATE]. The Incident Description on [DATE] documented CNA (Certified Nursing Assistant) (2) called us to room for assist, resident on floor with a pillow under her knees. Leaning against bed as if in prayer. Wearing incontinent brief and button down shirt, barefooted. Alert and oriented. Light was on, floor was dry, bed sheets turned down. Call bell was in reach. Resident was assisted up by CNA (2) and (3), no lift used. Nurse in room on standby. Resident was last checked 1 hour prior to incident. Resident stated that she was getting up to go to bathroom and her legs gave out. Also stated she wanted to know what the time was but couldn't find a clock. Interventions documented on the facility incident report were . Wear non skid footwear, CNA to monitor and apply as needed. educated resident to use call light for assistance. (Note: Both of those interventions were duplicate interventions that were originally initiated on [DATE].) The Incident Description on [DATE] documented Called into resident room by CNA (2). Resident was on floor on her knees in prayer position on the right side of her bed. Her roommate heard her and pushed the call light. Resident was barefoot and dressed only in a night shirt. Her soiled brief was hanging on her walker. Resident had beed (sic) checked about 1 hour before by CNA (4), and was resting in bed. CNA (2) and CNA (4) used Hoyer lift to get resident off floor. Resident description I rolled out of bed. Interventions documented on the facility incident report were . ensure walker is within reach of resident and within resident nightly changing preference. Encourage resident to call for staff assistance rather than disrobing self after being placed in bed. Task for aides to place Non-skid socks placed at bedtime. (Note: These interventions were duplicates of interventions initiated on [DATE] and [DATE].) A review of resident 2's CNA safety check documentation for [DATE] revealed that resident 2 had not been checked on since 11:33 PM on [DATE], resident 2 was found on the ground on [DATE] at 3:15 AM. Resident 2's most recent fall risk assessments were reviewed and revealed that she was assessed on [DATE] and [DATE]. On [DATE] resident 2 had a fall risk score of 100 which indicated High Risk for Falling. On [DATE] resident 2 had a fall risk score of [AGE] which indicated High Risk for Falling. (Note: High Risk was any score 45 and higher.) On [DATE] at 12:45 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she was familiar with resident 2. RN 1 stated that resident 2 was at risk for falls because she sometimes got dizzy and she had dementia. RN 1 stated that resident 2's fall prevention interventions were re-education to use her call light and keep her walker close to her, as well as non-skid socks. RN 1 stated that the interventions were communicated to staff verbally and new interventions were placed in the alert book for a week or so. RN 1 stated that resident 2 frequently forgot to use her walker and rarely used the call light. RN 1 stated that resident 2 sometimes retained education for a day or so, but not very often. RN 1 stated that fall risk assessments were completed on every resident quarterly, stated she did not know what was done with the results. On [DATE] at 1:00 PM, an interview was conducted with CNA 1. CNA 1 stated that she was very familiar with resident 2. CNA 1 stated that the fall prevention interventions for resident 2 were to watch her closely and keep resident 2's walker close to her. CNA 1 stated that interventions were communicated verbally from the nurse or other CNA's. CNA 1 stated that the resident rarely remembered to use her call light, stated resident 2 was pretty forgetful and confused. CNA 1 stated that she had not reviewed resident care plans for interventions since she was hired. CNA 1 stated that resident 2 never refused cares or interventions. On [DATE] at 1:23 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that fall risk assessment scores were entered into the resident care plan and staff was verbally educated about who was a fall risk. The DON stated that the nurse management placed interventions in the resident care plans, stated new interventions should be initiated after each fall and were re-evaluated if a resident fell again. The DON stated that they tried not to duplicate interventions but that there was room for improvement. The DON stated that new interventions were communicated to staff verbally and in the care plan. The DON stated that for resident 2, re-education probably wasn't effective for her due to resident 2's dementia.

Based on observation, interview and record review, it was determined for 1 of 19 sample residents, that the facility did not ensure that each resident received adequate supervision and services to prevent accidents. Specifically, one resident with weakness and [MEDICAL CONDITION] activity was not assisted nor interventions implemented to avoid a fall with a [MEDICAL CONDITION]. Resident identifier: 30. Findings include: Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 30 was subsequently diagnosed on [DATE] with difficulty walking. On 6/6/19 a record review was completed for resident 30. Nursing notes revealed the following : a. On 5/21/18 at 10:14, This Am resident wife called staff to room and said that her husband called her in the bathroom because he had become weak and intentionally kneeled to the floor. When (nurse) entered the room he was getting himself up off of the floor and into his chair. DON, Family and (Resident 30's physician) notified. Encouraged (Resident 30) and his wife to ask for assistance. b. On 5/21/18 at 10:35 AM, Resident said that he was weaker than he thought and that he had to get down on his knees before he fell . c. On 5/29/18 at 7:30 PM, .Resident has had increased confusion and his wife (who stayed in the room with resident 30) has expressed concern. d. On 7/5/18 at 3:28 PM, Resident confused with increased 'stutter step' noted today. Resident complained of 'being tired from his outing yesterday' . e. On 8/30/18 at 10:27 AM, resident 30 .refused his shower because he was feeling weak. He had walked back to his room with walker but leaned against the wall and said his legs just did not want to hold him up. Assisted to recliner . He had exaggerated tremors as he was awakened . Instructed to call for any assistance to avoid fall . f. On 8/30/18 at 3:58 PM, Resident has had complaints of dizziness and not feeling well orthostatic blood pressures taken, laying 106/62 sitting 100/60, standing 96/60 his urine was dipped . g. On 9/3/18 at 4:35 PM, Res (resident's) wife ., came out in the hallway to get the nurse to help (resident 30). Res was sitting on the bathroom floor. Res stated his legs got 'weak' so he intentionally sat on the floor. Res is weak et (and) shaky. Res lifted off floor with lift et sat in chair. Res had supper in his room. Advised res to use call light for any needs et placed in reach. Will continue to monitor. h. On 9/6/18 at 9:41 AM, Resident weak and unsteady after exercise with restorative CNA (certified nursing assistant) this morning. Resident sat in lobby for approx 30 min prior to amb (ambulating) with assist (assistance) to room. (Resident 30) was unsteady and weak after amb (ambulating) to room with assist but had refused to use wheelchair. Vital signsafter (sic) exercise B/P (blood pressure) 93/63 - P (pulse) 77 - R (respirations) - 18 T (temperature) - 35.9 O2 (oxygen saturation) - 93% room air. Will encourage to ask for assistance and monitor closely. i. On 9/6/18 at 11:32 AM, Dr notified of weakness would like (resident 30) to be monitored today for continuous weakness and would like a status update tomorrow of condition. j. On 9/8/18 at 9:50 AM, Res was walking out of bathroom et legs got weak. Res intentionally sat on the floor as he couldn't walk any further. Res is shaky et had some difficulty getting to his chair. Res is taking double steps, et quick steps. Res denies any injury or pain. Will continue to monitor. k. On 9/8/18 at 11:30 AM, Res didn't want to walk to lunch. Res wanted to stay in room. Res wife worried about him et wanted to stay with him l. On 9/11/18 at 2:02 PM, (Resident 30's physician) has been notified of episodes of weakness that resolve with rest . m. On 9/12/18 at 12:26 PM, . If episodes of weakness continue (resident 30's physician) would like (resident 30) to be seen by the physician managing his [MEDICAL CONDITION]. (Note: An appointment was made with resident 30's neurologist on 10/17/18, 35 days after the physician stated that resident 30 should be seen by his neurologist if weakness continued. Resident 30 saw his neurologist on 11/20/18, 69 days after the physician requested that resident 30 to be seen by his neurologist.) n. On 9/12/18 at 3:38 PM, . He is now having issues with not being able to ambulate having to sit or risk falling. This has been a sudden onset. Nursing is looking into medication ideas and therapy is working on improving movement and activity tolerance to reduce the risk of falling. o. On 10/5/18 at 9:02 AM, Res wife pushed call light to notify aid (sic) res couldn't make it out of the bathroom. Res found sitting on the floor in the bathroom doorway. Res states his legs, 'got too weak to hold me,' Res made an intentional position change to sitting on the floor so he didn't fall. Res has no complaints. Res lifted off the floor with a lift, et sat in recliner. Res advised to use his urinal or call for help when needing to use the bathroom when his legs are feeling weak. Res agreed with plan p. On 10/9/18 at 2:13 PM, Resident continues to have weakness, increased confusion and GI (gastrointestinal) upset. Increased assistance needed today with dressing and toileting. Will continue to monitor closely. (Resident 30) has been ou (sic) to room to meals but has not amb (ambulated) to meals as resident usually does. Appetite fair. (Note: There was no documentation that resident 30's physician was contacted regarding the change of condition.) q. 10/16/2018 19:25, Resident's wife called me to room and said (resident 30) was having one of his episodes. (Resident 30) was exhibiting [MEDICAL CONDITION] activity in his upper body including tongue and neck spasms. High pitched voice at times and difficulty with speech. Resident with no lose (sic) of consciousness and almost constant talking anxiously. Confusion on and off. episode [MEDICATION NAME] approximately 1 hour. Residents wife said he has had a hx (history) of episodes [MEDICATION NAME] as long as 5 hours. Monitored resident closely until he calmed with no further [MEDICAL CONDITION] activity. Vital signs stable Will continue to monitor. (Note: This [MEDICAL CONDITION] activity was reported to resident 30's neurologist on 11/20/18, 35 days after the [MEDICAL CONDITION] activity.) r. On 10/17/18 at 6:40 PM, .Resident weaker and tired this morning to x1 meal (breakfast) in wheelchair. s. On 10/19/18 at 2:41 PM, Res has been weak today. Res walked back from breakfast and halfway needed to be pushed on his walker. Res has c/o (complaints of) having diarrhea today, et feeling weak. Res has been stuttering words, et having difficulty putting full sentences together. Res refused lunch. Res doesn't want to be pushed in a wheelchair down the hall. Res expressed to nurse that he, 'doesn't want to be a burden, and is no good.' Talked with res for 10 minutes. Res will rest in room. Res had a banana et will come to supper. Will continue to monitor. (Note: There was no documentation that resident 30's physician was contacted regarding this change of condition.) t. On 10/28/18 at 9:15 AM, .Res stated that he didn't go to sleep until 0330 (3:30 AM) or 0400. The nurse brought the res alendronate et told him to stay up for 50 minutes. Res was up for 50 minutes et then tried to go back to sleep. Res c/o being tiredet (sic) shaky. Res wife informed staff that res had a difficult time in bathroom trying to get back to his chair. Re educated res to pull his call light when he's having a difficult time. Res agreed to call when he's having weakness. u. On 11/3/18 at 5:29 PM, Res had difficulty walking all the way to and from the dining room this am. Res was pushed in wheelchair (Note: Resident 30 was moved closer to the dining room on 11/8/18.) v. On 11/10/18 at 3:31 PM, Res has been c/o weakness today w. On 11/11/18 at 10:01 AM, Res call light turned on Aide went in to check on Res. Res was sitting on the floor in front of his recliner. Nurse called to room. Res states he 'went to the bathroom. When I came out I couldn't make it to the chair, so I sat on the floor.' Res intentionally changed position to the floor. Res denies any pain or injuries. Res up into recliner. Res has no needs or requests at this time. Call light in reach for Res. Advised to use when he needs to get up today. Educated on use. Will continue to monitor. x. On 11/15/18 at 3:44 PM, Resident has been weak and confused the last couple of days with confusion increasing today. Wife reports resident hallucinations throughout the day. Resident leaning to one side today and color slightly flushed .(Resident's doctor) notified. y. On 11/15/19 at 5:26 PM, (Resident's doctor) into see resident and has ordered . labs and a warm pack to resident 30's neck. MAR (medication administration record) has been updated to reflect orders. z. On 11/20/18 at 1:28 PM, Resident continues to have hoarse voice but no longer complaining of 'runny nose.' Increased confusion, incontinence and weakness noted today. Monitored closely due to high fall risk. Resident has an appointment this afternoon with (Neurologist) for [MEDICAL CONDITION] evaluation. aa. On 11/24/18 at 8:50 AM, Res found sitting on floor in front of his recliner. Res states he intentionally sat on the floor as he couldn't stand or move his legs anymore. Res pushed call light for help. Res was lifted from floor via hoyer lift by (two aides.) Res has no complaints of pain, or concerns. Res currently eating breakfast in room. Will continue to monitor. bb. On 11/24/18 at 11:56 AM, Res is weak today. Refusing lunch stating he 'didn't sleep at all last night.' Res wants to stay in room and sleep. Will continue to monitor. cc. On 11/30/18 at 7:25 AM, Res states he was walking into the bathroom et was too weak to make it. Res intentionally sat on the floor so he wouldn't fall. Res denies any pain, or problems from sitting on the floor. Res requesting to stay in his room . dd. On 12/1/18 at 5:28 PM, Res has c/o not sleeping well at times. Res was up x2 last night thinking it was time to get ready. Res denies any pain or concerns at this time. Res is continuing to get pain in his neck et weakness in legs at times. Res educated to ask for assistance when feeling weak. Res agreed . ee. On 12/8/18 at 5:28 PM, .Res has increased confusion. Res wife states he is confused at night about time of day, where his bed is, and where the bathroom is. Res reoriented by staff, but up again within 2 hours. Res remembers some of his night. Res weakness increased on days when c/o not sleeping well. Res has been wheeled to all meals today in wheelchair. (Note: There was no documentation that resident 30's physician was contacted regarding this change of condition.) ff. On 12/22/18 at 12:10 PM, Res had a fall today. Dr, (son), DON (Director of Nursing), et administrator notified. Res has R hip pain, skin tear R elbow. Sent for eval in ER (emergency room ). Resident 30 attempted to close his door while ambulating independently and the door hit resident 30, causing him to fall. The Emergency Department report stated that resident 30 had a minimally displaced right basicervical femoral neck fracture with varus angulation. (NOTE: The [MEDICAL CONDITION] required surgical intervention.) On 12/22/18 at 12:00, an incident report revealed that resident 30 was leaving room for lunch following his wife et pushed the door to walk past. Then attempted to pull the door closed behind him, but the door swung into him and knocked him off balance. Res fell to the R side and landed on his buttocks, then R side, stating later he hit his head Res stated he was uncomfortable, having pain 10/10 in R buttock, et needed to sit up. Res lifted off floor with hoyer lift per Res request et comfort by (RN and CNA) into wheelchair. Res had some pain relief from sitting up in wheelchair, pain at 8-9/10. Aide stayed in room with res while waiting for EMS (emergency medical services) to come as res was trying to move leg et cross his legs. Res stated 'I opened the door to go to lunch and close it behind me. It hit me on the side and I lost my balance and fell . I landed on my butt and side.' Resident was oriented to person, situation, place and time when he fell . When the aide reached the resident's room, the resident's call light was activated by the resident's wife. Resident was confused, had weakness/fainted and was ambulating without assistance with his wheeled walker. Restorative nursing assistant (RNA) notes were reviewed. Resident 30 started working with the RNA on 5/21/18 and stopped on 11/30/18. The RNA program was stopped due to resident is not feeling well keeping program PRN. Reevaluate in 30 days. The RNA goals were to assist the resident with the following: a. Maintain current level of mobility through review date. b. Work with active range of motion (ROM) with the RNA for 15 minutes each day. c. Walk 200 feet or more as tolerated for 15 minutes each day. (NOTE: No RNA notes could be located in the medical record dated 11/30/18 through 12/22/18 to see how he had participated in the RNA program and if he was able to ambulate with the RNA.) A physician's referral, dated 10/17/18, revealed that nursing staff referred resident 30 to his neurologist for [MEDICAL CONDITION] medication. On 11/20/18, resident 30's neurologist was notified of resident 30's [MEDICAL CONDITION] activity, frequent falls, increased weakness, and confusion. Resident 30 was examined by his neurologist, 69 days after the referral was made. On 11/13/18 at 10:03 AM a Multidisciplinary Care Conference was held. Resident 30 was identified that he had stutter steps and [MEDICAL CONDITION] episodes. (Note: No documentation could be located in the medical record to show that resident 30's physician had been contacted about the findings in the Care Conference.) On 11/29/18 at 2:24 PM, a Risk Meeting was conducted and revealed the following: (Resident 30) has experienced increased weakness and we arecontinuing (sic) to monitor him closely and notify physician of any changes. Fall Assessments for resident 30's fall risk were completed using the Morse Fall Scale. The assessments revealed the following: a. On 5/1/18 Resident 30 had a score of 65, which indicated a high risk for falling. Resident 30 had a weak gait. b. On 8/1/18 resident 30 had a score of 65, which indicated a high risk for falling. Resident 30 had a weak gait. c. On 11/1/18 resident 30 had a score of 90, with a mental status change of overestimates or forgets limits and an impaired gait. (NOTE: This was a significant increase due to resident 30's weakness and independence. Resident 30's ability to ambulate decreased due to increased shuffling.) A Comprehensive Assessment, recorded in the initial Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 30 required one person extensive, physical assistance to transfer and ambulate with a front wheeled walker (FWW). Resident 30 was not steady when turning, and was only able to stabilize with staff assistance. A quarterly assessment, completed on 11/13/18, also revealed that resident 30 required one person extensive, physical assistance to transfer and ambulate. Resident 30's MDS Care Area Assessments (CAA's) were completed on 5/1/18. A quarterly assessment was completed on 1/1/19. The assessments revealed that resident 30 was at risk for falls and warranted a falls care plan. Resident 30's Falls Care Plan was initiated on 5/1/18 with the following interventions: a. Anticipate and meet the resident's needs. b. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. c. PT (physical therapy) evaluate and treat as ordered or PRN (as needed). (Note: Resident 30's intentional position changes were not identified as falls and therefore resident 30's falls care plan was not updated until resident 30's fall with a [MEDICAL CONDITION] on 12/22/18.) Resident 30's falls care plan did not include utilizing a front wheel walker (FWW) or stand-by assistance, as indicated in resident 30's MDS assessments. Resident 30's falls care plan did not address increased weakness, [MEDICAL CONDITION] activity, or confusion. Resident 30's care plan was updated on 12/22/18, after resident 30 experienced a fall with a [MEDICAL CONDITION]. Resident 30's care plan was updated with the following interventions: a. Educate staff to be the last to leave the room last and shut the door per res preference. b. ADL (activities of daily living) evaluation referral sent to (staff member) for consideration of changing resident to extensive assist d/t functional decline. c. Educated res of importance of waiting for staff to walk with him for meals. Res to utilize call light more. On 11/14/18, a Physical Therapy Discharge Summary revealed that resident 30 required stand by assistance with ambulating on level surfaces. Resident 30 had an impaired gait. A physician's note dated 11/15/18 revealed that the physician ordered for resident 30 to continue with physical therapy modalities and review on an ongoing basis for continued or progressive concerns. (Note: Per the facility DON, staff was not aware of the physician's orders [REDACTED]. Physical therapy was discontinued on 11/14/18, and was not resumed until after resident 30 fell on [DATE].) Additional fall incident reports and other intentional position changes include the following: a. On 2/8/19 at 9:08 AM, resident 30 fell while attempting to open his door and received a hematoma and laceration (bruise and cut) to his head that required steri strips. Resident 30's fall care plan was updated to include the following interventions: 1. Staff will be certain pt is wearing non-skid socks at all times. 2. Staff will not allow pt to park his w/c near a doorway as pt will attempt to pull himself up with the door handle. 3. Staff will perform enhanced monitoring with pt to promote safety while awake. b. On 4/13/19 at 9:00 PM, resident 30 fell while unassisted in the activity room. Resident 30's right knee contacted the floor, and resident 30 received a sprain of the right hip, and a muscle strain to the right thigh. Resident 30 was examined at the Emergency Department. Resident 30's fall care plan was updated on 4/13/19 and on 4/17/19 to include the following interventions: 1. Staff educated via group huddle that while resident is using his walker staff must always be watching him and not turn around and take eyes off of resident even for a short time. 2. Staff educated that they must always stand alongside resident while resident is using walker so that they are close enough to assist him if he loses his balance. 3. Staff educated to turn down resident's bed in advance when they are assisting him to bed so that they are not in a position that would case them to need to take eyes off of resident while he is using his walker. 4. Re educated Res to wait for staff to assist with all transfers, and to use his call light for assistance. 5. Met with activity staff to ensure Res has someone with him at activities while attending, especially when his wife is not attending. 6. Educated Activity staff that Res should be sitting by a staff member while attending activities. c. On 5/3/19 at 12:00 AM, resident was found sitting on the floor in his room. d. On 5/13/19 at 2:05 AM, resident was found sitting on the floor in his room. e. On 5/18/19 at 8:00 PM, resident 30 experienced a fall without injury. Staff indicated that resident 30 was found sitting on the floor in front of his recliner. Resident 30's fall care plan was updated on 4/13/19 and on 4/17/19 to include the following interventions: 1. Chucks pad added to chair to make it less smooth. 2. Encouraged resident to leave door open until he is ready for bed so that staff can check on him and assist him as needed. 3. Educated staff to do a quick doorway assessment when walking down the hall. A Physical Therapy Discharge Summary, for therapy provided from 12/25/18 to 4/4/19 stated: For fall recovery, Patient requires MOD (moderate) A (assistance) but have not focus on this as we have not wanted to encourage to be on floor. The facility Policy and Procedure for Fall Prevention dated 3/1/16 through 4/15/19 revealed that the facility definition of a fall included the following: Definitions: Fall - An unplanned descent to the floor (or extension of the floor; i.e., trash can or other equipment), with or without injury to the resident. On 6/4/19 at 1:55 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 30 required assistance with most cares. CNA 1 stated that resident 30 gets stuck when he walked, due to his [MEDICAL CONDITION]. CNA 1 stated that resident 30 required encouragement and assistance with ambulation. CNA 1 stated that resident 30 was frequently weak and had not been able to do much since he fell on his knee (in April). CNA 1 stated that resident 30 required assistance with a gait belt for transfers and frequent visual checks to ensure his safety. On 6/6/19 at 10:00 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 30 was not capable of ambulating safely independently. CNA 2 stated that she walked behind him holding onto a gait belt placed around resident 30's abdomen. CNA 2 stated that resident 30 walked with a shuffling gait. CNA 2 stated that resident 30 sometimes needed to stop and take a break, and that some days were better than others. CNA 2 stated that If he's unsure or you feel that he's not as steady, we will use a wheelchair. CNA 2 stated that she was not aware of resident 30 choosing to sit on the floor for any activity. On 6/6/19 at 10:11 AM, an interview was conducted with LPN 1. LPN 1 stated that she believed resident 30 had several falls prior to 12/22/18, but involved sliding off the chair and that type of thing. LPN 1 stated that resident 30's [MEDICAL CONDITION] is good on some days, and bad on some days. LPN 1 stated that resident 30 was stronger when he was doing physical therapy, but he was very unsteady on his feet some days. LPN 1 stated that if a resident was purposefully sitting on the floor regularly, she would have said something to the physician. LPN 1 stated that she was the nurse on duty when resident 30 fell and broke his hip on 12/22/19. LPN 1 stated that resident 30 had ups and downs with his memory. LPN 1 stated that resident 30 responded to her questions with varied answers about his pain and recollection of what happened before his fall. LPN 1 stated that she was worried he was hurt. LPN 1 stated that resident 30 attempted to stand up and would not allow staff to assess him while sitting on the floor. LPN 1 stated that staff transferred resident 30 to his wheelchair using the Hoyer lift because he refused to sit on the floor until EMS arrived. On 6/5/19 at 8:55 AM, an interview was conducted with registered nurse (RN) 1. RN 1 stated that resident 30 attempted to ambulate himself and that resident 30 required assistance with transferring from a chair, toilet or bed. RN 1 stated that when resident 30 had a bad day, he didn't step well, and required more assistance from staff. RN 1 stated that resident 30 was encouraged to watch [NAME] Wayne movies in the common area so that nurses could monitor him. On 6/5/19 at 2:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when resident 30 lowered himself to the floor when he became weak, it was not considered a fall. The DON stated that it was considered an intentional position change if a resident stated that they had not fallen. The DON stated that these events did not warrant a change in a resident's care plan, and the physician was not notified. The DON stated that staff could not always walk with resident 30, because the facility didn't have sufficient staff to provide one-on-one monitoring. The DON stated that information reviewed in care conferences was not reported to the physician. The DON stated that she was not aware that resident 30's physician ordered continued physical therapy on 11/15/18. On 6/5/19 at 2:26 PM, an interview was conducted with the Administrator. The Administrator stated that when someone was found on the floor, the resident was asked if they had fallen. The Administrator stated that if they heard a crash or someone fall, then it was considered a fall. The Administrator stated that resident 30 had at one time crawled across the floor, so staff were aware that resident 30 would intentionally get down on the floor. The Administrator stated that before the fall on 12/22/18, resident 30's cognition had been intact and resident 30 could make decisions about sitting down on the floor. The Administrator stated that if a resident had an intentional position change, it was not considered a fall. The Administrator stated that after resident 30 fell and required subsequent surgery on 12/22/18, (Resident 30) had a significant cognitive decline.

Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, expired medications were found on the 300/400 medication cart and in the medication room refrigerator. Additionally, the facility emergency kit had no pharmacy label and had several expired medications inside. Findings include: 1. On 6/5/19 at 8:12 AM, an observation was made of a [MEDICATION NAME] pen with an open date of 5/2/19 and an expiration date of 6/2/19. On 6/5/19 at 8:12 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 verified the open and expiration date of the [MEDICATION NAME]. 2. On 6/5/19 at 8:45 AM, an observation was made of the facility emergency kit in the facility medication room. The emergency kit had no pharmacy label and contained the following expired medications: [REDACTED] a. [MEDICATION NAME] 5 milligrams (mg), 3 tablets, expired (MONTH) (YEAR). b. [MEDICATION NAME] 1 mg, 2 tablets, expired (MONTH) (YEAR). c. [MEDICATION NAME] 0.25 mg, 2 tablets, expired (MONTH) (YEAR). d. [MEDICATION NAME] 40 mg, 2 tablets, expired 9/5/19. e. [MEDICATION NAME] 875 mg, 2 tablets, expired 9/5/18. f. [MEDICATION NAME] 100 mg, 2 tablets, expired 8/15/18. g. [MEDICATION NAME] 2 vials, expired 5/1/19. h. [MEDICATION NAME] 25 mg, 5 tablets, expired (MONTH) 2019. 3. On 6/5/19 at 8:55 AM, an observation was made of the multi dose vial of [MEDICATION NAME] in the medication room refrigerator. The [MEDICATION NAME] had an open date of 3/29/19. On 6/5/19 at 8:55 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that the nursing staff always checked the expiration dates of the medication prior to administering medications, but, that in the case of an emergency, the [MEDICATION NAME] probably wouldn't happen. On 6/5/19 at 9:05 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they would call the pharmacy and get a label on the emergency kit.

Based on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically foods were expired, not labeled, the mop was not stored properly, a fridge had a sticky residue. Findings include: On [DATE] at approximately 9:40 AM an initial observation of the kitchen was conducted. The dietary manager (DM) was present for the initial observation. The following was identified: a. Buttermilk with a best date of [DATE] was in the main fridge b. There were 4 pies which lacked a date c. Turkey lunch meat with a best by date of [DATE] was in the small fridge d. The mop was stored down in the cleaning closet e. The pipe under the three compartment sink extended into the drain approximately ,[DATE] inches f. Sour cream with a best by date of [DATE] was in the upstairs fridge At 11:25 AM an observation of the lunch meal service was conducted. The following was identified: a. At 11:40 AM a resident was served with thumbs on the rim of the plate b. At 11:40 AM dietary aide (DA) 1 was observed to serve a resident with fingers on the rim of the plate, near ham c. At 11:42 AM DA 1 was observed to serve a resident with fingers on the rim of the plate, near the ham and corn d. At 11:44 AM the dietary manager in training (DMT) served a resident with fingers on the rim of the plate near the roll and ham e. At 11:49 AM DA 1 was observed to service a resident by clamping fingertips on the rim of a bowl of broccoli and a bowl of yams f. At 11:51 AM a staff member was observed to serve a resident with thumbs on the rim of the plate by the noodles. g. At 11:52 AM a staff member was observed to serve a resident with thumbs on the rim of the plate near the ham. h. At 11:55 AM a resident was served with thumbs on the rim of the plate At approximately 1:30 PM the dietary manager stated she had provided an inservice to the kitchen staff to get rid of expired foods. The DM provided a form which was an end of day check list. The DM stated she had updated the form to include checking for expired foods. At 3:26 PM an observation was made of the nursing fridge. The following was identified: a. A bottle of soda with a date of [DATE] b. A carton of thickened milk with a date of [DATE] c. Along the bottom shelf of the fridge was a sticky substance that extended approximately halfway across the length of the shelf and eight inches back. On [DATE] at 1:35 PM an interview was conducted with the dietary manager (DM) and the DMT. The DM stated that staff should not claw the top of cups or bowls. The DMT stated that plates should not be touched except the very rim.

Based on interview, observation and record review, it was determined for 4 of 19 sample residents, that the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that identified issues with respect to which Quality Assessment and Assurance activities were necessary. In addition, the QAA committee did not develop and implement appropriate plans of action to correct identified quality deficiencies. Specifically, deficient practices identified during the survey included repeat deficiencies in the areas of physician notification of resident's changes, developing and updating comprehensive care plans, prevention of accident hazards, residents free from unnecessary [MEDICAL CONDITION] medications and significant medication errors, proper label and storage of drugs and biologicals, and maintaining a sanitary kitchen. Resident identifiers: 15, 29, 30, and 33, Findings include: 1. For resident 30, the physician was not notified of changes of condition and increased weakness. (Cross refer to F580) 2. Comprehensive person centered care plans were not updated for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Residents 30 did not have a falls care plan updated and 33 did not have their care plans updated for anti-psychotic medication monitoring. (Cross refer to F656) 3. For resident 30, facility staff did not monitor and reassess a resident after the resident had several changes of condition. Additionally and a physician order [REDACTED].>(Cross refer to F684) 4. Resident 30 had increased weakness with multiple change in conditions and was not reassessed nor were interventions implemented in an attempt to avoid falls. (Cross refer to F689) 5. Residents 15 and 33 were prescribed an antipsychotic medication without an indicated use and resident 29 had duplicative therapy. (Cross refer to F758) 6. Resident 29 had an order dated 5/1/19 for [MEDICATION NAME]/[MEDICATION NAME] (HCTZ) 37.5/25 mg (milligrams) that was not implemented into the medical record and had not been administered. (Cross refer to F760) 7. Ten medications that were expired were available for resident use. An emergency kit (E-kit) contained 8 expired medications, including the facility's [MEDICATION NAME] supply in case of narcotic overdose. (Cross refer to F761) 8. Food was not stored in sanitary conditions. The kitchen contained foods were expired, not labeled, the mop was not stored properly, and a fridge had a sticky residue. (Cross refer to F812) On 6/6/19 at 1:33 PM, an interview was conducted with the facility's Administrator. The Administrator stated that the quality assurance focus during the past year included falls, decreasing [MEDICAL CONDITION] medications, and improving food. The Administrator stated that the falls goals were not met, and that different focuses were attempted. The Administrator stated that [MEDICAL CONDITION] medication prescriptions were decreased 36% in one month, and all department heads were involved in the QA process, as well as the facility's physician. The Administrator stated that an outside group also did surprise audits.

Based on interview and record review it was determined, for 1 of 19 sampled residents, that the facility did not immediately inform the resident representative when there was a need to alter the resident's treatment and commence a new form of treatment. Specifically, the physician was not notified of one resident's changes of condition and increased weakness. Resident identifier: 30. Findings include: Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 30 was subsequently diagnosed on [DATE] with difficulty walking. On 6/6/19 a record review was completed for resident 30. Nursing notes revealed the following : Resident 30's medical record contained no documentation that resident 30's physician was notified for the following events: a. On 7/5/18 at 3:28 PM, Resident confused with increased 'stutter step' noted today. Resident complained of 'being tired from his outing yesterday' . b. On 9/3/18 at 4:35 PM, Res (resident's) wife ., came out in the hallway to get the nurse to help (resident 30). Res was sitting on the bathroom floor. Res stated his legs got weak so he intentionally sat on the floor. Res is weak et (and) shaky. Res lifted off floor with lift et sat in chair. Res had supper in his room. Advised res to use call light for any needs et placed in reach. Will continue to monitor. c. On 9/6/18 at 9:41 AM, Resident weak and unsteady after exercise with restorative CNA (certified nursing assistant) this morning. Resident sat in lobby for approx 30 min prior to amb (ambulating) with assist to room. (Resident 30) was unsteady and weak after amb to room with assist but had refused to use wheelchair. Vital signsafter (sic) exercise B/P (blood pressure) 93/63 - P (pulse) 77 - R (respirations) - 18 T (temperature) - 35.9 O2 - 93% room air. Will encourage to ask for assistance and monitor closely. At 11:32 AM, Dr notified of weakness would like (resident 30) to be monitored today for continuous weakness and would like a status update tomorrow of condition. d. On 9/8/18 at 9:50 AM, Res was walking out of bathroom et legs got weak. Res intentionally sat on the floor as he couldn't walk any further. Res is shaky et had some difficulty getting to his chair. Res is taking double steps, et quick steps. Res denies any injury or pain. Will continue to monitor. At 11:30 AM, Res didn't want to walk to lunch. Res wanted to stay in room. Res wife worried about him et wanted to stay with him. e. On 10/5/18 at 9:02 AM, Res wife pushed call light to notify aid res couldn't make it out of the bathroom. Res found sitting on the floor in the bathroom doorway. Res states his legs, got too weak to hold me, Res made an intentional position change to sitting on the floor so he didn't fall. Res has no complaints. Res lifted off the floor with a lift, et sat in recliner. Res advised to use his urinal or call for help when needing to use the bathroom when his legs are feeling weak. f. On 10/9/18 at 2:13 PM, Resident continues to have weakness, increased confusion and GI (gastrointestinal) upset. Increased assistance needed today with dressing and toileting. Will continue to monitor closely. (Resident) has been ou (sic) to room to meals but has not amb (ambulated) to meals as resident usually does. Appetite fair. g. 10/16/2018 19:25, Resident's wife called me to room and said (resident 30) was having one of his episodes. (Resident 30) was exhibiting [MEDICAL CONDITION] activity in his upper body including tongue and neck spasms. High pitched voice at times and difficulty with speech. Resident with no lose (sic) of consciousness and almost constant talking anxiously. Confusion on and off. episode [MEDICATION NAME] approximately 1 hour. Residents wife said he has had a hx (history) of episodes [MEDICATION NAME] as long as 5 hours. Monitored resident closely until he calmed with no further [MEDICAL CONDITION] activity. Vital signs stable Will continue to monitor. h. On 10/17/18 at 6:40 PM, .Resident weaker and tired this morning to x1 meal (breakfast) in wheelchair. i. On 10/19/18 at 2:41 PM, Res has been weak today. Res walked back from breakfast and halfway needed to be pushed on his walker. Res has c/o (complaints of) having diarrhea today, et feeling weak. Res has been stuttering words, et having difficulty putting full sentences together. Res refused lunch. Res doesn't want to be pushed in a wheelchair down the hall. Res expressed to nurse that he, 'doesn't want to be a burden, and is no good.' Talked with res for 10 minutes. Res will rest in room j. On 10/28/19 at 9:15 AM, .Res stated that he didn't go to sleep until 0330 (3:30 AM) or 0400. The nurse brought the res alendronate et told him to stay up for 50 minutes. Res was up for 50 minutes et then tried to go back to sleep. Res c/o being tiredet (sic) shaky. Res wife informed staff that res had a difficult time in bathroom trying to get back to his chair. Re educated res to pull his call light when he's having a difficult time. Res agreed to call when he's having weakness. k. On 11/3/18 at 5:29 PM, Res had difficulty walking all the way to and from the dining room this am. Res was pushed in wheelchair l. On 11/10/18 at 3:31 PM< Res has been c/o weakness today m. On 11/11/18 at 10:01 AM, Res call light turned on.Aide went in to check on Res. Res was sitting on the floor in front of his recliner. Nurse called to room. Res states he 'went to the bathroom. When I came out I couldn't make it to the chair, so I sat on the floor.' Res intentionally changed position to the floor. Res denies any pain or injuries. Res up into recliner. Res has no needs or requests at this time. Call light in reach for Res. Advised to use when he needs to get up today. Educated on use. n. On 11/20/18 at 1:28 PM, Resident continues to have hoarse voice but no longer complaining of 'runny nose.' Increased confusion, incontinence and weakness noted today. Monitored closely due to high fall risk. Resident has an appointment this afternoon with (Neurologist) for [MEDICAL CONDITION] evaluation. o. On 11/24/18 at 8:50 AM, Res found sitting on floor in front of his recliner. Res states he intentionally sat on the floor as he couldn't stand or move his legs anymore. Res pushed call light for help. Res was lifted from floor via hoyer lift by (two aides.) Res has no complaints of pain, or concerns. Res currently eating breakfast in room. Will continue to monitor At 11:56 AM, Res is weak today. Refusing lunch stating he 'didn't sleep at all last night.' Res wants to stay in room p. On 12/1/18 at 5:28 PM, Res has c/o not sleeping well at times. Res was up x2 last night thinking it was time to get ready. Res denies any pain or concerns at this time. Res is continuing to get pain in his neck et weakness in legs at times. Res educated to ask for assistance when feeling weak. Res agreed . q. On 12/8/18 at 5:28 PM, .Res has increased confusion. Res wife states he is confused at night about time of day, where his bed is, and where the bathroom is. Res reoriented by staff, but up again within 2 hours. Res remembers some of his night. Res weakness increased on days when c/o not sleeping well. Res has been wheeled to all meals today in wheelchair. On 6/5/19 at 2:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when resident 30 lowered himself to the floor when he became weak, it was not considered a fall. The DON stated that it was considered an intentional position change if a resident stated that they had not fallen. The DON stated that these events did not warrant a change in a resident's care plan, and the physician was not notified. The DON stated that there was no documentation in resident 30's medical record that the physician had been notified.

Based on interview and record review, it was determined that for 1 of 19 sampled residents that the facility did not did not send a copy of the notice of a resident's transfer or discharge to a representative of the Office of the State Long-Term Care Ombudsman. Specifically, a resident was transferred to the hospital and the facility did not report the transfer to the ombudsman. Resident identifier: 28. Findings include: Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 6/4/19 resident 28's medical record was reviewed. The following progress notes were revealed: a. 2/13/2019 5:33 PM Health Status Note Note Text: CNA (certified nursing assistant) went to take resident to dinner at 1645 (4:45 PM) resident was unresponsive, vitals were immediately obtain BP (blood pressure)-123/82 R (respirations)-40 with retractions T (temperature)-98.2 02 (oxygen) 68% on RA (room air) placed resident on 4LPM (4 liters per minute) via nasal cannula. Resident was reported alert and oriented at 1645 (4:45 PM) by . CNA (The physician) was in the facility and was notified of resident condition, evaluation of resident by physician noted transfer to ED (emergency department). Resident was transported to ED via ambulance, Nurse report was given to .RN. On 6/5/19 at 2:50 PM an interview was conducted with the administrator. The administrator stated that the ombudsman would be contacted for family concerns and issues, or anything which would be reported to the state such as abuse or neglect. The administrator stated that hospitalization s weren't reported unless it was something such as a fall. On 6/6/19 at 8:45 AM a follow up interview was conducted with the administrator. The administrator stated that the local ombudsman had reported to her that notifications about hospitalization s had not been consistent. The administrator stated there was a miscommunication from the state ombudsman. The administrator stated the hospitalization s would be reported from that point forward.

Based on observation, interview and record review it was determined, for 2 of 19 sample residents, that the facility did not develop and implement a comprehensive person centered care plan of each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Resident identifiers: 30 and 33. Findings include: 1. Resident 33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/5/19 resident 33's medical record was reviewed. physician's orders [REDACTED]. According to the TAR for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019, there was no monitoring of side effects for resident 33 for the antipsychotic medication. A [MEDICAL CONDITION] Care Plan for resident 33 revealed that resident 33 uses [MEDICAL CONDITION] medications r/t (related to) [MEDICAL CONDITION] disorder and DEMENTIA WITH BEHAVIORAL DISTURBANCE diagnoses. The goal for resident 33 was The resident will remain free of [MEDICAL CONDITION] drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. The interventions for resident 33 included Administer [MEDICAL CONDITION] medications as ordered by physician. Monitor for side effects and effectiveness Q (every)-SHIFT. On 6/5/19 at 11:52 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that side effects should always be monitored for antipsychotic medication. 2. Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 30 was subsequently diagnosed on [DATE] with difficulty walking. On 6/6/19 a record review was completed for resident 30. Resident 30's initial falls care plan was initiated on 5/1/18 and included the following interventions: a, Anticipate and meet The resident's needs. b. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. c. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Resident 30's nursing notes revealed the following: a. On 5/21/18 at 10:14, This Am resident wife called staff to room and said that her husband called her in the bathroom because he had become weak and intentionally kneeled to the floor. When (nurse) entered the room he was getting himself up off of the floor and into his chair. DON, Family and (Resident 30's physician) notified. Encouraged (Resident 30) and his wife to ask for assistance. b. On 9/3/18 at 4:35 PM, Res (resident's) wife ., came out in the hallway to get the nurse to help (resident 30). Res was sitting on the bathroom floor. Res stated his legs got 'weak' so he intentionally sat on the floor. Res is weak et (and) shaky. Res lifted off floor with lift et sat in chair. Res had supper in his room. Advised res to use call light for any needs et placed in reach. Will continue to monitor. c. On 9/8/18 at 9:50 AM, Res was walking out of bathroom et legs got weak. Res intentionally sat on the floor as he couldn't walk any further. Res is shaky et had some difficulty getting to his chair. Res is taking double steps, et quick steps. Res denies any injury or pain. Will continue to monitor. d. On 10/5/18 at 9:02 AM, Res wife pushed call light to notify aid (sic) res couldn't make it out of the bathroom. Res found sitting on the floor in the bathroom doorway. Res states his legs, 'got too weak to hold me,' Res made an intentional position change to sitting on the floor so he didn't fall. Res has no complaints. Res lifted off the floor with a lift, et sat in recliner. Res advised to use his urinal or call for help when needing to use the bathroom when his legs are feeling weak. Res agreed with plan e. On 11/11/18 at 10:01 AM, Res call light turned on Aide went in to check on Res. Res was sitting on the floor in front of his recliner. Nurse called to room. Res states he 'went to the bathroom. When I came out I couldn't make it to the chair, so I sat on the floor.' Res intentionally changed position to the floor. Res denies any pain or injuries. Res up into recliner. Res has no needs or requests at this time. Call light in reach for Res. Advised to use when he needs to get up today. Educated on use. Will continue to monitor. f. On 11/24/18 at 8:50 AM, Res found sitting on floor in front of his recliner. Res states he intentionally sat on the floor as he couldn't stand or move his legs anymore. Res pushed call light for help. Res was lifted from floor via hoyer lift by (two aides.) Res has no complaints of pain, or concerns. Res currently eating breakfast in room. Will continue to monitor. g. On 11/30/18 at 7:25 AM, Res states he was walking into the bathroom et was too weak to make it. Res intentionally sat on the floor so he wouldn't fall. Res denies any pain, or problems from sitting on the floor. Res requesting to stay in his room . Resident 30's Incident Reports revealed the following: a. On 5/3/19 at 12:00 AM, resident 30 was found on the floor in his room. Staff explained the importance of using the call light when he needed help. Talked with CNAs about looking in on him anytime they are down the hall. DON Note- resident remains at risk for falls due to impaired cognition and impaired physical mobility. Staff are continuing to anticipate residents needs while still allowing as much independence as possible. b. On 5/13/19 at 2:05 AM, resident 30 was found on the floor in his room. Notes stated: (1) encourage pt to call for assistance when getting up (2) non skid sock during sleeping (3) educate aide to anticipate resident needs- look for signs of waking/agitation to anticipate need to use restroom Resident 30's falls care plan was not updated with new interventions after having the falls. Additionally, resident 30's care plan did not state that resident 30 had [MEDICAL CONDITION] activity. There were no interventions for these episodes. The following nursing note revealed: a. 10/16/2018 19:25, Resident's wife called me to room and said (resident 30) was having one of his episodes. (Resident 30) was exhibiting [MEDICAL CONDITION] activity in his upper body including tongue and neck spasms. High pitched voice at times and difficulty with speech. Resident with no lose (sic) of consciousness and almost constant talking anxiously. Confusion on and off. episode [MEDICATION NAME] approximately 1 hour. Residents wife said he has had a hx (history) of episodes [MEDICATION NAME] as long as 5 hours. Monitored resident closely until he calmed with no further [MEDICAL CONDITION] activity. Vital signs stable Will continue to monitor. On 6/4/19 at 1:55 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 30 required assistance with most cares. CNA 1 stated that resident 30 gets stuck when he walked, due to his [MEDICAL CONDITION]. CNA 1 stated that resident 30 required encouragement and assistance with ambulation. CNA 1 stated that resident 30 was frequently weak and had not been able to do much since he fell on his knee (in April). CNA 1 stated that resident 30 required assistance with a gait belt for transfers and frequent visual checks to ensure his safety. On 6/6/19 at 10:00 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 30 was not capable of ambulating safely independently. CNA 2 stated that she walked behind him holding onto a gait belt placed around resident 30's abdomen. CNA 2 stated that resident 30 walked with a shuffling gait. CNA 2 stated that resident 30 sometimes needed to stop and take a break, and that some days were better than others. CNA 2 stated that If he's unsure or you feel that he's not as steady, we will use a wheelchair. CNA 2 stated that she was not aware of resident 30 choosing to sit on the floor for any activity. On 6/6/19 at 10:11 AM, an interview was conducted with LPN 1. LPN 1 stated that she believed resident 30 had several falls prior to 12/22/18, but involved sliding off the chair and that type of thing. LPN 1 stated that resident 30's [MEDICAL CONDITION] is good on some days, and bad on some days. LPN 1 stated that resident 30 was stronger when he was doing physical therapy, but he was very unsteady on his feet some days. LPN 1 stated that if a resident was purposefully sitting on the floor regularly, she would have said something to the physician. LPN 1 stated that she was not aware of which interventions were included on resident 30's care plan. On 6/5/19 at 8:55 AM, an interview was conducted with registered nurse (RN) 1. RN 1 stated that resident 30 attempted to ambulate himself and that resident 30 required assistance with transferring from a chair, toilet or bed. RN 1 stated that when resident 30 had a bad day, he didn't step well, and required more assistance from staff. RN 1 stated that resident 30 was encouraged to watch [NAME] Wayne movies in the common area so that nurses could monitor him. RN 1 stated that some interventions for resident 30's falls were not in resident 30's care plan. On 6/5/19 at 2:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when resident 30 lowered himself to the floor when he became weak, it was not considered a fall. The DON stated that it was considered an intentional position change if a resident stated that they had not fallen. The DON stated that these events did not warrant an update to a resident's care plan. The DON stated that the only thing that would have been put on care plan would be witnessed or unwitnessed falls. The DON stated that for interventions not included in the care plan, staff would have been responsible to pass on new interventions in group huddle. The DON stated that there was no outline or documentation for group huddles. On 6/5/19 at 2:26 PM, an interview was conducted with the Administrator. The Administrator stated that when someone was found on the floor, the resident was asked if they had fallen. The Administrator stated that if they heard a crash or someone fall, then it was considered a fall. The Administrator stated that resident 30 had at one time crawled across the floor, so staff were aware that resident 30 would intentionally get down on the floor. The Administrator stated that if a resident had an intentional position change, it was not considered a fall, and the care plan would not have been updated.

Based on observation, interview, and record review it was determined, for 1 of 19 sampled residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not monitor and reassess a resident after the resident had several changes of condition. Additionally, facility staff did not monitor and reassess the resident after an hour long [MEDICAL CONDITION] episode and a physician order [REDACTED]. Findings include: Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 30 was subsequently diagnosed on [DATE] with difficulty walking. On 6/6/19, resident 30's medical record was reviewed. Nursing progress notes revealed the following entries: a. On 7/5/18 at 3:28 PM, Resident confused with increased 'stutter step' noted today. Resident complained of 'being tired from his outing yesterday' . b. On 9/12/18 at 12:26 PM, . If episodes of weakness continue (resident 30's physician) would like (resident 30) to be seen by the physician managing his [MEDICAL CONDITION]. (Note: An appointment was made with resident 30's neurologist on 10/17/18, 35 days after the physician stated that resident 30 should be seen by his neurologist if weakness continued. Resident 30 saw his neurologist on 11/20/18, 69 days after the physician requested that resident 30 to be seen by his neurologist.) c. On 10/9/18 at 2:13 PM, Resident continues to have weakness, increased confusion and GI (gastrointestinal) upset. Increased assistance needed today with dressing and toileting. Will continue to monitor closely. (Resident 30) has been ou (sic) to room to meals but has not amb (ambulated) to meals as resident usually does. Appetite fair. (Note: No documentation could be located in the medical record to show that resident 30's physician had been notified regarding this change of condition.) d. On 10/16/2018 19:25, Resident's wife called me to room and said (resident 30) was having one of his episodes. (Resident 30) was exhibiting [MEDICAL CONDITION] activity in his upper body including tongue and neck spasms. High pitched voice at times and difficulty with speech. Resident with no lose (sic) of consciousness and almost constant talking anxiously. Confusion on and off. episode [MEDICATION NAME] approximately 1 hour. Residents wife said he has had a hx (history) of episodes [MEDICATION NAME] as long as 5 hours. Monitored resident closely until he calmed with no further [MEDICAL CONDITION] activity. Vital signs stable Will continue to monitor. (Note: No documentation could be located in the medical record to show that resident 30's physician had been notified of the [MEDICAL CONDITION] activity until resident 30 saw his neurologist on 11/20/18.) e. On 10/19/18 at 2:41 PM, Res has been weak today. Res walked back from breakfast and halfway needed to be pushed on his walker. Res has c/o (complaints of) having diarrhea today, et feeling weak. Res has been stuttering words, et having difficulty putting full sentences together. Res refused lunch. Res doesn't want to be pushed in a wheelchair down the hall. Res expressed to nurse that he, 'doesn't want to be a burden, and is no good.' Talked with res for 10 minutes. Res will rest in room. Res had a banana et will come to supper. Will continue to monitor. (Note: No documentation could be located in the medical record to show that resident 30's physician had been notified regarding this change of condition.) f. On 12/8/18 at 5:28 PM, .Res has increased confusion. Res wife states he is confused at night about time of day, where his bed is, and where the bathroom is. Res reoriented by staff, but up again within 2 hours. Res remembers some of his night. Res weakness increased on days when c/o not sleeping well. Res has been wheeled to all meals today in wheelchair. (Note: No documentation could be located in the medical record to show that resident 30's physician had been notified regarding this change of condition.) On 11/13/18 at 10:03 AM a Multidisciplinary Care Conference was held. Resident 30 was identified that he had stutter steps and [MEDICAL CONDITION] episodes. (Note: No documentation could be located in the medical record to show that resident 30's physician had been notified about the findings of the Care Conference.) On 11/1/18, a Morse Fall Scale was completed for resident 30. Resident 30 had a score of 90, with a mental status change of overestimates or forgets limits and an impaired gait. (NOTE: This was a significant increase after the previous Fall Scale (with a score of 65), completed on 8/1/18. The increased risk was due to resident 30's increased weakness and failure to recognize his limits. Resident 30's ability to ambulate decreased, due to a shuffling gait. No documentation could be located in the medical record to show that resident 30's physician had been notified.) A physician's note dated 11/15/18 revealed that the physician ordered for resident 30 to continue with physical therapy modalities and review on an ongoing basis for continued or progressive concerns. (Note: Per the facility DON, staff was not aware of the physician's orders [REDACTED].) On 6/4/19 at 1:55 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 30 required assistance with most cares. CNA 1 stated that resident 30 gets stuck when he walked, due to his [MEDICAL CONDITION]. CNA 1 stated that resident 30 required encouragement and assistance with ambulation. CNA 1 stated that resident 30 was frequently weak and had declined. CNA 1 stated that resident 30 required assistance with a gait belt for transfers and frequent visual checks to ensure his safety. On 6/6/19 at 10:00 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 30 was not capable of ambulating safely independently. CNA 2 stated that she walked behind him holding onto a gait belt placed around resident 30's abdomen. CNA 2 stated that resident 30 had not always required a gait belt. CNA 2 stated that resident 30 walked with a shuffling gait, which was new. CNA 2 stated that resident 30 sometimes needed to stop and take a break, and that some days were better than others. CNA 2 stated that If he's unsure or you feel that he's not as steady, we will use a wheelchair. CNA 2 stated that she was not aware of resident 30 choosing to sit on the floor for any activity. On 6/6/19 at 10:11 AM, an interview was conducted with LPN 1. LPN 1 stated that she believed resident 30 had several falls prior to 12/22/18, but involved sliding off the chair and that type of thing. LPN 1 stated that resident 30's [MEDICAL CONDITION] is good on some days, and bad on some days. LPN 1 stated that resident 30 was stronger when he was doing physical therapy, but he was very unsteady on his feet some days. LPN 1 stated that if a resident was purposefully sitting on the floor regularly, she would have said something to the physician. LPN 1 stated that she was the nurse on duty when resident 30 fell and broke his hip on 12/22/19. LPN 1 stated that resident 30 had ups and downs with his memory. On 6/5/19 at 8:55 AM, an interview was conducted with registered nurse (RN) 1. RN 1 stated that resident 30 attempted to ambulate himself and that resident 30 required assistance with transferring from a chair, toilet or bed. RN 1 stated that when resident 30 had a bad day, he didn't step well, and required more assistance from staff. RN 1 stated that resident 30 was encouraged to watch [NAME] Wayne movies in the common area so that nurses could monitor him. RN 1 stated that resident 30 had experienced some changes while at the facility. RN 1 stated that resident 30 had required more intervention to prevent falls. On 6/5/19 at 2:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when resident 30 lowered himself to the floor when he became weak, it was not considered a fall. The DON stated that it was considered an intentional position change if a resident stated that they had not fallen. The DON stated that these events did not warrant a change in a resident's care plan, and the physician was not notified. The DON stated that staff could not always walk with resident 30, because the facility didn't have sufficient staff to provide one-on-one monitoring. The DON stated that information reviewed in care conferences was not reported to the physician. The DON stated that she was not aware that resident 30's physician ordered continued physical therapy on 11/15/18. On 6/5/19 at 2:26 PM, an interview was conducted with the Administrator. The Administrator stated that when someone was found on the floor, the resident was asked if they had fallen. The Administrator stated that if they heard a crash or someone fall, then it was considered a fall. The Administrator stated that resident 30 had at one time crawled across the floor, so staff were aware that resident 30 would intentionally get down on the floor. The Administrator stated that before the fall on 12/22/18, resident 30's cognition had been intact and resident 30 could make decisions about sitting down on the floor. The Administrator stated that if a resident had an intentional position change, it was not considered a fall. The Administrator stated that after resident 30 fell and required subsequent surgery on 12/22/18, (Resident 30) had a significant cognitive decline.

Based on interview and record review it was determined, for 2 of 19 sample residents, that the pharmacist did not report irregularities in the drug regimen review to the attending physician, the facility's Medical Director, and Director of Nursing. Irregularities include, but are not limited to, any medication when used without adequate monitoring or without adequate indications for its use. Specifically, the pharmacist did not report the irregularity of the use of antipsychotics for residents that did not have a [DIAGNOSES REDACTED]. Resident identifiers: 15 and 33. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., anxiety and unspecified [MEDICAL CONDITION] not due to a substance or known physiologic condition. On 6/5/19 resident 15's medical record was reviewed. physician's orders [REDACTED]. The pharmacy review notes revealed the following entries: a. 1/14/19 at 19:18 (7:18 PM), Medications and chart reviewed. No medication irregularities noted. b. 2/18/19 at 14:32 (2:32 PM), Medications and chart reviewed. Res (resident) currently the best we have seen re (regarding) mood/behavior/distress and [MEDICAL CONDITION] medications. No further GDR (gradual dose reduction) recommended. No medication irregularities noted. c. 3/16/19 at 16:04 (4:04 PM), Medications and chart reviewed. [MEDICATION NAME] helped some. her rocking, chanting/yelling get worse when GDR of [MEDICATION NAME] ([MEDICATION NAME]) is attempted. No medication irregularities noted. d. 4/17/19 at 12:59 PM, Medications and chart reviewed. (Resident 15) continues w (with)/less frequent episodes of distressing delusions or hallucinations with rocking, chanting which escalate to yelling out. After multiple trials of different medications and approaches [MEDICATION NAME] seems to bemost (sic) effective in reducing episodes. No ASE (adverse side effects) noted. No medication irregularities noted. e. 5/17/19 at 13:13 (1:13 PM), Medications and chart reviewed. Res reviewed in PRC (Pharmacy Review Committee) this week. Rec (recommend) to change timing of [MEDICATION NAME] to relieve [MEDICAL CONDITION] related rocking and yelling, which increases in the evening hours. [MEDICATION NAME] stopped as benefit not realized. vss (vital signs stable). No ASE reported. no medication irregularities noted. According to the Nursing (YEAR) Drug Handbook by Wolters Kluwer, [MEDICATION NAME] had a black box warning which revealed Drug may increase risk of CV (cardiovascular) or infection-related death in elderly patients with dementia. [MEDICATION NAME] isn't approved to treat patients with dementia-related [MEDICAL CONDITION]. 2. Resident 33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/5/19 resident 33's medical record was reviewed. physician's orders [REDACTED]. Pharmacy review notes revealed the following entries: a. 1/12/19 at 22:51 (10:51 PM), Medications and chart reviewed for possible unnecessay (sic) medications. All current meds appear to be necessary and appropriate. no medication irregularities noted. b. 2/18/19 at 15:25 (3:25 PM), Medications and chart reviewed. No recent changes. No ASE reported. No medication irregularities noted. c. 3/16/19 at 16:38 (4:38 PM), Medications and chart reviewed. vss. wt (weight) loss noted. Worsening confusion, delusions, exposing privates in common room. No medication irregularities noted. d. 4/17/19 at 14:23 (2:43 PM), medications and chart reviewed. Advanced dementia. Up much of the night, drowsy during the day. No ASE reported. No medication irregularities noted. e. 5/17/19 at 14:44 (2:44 PM), Medications and chart reviewed. Res (resident) continues w/distressing delusions at times. Multiple adjustments to [MEDICATION NAME] have been made to avoid sedation and still control delusions. vss. glucose improved p (after) [MEDICATION NAME] reduction. No medication irregularities noted. According to the TAR for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 revealed that there was no monitoring of side effects for resident 33 for the antipsychotic medication. According to the (YEAR) Drug Handbook by Wolters Kluwer, [MEDICATION NAME] had a black box warning that revealed Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotics are at increased risk for death. Drug isn't approved to treat elderly patients with dementia-related [MEDICAL CONDITION]. On 6/5/19 at 11:52 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that she had spoken to the facility pharmacist and that she had been informed by the facility pharmacist that [MEDICAL CONDITION] was an appropriate [DIAGNOSES REDACTED].

Based on interview and record review, it was determined for 1 of 19 sample residents, that the facility did not ensure that a resident who used [MEDICAL CONDITION] drugs was not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, resident 29 had been receiving an antipsychotic medication without a clear indication for its use and in the presence of adverse side effects. Findings include: Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/6/19, a review was conducted of resident 29's electronic medical record. Resident 29's physicians orders included the following anti-psychotic medications: [REDACTED] a. [MEDICATION NAME] 0.5 mg (milligram) tablets, twice daily for dementia with behavioral disturbances. This was prescribed on 10/16/18. A Black Box Warning stated: Increased mortality in elderly patients with dementia-related [MEDICAL CONDITION]. Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. b. [MEDICATION NAME] 10 mg tablet, once daily in the morning for [MEDICAL CONDITION]. This was prescribed on 5/30/19. A Black Box Warning for [MEDICATION NAME] stated the following: Dementia-Related [MEDICAL CONDITION] - not approved for dementia-related [MEDICAL CONDITION]; incr. (increased) mortality risk in elderly dementia pts (patients) on conventional or atypical antipsychotics; most deaths due to cardiovascular or infectious events; extent to which incr. mortality attributed to antipsychotic vs. some pt characteristic(s) not clear. On 12/14/16, the PASRR Level I revealed that a PASRR Level II was required for a [DIAGNOSES REDACTED]. On 4/2/19 a Multidisciplinary Care Conference note revealed that resident 29 had not attended many group activities, she will say NO when invited. She struggles when attending with anxiety and becoming easily agitated. On 5/8/19 at 2:18 PM, a physician's office/clinic note revealed that resident 29's husband had reported that she was withdrawn and sedated most of the day. She no longer participates in crafts and activities and this is a marked departure from her baseline personality and activity. The neurologist recommended reducing the [MEDICATION NAME] if her behaviors allow it. The physician stated that resident 29 had agitation - acting over medicated - reduce [MEDICATION NAME] to 0.5 mg po (by mouth) BID (twice daily). Monitor for aggressive behaviors and notify me if escalating. On 5/15/19 at 6:00 PM, a physician's orders [REDACTED]. Resident 29 was restricted to 750 ml (milliliters) day shift and dietary, 500 ml night shift, every shift related to [MEDICAL CONDITION]. On 5/21/19 at 10:26 AM, a physician's office/clinical note revealed that resident 29 felt her mood has improved and she is participating in activities better. A review of resident 29's Behavioral Symptoms tracking revealed one negative behavior between 5/7/19 through 6/4/19. On 5/29/19, one episode of repeats movement was recorded. On 6/5/19 at 11:30 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that when a physician ordered a medication for a resident, the staff did not question the order. The MDS Coordinator stated that the staff did not discuss the black box warnings with providers. On 6/5/19 at 11:50 AM, an interview was conducted with the DON. The DON stated that resident 29 was obsessed about having water after a fluid restriction was ordered for resident 29. Resident 29 demanded water and was told no, so she knocked a pitcher of water off the nurses' cart. The DON stated that the physician had been contacted by the nursing staff in order to obtain a new prescription for resident 29's obsessive behavior. The DON stated that the physician had not specifically addressed the issue that the [MEDICATION NAME] and [MEDICATION NAME] had black box warnings for individuals with dementia. The DON stated that resident 29 had not been given the opportunity to initiate a risk-vs-benefit in order to have water on-demand. The DON stated that there were no other documented tracked behaviors in the nursing notes, TAR or tasks for resident 29 in the month before [MEDICATION NAME] was prescribed.

Based on observation, interview and record review, it was determined for 2 of 19 sample residents, that the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 27 medication opportunities, on 6/6/19, revealed two medication errors which resulted in a 7.41% medication error rate. Specifically, one resident was observed to have medications prepared by the nurse for a [MEDICATION NAME]/HCTZ ([MEDICATION NAME]) 37.5/25 mg (milligrams) rather than Losartan 100 mg and one resident was allowed to use the [MEDICATION NAME] Spray as the nurse turned her back and did not use the spray according to the physician orders. Resident identifiers: 25 and 29. Findings include: 1. On 6/6/19 at 8:39 AM, an observation was made as Licensed Practical Nurse (LPN) 2 prepared medications for resident 29. LPN 2 was observed to hold the medications [MEDICATION NAME]/HCTZ 37.5/25 mg bubble pack in one hand and Losartan 100 mg bubble pack in the other hand. LPN 2 went back and forth and stated that she thought the [MEDICATION NAME]/HCTZ 37.5/25 mg was the correct medication. LPN 2 was observed to pull the [MEDICATION NAME]/HCTZ 37.5/25 mg and place it in the medication cup. When LPN 2 was finished preparing the medications for resident 29, LPN 2 was observed to close down the medical record and lock the medication cart. LPN 2 was observed to take a step toward resident 29's room and was asked by this surveyor if she was finished and ready to administer the medications. LPN 2 stated yes, I'm ready. LPN 2 was then stopped. This surveyor and LPN 2 went through resident 29's medical record. No order could be located in the medical record for resident 29 to receive [MEDICATION NAME]/HCTZ 37.5/25 mg. There was an order for [REDACTED]. LPN 2 stated no. When asked why she did not follow up on the discrepancy, LPN 2 stated I don't know. (NOTE: Both medications were the same color and shape, but one medication was smaller than the other.) On 6/6/19 resident 29's medical record was reviewed for the reconciliation of medications. physician's orders [REDACTED]. 2. On 6/6/19 at 8:55 AM, an observation was made as LPN 2 prepared and administered medications to resident 25. LPN 2 was observed to hand the [MEDICATION NAME] Spray to resident 25 and allow him to spray the [MEDICATION NAME] himself as she turned away from resident 25. Resident 25 was observed to spray 2 sprays into his right nostril and 3 sprays into his left nostril. On 6/6/19 resident 25's medical record was reviewed for the reconciliation of medications. physician's orders [REDACTED]. On 6/6/19 at 9:05 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they had looked into the medication error for resident 29 and realized that resident 29 was to receive [MEDICATION NAME]/HCTZ 37.5/25 mg daily per a physician's prescription that was written on 5/1/19 but had never been implemented into resident 29's medical record.

Based on interview and record review it was determined, for 1 of 19 sample residents, that the facility did not ensure that resident were free of any significant medication errors. Specifically, one resident had an order for [REDACTED]. Findings include: On 6/6/19 at 8:39 AM, an observation was made as Licensed Practical Nurse (LPN) 2 prepared medications for resident 29. LPN 2 was observed to hold the medications [MEDICATION NAME]/HCTZ 37.5/25 mg bubble pack in one hand and Losartan 100 mg bubble pack in the other hand. LPN 2 went back and forth and stated that she thought the [MEDICATION NAME]/HCTZ 37.5/25 mg was the correct medication. LPN 2 was observed to pull the [MEDICATION NAME]/HCTZ 37.5/25 mg and place it in the medication cup. When LPN 2 was finished preparing the medications for resident 29, LPN 2 was observed to close down the medical record and lock the medication cart. LPN 2 was observed to take a step toward resident 29's room and was asked by this surveyor if she was finished and ready to administer the medications. LPN 2 stated yes, I'm ready. LPN 2 was then stopped. This surveyor and LPN 2 went through resident 29's medical record. No order could be located in the medical record for resident 29 to receive [MEDICATION NAME]/HCTZ 37.5/25 mg. There was an order for [REDACTED]. LPN 2 stated no. When asked why she did not follow up on the discrepancy, LPN 2 stated I don't know. (NOTE: Both medications were the same color and shape, but one medication was smaller than the other.) On 6/6/19 resident 29's medical record was reviewed for the reconciliation of medications. physician's orders [REDACTED]. On 6/6/19 at 9:05 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that there had been a prescription written by resident 29's physician for the [MEDICATION NAME]/HCTZ 37.5/25 mg on 5/1/19, but, that the medication had inadvertently not been entered into resident 29's medical record and that resident 29 had not been receiving the medication, even though the medication had been filled on 5/1/19 and was available in the medication cart for administration.

Based on observation, interview and record review, it was determined for 5 of 29 sample residents, that the facility did not ensure the resident environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically, a resident sustained [REDACTED]. Additionally, four residents were transferred not according to their plan of care which resulted in falls (Resident identifiers: 4, 21, 33 and 40). The deficient practice identified for resident 28 was found to have occurred at a harm level. The deficient practice identified for residents 4, 21, 33 and 40 was found to have occurred at a potential for harm. Resident identifiers: 4, 21, 28, 33 and 40. Findings include: A. HARM Resident 28 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 4:43 PM, the facility Staff Development Coordinator (SDC), documented in an electronic progress note, While transferring resident from shower chair to bed, strap on hoyer came undone, resident fell with assist from (name redacted), CNA (Certified Nurse Assistant). Husband, DON (Director of Nursing), and Physician notified. Resident 28's medical record was reviewed on [DATE]. On [DATE], the facility staff completed a quarterly Minimum Data Set (MDS) assessment. Resident 28 was assessed as having been cognitively intact with a Brief Interview for Mental Status score of 13. The facility staff assessed resident 28 has having had impairment of the both the upper and lower extremities. The facility staff documented that resident 28 required two or more people when being transferred. Resident 28 was unable to move on or off the toilet, turn and face the opposite direction, walk, moving from a seated to a standing position, or ambulate during the assessment period. Review of the Activities of Daily Living (ADL) care plan, developed on [DATE], revealed that resident 28 was to be transferred with a bariatric lift for comfort with extensive assistance from two or more people. Resident 28 was seen at the hospital emergency roiagnom on [DATE] at 1:14 PM. The emergency room physician documented that resident 28 had severe tenderness to movement of the left hip and moderate tenderness to the left thigh. The emergency room physician documented that resident 28 sustained an Intertrochanteric and subtrochanteric [MEDICAL CONDITION] hip. Intertrochanteric left [MEDICAL CONDITION], which is mildly comminuted. There is varus angulation of the femoral neck displacement of the lesser trochanteric fracture segment. On [DATE] at 4:25 PM, The Staff Development Coordinator (SDC) completed an incident report related to resident 28's fall from the mechanical lift. The SDC documented, .Nursing Description: CNA (1) was transferring resident from shower chair to bed with hoyer lift, left leg strap on hoyer came undone and resident started to slide. (CNA 1) grabbed resident and assisted her to the room.Immediate Action Taken Description: Resident was assessed by (SDC). Pain noted to L (left) hip. Resident was turned to place sling under her and then lifted with the hoyer into bed.Resident was assessed again. Only complained of pain to L hip. Resident seen by (name of physician redacted). resident sent by ambulance to (local hospital) ER via ambulance. The following interventions were documented on the incident report: [DATE] Intervention #1 - Evaluation of sling and shower chair for safety or alternative options. [DATE] Intervention #2 - One on one education with (CNA 1) regarding hoyer lifts. Competency demonstrated to SDC (name redacted) [DATE] Intervention #3 - Group huddle - Two person assist for all transfers involving lifts. Check all straps before lifting. [DATE] DON (Director of Nursing) Note: All staff competencies reviewed and all staff re-educated on two person transfers to include safe sling placement, use of safety practices, etc. On [DATE], the facility Administrator (ADM) provided the following timeline related to resident 28's fall from the mechanical lift: XXX[DATE] 12:30 - (resident 28) fall reported 12:30 - (SDC) responded to begin assessment. Resident refused ER (emergency room ) transfer. 12:35 - Resident transferred to bed via lift d/t (due to) resident request and painful positioning. 12:42 - Physician, family and DON notified - husband requested ER transfer. 12:50 - DON notified administrator 1314 (1:14 PM) - Initial documentation started in ER. (Time stamp of transfer.) 1400 (2:00 PM) - Administrator ruled out abuse based on information obtained and interview with traveling aide. Injury unknown at time of investigation. The timeline was signed and dated by the ADM. An interview was conducted with the SDC on [DATE] at 1:31 PM, related to resident 28's fall from the mechanical lift on [DATE]. The SDC stated that resident 28 was nonweight bearing to the lower extremities and required transfer assistance of two people with a mechanical lift. The SDC stated at approximately 11:50 AM, CNA 1 completed resident 28's shower. The SDC stated that CNA 1 told her that she was transferring resident 28 from the shower chair to the bed using the mechanical lift. The SDC stated CNA 1 told her that the sling was wet. The SDC stated that CNA 1 told her that she did not ensure that the sling loops were securely attached to the mechanical lift prior to rising resident 28 up. The SDC stated CNA 1 told her that the lower left sling loop fell of the hook resulting in resident 28 sliding out of the mechanical lift sling. The SDC stated that CNA 1 told her resident 28 hit the floor, approximately ,[DATE] inches away from the bed, when she went down. The SDC stated that when she entered resident 28's room, resident 28 was partially propped up against CNA 1. The SDC stated that resident 28 complained of pain to the left groin and hip area. The SDC stated that resident 28's pain was rated at a 9 on a scale of ,[DATE] with 10 being excruciating. The SDC stated that resident 28's physician was not notified of the fall until 12:42 PM, 52 minutes after the fall occurred. The SDC stated that resident 28's physician assessed resident 28 and gave an order for [REDACTED]. The SDC stated that resident 28's husband stated that he wanted resident 28 to be sent to the hospital for an evaluation. An interview was conducted with the DON on [DATE] at 1:57 PM, related to resident 28's fall from the mechanical lift. The DON stated that CNA 1 showered resident 28. The DON stated CNA 1 told her that the sling was wet when CNA 1 hooked her (resident 28) up. The DON stated that CNA 1 did not call for a second person to assist with the transfer and transferred resident 28 by herself. The DON stated that one of the sling hooks was not fully attached to the mechanical lift. The DON stated that when resident 28 was being transferred from the shower chair to the bed, a sling hook fell off the mechanical lift which resulted in resident 28 falling out of the mechanical lift sling. An interview was conducted with Licensed Practical Nurse (LPN) 1 on [DATE] at 2:35 PM, related to resident 28's fall from the mechanical lift. LPN 1 stated that resident 28 required a mechanical lift when being transferred. LPN 1 stated that sling was wet and that only 3 of the loops on the sling were hooked to the mechanical lift. LPN 1 stated that CNA 1 got (resident 28) to the position next to her bed when she (resident 28) began sliding to the floor. LPN 1 stated that CNA 1 told her that she tried to break resident 28's fall and upon entering resident 28's room, resident 28's head was resting on top of CNA 1's thighs. LPN 1 stated that resident 28 hit one of the legs of mechanical lift as she landed on the ground. LPN 1 stated that resident 28, Should be transferred with two CNA's, not one. An interview was conducted with CNA 1 on [DATE] at 4:05 PM, related to resident 28's fall from the mechanical lift. CNA 1 stated she was a contracted employee and that she had not received any training prior to working on the floor. CNA 1 stated that she was to, go out there and do it. CNA 1 stated that she asked CNA 2 for assistance with transferring resident 28 from the shower chair to the bed. CNA 1 stated that CNA 2, Didn't want to help and kept walking down the hall. CNA 1 stated that she asked CNA 3 for assistance with transferring resident 28 from the shower chair to the bed. CNA 1 stated that CNA 3 was slow with responding to her request for assistance. CNA 1 stated that she transferred resident 28 without assistance. CNA 1 stated that the sling to the mechanical lift fell off and resident 28 slid out of the sling. CNA 1 stated that she had transferred resident 28 multiple times by herself. B. Potential for Harm 1. Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 21's medical record was reviewed on [DATE]. A significant change MDS dated [DATE] revealed that resident 21 required extensive 2 or more person physical assistance with transfers. A care plan dated [DATE] and updated on [DATE] revealed a Problem of The resident has an ADL self-care performance deficit r/t (related to) dementia. The goal was, The resident will maintain current level of function in ADLs through the review date. One of the interventions updated on [DATE] revealed Transfer: The resident requires Extensive assist with (2) staff assistance for transfers. Resident 21's incident report dated [DATE] revealed, CNA called me to room resident was sitting on the floor with his back against the bed. No injuries noted. 'I am weak and my leg gave out.' The Immediate Action Taken revealed, Assisted resident up onto wheelchair with 2 person assist (assistance).Encourage staff to transfer with teo (sic) person assist until resident is stronger. Resident 21's CNA documentation revealed that resident 21 was transferred with one person physical assistance on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 2:40 PM, an interview was conducted with CNA 7. CNA 7 stated that she transferred resident 21 by herself on [DATE]. CNA 7 stated that resident 21's leg gave out and he was lowered to the floor. CNA 7 stated she was not aware that resident 21 was a 2 person extensive assistance when she transferred him alone. On [DATE] at 3:30 PM, an interview was conducted with the DON. The DON confirmed that resident 21 was not transferred according to the care plan and resident 21 sustained a fall. 2. Resident 40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 40's medical record was reviewed on [DATE]. A significant change MDS dated [DATE] revealed resident 40 required 2 or more person extensive assistance with transfers. A care plan dated [DATE] and updated on [DATE] revealed a Problem of The resident has an ADL self-care performance deficit r/t muscle weakness. One of the goals developed was, The resident will maintain current level of function in ADLs through the review date. One of the interventions dated [DATE] and revised on [DATE] revealed, Transfers: The resident uses Hoyer to maximize independence with transferring. A progress note dated [DATE] revealed, Resident was lowered to the floor during transfer. No injuries noted. Resident 40's incident report dated [DATE] revealed, When transfering (sic) resadient (sic) with student aid. ( I was unaware that resadient (sic) was a lift). We went to do a two person lift, when the student aid tripped and fell , pushing wheel chair back. I then lowed resident to the floor went and got the nurse. I had the student aid sit with the resident until I had someone to do a two person lift off the ground. On [DATE] at 1:57 PM, an interview was conducted with CNA 6. CNA 6 stated that she was not aware that resident 40 required a lift for transfers. CNA 6 stated that she arrived 15 to 20 minutes prior to her shift each day to review the new resident medical records. CNA 6 stated the morning of [DATE] she did not have time to review the medical records. CNA 6 stated that resident 40 told her to lift her to transfer her. CNA 6 stated that her and a student CNA were transferring resident 40 when the student CNA tripped and started to fall. CNA 6 stated that resident 40 was lowered to the floor. CNA 6 stated that after resident 40 fell she reviewed resident 40's medical record. CNA 6 stated that she found that resident 40 was care planned to transfer with a hoyer lift. On [DATE] at 3:30 PM, an interview was conducted with the DON. The DON confirmed that resident 40 was not transferred according to care plan and resident 40 sustained a fall. 3. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], resident 4's medical record was reviewed. Resident 4's Nursing Progress Notes revealed on [DATE], resident 4 experienced a fall in his bathroom during an assisted transfer and sustained a bruise to his right hand. The following statements from the facility staff and resident 4 were documented in an incident report dated [DATE]: a. Nursing Description: Resident found sitting on the bathroom floor with his back up against the toilet seat. Resident had a gait belt around his waist and socks with no shoes, c/o (complains of) hurting his hand but no further injuries noted. CNA reported he fell during transfer. She stood him up and he was holding on the sink and didn't stand long enough to make it to the toilet.(CNA 5) reported that she was assisting resident onto the toilet and he was standing with assist but did not stand long enough to get to the toilet and she assisted him to the floor.Communication to staff to transfer resident with 2 person assist when toileting. A review of resident 4's MDS assessment from [DATE] revealed that the resident was assessed as requiring extensive physical assistance from two or more people during toilet use. The instructions on the MDS assessment revealed that toilet use included how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet . (Note: Only one CNA was documented as assisting resident 4 on [DATE] when he experienced a fall while transferring to the toilet.) On [DATE] at 10:22 AM, the Director of Nursing (DON) was interviewed. No additional information was provided. 4. Resident 33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 33's medical record was reviewed on [DATE]. Resident 33's Nursing Progress Notes dated [DATE] revealed,Resident had an assisted fall her family, (Name of MD) and DON (Director of Nursing) have all been notified. The incident report for the fall on [DATE] revealed, Resident was being transferred with the use of a sit to stand with the assistance of (CNA 4), the battery died on the sit to stand and the (sic) while the resident was hanging in the air, the harness slipped up and the resident slid down to the floor with the assistance of (CNA 4). (CNA 4) then called (LPN 4) who completed a physical evaluation and assisted (CNA 4) in getting the resident off the floor and into her wheelchair. Resident stated that the lift stopped working, the harness slid off and (CNA 4) helped her to the floor. (CNA 4): While transferring the resident in the sit to stand lift the battery died and harness began to slide up the resident's back and she started to slide down toward the floor. I assisted her to the ground by releasing one side of the harness while standing behind her assisting her to the ground and then I call (LPN 3) for assistance. Notes . 2. Staff educated on how to properly use the battery charger and how to tell if the battery is fully charged, and proper usage of a harness. 3. Harness evaluated for proper fit and found that the harness in use was too small, a larger harness was placed for use during sit to stand transfers. A review of resident 33's MDS Assessment from [DATE] revealed that the resident was assessed as requiring extensive physical assistance from two or more people during transfers. The facility's Resident Transfer Protocol - Safety Techniques in Transfer policy from [DATE] was reviewed. The policy stated, At least two (2) staff members are needed to transfer a resident when using a lift device . A sit-to-stand device should only be used with residents/patients that can bear some body weight . On [DATE] at 7:35 AM, the Director of Nursing (DON) was interviewed. The DON stated that resident 33 can bear some weight (and) it depends on a good day or a bad day. On [DATE] at approximately 11:30 AM, the Restorative Nursing Aide (RNA) was interviewed. The RNA stated that two people should be used during a resident transfer with a sit-to-stand lift. The RNA stated for an appropriate transfer, the staff needed to make sure the sling is the right size by lifiting it up and looking at the resident's body size. On [DATE] at 2:11 PM, CNA 4 was interviewed. CNA 4 stated that she was not sure how to check the battery on the sit-to-stand lift that was used to transfer resident 33 on [DATE]. CNA 4 stated I don't know that they had (a sling) that was big enough for (resident 33) yet. She was fairly new.

Based on interview and record review, it was determined for 1 of 29 sample residents, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice. Specifically, a resident who was diagnosed with [REDACTED]. Resident identifier: 28. Findings include: Resident 28 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 28's medical record was reviewed on 4/3/18. On 12/20/17 at 4:43 PM, the facility Staff Development Coordinator (SDC), documented in an electronic progress note, While transferring resident from shower chair to bed, strap on hoyer came undone, resident fell with assist from (name redacted), CNA (Certified Nurse Assistant). Husband, DON (Director of Nursing), and Physician notified. On 10/9/17, the facility staff completed a quarterly Minimum Data Set (MDS) assessment. Resident 28 was assessed as having been cognitively intact with a Brief Interview for Mental Status score of 13. The facility staff assessed resident 28 as having had impairment of the both the upper and lower extremities. The facility staff documented that resident 28 required two or more people when being transferred. Resident 28 was unable to move herself on or off the toilet, turn and face the opposite direction, walk, moving from a seated to a standing position, or ambulate during the assessment period. Review of the Activities of Daily Living (ADL) care plan, developed on 11/10/17, revealed that resident 28 was to be transferred with a bariatric lift for comfort with extensive assistance from two or more people. An order was received on 8/1/17 to administer [MEDICATION NAME]-[MEDICATION NAME] 5/325 milligrams(mg) 1-2 tablets every 8 hours as needed for pain. On 12/20/17 at 4:25 PM, The Staff Development Coordinator (SDC) completed an incident report related to resident 28's fall from the mechanical lift. The SDC documented, .Nursing Description: CNA (Certified Nurse Assistant) (1) was transferring resident from shower chair to bed with hoyer lift, left leg strap on hoyer came undone and resident started to slide. (CNA 1) grabbed resident and assisted her to the floor.Immediate Action Taken Description: Resident was assessed by (SDC). Pain noted to L (left) hip. Resident was turned to place sling under her and then lifted with the hoyer into bed.Resident was assessed again. Only complained of pain to L hip. Resident seen by (name of physician redacted). Resident sent by ambulance to (local hospital) ER via ambulance. An interview was conducted with the SDC on 4/3/18 at 1:31 PM, related to resident 28's fall from the mechanical lift on 12/20/17. The SDC stated that resident 28 was nonweight bearing to the lower extremities and required transfer assistance of two people with a mechanical lift. The SDC stated at approximately 11:50 AM, CNA 1 completed resident 28's shower and was transferring resident 28 from the shower chair to the bed using the mechanical lift. The SDC stated that the sling was wet. The SDC stated that CNA 1 did not ensure that the sling loops were securely attached to the mechanical lift prior to rising resident 28. The SDC stated that the lower left sling loop fell of the hook resulting in resident 28 sliding out of the mechanical lift sling. The SDC stated that resident 28 hit the floor, approximately 6 to 8 inches away from the bed, when she went down. The SDC stated that when she entered resident 28's room, resident 28 was partially propped up against CNA 1. The SDC stated that resident 28 complained of pain to the left groin and hip area. The SDC stated that resident 28's pain was rated at a 9 on a scale of 1-10 with 10 being excruciating. The SDC stated that despite resident 28 complaining of pain to the left hip area, the decision was made to put resident 28 back in the sling (requiring resident 28 to be rolled on her left side to place the sling underneath her) and lifted in the mechanical lift (placing resident 28 in a cradled position while being lifted) thus causing resident increased pain and discomfort. The SDC stated that resident 28 was placed back in the bed to complete a full trauma assessment before resident 28's physician was notified. The SDC stated that the resident 28's physician was not notified of the fall until 12:42 PM, 52 minutes after the fall occurred. The SDC stated that resident 28's physician assessed resident 28 and gave an order for [REDACTED]. The SDC stated that resident 28's husband stated that he wanted resident 28 to be sent to the hospital for an evaluation. An interview was conducted with Licensed Practical Nurse (LPN) 1 on 4/3/18 at 2:35 PM, related to resident 28's fall from the mechanical lift. LPN 1 stated that resident 28 required a mechanical lift when being transferred. LPN 1 stated that sling was wet and that only 3 of the loops on the sling were hooked to the mechanical lift. LPN 1 stated that CNA 1 got (resident 28) to the position next to her bed when she (resident 28) began sliding to the floor. LPN 1 stated that CNA 1 tried to break resident 28's fall and upon entering resident 28's room, resident 28's head was resting on top of CNA 1's thighs. LPN 1 stated that resident 28 hit one of the legs of mechanical lift as she landed on the ground. LPN 1 stated that resident 28 complained of pain to the left hip area with light touch. LPN 1 stated that range of motion was not checked because of resident 28 complained of pain after the fall. LPN 1 was asked why resident 28 was placed back in a sling to be transferred into bed. LPN 1 stated that resident 28 was uncomfortable on the floor and wanted to get back in bed despite complianing of pain when being touched or moved. LPN 1 stated that the [MEDICATION NAME] with [MEDICATION NAME] 5/325 mg was not administered to resident 28 after sustaining the fall from the mechanical lift with a suspected hip injury. An interview was conducted with CNA 1 on 4/3/18 at 4:05 PM related to resident 28's fall from the mechanical lift. CNA 1 stated she was a contracted employee and that she had not received any training prior to working with residents. CNA 1 stated that she was to, go out there and do it. CNA 1 stated that she asked CNA 2 for assistance with transferring resident 28 from the shower chair to the bed. CNA 1 stated that CNA 2, Didn't want to help and kept walking down the hall. CNA 2 stated that she asked CNA 3 for assistance with transferring resident 28 from the shower chair to the bed. CNA 1 stated that CNA 3 was slow with responding to her request for assistance. CNA 1 stated that she transferred resident 28 without assistance. CNA 1 stated that the sling to the mechanical lift fell off and resident 28 slid out of the sling. CNA 1 stated that she had transferred resident 28 multiple times by herself. CNA 1 further stated that resident 28 cried out in pain when there was pressure applied or movement to the left hip area. Resident 28 was seen at the hospital emergency roiagnom on [DATE] at 1:14 PM. The emergency room physician documented that resident 28 had severe tenderness to movement of the left hip and moderate tenderness to the left thigh. The emergency room physician documented that resident 28 sustained an Intertrochanteric and subtrochanteric [MEDICAL CONDITION] hip. Intertrochanteric left [MEDICAL CONDITION], which is mildly comminuted. There is varus angulation of the femoral neck displacement of the lesser trochanteric fracture segment.

Based on observation, interview and record review it was determined, for 3 of 29 sample residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose (including duplicate drug therapy); for excessive duration; without adequate monitoring; and without adequate indications for its use. Specifically, a resident was administered medication with drug interaction warnings which resulted in a critically high laboratory potassium and resident was admitted to the ICU (Intensive Care Unit), resident 45. The deficient practice for resident 45 was found to occur at a harm level. In addition, another resident was administered blood pressure medication outside of parameters and another resident was administered the wrong dose of medication. The deficient practice for residents 9 and 19 were found to occur at a potential for harm level. Resident identifiers: 9, 19 and 45. Findings include: A. Harm 1. Resident 45 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. On 4/5/18, resident 45's closed medical record was reviewed. Resident 45's physicians orders revealed the following: a. 2/21/18, [MEDICATION NAME] Tablet 25 MG (milligrams). Give 1 tablet by mouth one time a day for hypertension. b. 2/21/18, [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth one time a day for hypertension. c. 2/22/18, Potassium Chloride ER (extended release) tablet.10 MEQ (milliequivalents) Give 1 tablet by mouth one time a day related to Acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. d. 2/26/18, Potassium Chloride ER tablet.10 MEQ. Give 2 tablets by mouth two times a day related to [DIAGNOSES REDACTED]. According to Nursing (YEAR) Drug Handbook potassium chloride has an interaction with potassium-sparing diuretics. The interaction, (MONTH) cause [MEDICAL CONDITION]. Use together with extreme caution. Monitor potassium level. Reference: Nursing (YEAR) drug handbook. (2016). Philadelphia, PA: Wolters Kluwer. A review of resident 45's progress notes revealed the following entries: a. 2/22/18 at 11:37 AM, Note Text: The order you have entered Potassium Chloride ER Tablet Extended Release 10 MEQ. Give 1 tablet by mouth one time a day related to ACUTE [MEDICAL CONDITION] WITH [MEDICAL CONDITION]. Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The system has identified a possible drug interaction with the following orders: [MEDICATION NAME] Tablet 25 MG. Give 1 tablet by mouth one time a day for hypertension Severity: Severe. Interaction: Co-administration of Potassium Chloride ER Tablet Extended Release 10 MEQ and [MEDICATION NAME] Tablet 25 MG may cause [MEDICAL CONDITION], possibly leading to cardiac arrhythmias or [MEDICAL CONDITION]. [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth one time a day for hypertension Severity: Moderate. Interaction: [MEDICAL CONDITION], possibly with cardiac arrhythmias or [MEDICAL CONDITION], may occur with the combination of angiotensin antagonists and potassium products. Serum potassium concentrations should be monitored. b. On 2/26/18 at 5:34 PM, Note Text: Spoke with (resident 45's physician) regarding K+ (potassium) level 3.3. Order received to increase Potassium dose to 10 mEq two caps BID. (Note: Resident 45's was increased from 10 mEq per day to 40 mEq per day.) c. On 2/26/18 at 5:37 PM, Note Text: The order you have entered. Potassium Chloride ER Tablet Extended Release 10 MEQ. Give 2 tablet by mouth two times a day related to ACUTE [MEDICAL CONDITION] WITH [MEDICAL CONDITION]. Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction. The system has identified a possible drug interaction with the following orders: [MEDICATION NAME] Tablet 25 MG Give 1 tablet by mouth one time a day for hypertension Severity: Severe. Interaction: Co-administration of Potassium Chloride ER Tablet Extended Release 10MEQ and [MEDICATION NAME] Tablet 25MG may cause [MEDICAL CONDITION], possibly leading to cardiac arrhythmias or [MEDICAL CONDITION]. [MEDICATION NAME] Tablet 20 MG. Give 1 tablet by mouth one time a day for hypertension. Severity: Moderate. Interaction: [MEDICAL CONDITION], possibly with cardiac arrhythmias or [MEDICAL CONDITION], may occur with the combination of angiotensin antagonists and potassium products. Serum potassium concentrations should be monitored. d. On 2/26/18 at 5:38 PM, Note Text: Also received order to recheck BMP on Thurs (Thursday) 3/1. e. On 2/27/18 at 1:39 AM, Note Text: resident c/o mouth and throat being extremely dry with ice not helping much. Staff instructed to try hard candy or gum to increase saliva in oral cavities. f. On 3/6/18 at 3:11 PM, Note Text: Called (resident 45's physician) regarding pt.'s (patients) c/o (complaints of) HA (headaches) with nausea (times) 2 days with Tylenol not effective. (Resident 45's physician) ordered Phenergren (sic) 25mg 1-2 tabs (tablets) BID and [MEDICATION NAME] 500mg 1 tab BID with the Phenergren (sic) for HA and nausea. He will review next week. g. On 3/9/18 at 1:17 PM, Note Text: (resident 45's physician) called to ask how pt. was doing. He stated her Potassium was 7 (critical), creatinine 3.2, and BUN was 79. He wants her sent to the ER for fluids to get her potassium level down. Will notify DON (Director of Nursing) and pt. on plans. ( (Resident 45's physician) stated he was going to call the ER (emergency room ) to give report. Resident 45's physician visits were reviewed and revealed the following: a. 2/23/18, .PLAN: Continue current care for now in rehabilitation setting with anticipated ongoing review. b. 2/27/18, .The patient's current medications were reviewed and discussed as appropriate and any recent pertinent labs (laboratory) were discussed and reviewed as well. PLAN:.Recent lower serum potassium is noted on labs with adjustments implemented in potassium dosing. Repeat potassium level anticipated. (Note: There was no follow up date in resident 45's physician note.) c. 3/1/18, .PLAN: Continue current care for now in rehabilitation setting with ongoing review. (Note: There was no information regarding drug interactions with Potassium chloride, [MEDICATION NAME] and [MEDICATION NAME].) A care plan dated 2/22/18 revealed, I am newly admitted to the community with a [DIAGNOSES REDACTED]. One of the goals developed was, Resident will have no decline in psychosocial well-being during adjustment to placement in the community. Interventions developed revealed, Evaluate medications for possible interactions: obtain DX (diagnoses) for each medication. The Emergency Department note dated 3/9/18 at 4:37 PM, revealed that resident 45 had, loss of appetite, a headache, fatigue and weakness. The Course of Care revealed, Patient is [AGE] year-old female that was sent over from the (name of nursing home) for acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. Patient had an IV (intravenous) placed and started on IV fluids. Labs were rechecked, including kidney function as well as potassium levels. Patient noted to be in acute [MEDICAL CONDITION] with [MEDICAL CONDITION].patient being admitted to the ICU. A form titled, Flowsheet Print Request revealed the following laboratory results for resident 45: (Note: There were no reference ranges for the laboratory values on the form.) a. 2/20/18 (Prior to Admission), Sodium level was 142, Potassium level was 3.7, Blood Uria Nitrogen (BUN) was 32 which was indicated as high, and creatinine level was .80. b. 2/21/18 (Date of Admission), Sodium level was 144, Potassium level 3.8, BUN 37 which was indicated as high, and creatinine level was 0.80. c. On 2/26/18, Sodium level was 143, Potassium level was 3.3 which was indicated as low, BUN was 35 which was high, and creatinine level was 0.90. d. On 3/1/18, Sodium level was 142, Potassium level was 3.8, and BUN level was 44 which was indicated as high and creatinine level was 1.1 which was indicated as high. e. On 3/9/18 at 8:20 AM, Sodium level was 141, potassium level was 6.9 with an asterisk and exclamation point by the laboratory value, and BUN level was 79 which was indicated as high and a Creatinine level of 3.2 which was indicated as high. On 4/3/18 at 3:35 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 45 was admitted to the facility to get stronger. RN 2 stated that resident 45 had a couple of headaches that were treated with Tylenol. RN 2 stated that resident 45 had a headache that caused nausea. RN 2 stated the warning medication interaction note appeared on the computer screen when ordered medications were entered by the nurses. RN 2 stated that she notified physicians of medication interaction warning and documented the notification to the physician on the warning. RN 2 stated that physician called her the morning that resident 45 was discharged to the hospital. RN 2 stated that the physician asked how resident 45 was and informed her that resident 45's potassium level was critically high. On 4/4/18 at 8:59 AM, an interview was conducted with the contract Pharmacist. The Pharmacist stated that resident 45 needed to have potassium levels monitored when taking the medications [MEDICATION NAME] and Potassium Chloride. The Pharmacist stated that resident 45 needed to be monitored for symptoms of muscle cramping, headaches and nausea for possible [MEDICAL CONDITION]. On 4/4/18 at 10:06 AM, an interview was conducted with the facility Medical Director (MD). The MD stated that he was resident 45's physician since admission to the facility on [DATE]. The MD stated that resident 45 was admitted to the facility with orders for the Spirolactone and Potassium Chloride. The MD stated he was aware that there was a medication to medication interaction but did not document the risks. The MD stated that he would expect for weekly monitoring of potassium levels. The MD stated that he was not sure if resident 45 had a history of [REDACTED]. The MD stated that the laboratory informed him of the high potassium level and he called the nurse at the facility to send resident 45 to the ER. The MD stated that he was notified that resident 45 had complained of nausea and headaches. The MD stated that if the symptoms persisted he would have ordered laboratory values. The MD stated he did not know why the laboratory was done at 8:20 AM and resident 45 was not sent to the hospital until the afternoon. (Note: The ED report revealed that resident 45 was at the hospital at 4:37 PM.) On 4/4/18 at 11:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the laboratory was collected at 8:20 AM. The DON stated that the laboratory classified the critically high potassium level as medium priority. The DON stated that she did not know why the laboratory classified it as medium. The DON stated that she did not know why a basic metabolic panel was not done when resident complained of headaches and nausea. The DON provided a copy of the laboratory report which was printed on 4/4/18 at 11:17 AM revealed, Medium Importance.Results called to (resident 45's physician) by (name redacted) at 3/9/18 13:06 (1:06 PM). The report further revealed the potassium level was 6.9 mmol/L (millimoles per liter) which was critically high. The DON did not have any additional information. B. Potential for Harm: 1. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/3/18, resident 9's medical record was reviewed. physician's orders [REDACTED]. a. 8/1/17, [MEDICATION NAME] ER (extended release) 25 milligrams (mg) tablet, Give 1 tablet orally in the morning related to Chronic Diastolic [MEDICAL CONDITION]. b. 8/1/17, [MEDICATION NAME] ER 25 milligrams (mg) tablet, Give 1 tablet orally in the evening related to Chronic Diastolic [MEDICAL CONDITION]. The Medication Administration Records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following entries: a. 8/27/17, PM BP (blood pressure) 98/66, [MEDICATION NAME] ER 25 mg administered. b. 9/20/17, AM BP not monitored, [MEDICATION NAME] ER 25 mg was administered. c. 10/26/17, AM BP 109/69, [MEDICATION NAME] ER 25 mg was administered. d. 10/28/17, AM BP 105/64, [MEDICATION NAME] ER 25 mg was administered. e. 10/31/17, AM BP 107/67, [MEDICATION NAME] ER 25 mg was administered. f. 11/8/17, AM BP 108/73, [MEDICATION NAME] ER 25 mg was administered. g. 11/13/17, PM BP 113/71, [MEDICATION NAME] ER 25 mg was held. h. 11/16/17, PM BP not monitored, [MEDICATION NAME] ER 25 mg was administered. i. 11/27/17, PM BP not monitored, [MEDICATION NAME] ER 25 mg was administered. j. 11/30/17, PM BP 114/73, [MEDICATION NAME] ER 25 mg was held. k. 12/4/17, AM BP 110/64, [MEDICATION NAME] ER 25 mg was held. l. 12/16/17, PM BP 111/65, [MEDICATION NAME] ER 25 mg was held. m. 12/17/17, PM BP 84/53, [MEDICATION NAME] ER 25 mg was administered. n. 12/18/17, PM BP 103/56, [MEDICATION NAME] ER 25 mg was administered. o. 12/18/17, AM BP 103/56, [MEDICATION NAME] ER 25 mg was administered. p. 12/21/17, PM BP not monitored, [MEDICATION NAME] ER 25 mg was administered. q. 12/22/17, PM BP not monitored, [MEDICATION NAME] ER 25 mg was administered. r. 12/27/17, PM BP not monitored, [MEDICATION NAME] ER 25 mg was administered. s. 1/2/18, PM BP 109/66, [MEDICATION NAME] ER 25 mg was administered. t. 1/13/18, PM BP 113/73, [MEDICATION NAME] ER 25 mg was held. u. 1/15/18, PM BP 115/51, [MEDICATION NAME] ER 25 mg was held. v. 1/22/18, AM BP 108/78, [MEDICATION NAME] ER 25 mg was administered. w. 1/22/18, PM BP 106/64, [MEDICATION NAME] ER 25 mg was administered. x. 1/23/18, AM BP 106/64, [MEDICATION NAME] ER 25 mg was administered. y. 1/27/18, PM BP 99/56, [MEDICATION NAME] ER 25 mg was administered. z. 1/28/18, PM BP 107/68, [MEDICATION NAME] ER 25 mg was administered. aa. 1/29/18, AM BP 107/68, [MEDICATION NAME] ER 25 mg was administered. bb. 1/29/18, PM BP 110/68, [MEDICATION NAME] ER 25 mg was held. cc. 1/30/18, PM BP 108/53, [MEDICATION NAME] ER 25 mg was administered. dd. 1/31/18, AM BP 108/53, [MEDICATION NAME] ER 25 mg was administered. ee. 2/6/18, AM BP 91/59, [MEDICATION NAME] ER 25 mg was administered. ff. 2/10/18, PM BP not monitored, [MEDICATION NAME] ER 25 mg was administered. gg. 2/14/15, AM BP 102/68, [MEDICATION NAME] ER 25 mg was administered. hh. 2/14/18, PM BP 110/70, [MEDICATION NAME] ER 25 mg was held. ii. 2/21/18, PM BP 110/68, [MEDICATION NAME] ER 25 mg was held. jj. 3/7/18, AM BP 109/69, [MEDICATION NAME] ER 25 mg was administered. kk. 3/7/18, PM BP 116/72, [MEDICATION NAME] ER 25 mg was held. ll 3/16/18, PM BP 126/70, [MEDICATION NAME] ER 25 mg was held. mm. 3/23/18, PM BP 113/78, [MEDICATION NAME] ER 25 mg was held. nn. 3/26/18, AM BP 106/72, [MEDICATION NAME] ER 25 mg was administered. oo. 3/27/18, AM BP 102/68, [MEDICATION NAME] ER 25 mg was administered. On 4/3/18 at 3:01 PM, an interview was conducted with the facility DON. The DON stated that there were standing orders in the policy and procedure guide to hold hypertensive medications if they were outside of parameters set by the physician. The facility Policy and Procedure revealed the following: Hypertension/Beta Blocker Management. Purpose: To establish guidance for the administration of hypertensive medications when physician specific orders are not present. Policy: -Standing policy to be utilized when physician specific parameters are not present. -Policy includes the following medications: [REDACTED] a. Carvedilol b. [MEDICATION NAME] c. [MEDICATION NAME] -Consult physician for other medications. Procedure: -Hold medication if systolic pressure is less than 110. -If medication is held for more than 7 consecutive days, contact Medical Director or PCP (Primary Care Physician) for further instructions. 2. Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/3/18, resident 19's medical record was reviewed. A review of resident 19's Order Listing Report revealed the following medication orders [REDACTED] a. On 8/1/17, 20 milligrams (mg) of Trintellix (an antidepressant) in the morning. b. On 1/10/18, 10 mg of Trintellix in the morning. The following entry was documented under resident 19's Nursing Progress Notes. On 1/24/18 at 8:48 AM, Resident supply of Trintellix in the cart is wrong dosage. Pharmacy sent new supplies on 01-22-18. Pharmacy contacted to clear up errors. (Name of Pharmacy Technician) fixed the issue. New meds to be delivered this afternoon. Will continue to monitor. A review of the facility's pharmacy delivery record revealed that on 1/22/18, a supply of Trintellix 20-mg tablets for resident 19 was delivered. (Note: Per the MD's order on 1/10/18, a supply of 10-mg tablets should have been delivered.) On 1/24/18, a supply of 10-mg tablets for resident 19 was delivered to the facility at 3:53 PM. A review of resident 19's MAR for (MONTH) (YEAR) revealed that the Trintellix was administered in the morning on 1/23/18 and 1/24/18. (Note: The correct dose of Trintellix did not arrive at the facility until after two incorrect doses had been administered.) On 4/4/18 at 10:22 AM, the Director of Nursing (DON) was interviewed. No additional information was provided.

Based on interview and record review, it was determined that the facility did not prevent verbal abuse for one sample resident that resulted in the resident being tearful and fearful. Resident identifier: 25. Findings include: Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/12/11 at 10:30 AM an interview was conducted with resident 25. Resident 25 stated that Registered Nurse (RN) 3 yelled at her and stated that resident 25 either had to start participating and moving or they were going to send her over to the long term care (LTC) area of the facility. Resident 25 then stated that RN 3 gave the certified nursing assistant (CNA) "a look" that made resident 25 feel like she was being "treated like a child". Resident 25 was hesitant to explain what happened to her, and stated that she was afraid of retaliation from facility staff. On 9/15/11 resident 25's medical record was reviewed. Nurses notes within the medical record revealed that resident 25 had reported the yelling incident to Registered Nurse (RN) 4. On 8/30/11 RN 4 documented that resident 25 was "tearful, complained of nurse on day shift, (RN 3), yelling at her today when trying to get her to move and then giving the aide looks that made patient feel bad. Patient stated 'I don't like being treatment (sic) like a kid. I apologized to her if I offended her, but I do really want to move again'." On 9/15/11 at 2:25 PM a telephone interview was conducted with RN 3 regarding the incident with resident 25. RN 3 stated that "I raised my voice with her. I guess I was yelling at her but I wasn't trying to be mean . . I was yelling at her to get her attention." On 9/15/11 at 2:29 PM a telephone interview was conducted with RN 4. She stated that all she knew about the incident with resident 25 on 8/30/11 was documented in her nurses note. RN 4 stated that she wrote a note on a sticky paper and put it on the Assistant Director of Nursing's (ADON's) computer, indicating that resident 25 had trouble with the staff on day shift on 8/30/11. On 9/15/11 at 2:39 PM an interview was conducted with the ADON. She stated that she did receive a note on her computer. The ADON stated that she also visited with resident 25 regarding the incident with staff on 8/30/11. She stated that because resident 25 was unable to give a time or situation or specifics regarding the incident, she did not think that it was abuse and did not report the incident to the Director of Nursing (DON) or administrator. On 9/15/11 at 2:00 PM a review of the policy and procedure was conducted. The policy and procedure for abuse stated that verbal abuse was defined as: "the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance, regardless of their age, ability to comprehend or disability". The policy further stated that "any person, including, but not limited to, a social worker, physician, psychologist, nurse, teacher, or employee of a private or public facility serving adults, who has reason to believe that any disabled or elder adult has been the subject of abuse, emotional or psychological abuse, neglect or exploitation shall immediately notify the nearest police officer, law enforcement agency or local office of adult protective services within the division". The policy further documented that "the facility will report the results of its findings within five working days to the required state agencies as above as well as to the resident's physician and the resident or his/her legal representative."

Based on observation, interview, and record review, the facility did not ensure that a resident who entered the facility without a pressure sore did not develop a pressure sore. Resident identifier: 78. Findings include: Resident 78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 78's medical record was reviewed on 9/12/11. A nursing assessment done on 9/3/10 documented that resident 78 did not have a pressure sore, but was at high risk for developing one. A Minimum Data Set ((MDS) dated [DATE] documented that resident 78 was at risk of developing presure ulcers, but had none at the time. An MDS dated [DATE] documented that resident 78 was not at risk of developing pressure ulcers, but had an unstageable pressure ulcer. A care plan for "Skin Integrity" was initiated on 2/10/11. The care plan documented that resident 78's skin integrity was fair, and that resident 78 did not have any wounds at the time. The care plan also documented that resident 78 was at high risk for developing a pressure sore, and that resident 78 should have had her turning frequency increased. A care plan for "Self Care Deficit" was initiated on 2/10/11. The care plan documented that resident 78 needed "extensive assist with ADLs (Activities of Daily Living)" related to her [DIAGNOSES REDACTED]. On 6/15/11 a physical therapist documented in his progress notes that resident 78 was "dependent on staff for all mobility and positioning". A physician's progress note dated 7/12/11 documented that resident 78's "skin is warm and dry." A nurses note dated 8/1/11 documented that staff had "checked pt (patient) pressure ulcer on coccyx. . . Foul odor coming from wound." No nurses notes were located that indicated when the pressure ulcer had been discovered. A wound measurement sheet dated 8/1/11 documented that resident 78 had an "unstagable (sic)" pressure sore on her coccyx that measured 6 x 5.2 centimeters (cm) and was 0.4 cm deep. The measurement sheet also documented that resident 78's wound had a "foul odor" as well as "drainage". A physician's progress note dated 8/2/11 documented that "it was discovered yesterday that she was developing a pressure sore on her coccyx. She is pretty much bedridden all the time anyway.. . .she got pretty close to a stage 3 pressure sore with some blood blister looking skin and possible (sic) a little deeper even than that over the area of the coccyx, about somewhere around 4 cm in diameter. It looks like 3 to 4 cm in diameter..." On 8/7/11 resident 78 was seen at the local acute care hospital and was diagnosed with [REDACTED]. A physician's progress note dated 8/8/11 documented that resident 78 was "seen today for follow-up on her stage 3 pressure ulcer on her coccyx. She was apparently starting to look a little septic over the weekend and was sent to the emergency room yesterday . . . and . . started her on IV [MEDICATION NAME]. . . The pressure ulcer generally looks better and smaller than it did last week when I saw it, but she does have in the center a couple of spots, about 3 in 2 cm (centimeters) of some necrotic tissue in the center that is stage 3 . . The tissue around it has been debrided and looks pretty healthy at this point with just some slight redness from the infection that she is being treated for [REDACTED]. A document entitled "Wound Care Skin Integrity Evaluation" was reviewed. It documented that as of the assessment date of 8/18/11, there was a full thickness pressure sore on resident 78's coccyx that was unstageable and measured 6 x 5 x 0.3 cm. On 9/12/11 at 3:00 PM an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 78 currently had a stage 2 pressure ulcer, that used to be a stage 3. RN 2 stated that the pressure sore had been aquired at the facility. On 9/14/11 at 10:40 AM an interview was conducted with Certified Nurse Aide (CNA) 5. CNA 5 stated that resident 78 needed to be repositioned every hour because resident 78 could not do it by herself. CNA 5 then stated that resident 78 was dependent on staff for all repositioning. When asked about resident 78's skin integrity, CNA 5 stated that resident 78 had a "sore" on her coccyx that she got from "being in bed all the time". On 9/14/11 an interview was conducted with the Director of Nursing (DON). The DON stated that "we had some problems getting some measurements done" for resident 78 and "we are changing the process. We had a treatment nurse, but the regular nurse does it now. We have a measurement process in place they do every week." With regard to resident 78, the DON stated that "there was a delay in treatment" from when the sore got discovered to when we started treatment, but could not clarify how the delay occcured. The DON stated that she was informed of the sore, she did an investigation and determined the sore to be a "deep tissue injury" from not being repositioned since resident 78 was "totally dependent on staff for mobility." The DON stated that a wound care committee meeting was held weekly with herself and the Assistant Director of Nursing (ADON) along with multiple other staff members. The DON also stated that she did not have a policy or written protocol regarding pressure sores. On 9/14/11 notes from the wound care committee were reviewed. The notes documented the following: a) Resident 78 was not discussed in the meeting held on 8/2/11 week due to "no wound care report" having been received from the section of the facility where resident 78 was residing. b) No meeting was held on 8/9/11 c) Resident 78 was not discussed in the meeting held on 8/16/11 due to "no wound care measurement" having been received from the section of the facility where resident 78 was residing. d) Resident 78 was discussed in the meeting held on 8/23/11. e) Resident 78 was not discussed in the meeting held on 8/30/11. On 9/14/11 at 1:20 PM an interview was conducted with the ADON, who stated that she was the wound care committe chairperson. The ADON stated that she did not discuss resident 78's sore on 8/30/11 because she "didn't have the sheets done yet." The ADON stated that residents are "only discussed (at the meeting) if we get the measurements." The ADON stated that she did not discuss resident 78's sore on 8/9/11 because she was at a conference. The ADON then stated that there was no official protocol regarding wounds and that she did not participate in the Qualtiy Assurance committee to discuss wounds.