Every finding on record at Umpqua Valley Nursing & Rehabilitation Center

Based on observation, interview and record review it was determined the facility failed to ensure narcotic records were maintained accurately, and an account of all controlled substances were kept for 4 of 4 medication carts reviewed for medication administration. This placed residents at risk for drug diversion. Findings include:On 8/20/25 at 2:00 PM, the narcotic logbook for the Skilled Hall medication cart showed 114 instances out of 300 opportunities in which facility staff did not sign to verify the narcotic count.On 8/20/25 at 2:04 PM, the narcotic logbook number 13 for the 200/300 hall medication cart showed 126 instances out of 300 opportunities in which facility staff did not sign to verify the narcotic count.On 8/20/25 at 2:06 PM, the narcotic logbook number 15 for the 200/300 hall medication cart showed 129 instances out of 300 opportunities in which facility staff did not sign to verify the narcotic count.On 8/20/25 at 2:10 PM, the narcotic logbook number 20 for the 100/300 hall medication cart showed 92 instances out of 300 opportunities in which facility staff did not sign to verify the narcotic count.On 8/19/25 at 3:01 PM Staff 15 (CMA) stated two staff members (CMA or Licensed Nurse) are required to reconcile the narcotics at the end of each shift to ensure narcotics are not missing. Staff 15 stated both staff members are required to sign the narcotic logbook which indicated the narcotic reconciliation was correct. Staff 15 stated if the narcotic reconciliation was not accurate Staff 2 (DNS) was to be notified.On 8/20/25 at 9:19 AM Staff 16 (CMA) stated at the end of each shift two staff members (CMA or Licensed Nurse) reconcile the narcotics after each shift to ensure narcotics are not missing. Staff 16 stated both staff sign the narcotic logbook which indicated the reconciliation was accurate. Staff 16 stated if narcotics are missing Staff 2 should be notified.On 8/20/25 at 2:12 PM, the narcotic logbook for the (TCU) Transitional Care Unit hall medication cart showed 110 instances out of 300 opportunities in which facility staff did not sign to verify the narcotic count.On 8/20/25 at 2:28 PM, Staff 2 (DNS) verified the missing signatures in the narcotic logbooks. Staff 2 stated the process for the narcotic logbooks were for two nurses or CMAs to verify the narcotic count was accurate.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary medications and provide rationale for PRN psychoactive medication beyond 14 days for 1 of 5 sampled residents (#75) reviewed for medications. This placed residents at risk for adverse side effects. Findings include: Resident 75 readmitted to the facility in 2024 with diagnoses including depression and dialysis dependence.A 6/5/25 physician order indicated trazodone in the evening for sleep as needed (PRN). No end date was indicated on the order.Review of Resident 75's MARs from 6/2025 through 8/2023 indicated trazodone was administered the following times:- 6/2025: 19 times of out 26 days.- 7/2025: 22 times out of 31 days.- 8/2025: 12 times out of 18 days.A 7/25/25 Pharmacy review indicated the PRN trazodone was requested 19 times in the past 30 days. The pharmacy review indicated the PRN medication was past the 14-day requirement and recommended to discontinue the medication or to provide a clinical rationale and duration for the medication. The pharmacy review directed the provider to use the facility's fax number to respond.A review of Resident 75's medical record revealed no clinical rationale for the continued use of the PRN trazodone past 14 days since the order date on 6/5/24.On 8/21/25 at 11:43 AM Staff 5 (RCM LPN) acknowledged Resident 75 continued to use the PRN trazodone and there was no clinical rationale in the medical record for the continued use of the medication beyond the required 14 days since the order date in 6/2025.

Based on observation, interview and record review it was determined the facility failed to provide adequate supervision to prevent accidents for 1 of 4 sampled residents (# 17) reviewed for accidents. This placed residents at risk for increased falls. Findings include: Resident 17 was admitted to the facility in 7/2025 with diagnoses of dementia and a history of falls.A Care assessment dated [DATE] noted increased fall risk due to personal history of falls, wandering behavior, poor memory, frequent self-transfers, and dementia. Staff were directed to anticipate her/his needs and perform frequent safety checks.A Nursing Facility Incident Form dated 7/30/25 indicated resident 17 had an unwitnessed fall during an attempt to reach the bathroom in her/his room.On 8/15/25 Resident 17 tested positive for Covid-19 and had been placed on droplet (tiny liquid particles) isolation. Staff were to keep the bedroom door closed at all times.Random observation from 8/11/25 through 8/15/25 on day and evening shifts revealed Resident 17 was in her/his room the entire time with staff entering when the resident's call light was activated.On 8/21/25 at 10:39 AM Staff 12 (CNA) and at 10:58 AM Staff 14 (CNA) both stated the resident was impulsive and tried attempted to exit the bed unassisted. Staff 12 stated staff were expected to perform frequent checks, but with Resident 17 being on droplet precautions and ensuring the door remained closed made it difficult to monitor the resident appropriately. On 8/21/25 at 10:55 AM Staff 13 (LPN) stated Resident 17 displayed forgetfulness and attempted self-transfers. Staff 13 reported Covid-19 precautions required Resident 17's door to be closed. Staff 13 stated more frequent checks were necessary given the resident's increased fall risk. On 8/22/25 at 8:47 AM Staff 2 (DNS) stated Covid-19-positive residents required the doors to be closed for droplet isolation. Staff 2 stated staff were expected to check high fall-risk residents every 30 minutes even if the residents were on precautions.

Based on interview and record review it was determined the facility failed to provide therapy services for 1 of 1 sampled residents (#78) reviewed for rehabilitation. This placed residents at risk for functional decline and immobility. Findings include:Resident 78 was admitted to the facility in 10/2024 with diagnoses including stroke with weakness to the non-dominant side. A 7/10/25 Provider Encounter Note revealed an order for physical therapy evaluation due to reduced mobility. On 8/19/25 at 10:03 AM Resident 78 stated she/he wanted physical therapy in order to walk again and felt frustrated because she/he was promised PT and never received it. On 8/20/2025 at 9:56 AM Staff 13 (LPN) stated when he reviewed the provider notes after a physician visit, he checked for any new orders and input them into the system. Staff 13 stated if there was any therapy order he would print out the order for therapy services. Staff 13 stated he was unaware Resident 78 had PT orders. On 8/21/2025 at 11:44 AM Staff 5 (LPN-Resident Care Manager) stated she was not unaware Resident 78 had PT orders from 7/2025. Staff 5 stated she expected the provider to either tell the floor nurse of therapy orders or to input the therapy orders into the EMR (electronic medical record).On 8/21/25 at 1:25 PM Staff 2 (DNS) she acknowledged Resident 78 had PT orders from 7/2025 and was not evaluated by therapy. Staff 2 stated she expected the provider to inform floor staff of any therapy orders and for the floor staff to review any providers notes.

Based on observation and interview it was determined the facility failed to follow proper infection control precautions for 1 of 1 sampled resident (#60) reviewed for infection control. This placed residents at risk for cross contamination and risk of infection. Findings include:According to the Center for Disease Control and Prevention: Guidelines for Prevention of Catheter-Associated Urinary Tract Infections (2009) III. B.2: -Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Resident 60 admitted to the facility in 8/2025 with diagnoses including a urinary tract infection.On 8/20/25 at 12:38 PM Resident 60's catheter bag and tubing were observed lying on the floor.On 08/20/2025 1:00 PM Staff 18 (CNA) stated the resident's catheter bag was placed on the floor with a towel underneath due to the resident's bed being in the lowest position.On 8/20/25 at 1:08 PM Staff 4 (LPN Resident Care Manager) entered Resident 60's room and confirmed the catheter bag and tubing were placed on the floor with a towel underneath and stated it was not appropriate infection control related to catheter care.

Based on observation and interview it was determined the facility failed to ensure air conditioning units were free from leaks and bathroom doors were operational in resident rooms for 2 of 5 facility hallways reviewed for physical environment. This placed residents at risk for an unsafe, lack of privacy and unsanitary environment that was not homelike. Findings include: 1. On 8/18/25 at 12:07 PM room [ROOM NUMBER]'s air conditioning was observed dripping water along the entire bottom panel onto the bedside table and down the wall causing the wall panel to [NAME]. On 8/19/2025 at 3:04 PM Staff 21 (CNA) stated the air conditioning unit had been leaking for the entire summer and the maintenance department was in the room to look at the unit several times, but the problem was ongoing. On 8/19/25 at 3:13 PM Staff 22 (CNA) stated she noticed the air conditioning leaking about six weeks ago and notified the nurse and maintenance staff of the concern.On 8/20/25 at 11:20 AM Staff 23 (Maintenance Assistant) acknowledged the air conditioning unit in room [ROOM NUMBER] was dripping water along the bottom panel to the dresser and along the wall. Staff 23 stated he unaware the unit was leaking. Staff 23 stated the maintenance department did not complete monthly audits and relied on housekeeping and nursing staff to report concerns regarding room repairs.On 8/21/25 at 10:44 AM Staff 11 (Maintenance Director) stated he was aware the air conditioning unit in room [ROOM NUMBER] was leaking. Staff 11 stated the leak was caused from the coils in the unit forming ice when the temperature was turned down too low and then would melt when the unit was turned off.On 8/21/25 at 2:24 PM Staff 1 (Administrator) stated the facility was in the process of replacing air conditioning units and expected all the units to be functioning properly.a. On 8/20/25 at 2:26 PM during a Resident Council meeting residents reported room [ROOM NUMBER]'s air conditioning was leaking and ruining posters and shelving below the unit.On 8/21/25 at 10:15 AM Staff 27 (CNA) stated she reported the air conditioning leaking in room [ROOM NUMBER] to nursing and maintenance.On 8/21/25 at 10:44 AM Staff 11 (Maintenance Director) stated he was aware the air conditioning unit in room [ROOM NUMBER] was leaking. Staff 11 stated the leak was caused from the coils in the unit forming ice when the temperature was turned down too low and then would melt when the unit was turned off.On 8/21/25 at 2:24 PM Staff 1 (Administrator) stated the facility was in the process of replacing air conditioning units and expected all the units to be functioning properly.2. On 8/20/25 at 2:26 PM during the Resident Council meeting it was revealed the pocket doors for the bathroom in room [ROOM NUMBER] and room [ROOM NUMBER] were broken and were replaced with shower curtains. Residents stated they did not feel they had privacy, odor control and was a potential fire safety concern without an appropriate door.On 8/21/25 at 10:44 AM Staff 11 (Maintenance Director) acknowledged room [ROOM NUMBER] and room [ROOM NUMBER] pocket doors were broken and shower curtains were used as a replacement. Staff 11 stated parts for the pocket doors were no longer available.On 8/21/25 at 2:24 PM Staff 1 (Administrator) acknowledged the pocket doors were broken, and the facility was in the process of repairing the doors.

Based on interview and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 7 sampled resident (#77) and 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Resident 77 admitted to the facility in 2023 with a diagnosis of stroke. A 6/21/23 MDS indicated Resident 77 was moderately impaired in cognition and required extensive two-person assist with toilet use. Resident 77 was at risk for increased incontinence which could lead to skin rashes, infections, altered skin integrity, falls and isolation. An 8/7/23 care plan revealed Resident 77 had incontinence and decreased awareness of the need to eliminate. Interventions included a bladder retraining program. Resident 77 required assistance with ADLs with interventions including provide reminders and cueing as needed, and assistance of staff for toilet use and incontinence care. The plan also indicated to ensure Resident 77's call light was in reach while she/he was in the bathroom. A review of Council Minutes revealed the following: -6/2/23 after dinner CNAs could not be located. -9/14/23 call lights wait times at night were too long and CNAs did not check in on independent residents. -11/2023 after dinner call light wait times were too long. Review of the Direct Care Staff Daily Report sheets from 6/15/23 through 7/15/23, 9/1/23 through 9/15/23, and 11/1/23 through 11/15/23 revealed the facility did not meet State minimum CNA staffing requirements for 97 shifts out of 366 shifts. A public complaint was received on 2/1/24 which indicated Witness 1 (Complainant) observed call light wait times up to one to two hours long, staff did not respond timely to Resident 77's call light for toileting, and she/he had incontinent episodes as a result when otherwise she/he would not if calls were responded to timely. On 5/13/24 at 11:11 AM Witness 1 confirmed the above complaint and stated Resident 77 tried to hold bowel movements for a long time because of the call light wait times, and had incontinent episodes because she/he had to wait a long time for the call light to be answered. Witness 1 stated since Resident 77 discharged home she/he did not have incontinent episodes with the timely assistance at home. On 5/16/23 at 8:02 AM Staff 16 (Agency CNA) stated she worked in the facility between 8/2023 and 11/2023 and was assigned up to 15 residents on day shift. Staff 16 stated she did not have enough time to complete all care and services for residents. Some residents complained of long call light wait times. Residents also had incontinent episodes because they could not wait any longer for staff to assist them. At times residents had to wait over 30 minutes for call lights to be answered after activation. On 5/16/24 at 9:45 AM Staff 21 (Agency LPN) stated during 11/2023 and 12/2023 the facility was short-staffed. Staff 21 stated staff were running around trying to get everything done and it was overwhelming for some of the nurses. Staff 21 stated he had to help CNAs constantly because they were short-staffed and needed assistance with residents. On 5/17/24 at 8:15 AM Staff 23 (CNA) stated during the Summer and Fall of 2023 it was difficult because of low staffing at the facility. At times she did not have enough time to do all her rounds of checking on the residents and did not have time to complete all required showers for residents. Call light wait times were extensively long during mealtimes as the system for delivering meals did not allow time for CNAs to answer call lights. Residents were left on the toilet, bedside commode or bed pan too long for about one time period per shift. On 5/17/24 at 1:45 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of staffing concerns. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 24, 25, 26, 27 and 28) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of staff records conducted on 5/14/24 revealed the following: - Staff 24 was hired on 3/9/22, performance evaluation not found. - Staff 25 was hired on 1/2/18, performance evaluation not found. - Staff 26 was hired on 1/25/17, performance evaluation not found. - Staff 27 was hired on 3/23/18, performance evaluation not found. - Staff 28 was hired on 5/13/20, performance evaluation not found. On 5/14/24 at 3:49 PM Staff 1 (Administrator) acknowledged the performance evaluations were not completed annually for Staff 24 (CNA), Staff 25 (CNA), Staff 26 (CNA), Staff 27 (CNA) and Staff 28 (CNA).

Based on observation, interview, and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information. Findings include: A review of the DCSDR (Direct Care Staff Daily Reports) from 6/15/23 through 7/15/23, 9/1/23 through 9/15/23 and 11/1/23 through 11/15/23 revealed the following: -6/15/23 no staff hours listed on day shift. -6/16/23 no staff hours on day shift. -6/20/23 no staff hours for CNAs on evening shift. -6/21/23 no staff hours for CNAs on evening shift. -7/14/23 no staff hours for CNAs on evening shift. -9/8/23 no staff hours for CNAs on day shift. -11/3/23 no staff hours for CNAs on evening shift and no census on night shift. -11/15/23 no staff hours for CNAs on evening shift. On 5/13/24 at 11:36 AM the DCSDR was observed with no day shift resident census posted. At 3:53 PM the DCSDR was observed posted and not updated to include the evening shift information. On 5/15/24 at 4:11 PM the DCSDR was observed posted with no resident census completed on day shift and evening shift. On 5/17/24 at 1:45 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the incomplete postings. No additional information was provided.

Based on interview and record review it was determined to facility failed to consistently monitor residents for adverse side effects to anticoagulant medication for 3 of 5 (#s 18, 32 and 52) sampled residents reviewed for unnecessary medications. This placed residents at risk for adverse side effects to medications. Findings include: 1. Resident 18 admitted to the facility in 2/2023 with diagnoses including atrial fibrillation (an irregular heart beat). A review of Resident 18's orders revealed a 1/29/24 order for Eliquis (an anticoagulant medication that thins the blood). A 5/16/24 review of Resident 18's 4/2024 MARs revealed an order to monitor twice a day for adverse side effects to the anticoagulant medication and revealed the task was signed as completed 11 out of 60 times. A 5/16/24 review of Resident 18's 5/1/24 through 5/15/24 MARs revealed an order to monitor twice a day for adverse side effects to the anticoagulant medication and revealed the task was signed as completed one out of 30 times. On 5/16/24 at 4:15 PM Staff 10 (LPN Unit Manager) stated adverse side effects to anticoagulant medications were monitored by the nurse twice a day and documented in the MAR. Staff 10 acknowledged the documentation in 4/2024 was sporadic and the task was signed as complete only once so far for Resident 18 in 5/2024. 35855 2. Resident 32 admitted to the facility in 2024 with a diagnosis of peripheral vascular disease (a buildup of fatty plaque in the arteries which narrows or blocks and reduces blood flow). An 4/8/24 signed physician order instructed staff to administer warfarin (blood thinner to prevent blood clots) five milligrams by mouth one time a day every day except Thursday and one and half milligrams on Thursdays. The 4/2024 MAR instructed staff to administer warfarin five milligrams by mouth one time a day every day except Thursday and one and half millagrams on Thursdays. Documentation indicated Resident 35 was administered warfarin as ordered. A Monitors report from 4/8/24 through 4/30/24 instructed staff to monitor of adverse reactions for use of the warfarin every day and night shift. Out of 46 opportunities there were 31 times Resident 35 was not monitored for adverse reactions for the use of an anticoagulant. On 5/17/24 at 8:41 AM Staff 10 (LPN Unit Manager) confirmed staff were not monitoring as expected. 34667 3. Resident 52 admitted to the facility in 2023 with diagnoses including a stroke. An order dated 1/4/24 instructed staff to monitor for adverse side effects of an anticoagulant medication on day and night shift. A review of the clinical record indicated adverse side effects of the anticoagulant medication were monitored 11 of 60 opportunities in 4/2024 and 2 of 16 opportunities in 5/2024. On 5/16/24 at 4:56 PM Staff 2 (DNS) and Staff 29 (Regional Director of Clinical) were asked about evaluation of medications, effectiveness, adverse side effects and resident behaviors. Staff 29 stated staff were expected to document each shift for behaviors and adverse side effects of medications.

Based on observation, interview and record review it was determined the facility failed to consistently and thoroughly monitor residents on psychotropic medications for 4 of 6 sampled residents (#s 4, 18, 52 and 77) reviewed for psychotropic medications and change of condition. This placed residents at risk for receiving unnecessary psychotropic medications. Findings include: 1. Resident 4 admitted to the facility in 2021 with diagnoses including depression and psychosis (mental disruptions of reality). A 1/10/24 physician order indicated to administer quetiapine (antipsychotic medication) to Resident 4 twice daily due to psychotic disturbances. A 1/11/24 physician order indicated to administer Zoloft (antidepressant medication) to Resident 4 daily due to major depression. The 3/2024 through 5/14/24 nursing Monitors for Resident 4 indicated to monitor for behaviors and side effects of medication which included: excessive sleepiness, verbal expression of sadness, distressing hallucinations (a false perception of objects or events), yelling, combativeness during care or to reference progress notes every day and night related to the resident's antipsychotic and antidepressant medications. No behaviors or side effects were documented for Resident 4. The 4/2024 Documentation Survey Report (document completed by CNAs) indicated Resident 4 had 13 occurrence of behaviors during the month which included yelling and screaming. There was no option to document if Resident 4 had hallucinations. The 5/2/24 Psychotropic Medication Review indicated Resident 4's targeted behaviors related to the resident's antidepressant and antipsychotic medications included her/his hallucinations and tearfulness. On 5/14/24 at 8:10 AM Staff 28 (CNA) stated Resident 4 typically had hallucinations three times in a week, CNAs had no place to chart these episodes and nurses were aware. Resident 4 was observed to fall asleep while Staff 28 assisted with her/his meal intake. On 5/15/24 at 4:33 PM an attempted conversation with Resident 4 was not completed due to her/his inability to stay awake. On 5/16/24 at 9:05 AM Staff 38 (RD) stated Resident 4 was routinely awake for three days and then slept for three days. On 5/17/24 at 8:16 AM Staff 5 (Social Services) stated Resident 4's behaviors and hallucinations both required documentation in order to appropriately monitor any increase or decrease in behaviors and side effect episodes. On 5/17/24 at 12:00 PM Staff 29 (Regional Director of Clinical) acknowledged there were opportunities for improved documentation related to Resident 4's behaviors and medication side effects. 47001 2. Resident 18 admitted to the facility in 2/2023 with diagnoses including depression and insomnia. A review of Resident 18's orders revealed a 2/15/23 order for trazodone (a medication used to treat depression and insomnia) and a 5/11/23 order for citalopram (a medication used to treat depression). A 5/16/24 review of Resident 18's 4/2024 MARs revealed an order to monitor for adverse side effects to antidepressant medications twice a day and revealed the task was signed as completed 11 out of 60 opportunities. A 5/16/24 review of Resident 18's 5/1/24 through 5/15/24 MARs revealed an order to monitor for adverse side effects to antidepressant medications twice a day and revealed the task was signed as completed one time out of 30 opportunities. On 5/16/24 at 4:15 PM Staff 10 (LPN Unit Manager) stated adverse side effects to antidepressant medications were monitored by the nurse twice a shift and documented in the MAR. Staff 10 acknowledged the documentation in 4/2024 was sporadic and the task was signed as complete only once so far for Resident 18 in 5/2024. 34667 3. Resident 52 admitted to the facility in 2023 with diagnoses including a stroke. The clinical record indicated Resident 52 received antidepressant and antianxiety medications. The medications were ordered to be monitored for adverse side effects twice a day. Resident 52 was also having behaviors of aggression toward others which were to be monitored twice a day. Review of the 4/2024 and 5/2024 MARs revealed: -the antidepressant side effects and behaviors were monitored 11 of 60 opportunities in 4/2024. -the antidepressant side effects and behaviors were monitored 2 of 32 opportunities in 5/2024. -the antianxiety side effects were monitored one time in six opportunities in 5/2024. There was no consent for the use of Buspar (antianxiety medication) in the clinical record. On 5/16/24 at 11:27 AM Staff 11 (LPN) stated Resident 52 had a stroke and the facility was unable to determine what triggered her/his aggressive and combative behaviors, but added Resident 52 was difficult to redirect. On 5/17/24 at 9:26 AM Staff 10 (LPN Unit Manager) was asked about Resident 52's consent for the use of Buspar. Staff 10 stated she did not discuss the medication with Resident 52's son. Staff 10 was asked if Resident 52's son was the decision maker. Staff 10 stated she assumed Resident 52's son could sign the consent. On 5/16/24 at 4:56 PM Staff 2 (DNS) and Staff 29 (Regional Director of Clinical) were asked about evaluation of medications, effectiveness, adverse side effects and resident behaviors. Staff 29 added staff were expected to document each shift for behaviors and adverse side effects of medications. Surveyor: [NAME], [NAME] K. 4. Resident 77 admitted to the facility in 2023 with a diagnosis of stroke. A 6/18/23 physician order instructed staff to administer one tablet of Ativan (to treat anxiety) by mouth every eight hours PRN for anxiety and two tablets by mouth every eight hours PRN for anxiety. A 6/21/23 nurse practitioner order instructed staff to administer Escitalopram Oxalate (to treat depression and anxiety) one time a day for depression. A 6/23/23 nurse practitioner order instructed staff to administer buspirone (to treat anxiety) two times a day for anxiety and to obtain a urinalysis one time only for possible UTI for one day. A 6/30/23 signed nurse practitioner order instructed staff to administer Seroquel (an antipsychotic to treat certain mental and mood disorders such as schizophrenia, bipolar, and sudden episodes of mania) every four hours as needed for anxiety. A 6/2024 MAR instructed staff to administer the following medications: -Ativan: administer one tablet by mouth every eight hours PRN with start date of 6/18/23 and a discontinue date of 6/30/23; Ativan was administered three times in 6/2024 under this order; Administer two tablets every eight hours PRN for anxiety; Ativan was administered six times in 6/2024 under this order. -Escitalopram: administer one time a day for depression with a start date of 6/22/23; Escitalopram was administered daily in 6/2024. -Buspirone: administer one tablet two times a day with start date of 6/24/23; buspirone was administered daily in 6/2024. -Seroquel: administer every six hours PRN for mood with start date of 6/18/23 and a discontinue date of 6/21/23; Seroquel was administered on 6/19/23 and 6/20/23. A 6/30/23 care plan indicated Resident 77 used psychotropic medications for anxiety and depression with interventions including to monitor for side effects and effectiveness every shift. A 7/2023 MAR instucted staff to administer Ciprofloxacin for UTI from 7/1/23 through 7/7/23. No documentation was found in clinical records Resident 77 was reassessed for the use of Ativan, Escitalopram and Buspirone after the treatment of UTI. An 8/13/23 Note to Attending Physician Prescriber revealed the pharmacist requested a review at the PRN Ativan which continued beyond 14 days for a clinical rationale. No clinical rationale was documented, but it was documented to continue for another 90 days. A Monitors reports for the following months instructed staff to monitor the following: 6/18/23 through 6/30/23: -Adverse reactions for use of antidepressant medication; out of 19 opportunities monitoring was not completed six times. -Adverse reactions for antianxiety medications; out of 21 opportunities monitoring was not completed six times. 7/2023: -Adverse reactions for use of antidepressant medication; out of 62 opportunities monitoring was not completed 26 times. -Adverse reactions for antianxiety medications; out of 62 opportunities monitoring was not completed 26 times. 8/2023: -Adverse reactions for use of antidepressant medication; out of 62 opportunities monitoring was not completed 17 times. -Adverse reactions for antianxiety medications; out of 62 opportunities monitoring was not completed 17 times. 9/2023: -Adverse reactions for use of antidepressant medication; out of 60 opportunities monitoring was not completed nine times. -Adverse reactions for antianxiety medications; out of 60 opportunities monitoring was not completed nine times. 10/2023: -Adverse reactions for use of antidepressant medication; out of 62 opportunities monitoring was not completed 15 times. -Adverse reactions for antianxiety medications; out of 62 opportunities monitoring was not completed 15 times. 11/2023: -Adverse reactions for use of antidepressant medication; out of 60 opportunities monitoring was not completed 21 times. -Adverse reactions for antianxiety medications; out of 60 opportunities monitoring was not completed 21 times. 12/1/23 through 12/12/23: -Adverse reactions for use of antidepressant medication.; out of 23 opportunities monitoring was not completed 17 times. -Adverse reactions for antianxiety medications; out of 23 opportunities monitoring was not completed 17 times. On 5/17/24 at 8:41 AM Staff 10 (LPN Unit Manager) confirmed staff were not monitoring as required. Refer to F684 35855

Based on observation, interview, and record review it was determined the facility failed to implement EBP (Enhanced Barrier Precautions: implementation of personal protective equipment [gown, gloves, masks and/or goggles] when a resident has an indwelling medical device or wound) timely for 4 of 9 sampled residents (#s 6, 9, 32, and 127) reviewed for infection control and unnecessary medications. This placed residents at risk for cross-contamination. Findings include: 1. Resident 6 admitted to the facility 4/11/24 with a diagnosis of wound infection. Resident 6's Care Plan revealed she/he was not started on EBP for her/his chronic wound infection until 5/2/24. On 5/14/24 at 1:52 PM Staff 3 (IP) stated all new residents, prior to admission, were reviewed for the need for EBP. Staff 3 acknowledged EBP were to be implemented in nursing homes, effective 4/1/24, but the facility did not educate and implement the process until the end of 4/2024. Staff 3 acknowledged Resident 6 was not placed on EBP until 5/2/24. 2. Resident 9 admitted to the facility on [DATE] with a diagnosis of a fractured ankle. A 2/26/24 Admission CAA revealed Resident 9 had cellulitis (infection of the deeper layers of the skin usually caused by bacteria) of her/his left leg. An 4/15/24 Progress Note revealed Resident 9 was started on an antibiotic for cellulitis of the left leg. The leg had three open areas with yellow drainage. A 5/2024 TAR revealed Resident 9 had open areas to the left leg On 5/16/24 Resident 9's room was not identified to require EBP. On 5/16/24 at approximately 12:00 PM Staff 11 (LPN) stated Resident 9 had MRSA (methicillin-resitant Staphylococcus aureus [drug resistant bacteria]) in the past to the left leg and currently had blisters to the leg. Staff 11 also stated the blisters resolved then reappeared. On 5/16/24 at 12:04 PM Staff 10 (LPN Unit Manager) stated Resident 9 had abrasions and swelling which leaked fluid which started on 5/14/24. Staff 10 stated, previously, the resident was on EBP for this condition and when her/his skin issue resolved the EBP were removed. Staff 10 stated the EBP were not re-implemented on 5/14/24. On 5/16/24 at 12:16 PM Staff 3 (IP) stated she was not notified Resident 9's skin condition reopened. Staff 9 stated due to the resident's history of MRSA the resident should have been placed on EBP due to the drainage. A wound culture was sent but results were not yet available. 3. Resident 32 admitted to the facility 4/5/24 with a nephrostomy tube (surgically placed tube in the kidney to drain urine). Resident 32's care plan indicated EBP were not implemented until 5/2/24. On 5/14/24 at 1:52 PM Staff 3 (IP) stated all new residents, prior to admission, were reviewed for the need for EBP. Staff 3 acknowledged EBP were to be implemented in nursing homes effective 4/1/24 but the facility did not educate and implement the process until the end of 4/2024. Staff 3 acknowledged Resident 32 was not placed on EBP until 5/2/24. 4. Resident 127 was admitted to the facility 4/26/24 with a surgical wound infection and received medications through a surgically placed catheter in a vein. Resident 6's care plan revealed EBP were implemented 5/6/24. On 5/14/24 at 1:52 PM Staff 3 (IP) stated all new residents, prior to admission, were reviewed for the need for EBP. Staff 3 acknowledged EBP were to be implemented in nursing homes effective 4/1/24 but the facility did not educate and implement the process until the end of 4/2024. Staff 3 acknowledged Resident 127 was not placed on EBP until 5/6/24.

Based on interview and record review it was determined the facility failed to ensure antibiotic stewardship for 3 of 9 sampled residents (#s 1, 32, and 77) reviewed for infection control, UTIs and change of condition. Findings include: 1. Resident 1 admitted to the facility in 10/2023 with diagnoses including bladder cancer. A review of Resident 1's medical record revealed 4/19/24 orders to start Augmentin (an antibiotic) for 21 days. A review of Resident 1's labs revealed an 4/22/24 urine analysis (UA) with culture and sensitivity which grew pseudomonas aerugimosa (a type of bacteria), which was not sensitive to Augmentin. On 5/15/24 at 11:19 AM Staff 3 (Infection Preventionist) stated Resident 1's 4/22/24 UA was sent to the urologist. Staff 3 was unable to produce documentation of the urologist's review of the UA. A 5/15/24 review of Resident 1's medical record revealed no evidence for an antibiotic time-out. On 5/15/24 at 3:16 PM Staff 2 (DNS) and Staff 30 (Regional Director of Clinical) acknowledged an antibiotic time-out was not completed and pseudomonas aerugimosa was not sensitive to Augmentin. 26991 2. Resident 32 admitted to the facility in 2024 with a diagnosis of kidney stones. An 4/12/24 Emergency Department Document revealed Resident 32 was evaluated for increased pain and was started on an antibiotic for a possible UTI. An 4/2024 MAR revealed Resident 32 was administered antibiotics from 4/13/24 through 4/17/24. An 4/14/24 urine culture revealed no growth. Resident 32's clinical record did not reveal the facility staff communicated with the resident's physician for the continued use of an antibiotic when the resident's culture showed no growth. On 5/15/24 at 10:44 AM Staff 3 (IP) acknowledged Resident 32's urine culture was negative but the resident's antibiotics continued to be administered. Staff 3 stated if the floor staff obtained the urine culture and it was negative they should have notified the physician to determine if the resident benefitted from continued antibiotic use. A request was made to Staff 3 to provide documentation Resident 32's physician assessed the risk versus benefit of continued use of an antibiotic. No additional information was provided. 35855 3. Resident 77 admitted to the facility in 2023 with diagnosis of stroke. A 6/18/23 Administration Notes revealed the following: -6:44 AM Resident 77 was agitated and yelling and screaming out she/he was in pain and was going to die. Resident 77 stated she/he was getting worse and not better. Resident 77 only had Tylenol (to treat mild to moderate pain) available. -7:34 AM indicated Resident 77 was still agitated and yelling about random things and less about pain. -9:16 AM the on-call provider was notified the Tylenol was not effective. -9:36 AM verbal order of Seroquel (to treat certain mental and mood disorders such as schizophrenia, bipolar, and sudden episodes of mania) every six hours as needed for mood. A 6/23/23 Physician order instructed staff to obtain a urinalysis one time only for possible UTI for one day. A 6/2023 Lab and Diagnostic Administration Report instructed staff to obtain a urinalysis one time only for possible UTI for one day. It was documented as completed on 6/24/23. No documentation was found in clinical records Resident 77 received the 6/23/23 ordered urinalysis. A 7/1/23 Nursing Note revealed Resident 77 was found with blood and urine-soaked incontinent pad. Resident 77 stated she/he had to urinate, and a bed pan was placed with no urine output. When the bed pan was removed Resident 77 stated here it comes and bloody fluid drained out onto the incontinent pad in copious amounts. Resident 77 was on blood thinners. Relevant areas of change in condition: increased confusion, increased agitation, restless and not able to adequately verbalize what was bothering her/him, painful urination, blood in urine, new or worsening incontinence. An order was received to start Ciprofloxacin (antibiotic to treat bacterial infections) and to complete a urinalysis and a bladder scan. A 7/2023 Lab and Diagnostic Administration Report instructed staff to obtain a urinalysis one time only for bladder pain and bleeding for three days. On 7/1/24 the report documented to hold and referred the reader to progress notes at 5:24 PM. 7/2/23 through 7/4/23 notes were blank with no documentation. A 7/1/23 Administration Note revealed to obtain a urinalysis one time only for bladder pain and bleeding for three days. A urinalysis was not obtained because Resident 77 was no longer having pain, and the bleeding was starting to subside. A 7/2023 MAR instructed staff to administer Ciprofloxacin one tablet two times a day for UTI, bladder infection for seven days with a start date of 7/1/23. Resident 77 was administered Ciprofloxacin from 7/1/23 through 7/7/23. No documentation was found in clinical records Resident 77 received a urinalysis or a bladder scan. On 5/17/24 at 10:28 AM Staff 29 (Regional Director of Clinical) was informed of the above findings, and she stated she would like to review the issue. No additional information was provided.

Based on interview and record review it was determined the facility failed to provide medication-related risk and benefits information to residents or resident representatives prior to administration for 2 of 6 sampled residents (#s 77 and 52) reviewed for medications. This placed residents and resident representatives at risk for lack of informed consent. Findings include: 1. Resident 77 admitted to the facility in 2023 with a diagnosis of stroke. A 6/18/23 physician order instructed staff to administer one tablet of Ativan (to treat anxiety) by mouth every eight hours PRN for anxiety and two tablets by mouth every eight hours PRN for anxiety. A 6/21/23 nurse practitioner order instructed staff to administer Escitalopram Oxalate (to treat depression and anxiety) one time a day for depression. A 6/23/23 nurse practitioner order instructed staff to administer buspirone (to treat anxiety) two times a day for anxiety. A 6/30/23 signed nurse practitioner order instructed staff to administer Seroquel (an antipsychotic to treat certain mental and mood disorders such as schizophrenia, bipolar, and sudden episodes of mania) every four hours as needed for anxiety. A 6/2024 MAR instructed staff to administer the following medications: -Ativan: administer one tablet by mouth every eight hours PRN with start date of 6/18/23 and a discontinue date of 6/30/23; Ativan was administered three times in 6/2024 under this order; Administer two tablets every eight hours PRN for anxiety; Ativan was administered six times in 6/2024 under this order. -Escitalopram: administer one time a day for depression with a start date of 6/22/23; Escitalopram was administered daily in 6/2024. -Buspirone: administer one tablet two times a day with start date of 6/24/23; buspirone was administered daily in 6/2024. -Seroquel: administer every six hours PRN for mood with start date of 6/18/23 and a discontinue date of 6/21/23; Seroquel was administered on 6/19/23 and 6/20/23. No documentation was found in clinical records risk and benefits information or consent was provided or received for Resident 77 or her/his representative for the use of Ativan, Escitalopram, buspirone, or Seroquel. On 5/16/23 at 9:07 AM Witness 2 (Family Member and Representative) stated she did not receive any information about Resident 77's Ativan, Escitalopram, buspirone, or Seroquel. On 5/17/24 at 10:12 AM Staff 14 (LPN Unit Manager) confirmed no consents were completed for the above medications and it was expected of staff to complete these before administering the medications. 34667 2. Resident 52 admitted to the facility in 2023 with diagnoses including a stroke. On 5/7/24 a physician order was obtained to start Buspar (antianxiety medication). A review of the clinical record revealed no information Resident 52 was notified of the new medication and it's risks and benefits. There was no indication Resident 52 had a surrogate decision maker. On 5/17/24 at 9:26 AM Staff 10 (LPN Unit Manager) was asked about Resident 52's consent for the use of Buspar. Staff 10 stated she did not discuss the medication with Resident 52's son. Staff 10 was asked if Resident 52's son was Resident 52's representative. Staff 10 stated she assumed Resident 52's son could sign the consent.

Based on interview and record review it was determine the facility failed to honor a resident's right to refuse a transfer to another room for 1 of 2 sampled residents (#25) reviewed for positioning. This placed residents at risk for lack of honored choices. Findings include: Resident 25 admitted to the facility in 2023 with diagnoses including depression and seizures. An 4/3/24 Written Notice of Room Change indicated Resident 25 was asked to move to a semi-private room from a private room on 4/17/24 and Resident 25 refused to sign the room change notification. An 4/3/24 facility Daily Census indicated multiple vacant resident rooms were available on this date. An 4/25/24 Profile for Resident 25 indicated she/he was moved to a different room. On 5/13/24 at 3:53 PM Resident 25 stated she/he refused to sign the 4/3/24 Written Notice of Room Change because she/he had the right to remain in her/his room and did not want to move. On 5/14/24 at 3:33 PM Staff 5 (Social Services) acknowledged the 4/3/24 notification was given to Resident 25 because the facility was choosing to repurpose the use of the resident's private room for the benefit of a new hospice admission. Staff 5 stated she was unsure if Resident 25's refusal to sign the document was an indication of her/his room transfer refusal. On 5/16/24 at 4:15 PM Staff 1 (Administrator) and Staff 2 (DNS) stated the room transfer for Resident 25 was completed because of the benefit to the facility and community. Staff 1 acknowledged she was unaware of the details of the requirements under the regulation.

Based on interview and record review it was determined the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) for 1 of 3 (#378) sampled residents reviewed for beneficiary notification. This placed residents at risk for lack of appeal information. Findings include: Resident 378 admitted to the facility with Medicare Part A services on 12/1/23 with diagnoses including cellulitis (an infection of the skin) of the right lower limb. A 1/12/2024 Social Services Note revealed Resident 378 had home health set up upon discharge from the facility, a ramp in place at home and Resident 378 was ready to discharge home once her/his IV antibiotics were completed. A 1/17/24 Progress Note revealed Resident 378's IV antibiotics were completed. Resident 378 discharged from the facility on 1/19/24. A 5/14/24 medical record review revealed no evidence the facility issued a NOMNC for Resident 378. On 5/14/24 at 1:24 PM Staff 35 (Social Service Director) confirmed Resident 378 discharged on [DATE] once her/his goals were met. Staff 35 stated Resident 378 was not issued a NOMNC prior to discharge.

Based on observation, interview, and record review it was determined the facility failed to resolve a resident's report of missing clothing for 1 of 2 sampled residents (#6) reviewed for personal property. This placed residents at risk for missing items. Findings include: Resident 6 admitted to the facility in 2024 with diagnoses including a surgical infection. An 4/17/24 Admission MDS revealed Resident 6 was cognitively intact. On 5/13/24 at 1:12 PM Resident 6 stated over one week prior she reported to the laundry staff her/his black jacket and a shrinker sock (special sock to wear over an amputation prior to placing a prosthetic) was missing. On 5/14/24 at 1:04 PM Staff 6 (Laundry) stated if a resident reported a missing item staff immediately looked for the item. If the item was not found, staff wrote the resident's name and missing item on a chalk board and also on a piece of paper to alert staff to look for the item. With Staff 6 the chalk board was observed to not have Resident 6's name or missing items listed. Staff 6 stated she did not see Resident 6's name on any paper to alert staff to look for the missing items. Staff 6 also stated she was not aware Resident 6 was missing a shrinker sock or jacket. On 5/15/24 at 12:19 PM Staff 5 (Social Services) stated in 2023 Resident 6 had a shrinker sock replaced but she was not aware of current missing items. Staff 5 stated in addition to the laundry process for monitoring for reported lost items, grievances were addressed in the daily staff meetings. On 5/15/24 at 4:07 PM Staff 7 (Regional Activities and Social Service Consultant) stated if staff did not log a resident's missing item on a Grievance sheet the facility would not be able to track if the item was found, replaced, or if the concern had a resolution. Staff 7 also indicated grievances were to be addressed within seven days.

Based on interview and record review it was determined the facility failed to report allegations of abuse and misappropriation to the state agency or local law enforcement for 2 of 6 sampled residents (#s 1 and 47) reviewed for abuse and medications. This placed residents at risk for abuse. Findings include: 1. Resident 1 admitted to the facility in 10/2023 with diagnoses including quadriplegia. A review of a 2/22/24 grievance revealed Resident 1 had $160 go missing on 2/15/24, and the facility replaced the money on 3/21/24. A review of an 4/22/24 MDS revealed Resident 1 was cognitively intact. On 5/16/24 at 10:48 AM Staff 1 (Administrator) stated she did not think the money was missing to begin with. Staff 1 acknowledged the allegation of missing money was not reported to the state agency or to local law enforcement, and stated if there was a trend of missing money in the facility, it would have been reported. 34667 2. Resident 47 admitted to the facility in 2021 with diagnoses including stroke and severe cognitive impairment. Resident 52 admitted to the facility in 2023 with diagnoses including a stroke. The clinical record indicated on 5/4/24 at 10:30 PM Resident 52 was sitting in the 100 hall near the nursing station. Resident 47 was mobilizing in her/his wheelchair on the 100 hall toward the nursing station and when she/he got near Resident 52, Resident 52 reached out and hit Resident 47 in the face. A nurse intervened and attempted to educate Resident 52 about the inappropriateness of hitting others and Resident 52 stated I do what I want. An investigation, finalized on 5/9/24, concluded there was no abuse as Resident 52 was not injured in the altercation and Resident 47 did not recall the event. On 5/17/24 at 10:52 AM Staff 1 (Administrator) acknowledged the facility reported the altercation late on 5/16/24 and additional education was needed.

Based on interview and record review it was determined the facility failed to complete thorough investigations for allegations of abuse for 2 of 6 sampled residents (#s 1 and 47) reviewed for abuse and medications. This placed residents at risk for abuse. Findings include: 1. Resident 1 admitted to the facility in 10/2023 with diagnoses including quadriplegia. A review of a 2/22/24 grievance revealed Resident 1 had $160 go missing on 2/15/24, the facility replaced the money on 3/21/24. A review of an 4/22/24 MDS indicated Resident 1 was cognitively intact. On 5/16/24 at 10:48 AM Staff 1 (Administrator) stated she did not think the money was missing to begin with, and acknowledged the allegation of missing money was not investigated. 34667 2. Resident 47 admitted to the facility in 2021 with diagnoses including a stroke and cognitive impairment. Resident 52 admitted to the facility in 2023 with diagnoses including a stroke. A progress note dated 5/4/24 at 10:30 PM documented Resident 52 was sitting in her/his wheelchair on the 100 hall near the nursing station. Resident 47 was mobilizing in her/his wheelchair on the 100 hall toward the nursing station and as she/he got near Resident 52, Resident 52 reached out and started hitting Resident 47 in the face. On 5/16/24 at 11:27 AM Staff 11 (LPN) stated Resident 52 had a stroke and the facility was unable to determine what triggered her/his aggressive and combative behaviors but added Resident 52 was difficult to redirect. On 5/16/24 at 2:27 PM Staff 10 (LPN Unit Manager) stated Resident 52 was transferred to the 300 hall to maintain a distance from Resident 47. Staff 10 stated Resident 52 was always agitated and he clocked Resident 47 when passing in the hall. On 5/17/24 at 9:37 Staff 14 (LPN Unit Manager) relayed the event and added the residents passed each other often over the past few months and there were no issues. Staff 14 stated Resident 52 made it clear she/he hit Resident 47 on purpose. The Investigation dated 5/4/24 did not include witness statements, evaluation of either residents orientation, contained inaccurate cognitive information for Resident 52 or statements from the residents involved. The investigation ruled out abuse and neglect based on lack of injury to Resident 52 and Resident 47's lack of recall of the event. On 5/17/24 at 10:55 AM Staff 29 (Regional Director of Clinical) stated abuse was ruled out because Resident 47 was not injured and there was no mental anguish related to the event. Staff 29 was asked about witness statements from staff working on 5/4/24. Staff 29 added there may have been additional witness information completed on separate papers. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure a safe and orderly discharge for 1 of 2 sampled residents (#77) reviewed for discharge. This placed residents at risk for unmet medications needs. Findings include: Resident 77 admitted to the facility in 2023 with a diagnosis of stroke. A 12/7/23 Discharge Orders and Instructions (discharge packet) revealed instructions for Resident 77 to continue medication on the Discharge Medication List and the medications were sent to pharmacy of choice. The signed Orders and Summary report included the following: Amlodipine (to treat high blood pressure), Atorvastatin (to treat high bad cholesterol), Baclofen (to treat muscle spasms), buspirone (to treat anxiety), clopidogrel (used to prevent heart attacks and strokes), Diclofenac (to treat mild to moderate pain and swelling), Docusate (to treat constipation), Escitalopram (to treat depression), Ibuprofen (to treat mild to moderate pain), Insulin (to treat diabetes), Levoxyl (to treat an underactive thyroid), Lisinopril (to treat high blood pressure), and Miralax (to treat constipation). The Discharge Planning Review revealed a section to document medications sent with Resident 77 at the time of discharge, but the area was blank with no documentation of which medications were sent. No documentation was found in Resident 77's clinical record which medications were sent with the resident at the time of discharge, or if the pharmacy was provided the prescriptions by the facility. A public complaint was received on 2/1/24 which indicated Resident 77 was not provided her/his insulin and other medications upon discharge from the facility. Witness 1 (Complainant) stated during a discharge planning meeting she was informed she would receive 30 days of medications and the prescriptions. On the day of discharge Staff 21 (Agency LPN) informed Witness 1 Resident 77 was not on insulin which was not correct. When Witness 1 went to the pharmacy she was informed it was a typed list of medications and not a prescription. It took two days to get Resident 77's insulin and approximately three weeks to obtain all of Resident 77's medications. On 5/13/24 at 11:11 AM Witness 1 confirmed the above information. No documentation was found in Resident 77's clinical record the pharmacy was contacted for the missing medications. On 5/16/24 at 9:45 AM Staff 21 stated he did not complete many discharges at the facility. Staff 21 stated the facility did not go over the directions, policy, or check list with him on how to discharge a resident from the facility. Staff 21 stated he went over upcoming appointments and went over the medications list. On 5/17/24 at 10:12 AM Staff 14 (LPN Unit Manager) stated she was notified Resident 77 did not get all her/his medications upon discharge and she called the pharmacy the day after discharge. Staff 14 stated she did not remember which medications were missing and she did not document in Resident 77's clinical record about the missing medications or notify the pharmacy.

Based on interview and record review it was determined the facility failed to provide appropriate services to prevent, treat and identify changes in pressure ulcers for 1 of 2 sampled residents (#67) reviewed for pressure ulcers. Resident 67 acquired a pressure ulcer which became severely infected resulting in gas gangrene (a life threatening condition in which a bacterial infection produces toxins that release gas and cause tissue death) and required acute care intervention. Findings include: Resident 67 admitted to the facility in 11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received hospice services. The 11/29/21 Admission Assessment indicated the resident had no pressure ulcers upon admission to the facility. The resident's 12/1/21 Care Plan indicated the resident had potential for impairment to skin related to her/his fragile skin. Interventions in place to prevent skin impairments included the following: *Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. *Educate resident of causative factors and measures to prevent skin injury. *Encourage good nutrition and hydration in order to promote healthier skin. *Use a draw sheet or lifting device to move resident to prevent shearing. *Report any areas of concern to the nurse. *Keep skin clean and dry. Use lotion on dry skin. *Perform and document weekly skin checks. Notify MD if skin integrity becomes compromised. *Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The 12/1/21 Care Plan did not include interventions for pressure ulcer prevention. A 12/6/21 New Pressure Investigation revealed a CNA reported the resident had a new sore on her/his right ankle. Staff 12 (RN) completed the incident report and indicated she noted a 3 cm x 2 cm Stage 2 pressure ulcer (a partial thickness wound which presents as a shallow, open ulcer with a red or pink wound bed) on the resident's right outer ankle. A 12/6/21 wound care order instructed staff to cleanse the ulcer with wound cleanser, pat dry and apply a foam dressing every other day and PRN. The first Wound Evaluation was done four days later on 12/10/21 and revealed Resident 67 developed an unstageable pressure ulcer (a pressure ulcer covered with a significant amount of dead tissue which prevents viewing of the wound bed) on her/his right lateral malleolus (outer ankle). The pressure ulcer measured 2.12 cm x 1.21 cm. The Wound Evaluation indicated additional treatment provided was a foam mattress and a repositioning program. The care plan was not updated at the time of identification of the pressure ulcer or with the first evaluation. The wound care orders were changed to: cleanse, apply calcium alginate (a dressing made of natural fibers designed to be highly absorbent of wound drainage) and foam dressing every two days. A week after the initial discovery of the pressure ulcer, a 12/13/21 Hospice Clinical Note indicated Staff 12 requested an alternating pressure and pump (AP&P) mattress for Resident 67. The following day, on 12/14/21, it was documented Staff 12 called again to clarify the resident required a bariatric AP&P mattress. A 12/15/21 Hospice Clinical Note revealed an AP&P mattress was not available in the bariatric size and a low air loss bariatric mattress was delivered to the facility instead. A 12/15/21 Wound Evaluation indicated the pressure ulcer grew in size by 63% and deteriorated. The pressure ulcer measured 2.58 cm x 1.38 cm x 0.1 cm. On 12/15/21 the resident's Care Plan was revised to indicate the resident had actual impaired skin integrity to her/his right outer ankle. The interventions were updated to include float the resident's heels while in bed and reposition every two hours as the resident allowed. A 12/21/21 Hospice Clinical Note revealed Staff 16 (RN) contacted hospice to inform them the mattress delivered on 12/15/21 did not fit the bed frame. A 12/22/21 Hospice Clinical Note indicated a new mattress was delivered and was in use. The 12/22/21 Wound Evaluation indicated the pressure ulcer was stable and measured 2.76 cm x 1.05 cm x 0.1 cm. It was noted the ulcer had a small amount of drainage. The wound care orders were changed to: cleanse, apply Hydrogel (a dressing for dry to minimally draining wounds used to breakdown slough) to wound bed and cover with foam dressing every day. The 12/27/21 Wound Evaluation indicated the pressure ulcer was stable and measured 2.47 cm x 1.63 cm x 0.1 cm. According to the Wound Evaluation the ulcer had a light amount of drainage and no odor. Additional care included an air flow pad and a heel suspension device. The 1/4/22 Wound Evaluation revealed the pressure ulcer was deteriorating and increased in size by 90%. The pressure ulcer measured 3.31 cm x 2.51 cm. According to the Wound Evaluation the ulcer had a light amount of drainage and no odor. It was noted Resident 67 was resistant to elevation of the foot of the bed and was educated related to compliance with elevation. On 1/4/22 the wound care orders were updated to include: secure foam dressing with an ace wrap to ensure the dressing did not become displaced. Additionally a nursing order instructed staff to check every six hours to ensure the dressing was intact and the right foot was elevated. A 1/8/22 12:36 AM progress note revealed the dressing change was uncomfortable for the resident. A 1/9/22 12:52 AM progress note revealed Resident 67 reported pain with movement of her/his right leg and dressing change. On 1/9/22 at 3:15 PM a progress note indicated the resident again reported pain in her/his right leg. The dressing was found to be partially saturated and was removed. According to the progress note after cleansing the wound Staff 16 noted an exposed and necrotizing (dying) tendon that smelled like rotting flesh. The resident was sent to the hospital. A review of all facility MD and Nurse Practitioner encounter notes from 11/24/21 through 1/10/22 revealed no mention of the pressure ulcer. On 1/10/22 at 3:21 PM Staff 16 stated he began working in the wound care nurse position a month prior but had not received training on wounds yet. He stated there were issues with getting a pressure relieving mattress for Resident 67 after the identification of the pressure ulcer. Staff 16 reported he assessed the ulcer on 1/4/22 during the weekly wound evaluation and when he saw it next on 1/9/22, it had major changes and went downhill really fast. Staff 16 reported the dressing was saturated and once he removed it, the site was likely infected and was black around the wound's border. A 1/10/22 Hospital Progress Record revealed Resident 67 had [CONDITION(S)] (bone infection) of the right foot with gas gangrene and would likely require a below the knee amputation. The resident ended her/his hospice services to pursue treatment. On 1/12/22 at 12:34 PM Staff 21 (CNA) reported she assisted the nurse with the resident's dressing change on 1/8/22 and the ulcer looked much worse. On 1/12/22 at 4:58 PM Staff 12 reported she did the dressing change on the resident's pressure ulcer on 1/7/22 and stated it had increased drainage but did not appear infected. Staff 12 further reported the facility MD and Nurse Practitioner never looked at the resident's wounds themselves. On 1/12/22 at 6:00 PM Staff 16 reported he put wound care orders into the system. He stated he would discuss the wounds and orders with Staff 2 (Director of Nursing) as needed. Staff 16 stated he did not know if the facility MD or Nurse Practitioner reviewed the orders. On 1/13/22 at 6:01 PM Staff 25 (RN), who documented she provided the wound care on the two evenings prior to the resident's hospitalization , reported the resident's pressure ulcer was about baseball size, blackish with stringy stuff coming out of it and was horribly smelly. She stated she provided wound care for Resident 67 on two days the previous week and the ulcer was much worse on 1/9/22. Staff 25 stated she would not call anyone about concerns related to wounds because she worked the night shift and instead she would pass it on to the oncoming nurse. On 1/13/22 at 3:43 PM and 6:08 PM Staff 2 stated the wound care treatments were decided by the nurse who did the weekly wound evaluation and was based on the facility's wound care protocol. She reported the facility MD or Nurse Practitioner did not personally see the wound. Staff 2 stated staff did not report a worsening pressure ulcer to her. She said she expected nurses to notify the MD if they noticed a wound worsened or appeared infected.

Based on interview and record review it was determined the facility failed to execute fall risk interventions for 1 of 3 residents (#5) reviewed for abuse. Resident 5 experienced a fall and sustained a right proximal humeral fracture (a break in the upper part of the bone in the arm) and experienced increased pain. Findings include: A public complaint was received on 4/30/21 indicating Resident 5 fell out of her/his bed onto the floor during the process of morning resident care. Resident 5 was transported to the emergency room . It was reported there was only one caregiver providing care. Resident 5 admitted to the facility in 2018 with diagnoses including stroke and muscle weakness. Resident 5's care plan for ADLs, last updated 1/24/19, indicated Resident 5 required assistance with ADLs. Interventions included two staff to assist with repositioning, turning in bed and for transferring with a mechanical lift. The 4/1/21 Annual MDS indicated Resident 5 was cognitively intact. Resident 5 was at risk for falls with a history of falls. Resident 5 required extensive two person assist with most ADLs including: bed mobility, transfers, toileting and dressing. Resident 5 had left-sided visual deficits. The 4/6/21 Pain Evaluation indicated Resident 5 was capable of verbalizing pain and her/his pain was at a level of zero on a numeric pain scale of zero to 10. The 4/2021 MAR instructed staff to administer the following medications for pain: -Acetaminophen every eight hours PRN for pain. Resident 5 requested the medication on 4/8/21, 4/10/21 and 4/30/21. -[MEDICATION(S)] (pain medication) every four hours PRN for moderate and severe pain for seven days with a start date of 4/30/21. Resident 5 received the medication on 4/30/21 with a pain level of six. A 4/2021 Documentation Survey Report revealed Resident 5 was assisted by one person for bed mobility on 20 instances on day shift out of 30 opportunities, 21 instances on evening shift out 30 opportunities, and 10 instances on night shift out of 36 opportunities. The report revealed Resident 5 was assisted by one person for transfers four instances on day shift out of 30 opportunities, and 14 instances on evening shift out of 30 opportunities. A 5/5/21 Investigation indicated on 4/30/21 Resident 5 experienced a witnessed fall. During the process of morning care Resident 5 was rolled over by Staff 3 (CNA) and Resident 5's legs slid off of the side of the bed, causing her/his entire body to roll off the bed to the floor. Staff 3 stated she repositioned the resident by herself when the care plan indicated Resident 5 required the assistance of two staff for repositioning. Resident 5 sustained a right knee bruise and abrasion, and a bruise to her/his thigh and left upper arm. Due to right shoulder pain an X-ray was ordered, the results of which revealed a right proximal humeral fracture. Resident 5 was transferred to the hospital for further evaluation. Physician orders were obtained for pain management. Abuse and neglect could not be ruled out because the care plan was not followed and only one person was assisting with care. A review of Resident 5's progress notes from 4/30/21 through 5/11/21 revealed: -4/30/21 Staff 9 (LPN) went into Resident 5's room after Staff 3 (CNA) informed her Resident 5 fell . Resident 5 was face down on the floor stating her/his right shoulder hurt. Staff 3 placed Resident 5 back into bed. Resident 5 could not move her/his arm, the on-call doctor was notified and an X-ray was ordered. -4/30/21 Resident 5 was administered acetaminophen due to pain from the fall. -5/2/21 [MEDICATION(S)] administered due to arm pain. -5/3/21 [MEDICATION(S)] administered; Resident 5's right arm was very painful. -5/4/21 [MEDICATION(S)] administered due to arm pain. -5/5/21 [MEDICATION(S)] administered due to arm pain. -5/10/21 acetaminophen administered due to arm pain. The 4/30/21 right shoulder X-ray indicated Resident 5 sustained an acute proximal humeral fracture. The 4/30/21 hospital notes indicated Resident 5 sustained a right humeral fracture. A shoulder sling was placed for comfort and recommendation was made to continue [MEDICATION(S)] (used to treat arthritis) for pain, and to apply ice to the shoulder. A POC Response History from 5/1/21 through 5/12/21 revealed Resident 5 was provided one person physical assistance for the following reasons on the following dates: - Bed Mobility four instances on 5/1/21, 5/6/21, 5/10/21 and 5/11/21. - Transfers two instances on 5/1/21 and 5/10/21 The 5/2021 MAR instructed staff to administer the following medications for pain: -Acetaminophen every eight hours PRN for pain. Resident 5 requested the medication on 5/9/21, and 5/10/21. -[MEDICATION(S)] every four hours PRN for moderate and severe pain for seven days with a start date of 4/30/21. Resident 5 was administered [MEDICATION(S)] on 5/1/21 five instances with the highest pain level of seven. On 5/2/21 she/he was administered [MEDICATION(S)] two instances with pain levels of six and seven. On 5/3/21 Resident 5 was administered [MEDICATION(S)] two instances with pain levels of six and three, on 5/4/21 one instance with a pain level of six and on 5/5/21 one instance with a pain level of five. On 5/14/21 at 11:24 AM and on 5/25/21 at 11:05 AM Staff 2 (DNS) stated the pain medication was effective without the use of ice for Resident 5's shoulder. Staff 2 confirmed Staff 3 failed to follow Resident 5's care plan. Staff 3 was placed on administrative leave and did not return to work with residents at the facility.

Based on interview and record review it was determined the facility failed to ensure 1 of 3 residents (#6) reviewed for [MEDICATION NAME] medications were free from significant medication errors. Resident 6 was hospitalized for [REDACTED]. Resident 6 was admitted to the facility in 9/2019 with [DIAGNOSES REDACTED]. A 10/21/19 Clinical Laboratory Report revealed Resident 6's [MEDICATION NAME] (PT)/INR test was performed (measures how long it takes for blood to clot). The PT results were 12.3 and INR was 1.18. Resident 6's [MEDICATION NAME] (an anticoagulant medication) dosage was adjusted according to the INR result. New orders for [MEDICATION NAME] were 4 milligrams all days except 3 milligrams on Sunday. Normal therapeutic range for INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people taking [MEDICATION NAME] for disorders such as [MEDICAL CONDITION]. An 10/23/19 Dosage Schedule and INR revealed Resident 6's INR was 1.26 and the dosage schedule was ordered for four milligrams of [MEDICATION NAME] daily. An 10/2019 MAR indicated [REDACTED] -Four milligrams one time a day all days except Sunday with a start date of 10/21/19 and discontinue date of 10/28/19. The medication was administered 10/24/19 through 10/26/19. -Four milligrams one time a day all days with start date 10/24/19 and discontinue date of 10/28/19. The medication was administered 10/24/19 through 10/27/19. -Three milligrams every Sunday with start date of 10/27/19 and discontinue date of 10/28/19. The medication was administered 10/27/19. -Four milligrams in the evening one time a day on Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday with start date of 10/29/19 and discontinue date of 11/5/19. The medication was administered on 10/29/19 and 11/1/19. The nurse who received the [MEDICATION NAME] orders failed to discontinue previous [MEDICATION NAME] orders. As a result, Resident 6 received [MEDICATION NAME] eight milligrams for three days from 10/24/19 through 10/26/19 and seven milligrams for one day on 10/27/19. Resident 6 received double the order of [MEDICATION NAME] for four consecutive days. On 10/28/19 the resident's INR results were critically high. A 10/28/19 Facsimile Cover Sheet from the physician revealed Resident 6's INR was critical at 4.21 and the current [MEDICATION NAME] order was four milligrams Monday through Saturday and three milligrams on Sunday. The physician ordered to hold [MEDICATION NAME] 10/28/19 then administered four milligrams once a day per the PT/INR results in one week. A 11/11/19 Investigation Nurses Note revealed on 10/23/19 the doctor was notified regarding possible [MEDICAL CONDITION] (a blood clot within a deep vein, typically in the thigh or leg). New orders included to send Resident 6 to urgent care for evaluation. At urgent care a PT/INR test was conducted with INR results 1.26. New orders were received for [MEDICATION NAME] 4 mg daily and recheck next PT/INR on 10/28/19. The nurse who received the [MEDICATION NAME] orders failed to discontinue previous [MEDICATION NAME] orders. This resulted in Resident 6 receiving [MEDICATION NAME] eight milligrams for three days from 10/24/19 through 10/26/19 and seven milligrams of [MEDICATION NAME] for one day on 10/27/19. On 10/28/19 Resident 6's INR results were critically high at 4.21. Orders were received to hold Resident 6's [MEDICATION NAME] dose on 10/28/19; and resume four milligrams daily on 10/29/19, recheck PT/INR on 11/04/19. During a chart review on 10/31/19 it was discovered Resident 6 received double her/his [MEDICATION NAME] dose for four consecutive days. An facility audit was completed on 10/31/19 which identified a transcription error for Resident 6's [MEDICATION NAME] orders. A 11/1/19 Nurses Note revealed Staff 8 (LPN) observed Resident 6 with a rectal bleed. Blood was on the fitted bed sheet staining an area of over 20 centimeters in diameter. Resident 6 was on the toilet and appeared weak and voiced she/he was not feeling well. The toilet was visualized to have blood clots and fecal matter. Recent INR were critical at 4.2 on 10/29/19 and [MEDICATION NAME] continued to be administered since the date of the blood draw for the test. The physician questioned why Resident 6's [MEDICATION NAME] was not held. Staff 8 found no explanation in clinical records. The physician requested Resident 6 be sent to the emergency room for observation. A 11/2/19 Hospital Discharge Summary revealed Resident 6 was admitted to the intensive care unit. Resident 6 required a blood transfusion for her/his [MEDICAL CONDITION]. Resident 6 was found to have bleeding diverticula (form in the walls of the digestive tract. The inner layer of the intestine pushes through weak spots in the outer lining making them bulge out to create little pouches). and was treated with argon plasma coagulation (a medical procedure used to control bleeding from certain [MEDICAL CONDITION] in the gastrointestinal tract). A 11/4/19 facility Plan of Correction revealed the Director of Nursing educated the licensed nurses, unit managers and MDS coordinators related to accurate transcription of [MEDICATION NAME] orders and related standards with INR monitoring for therapeutic levels of [MEDICATION NAME] use. Audits were analyzed weekly to determine effectiveness of the plan and results were reported to the Quality Assurance committee for review and further recommendations. On 2/5/20 at 10:05 AM Staff 8 (LPN) stated she observed Resident 6's rectal bleeding and sent her/him to the hospital. Staff 8 stated she believed the bleeding occurred due to a failure to hold Resident 6's [MEDICATION NAME] medication. On 2/11/20 at 4:55 PM Staff 2 (DNS) confirmed the investigation information regarding to Resident 6 receiving double her/his [MEDICATION NAME] dose for four consecutive days. Staff 2 stated a plan of correction was already in place due to a previous citation with a compliance date of 11/4/19. Resident 6's error was discovered on 10/31/19 and addressed through the audit process. The facility did not identify any additional concern since 11/4/19 for [MEDICATION NAME] order transcriptions.

Based on interview and record review the facility failed to accurately assess underlying causes of pain, develop person centered plans and provide pain medications as ordered for 1 of 3 sampled residents (#24) reviewed for medications. Resident 24 experienced severe pain and hospitalization . Findings include: Resident 24 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. An 8/8/18 care plan revealed Resident 24 had chronic pain due to a right [MEDICAL CONDITIONS] arthritis and [MEDICAL CONDITION] with the goal to not have an interruption in normal activities due to pain. Interventions included the following: -Anticipate Resident 24's need for pain relief and respond immediately to any complaint of pain. -Evaluate the effectiveness of the resident's pain interventions and review for compliance. -Alleviate symptoms. -Dosing schedules and resident satisfaction with results and impact on cognition. -Monitor and document pain on a scale of zero to ten before and after implementing measures to reduce pain -Probable cause of each pain episode, the anatomical location, duration, aggravating factors and relieving factors. -Notify physician if interventions are unsuccessful or if current complaint was a significant change from the residents past experience of pain. An 8/9/18 physician order [REDACTED]. An 8/9/18 Approved Prescription instructed staff to administer one tablet of [MEDICATION NAME] 10/325 every six to eight hours for pain. One prescription was faxed from the pharmacy to the facility on [DATE] at 3:23 PM and the same prescription was faxed from the pharmacy to the facility on [DATE] at 1:05 AM. No information was located in medical records [MEDICATION NAME] 10/325 every six to eight hours for pain was administered on a scheduled basis. The 8/2018 MAR indicated [REDACTED] -8/7/18: 9:47 PM level eight pain. -8/8/18: 3:52 AM level eight pain. 9:41 AM level eight pain. 1:36 PM level six pain, medication was ineffective. 5:42 PM level eight pain. 9:44 PM level nine pain, medication was ineffective. An 8/8/18 at 11:00 PM Skilled Nursing Note revealed Resident 24 was administered [MEDICATION NAME] for pain. She/he was sitting on the side of the bed about an hour later in extreme pain rocking back and forth and feeling nauseous. Resident 24 was standing up and down due to the pain. The resident's blood pressure and pulse were elevated. The The Physician was notified to request additional medication. The 8/2018 MAR, which instructed staff to administer [MEDICATION NAME] 10/325 one tablet every four hours as needed for moderate pain with a start date of 8/8/18 and a discontinue date 8/10/18, revealed the following: -8/8/18: 11:42 PM level ten pain. The 8/2018 MAR, which instructed staff to administer [MEDICATION NAME] 10/325, give two tablets every four hours for pain with a start date of 8/8/18 and a discontinue date of 8/10/18, revealed the following: -8/9/18: 9:02 AM level eight pain. 1:04 PM level eight pain. 5:12 PM level eight pain. 9:33 PM level eight pain. -8/10/18: 2:30 AM level seven pain. 9:58 AM level seven pain. An 8/9/18 at 4:39 PM Administration Note revealed the PRN administration of [MEDICATION NAME] 2 tablets every four hours was effective with a follow up pain of seven. An 8/9/18 at 7:17 PM Skilled Nursing Note revealed Resident 24 requested PRN pain medications two tablets every time. A family member encouraged the nurse to offer the PRN pain medications. An 8/9/18 at 8:30 PM Skilled Nursing Note revealed Resident 24 had pain and it was too soon for pain medication. The 8/2018 MAR indicated [REDACTED] -8/10/18: 3:06 PM level eight pain. 7:33 PM level seven pain. -8/11/18: 1:50 AM level eight pain. 1:31 PM level seven pain. -8/12/18: 8:57 AM level ten pain. 1:20 PM level seven pain. An 8/12/18 at 8:57 AM Administration Note Revealed Resident 24 was experiencing severe pain of ten. Two tablets of pain medication were administered. An 8/12/18 at 9:21 AM Emergency C II Prescription Request revealed a request for authorization for emergency dispensing of [MEDICATION NAME] 10/325 one tablet by mouth every four hours as needed for severe pain. The 8/2018 MAR, which instructed staff to administer [MEDICATION NAME] 10/325 one tablet every four hours as needed for moderate pain with a start date of 8/10/18 and a discontinue date of 8/15/18, revealed the following:. -8/11/18: 9:13 AM level five pain, medication was ineffective. 5:27 PM level five pain. 9:30 PM level six pain. -8/12/18: 1:50 AM level eight pain. 6:30 PM level five pain. 10:08 PM level seven pain. An 8/11/18 at 11:38 AM Administration Note revealed Resident 24 was administered pain medication and follow up pain was a six. The 8/2018 MAR, which instructed staff to administer [MEDICATION NAME] 10/325 two tablets every four hours as needed for pain with a start date of 8/10/18 and a discontinue date of 8/15/18, revealed the following: -8/13/18: 2:16 AM level nine pain. 7:37 AM level six pain. 11:40 AM level six pain. 4:11 PM level eight pain. -8/14/18: 1:29 AM level six pain. 6:43 AM level eight pain. 10:45 AM level eight pain. 3:30 PM level eight pain. 8:15 PM level seven pain. An 8/14/18 at 7:51 AM Administration Note revealed two tablets of [MEDICATION NAME] were administered with effective results and a follow up pain level of six. An 8/14/18 IDT note revealed Resident 24 had frequent pain the past five days with a pain level of eight out of ten. An 8/14/18 at 5:16 PM Administration Note revealed two tablets of [MEDICATION NAME] were administered with effective results and a follow up pain level of six. An 8/15/18 at 1:14 AM Nursing Note revealed Resident 24 requested pain medication. Staff 33 (LPN) noted the order was changed to [MEDICATION NAME] 10/325 one tablet every six to eight hours and notified the resident it would be another hour before pain medication would be administered. The 8/2018 MAR, which instructed staff to administer [MEDICATION NAME] 10/325 one tablet every six hours as needed for moderate pain with a start date of 8/15/18 and a discontinue date of 8/15/18, revealed the following: -8/15/18: 2:10 AM level eight pain. 8:10 AM level eight pain. 2:59 PM level eight pain. An 8/15/18 at 7:45 PM Nursing Note revealed Resident 24 was in extreme pain after pain medications were reduced. A family member contacted the physician and the order was changed back to every four hours. The 8/2018 MAR, which instructed staff to administer [MEDICATION NAME] 10/325 one tablet every four hours as needed for pain with a start date of 8/15/18 and a discontinue date of 8/17/18, revealed the following: -8/15/18: 7:51 PM level nine pain. -8/16/18: 3:43 AM level seven pain, unknown if medication was effective. 7:50 AM level seven pain. 11:51 AM level six pain. 4:34 PM level seven pain, unknown if medication was effective. 8:46 PM level eight pain. -8/17/18: 12:53 AM level nine pain. 5:00 AM level eight pain. 10:09 AM level seven pain. An 8/15/18 at 9:44 PM Administration Note revealed one tablet [MEDICATION NAME] administered and effective follow up pain was eight. An 8/15/18 at 11:45 PM Nursing Note revealed the family was concerned of lack of pain control and the current pain management regimen. The family requested Resident 24 be sent to the hospital. An 8/16/18 at 1:48 AM Nursing Note revealed Resident 24 returned from the hospital and complained of a pain level of ten. An 8/16/18 at 1:17 PM Administration Note revealed one tablet [MEDICATION NAME] administered with effective results and a follow up pain level of seven. An 8/16/18 Controlled Substance (CII-CV) Prescription Request revealed a request for [MEDICATION NAME] 10/325 take one tablet by mouth every four hours for pain. An 8/17/18 at 12:53 AM Administration Note revealed Resident 24 had a pain level of nine, requested pain medication, and one tablet of [MEDICATION NAME] was administered. On 9/14/18 at 9:34 AM Witness 6 (Family Member) stated Resident 24 was historically on scheduled pain medication, the prescription changed from every four hours to every six to eight hours, it did not cover Resident 24's pain management needs, and her/his pain got so bad she/he went to the hospital. On 10/2/18 at 12:43 PM Staff 25 (LPN) stated Resident 24's pain effected her/his day to day activities and her/his sleep. Staff 25 stated it was awful and Staff 25 taught Resident 24 breathy techniques to manage the pain. The doctor had cut back Resident 24's pain medication and her/his pain was out of control and Resident 24 had to go to the hospital to catch up. Staff 25 stated That poor (resident) .have not seen someone in that type of agony. Staff 25 did not remember Resident 24 to have a scheduled pain medication for her/his chronic pain or [MEDICAL CONDITION] arthritis. On 10/2/18 at 11:17 AM Witness 14 (Pharmacy Technician) revealed on 8/13/18 an order was faxed to the facility for one tablet of [MEDICATION NAME] 10/325 every six to eight hours for pain. Witness 14 verified Resident 24 had one prescription of [MEDICATION NAME] scheduled every six to eight hours and another [MEDICATION NAME] prescription every four hours as needed. On 10/8/18 at 3:11 PM Staff 1 (Administrator) stated the facility had no additional information in regard to why Resident 24's scheduled [MEDICATION NAME] was not administered to the resident.

Based on interview and record review it was determined the facility failed to provide care planed supervision for showers for 1 of 4 sampled residents (#3) reviewed for accidents. The resident fell , was sent to a local hospital and diagnosed with [REDACTED]. Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of a care plan dated 2/26/18 revealed the resident required assistance with ADLs due to impaired mobility, weakness and dementia. The care plan indicated the resident needed supervision of one staff to provide a bath or shower. Review of an in-room care plan dated 4/9/18 revealed the resident needed supervision of one staff to provide a bath or shower. Review of a nurse's note dated 6/9/18 at 3:58 pm revealed the resident was found on the floor of the resident's shower. The resident complained of right hip pain, the resident's physician was notified and the resident was sent to a local hospital for evaluation. Review of a nurse's note dated 6/9/18 at 4:42 pm revealed the facility was informed by the local hospital the resident was diagnosed with [REDACTED]. Review of an incident investigation dated 6/10/18 revealed on 6/9/18 the resident was assisted to the shower by staff and the resident was left in the shower without supervision. The resident fell in the shower and was assessed to have a pelvic fracture. The investigation indicated the care plan was not followed by staff and neglect was not ruled out. Review of a physician's note dated 6/11/18 revealed the resident was seen after a fall in the bathroom. The note indicated the resident was diagnosed with [REDACTED]. In an interview on 6/29/18 at 11:19 am Staff 6 (LPN) said on 6/9/18 she heard a noise come from the resident's bathroom and found the resident on the floor of the shower. Staff 6 said the resident was in the bathroom alone and was not supervised. Staff 6 said the resident was assessed, complained of hip pain and was sent to a local hospital for evaluation. In an interview on 7/10/18 at 10:00 am Staff 1 (DNS) acknowledged the resident's care plan was not followed, the resident was left in the shower unsupervised and the resident fell . Staff 1 also acknowledged the resident was sent to a local hospital and was diagnosed with [REDACTED].

Based on observation, interview and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for 1 of 2 sampled residents (#16) reviewed for nutrition. As a result Resident 16 had a severe weight loss of greater than 10% in a six month period. Findings include: Resident #16 was admitted to the facility in 2012 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/2/17 Resident 16 weighed 107.9 pounds, on 7/3/17 the resident weighed 105.3 pounds and on 8/2/17 she/he weighed 103.4 pounds. The resident's 8/14/17 Annual MDS indicated the resident had no recent weight loss or gain and had no natural teeth. The Nutrition CAA revealed the resident's normal meal intake was 38%, the resident had the ability to make her/his dietary choices known and had a 4.63% weight loss in the previous 90 days. On 9/1/17 the resident weighed 105.2 pounds, on 10/2/17 101.2 pounds and on 11/2/2017 the resident weighed 99.7 pounds. The 11/12/17 Quarterly MDS indicated the resident had no recent weight loss or gain and had no natural teeth. It did not reflect the resident's 5.5 pound weight loss between 9/21/17 and 11/2/17. On 12/4/17 the resident weighed 91.7 pounds and on 1/2/18 the resident weighed 92.3 pounds for a greater than 10% weight loss in a six month period since 7/2017. The resident's care plan, last updated on 8/25/17, indicated the resident was edentulous and required one person assist for meal set up and cueing. The care plan identified the resident was on NEM (Nutritionally Enhanced Meal) /Mechanical Soft texture diet, was to eat in her/his room and the facility was to provide and serve the diet as ordered. The goal was for the resident to have no weight loss of 5% in 30 days or 10% in 180 days. The resident was last seen by the Nutrition At Risk (NAR) committee on 12/19/17. The NAR committee identified interventions in place as NEM (nutritionally enhanced meal) diet and texture and Med Pass 2.0 ( high calorie high protein nutritional supplement) three times a day. The NAR notes indicated the resident had a weight loss due to varied oral intake and indicated disease process progressing. There was no indication of which disease process the committee determined was progressing. The decision was made to not review the resident in the NAR meetings in the future. As a result on 1/21/18 the NAR committee had not identified, reviewed or documented the resident's weight loss of greater than 10% noted on 1/2/18. The resident's progress notes revealed the resident was last evaluated by an RD in 5/2017 and there was no evidence a referral was made for a re-evaluation in 1/2018 after the resident's weight loss of greater than 10%. On 11/14/17 the Family Nurse Practitioner (FNP) noted the resident required one-on-one feeding, continued with poor appetite and the resident's weight continued to decline by about 7 pounds over the past year. On 1/10/18 the FNP noted the resident's weight of 92.3 pounds. The FNP documented the resident's weight was stable over the last few months and then revealed the resident had lost 16 lb over the last year. On 1/19/18 at 1:01 PM Staff 42 (Dietary Supervisor) indicated the facility provided the resident health shakes and magic cups (high calorie and protein ice cream type product). She stated it was the facility's practice is to give health shake if the resident consumed less than 50% meal intake. Staff 42 verified the interventions were not listed on the resident's care plan or documented by the NAR committee and the resident's nutritional status had declined. On 1/19/18 at 1:51 PM Staff 34 and Staff 35 (LPN/Unit Managers) stated the resident was served Med Pass 2.0 three times a day with medications, NEM diet and received [MEDICATION(S)] (an antidepressant medication with the common side effect of increased appetite) 7.5 mg orally every evening for appetite stimulant since 3/2017. Staff 35 verified the use of the [MEDICATION(S)] had not made a difference in the resident's appetite. Staff 35 stated the resident liked sweets, drank health shakes before and between meals, and ate in her/his room for low stimuli. Staff 34 and Staff 35 verified the care plan was not updated to include current interventions such as meal preferences or consumption of health shakes and Med Pass 2.0 or direct staff to provide snacks. Staff 34 verified there was no RD referral and there were no new interventions implemented since the resident's greater than 10% weight loss in 6 months to 92.3 pounds. On 1/21/18 at 8:20 AM Staff 43 (CNA) stated it was the first time he had worked with Resident 16 and was unaware of the resident's care needs. Staff also stated he was only provided two 4-ounce containers of health shake to give the resident at breakfast and no NEM diet.

Based on interviews and record review it was determined the facility failed to thoroughly investigate the circumstances of falls and update care plans with fall interventions for 2 of 4 sampled residents (#s 1 and 2) reviewed for fall safety. Resident 1 fell when she/he removed the tab alarm, sustained a closed head injury and was treated at the local hospital emergency department. Findings include: The facility's 11/20/09 Incident Investigation and Follow-up Policies and Procedures indicated All occurrences will be thoroughly investigated and accurately documented so the facility can evaluate why they are occurring, take corrective measures to curtail the number of incidents, assure resident safety .A Resident Incident Report is completed by the person who witnesses, responds to or discovers what appears to be an incident or accident .The Charge Nurse or Department Manager in charge at the time of the incident, or at the time the incident was discovered will conduct the initial investigation .All incidents will be recorded in the resident's clinical record (chart) in the nursing progress notes and must include the following: a. Concise and known facts and observations. b. Causes or assessed causes of the incident .e. Actions taken to prevent further reoccurrence of the incident and assure resident safety .8. All incidents require thorough investigation in an attempt to determine what occurred and to make changes to prevent reoccurrences .It is important to seek to determine how an incident occurred to implement steps to prevent further incidents from happening .a. Interview the alleged resident or victim. b. Interview witnesses, including the assigned caregiver, caregivers in the immediate area, and remote or potential witnesses .e. Observe the environment where the incident reportedly occurred. f. Review the resident plan of care .Data collected will then be analyzed by the RCM, including the following: a. How and Why: Summarize analysis of facts gathered that either establish reasonable cause for the incident or establish the need for further investigation before a reasonable cause can be established. b. How did the incident occur? c. How was the incident avoidable? d. How did the injury occur as a result of the incident? e. Were the care-planned interventions followed? .During or after the investigative phases are completed, action must be taken based on the investigation findings to correct the known or reasonable causes, as well as to prevent further reoccurrence of the alleged incident 1. Resident 1 was admitted [DATE] with a [DIAGNOSES REDACTED]. The resident was assessed by the local hospital on [DATE] to have severe memory deficit, presumed Alzheimer's dementia The resident's Initial Data Collection form, completed upon admission, identified the resident's fall risk factors. The instructions indicated the LN (licensed nurse) to check all areas if applicable to the resident and if indicated complete preliminary care plan for Fall Risk .RCM to re-evaluate effectiveness of preliminary care plan and revise as needed within 72 hours) The Fall Risk Factors indicated the resident had an orthotic condition or diagnosis, neurological condition or diagnosis, had perceptual impairment, psychosocial factors, metabolic issues, acute medical condition and a history of falls. The 6/12/15 Temporary Resident Care Plan used by the CNAs indicated a tab alarm was to be used in the bed and wheelchair. The 6/22/15 Departmental Notes written at 1:37 pm indicated the resident was found on the floor. Had taken (her/his) shirt off which had tab alarm attached to it. Resident found lying on floor between bed and side table. (She/he) hit (her/his) table at side of bed and sustained a hematoma The 6/22/15 Resident Incident Report indicated contained no documentation of the results of an investigation of how and why the incident happened. There was no documentation interventions in place and actions taken. There was no documentation the incident investigation was reviewed by DNS and Administrator. The narrative of incident indicated the charge nurse was called to res (resident) room by CNA. Resident found on floor. (She/he) had taken off tab alarm and attempted to transfer self, fell , hit head on side table The 6/24/15 and 6/27/15 Departmental Notes indicated the resident had tab alarm in place The 6/30/15 Departmental Notes indicated pressure alarms were in place. The 7/3/15 Departmental Notes written at 11:53 pm indicated the resident was found on floor at 6:00 pm sitting on buttocks next to door in room The 7/3/15 Resident Incident Report contained no documentation of the results of an investigation of how and why the incident happened. There was no documentation interventions in place and actions taken. There was no documentation the incident investigation was reviewed by DNS and Administrator. The nurse who prepared the incident report indicated new interventions used was pressure alarm. The narrative of incident indicated Patient had taken alarm off (resident) found on floor next to door sitting. No apparent injury noted There was no documentation the resident's care plan was updated to include the use of a pressure alarm. The 7/4/15 Departmental Notes written at 8:47 am indicated the resident sets (sic) of pressure alarm frequently during the night when needing to void The 7/5/15 Departmental Notes written at 12:21 am indicated the pressure alarm was going off .patient standing in front of wheelchair holding on to it the wheelchair moved and patient landed on floor on her/his buttock There was a Resident Incident Report dated 7/4/15 which contained the narrative of incident documented in the 7/5/15 Departmental Notes. There was no documentation of the results of an investigation of how and why the incident happened. There was no documentation interventions in place and actions taken. There was no documentation the incident investigation was reviewed by DNS and Administrator. The 7/5/15 Departmental Notes written at 8:02 pm indicated tab alarm sounding from room. Resident walking around room .resident educated on importance to call for assistance if needing to ambulate or transfer. Tab alarm in place. Resident noted to continue ambulating in room without assistance There was no documentation of the use of pressure alarms. The 7/7/15 Departmental Notes indicated Patient found on floor in room behind (her/his) room behind (her/him) .moderate amount of blood on floor .EMTs responded within 5 minutes. Patient's tab alarm was disconnected from (her/him), but still connected to WC (wheelchair) (her/his) shoes were untied .Patient had been attempting to remove the alarm from wheelchair through shift but we have been able to keep an eye on (her/him) and dissuade (her/him) with activities There was no documentation of the use of pressure alarms. The 7/7/15 Resident Incident Report indicated the resident contained no documentation of the results of an investigation of how and why the incident happened. There was no documentation interventions in place and actions taken. There was no documentation the incident investigation was reviewed by DNS and Administrator. The nurse who prepared the incident report indicated devices in use was a tab alarm. The narrative of incident indicated Patient removed alarm and ambulate without assist in room fell and hit back of head. (Her/his) shoes were untied. Found on floor There was no documentation of the use of pressure alarms. The 7/7/15 Departmental Notes written at 9:13 pm indicated pt (patient) returned from ed (emergency department) .pt. in bed pressure alarm in place, fall mat in place to exit side of bed The Temporary Care Plan (Bedside Care Plan) indicated the care plan was updated on 7/7/15 to include the use of pressure alarm in bed and chair. There was no documentation on the care plan of a fall mat used on the exit side of the bed. The 7/9/15, 7/14/15 and 7/15/15 Departmental Notes indicated tab alarm was in place. There was no documentation of the use of pressure alarms. The 7/16/15 Departmental Notes written at 8:06 pm indicated Very agitated and refusing to stay in bed this evening. Tag (sic) and bed alarm on patient. (She/he) takes the tag alarm off. Found standing up at the bathroom door jam hanging on to it. Unable to redirect as soon as (she/he) was laid back down (she/he) was up again. Needs one on one care from early afternoon due to profound confusion and often aggression toward staff and anyone trying to redirect (her/him) There was no documentation of the use of pressure alarms. There was no documentation in the resident's care plan regarding the need for one on one care. The 7/17/15 Departmental Notes written at 10:00 pm indicated Patient sit down at end of the hallway out of (her/his) wheelchair after taking (her/him) tag alarm off . (family member) called and notified of resident falling .Assissted (sic) to w/c and returned to bed tag/bed alarm on and functioning .(resident) may need one on one direct supervision There was no documentation of the use of pressure alarms. There was no documentation in the resident's care plan regarding the need for one on one care. The 7/19/15 Departmental Notes written at 9:39 pm indicated Pt was observed by CNA trying to stand and then fell back into chair sliding out landing on bottom The 7/19/15 Resident Incident Report contained no documentation of the results of an investigation of how and why the incident happened. There was no documentation interventions in place and actions taken. There was no documentation the incident investigation was reviewed by DNS and Administrator. The charge nurse identified the new intervention to be used was one on one care. The narrative of incident indicated Resident was observed by CNA slipping from wheelchair to the floor hitting (her/his) buttocks There was documentation the resident's plan of care was updated to include the approach of one on one care. The 7/25/15 Departmental Notes indicated the resident had a tag/bed alarm on for safety as forgets to use call light There was no documentation of the use of pressure alarms. The 8/6/15 Departmental Notes indicated Tab alarm in place for safety There was no documentation of the use of pressure alarms. The 8/8/15 Departmental Notes indicated Tag/bed alarm on as forgets to use call light to ask for assisst (sic) There was no documentation of the use of pressure alarms. The Departmental notes contained documentation daily from 8/9/15 through 8/13/15 and 8/17/15 and 8/18/15 to indicate the resident had a functioning tab alarm in place. There was no documentation of the use of pressure alarms. The resident was discharged to a local facility on 8/18/15. On 9/17/15 at 10:05 am Staff 2 (LPN/MDS Specialist) stated the facility tried all different types of alarms for the resident while she/he was in bed and wheelchair. Staff 2 stated the resident did not like the use of the alarms and would remove and not be positioned on the alarms. Staff 2 stated the alarms didn't do it for (Resident 1). Resident had dementia so unable to retain information, did not understand her/his limitations and would try to ambulate independently. Staff 2 stated the only alarm the facility did not use was an alarm on the fall mat on the floor. On 9/17/15 at 10:30 am Staff 3 (CNA) and Staff 4 (RN) stated the resident had a fall mat, tab and pressure alarms in place. The resident was fiercely independent and disliked the alarms. The staff stated the resident enjoyed sitting by the nurses' station and was on a toileting schedule. On 9/17/15 at 10:40 am Staff 5 (CNA) stated she did not work when the resident had a fall. Staff 5 stated the facility used a tab and pressure alarm and tried to ensure her/his personal items were easily accessible for the resident. Staff 5 stated the resident hated the alarms. Staff 5 stated the resident enjoyed being by the nurses' station or in the hallway where she/he was able to be with other residents and staff. On 9/17/15 at 11:00 am Staff 6 (SSD/CNA) and Staff 7 (CNA) stated the resident had tab and pressure alarms in place for the bed and wheelchair. The staff stated the resident was irritated by the alarms. The staff stated they needed to redirect her/him a lot and the resident enjoyed looking at books and magazines. On 9/17/15 at 2:00 pm Staff 1 (Interim DNS/Corporate RN Consultant) stated she was the Interim DNS while the DNS was on maternity leave. Staff 1 stated for months the facility did not have an RNCM employed on the skilled section of the building where Resident 1 resided. Staff 1 stated the facility DNS tried to complete the RNCM's duties along with DNS role. Staff 1 acknowledged the incident investigations were not complete. Staff 1 was asked to provide any additional information regarding Resident 1's falls and fall interventions. On 9/21/15 Staff 2 (LPN/MDS specialist) provided a written statement In regards to (Resident 1's) fall with injury to head. Pressure alarm was initiated upon return from the hospital (7/7/15) by this LN. It was the intervention to help prevent further occurrences, as noted in nursing notes. Patient was using both tab and pressure alarms, fall matt (sic) beside bed. Patient with significant history of falls, agitation, combativeness, was frequently kept a nursing station as well as with nurse to help fold towels, do puzzles, read books and in activities. (Family member) had been called in to spend time with (her/him) to redirect (her/him) as well from trying to ambulate. On 9/22/15 at 11:25 am Staff 1 (Interim DNS/RN Corporate Consultant) was asked to provide a copy of the fall risk assessment for Resident 1, the investigation of the 7/17/15 fall the resident sustained [REDACTED]. Staff 1 stated she thought the care was provided though acknowledged the resident's care plan was not consistently updated to include all of the fall interventions. 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/6/15 Temporary Resident Care Plan (used by CNAs) indicated the resident required the assistance of two CNAs to transfer. The 8/7/15 Departmental Notes written at 7:28 pm documented the resident fell while being assisted (sic) to shower chair for a shower, chair slid out from under (her/him) and (she/he) landed on the floor on (her/his) back. It was a witnessed fall by (Staff 8 CNA). (Resident 2) stated that (she/he) did hit (her/his) head but that it did not hurt and neuro checks and vital signs WNL (within normal limits). Able to move extremities left slightly weaker grip than right, residual from CVA (stroke) in the past .Left knee was assessed as (she/he) was c/o (complaining of) increased pain .physician notified and gave order to transport via gurney to (local hospital) .Called ER (emergency room ) to check on patient and was notified that this patient had been admitted due to patellar fx (fracture) The 8/7/15 Resident Incident Report completed by Witness 4 (Agency RN) indicated the resident fell at 1:00 pm and the narrative of the incident was called to room by nursing students. (Resident 2) on the floor between (her/his) bed and (her/his) roommate's. Head facing foot of bed. Shower chair rolled out from under (her/him) as (she/he) was trying to sit down The 8/7/15 Resident Incident Report indicated the resident contained no documentation of the results of an investigation of how and why the incident happened. There was no documentation interventions in place and actions taken. There was documentation the incident investigation was reviewed by DNS and Administrator on 8/7/15. There was an 8/7/15 Witness Form completed by Staff 8 (CNA) indicated Placed patient on the locked shower chair per care plan (2 person gait belt). The patient then leaned forward and the shower chair slipped out from under (her/him). Patient landed on the floor, bottom first There was no documentation of an interview with the resident and the other nurse aide in training. There was an 8/7/15 fax to the physician written by Witness 4 (Agency RN) as FYI (for your information) Shower chair rolled out from under (her/him) and (she/he) fell . (She/he) did hit (her/his) head and we are doing neuro checks-vital signs. No noted injury-no other pain than (she/he) already had L) (left) knee/rib. CNA (Staff 8) observed that (she/he) did not hit (her/his) head but sat down on (her/his) bottom then laid down flat on the floor The 8/7/15 ER/Hospital Transfer indicated at 2:00 pm the resident was transferred to the local hospital. The 8/7/15 Therapy Department notes written at 4:16 pm indicated the resident had an PT evaluation initiated and completed as fully as possible; limited by pt fall today and unable to get out of bed. Awaiting possible x-ray orders. Consultation with rehab team regarding pt case The resident was admitted to the local hospital emergency department on 8/7/15 at 3:39 pm. The local hospital history and physical indicated the resident refractured her/his left knee and required surgical intervention. On 8/12/15 at 3:04 pm and 9/16/15 at 11:00 am Witness 1 (Complainant) stated the resident was admitted to the facility from the local hospital on [DATE]. Witness 1 stated the resident fell while at the facility on 8/7/15 and was transported back to the local hospital. Witness 1 stated the local hospital Social Work staff informed her of the fall though she did not know the cause of the fall. Witness 1 stated the resident refractured her/his knee and did not wish to return to the facility. On 9/17/15 at 9:23 am Witness 4 (Agency RN) stated she did not witness the fall though was able to remember the incident. Witness 4 stated the staff told her they were transferring the resident into the shower chair when the shower chair came out from under the resident. Witness 4 stated from what she could remember she assessed the resident and initially thought there were no injuries. When the resident had increased pain the physician was contacted and she obtained an order for [REDACTED]. On 9/17/15 at 9:38 am Staff 8 (CNA) stated Resident 2 slipped out of the shower chair in her/his room. Staff 8 stated there was a nurse aide student with her as the resident's care plan indicated two CNAs were required for a transfer. Staff 8 stated the shower chair was placed in between the two beds in the room with the shower chair facing the head of the bed. Staff 8 stated the shower chair was locked and placed next to the bed. Staff 8 stated the two staff in the room were in front of the resident in the shower chair. Staff 8 stated the resident was on the shower chair and Resident 2 reached down to adjust her/his knee immobilizer. Staff 8 stated when she/he reached over, the shower chair flew out from underneath her/him and the resident landed on her/his back. Staff 8 was not able to state the name of the nurse aide student who was with her. Staff 8 stated there was a large group of nurse aide students who were at the facility at the time. On 9/17/15 at 9:45 am Staff 8 brought a shower chair into the room where Resident 2 resided. Staff 8 locked the brakes of the shower chair and the shower chair moved when the chair was touched. Staff 8 verified the brakes didn't hold. Staff 8 stated the resident was seated in the shower chair when the resident reached down toward the knee immobilizer without telling Staff 8 and nurse aide student what she/he needed. Staff 8 stated she was not sure what happened though it seemed when the resident's weight shifted the shower chair moved out from under the resident. Staff 8 sat in the shower chair and demonstrated how Resident 2 reached down toward her/his leg immobilizer and the shower chair did not move. Staff 8 stated she was not aware of any other residents who fell out of a shower chair. On 9/17/15 at 10:05 am Staff 2 (LPN/MDS Coordinator) stated she was doing office work when Resident 2 requested to be given a shower. Staff 2 determined the resident needed two aides to assist with transfers. Staff 2 was not aware of what occurred and not aware of any problems with the shower chair. Staff 2 stated she was not aware of any other incidents when a resident slipped out of shower chair. Staff 2 stated Staff 9 (Maintenance Director) would know if there had been issues with the shower chair. On 9/17/15 at 10:15 am Staff 9 (Maintenance Director) stated he checked the brakes on the shower chairs on a monthly basis and was not aware of a problem with the shower chair brakes. Staff 9 stated the CNAs need to remove the shower chairs from use and alert her/him of the need to be fixed. Staff 9 was not aware of Resident 2's fall from a shower chair. Staff 9 stated he would check the shower chair Staff 8 (CNA) used to demonstrate Resident 2's fall. Staff 9 provided a log book of maintenance requests from the nursing staff and there was no documentation of a problem with the shower chair brakes. On 9/17/15 at 10:40 am Staff 5 (CNA) stated she was not aware of any other residents who fell out of a shower chair. On 9/17/15 at 2:00 pm Staff 1 (Interim DNS/Corporate RN Consultant) stated she was the Interim DNS while the DNS was on maternity leave. Staff 1 stated for months the facility did not have an RNCM employed on the skilled section of the building where Resident 2 resided. Staff 1 stated Staff 10 (DNS) tried to complete the RNCM's duties along with DNS duties. Staff 1 acknowledged the incident investigations were not complete. Staff 1 was asked to provide any additional information regarding Resident 2's fall. On 9/21/15 the facility faxed a handwritten note from Staff 10 (DNS) as F/U (follow up) for investigation of incident 8/7/15 (Resident 2) dated 8/10/15 .Pt (patient) A&O x3 (alert and oriented in three spheres, able to make needs known. Incident occurred after transfer successful to shower chair. Pt. unavailable for interview r/t (related to) being out to hospital with confirmed fx (fracture) after fall. CNA reports that pt leaned forward in the chair to adjust something on (her/his) brace and the chair tipped over. CNA reports brakes having been in place at time of transfer to the shower chair. Pt. did not request assistance with what (she/he) was doing at time of fall despite CNA and additional NA (nursing assistant) student being in room. LN (Licensed Nurse) notified and assessed pt. Pt was transferred to ER and admitted d/t pain increase. Abuse/neglect ruled out r/t care plan being followed and pt being cognitively intact and not requesting assist from staff. Nurse f/u appropriate There was no documentation of an interview conducted with the nurse aide student who was in the resident's room at the time of the fall. On 9/22/15 at 4:44 pm and 9/23/15 at 9:56 am Resident 2 stated there was one CNA and two nurse aide students in the room when she/he was being transferred to the shower chair. The resident stated she/he told the staff to please be careful not to bend my leg. Resident 2 stated then she/he tipped over backwards, hit her/his head and hit her/his left leg on the floor. The resident stated everything happened so fast it was difficult to comprehend what happened. Resident 2 stated she/he refractured her/his leg in two places and her/his leg was not healing. Resident 2 stated the staff were on both sides of her/his chair during the transfer. Resident 2 stated she/he fell during the transfer to the shower chair and was not on the shower chair when she/he fell . The resident stated she/he could not remember if the staff used a gait belt during the transfer. On 9/23/15 at 10:02 am Staff 11 (Rehabilitation Manager) stated the therapy department used the facility's shower chairs to assess the resident at least once prior to discharge. Staff 11 asked Staff 12 (Occupational Therapist) if there had been any problems with the shower chairs when conducting assessments of the residents. Staff 12 stated sometimes the wheels become sticky and don't move freely. Staff 12 stated there were no problems with the brakes on the shower chairs. Staff 11 was asked if there were any special precautions for a transfer to the shower chair of a resident with a knee immobilizer. Staff 11 stated the local hospital assessment of the resident's abilities would be in place until the therapy department was able to complete a thorough assessment of the resident. Staff 11 stated the therapy department usually conducted a thorough assessment of the resident on the second day after admission. After the thorough assessment the resident's care plan would be updated as needed. On 9/23/15 at 11:00 am Staff 1 (Interim DNS/Corporate RN Consultant) stated she reviewed the last six months of incident reports and there was no documentation of another resident fall from a shower chair. On 9/24/15 at 1:11 pm Witness 5 (CNA instructor) stated she had a nurse aide class at the facility on 8/7/15 and one of the students who was on the skilled section of the building was available for interview. On 9/24/15 at 1:13 pm Witness 6 (CNA instructor) stated there were two different agencies who were providing nurse aide classes at the facility. Witness 6 stated there were six nurse aide students on the skilled section of the building. Witness 6 stated he would provide any information he had available though it was very difficult to know which nurse aide student was present at the time of the fall. Witness 6 stated he was aware of a resident fall during a transfer though he did not witness the fall and did not know the name of the nurse aide involved. Witness 6 stated it was not possible for him to reach the nurse aide students for an interview. On 9/28/15 at 3:00 pm Witness 7 (nurse aide student) stated she was not able to remember being at the facility when Resident 2 fell from the shower chair.