Every finding on record at Zebulon Rehabilitation Center

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of dialysis and medications. This was for 1 of 1 resident (Resident #60) reviewed for dialysis and 1 of 5 residents (Resident #9) reviewed for unnecessary medications.Findings included:1. Resident #60 was admitted to the facility on [DATE].A physician's order for Resident #60 dated 5/30/25 revealed she received dialysis (a treatment for kidney failure) three times weekly on Monday, Wednesday and Friday.A review of Resident #60's July 2025 Medication Administration Record (MAR) revealed documentation indicating she received dialysis on 7/9/25 and 7/14/25.A review of Resident #60's quarterly MDS assessment dated [DATE] revealed she was not coded for receiving dialysis.On 7/22/25 at 1:17 PM an interview with the MDS Coordinator indicated she coded Resident #60's quarterly MDS assessment dated [DATE] in error. She reported she used a worksheet when she completed MDS assessments, and on the worksheet, she had for Resident #60's MDS assessment dated [DATE] she noted Resident #60 received dialysis. The MDS coordinator stated she meant to code Resident #60 for receiving dialysis on the 7/14/25 quarterly MDS assessment but she had not.2. Resident #9 was admitted to the facility on [DATE].A review of Resident #9's physician's orders for June 2025 did not reveal any orders to administer insulin to Resident #9. A physician's order dated 6/12/25 revealed to administer Plavix (an antiplatelet medication) 75 milligrams (mg) by mouth daily to Resident #9 for blood clot prevention.A review of Resident #9's June 2025 Medication Administration Record (MAR) did not reveal any documentation indicating an insulin injection was administered to her. It further revealed documentation indicating that Plavix 75 mg was administered to Resident #9 daily as ordered by her physician.A review of Resident #9's 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed she was coded as receiving 1 insulin injection and not coded as receiving antiplatelet medication during the look-back period of the assessment.In an interview on 07/23/2025 at 8:30 AM the MDS Coordinator stated she coded Resident #9's MDS assessment dated [DATE]. She reported the look back period for this assessment would be from 6/11/25-6/17/25. She indicated the coding of an insulin injection would be an error as there was no documentation Resident #9 received one. The MDS Coordinator stated documentation on Resident #9's MAR indicated Resident #9 received antiplatelet medication during the look back period of the 6/17/25 MDS assessment. She indicated her lack of coding this antiplatelet medication on Resident #9's 6/17/25 MDS assessment would be an error. She reported she had the worksheet she used for coding Resident #9's 6/17/25 MDS assessment indicating she had the anticipation of coding the antiplatelet medication, but she missed it and did not know why.On 7/24/25 at 11:24 AM an interview with the Administrator indicated resident's MDS assessments should be accurately coded to reflect the care and medications residents received.On 7/24/25 at 11:50 AM an interview with the Director of Nursing indicated that resident's MDS assessments should be accurately coded to reflect the care and medications residents received.

Based on observation and staff interviews, the facility failed to keep medications in a locked medication cart for 1 of 2 medication carts observed (Medication Cart #1).Findings included:During continuous observation on 7/22/25, which started at 8:30 AM, Medication Cart #1 was observed unlocked and unattended on the 100-hall. A nurse aide was observed near the unlocked medication cart, and she passed it as she moved to and entered another resident's room. One resident was observed on the hall and was 3 rooms away from the unlocked medication cart and then entered the room he was sitting in front of at 8:32 AM. At 8:32 AM a nurse aide walked past the unlocked medication cart. At 8:33 AM a human resources staff member walked past the unlocked medication cart. At 8:33 AM a nurse aide walked past the unlocked medication cart and at 8:34 AM a nurse aide and human resources staff member walked past the unlocked medication cart. At 8:35 AM a nurse aide walked past the unlocked medication cart. At 8:36 AM 2 nurse aides walked past the unlocked medication cart. At 8:37 AM a nurse aide walked past the unlocked medication cart. At 8:38 AM an occupational therapist walked past the unlocked medication cart pushing a resident in a wheelchair down the hall. At 8:39 AM an occupational therapist walked past the unlocked medication cart. At 8:40 AM a maintenance staff member and nurse aide walked past the unlocked medication cart. At 8:41 AM the Unit Manager walked up to the surveyor to ask if the surveyor needed anything and noted that the medication cart was unlocked and locked the medication cart. During an interview on 7/22/25 at 8:41 AM the Unit Manager stated the 100-hall medication cart was left unlocked and unattended and should have been locked when left unattended. He stated Nurse #1 was the one responsible for the 100-hall medication cart. She stated this was a safety hazard because with the cart unlocked people including staff, residents, and visitors could get into the medications and this also created a privacy issue due to resident names in the medications on the cart.During an interview on 7/22/25 at 8:45 AM Nurse #1 stated she usually locked her medication cart prior to leaving it unattended so no one else could go into the medication cart. She stated she thought she had locked the medication cart and did not know why it was unlocked.During an interview on 7/22/25 at 9:47 AM the Director of Nursing stated medication carts were to be locked when unattended. She concluded this was for the safety of the residents and staff.

Based on observations, record review, and resident and staff interviews the facility failed to complete a self-administration of medication assessment and care plan self-administration of medication before leaving medication at the bedside for 1 of 5 residents (Resident #5) reviewed for unnecessary medication. Findings included: Resident #5 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. A review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She had impaired functional limitation of range of motion of her upper extremity on one side. Resident #5's record revealed a physician's order dated 5/20/24 for albuterol 90 microgram inhaler 2 puffs inhale orally every 6 hours as needed for wheezing and shortness of breath, may leave at bedside, entered by Nurse #1. No assessment for self-administration of medication was found in Resident #5's record. Resident #5's comprehensive care plan dated last revised on 6/13/24 did not reveal any focus area or interventions regarding self-administration of medication. On 6/25/24 at 8:03 AM Resident #5 was observed returning to her bed from the restroom. She was observed to be short of breath. Resident #5 was observed to sit on the side of her bed, pick up a hand held albuterol (a bronchodilator which opens airways in the lungs) medication inhaler from her bedside table, and administer 2 puffs of the medication to herself orally. An interview with Resident #5 indicated this medication was her rescue respiratory medication. She stated she had been taking the medication for 3 years. She went on to say she took 2 puffs of the medication when she felt short of breath which really helped. Resident #5 reported that because it could take from 15 to 30 minutes for a nurse to come when she needed this medication, her physician allowed her to keep the medication with her to use herself. On 6/26/24 at 1:49 PM an interview with Nurse #1 indicated he obtained the physician's order for Resident #5 to keep her albuterol inhaler at her bedside on 5/20/24. He stated Resident #5 had requested this. He went onto say while he had made sure Resident #5 could use the medication safely herself and would keep the inhaler with her so it would not be accessible to any other residents, he had not completed a self-administration of medication assessment for Resident #5 or added self-administration of medication to her care plan. Nurse #1 reported he knew he was supposed to do these things but had gotten busy and forgotten. On 6/26/24 at 1:54 PM in an interview the Director of Nursing (DON) stated Nurse #1 should have completed a self-administration of medication assessment form and added self-administration of medication to Resident #5's care plan when he obtained the physician's order for Resident #5 to keep her albuterol medication at her bedside. On 6/27/24 at 10:56 AM an interview with the Administrator indicated there should have been a self-administration of medication assessment completed prior to Resident #5 being allowed to keep her inhaler at her bedside and self-administration of medication should have been added to Resident #5's care plan.

Based on staff interviews and record review the facility failed to accurately code anticoagulant use on a Minimum Data Set (MDS) assessment for 2 of 3 resident reviewed for resident assessments. (Resident #52, Resident #31) Findings included: 1. Resident #52 was admitted to the facility on [DATE]. Her active diagnoses included stroke, hypertension, and diabetes mellitus. Review of Resident #52's admission Minimum Data Set assessment dated [DATE] revealed she was coded as receiving an anticoagulant. Review of Resident #52's Medication Administration Record for 4/2024 and 5/2024 revealed she did not receive an anticoagulant medication during the 7-day lookback period of the Minimum Data Set assessment. During an interview on 6/26/24 at 10:09 AM the MDS Coordinator stated Resident #52 was not on an anticoagulant medication and it was coded inaccurately on the 5/2/24 Admission Minimum Data Set assessment. During an interview on 6/26/24 at 10:44 AM the Administrator stated MDS assessments should accurately reflect the medications the resident was receiving. 41009 2. Resident #31 was admitted to the facility on [DATE] with a diagnosis of coronary artery disease. A review of Resident #31's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired. He received anticoagulant (blood thinning) medication. A review of Resident #31's May 2024 Medication Administration Record (MAR) did not reveal any documentation anticoagulant medication was administered to Resident #31. A review of Resident #31's physician's orders did not reveal any orders for anticoagulant medication. On 6/26/24 at 10:08 AM an interview with the MDS Coordinator indicated she completed the medication section of Resident #31's MDS assessment dated [DATE]. She stated the look back period for this section would have been 7 days prior to the assessment date. She reported she would have used Resident #31's MAR as a reference to complete the section. She further indicated she did not see now where Resident #31 received any anticoagulant medication. She stated she completed the section incorrectly. The MDS Coordinator stated she could not say why she made the error. On 6/26/24 at 10:44 AM in an interview the Administrator stated Resident #31's MDS assessments should accurately reflect the medication he was receiving.

Based on observations, resident and staff interviews, and record review, the facility failed to provide facial shaving for residents who required extensive assistance for 2 of 3 residents reviewed for activities of daily living care. (Resident #4 and Resident #24) The findings included: 1.Resident #4 was originally admitted to the facility on [DATE], with diagnoses that included Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and Multiple Sclerosis (MS). Resident had history of recurrent hospital admission. Resident #4's care plan revised on 10/24/22 showed a focus for Activities of Daily Living (ADL) self-care performance deficit due to decreased strengthening and activity intolerance. Interventions included 1 person assistance with personal hygiene. Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact with no rejection/refusal of care or behaviors. Resident #4 required extensive assistance with personal hygiene. An observation of Resident #4 on 03/27/23 at 10:00 AM revealed there was facial hair on her chin and upper lip that was approximately 1/2 to 3/4 inches long. During an observation and interview of Resident #4 on 03/28/23 at 10:06 AM the facial hair to her upper lip and chin was still visible and approximately 1/2 to 3/4 inches long. Resident #4 shared that her face was shaved every 2 or 3 weeks, but she did not want the hair on her face and she was not always asked to be shaved during care. Resident #4 reported that if it was her choice, she would not have the facial hair. Resident #4 was unable to recall the last time she had been shaved. Review of the medical record indicated Resident #4 was sent out of the facility on 03/29/23 to the hospital. An interview on 03/30/23 at 10:25 AM with Nurse Aide #6 (NA) revealed she had cared for Resident #4 on the 7:00 AM - 3:00 PM shift on 03/28/23. NA #6 said she did not notice the facial hair during daily care. NA #6 reported that a resident could be shaved even if it was not a shower day. NA #6 revealed that she usually worked with Resident #4 and could not recall the Resident refusing care During a telephone interview on 03/29/23 at 6:11 PM with Nurse #6 she revealed she had worked with Resident #4 on 03/28/23 during the 7:00 AM - 3:00 PM shift. Nurse #6 said she did not notice the facial hair on Resident #4 but would have taken care of it if the resident had said something to her. Nurse #6 reported she did not ask the female residents about facial hair because it was a touchy subject, and they can be embarrassed by the question. An interview conducted with Director of Nursing (DON) on 03/31/23 at 10:16 AM revealed NAs should be checking residents for facial hair during daily care and showers. Shaving was supposed to be offered during showers and were a part of activities of daily living (ADL) care. Refusals of grooming care needed to be documented. The DON stated she would like to see all residents asked about their facial hair and would like to see them shaved if that was what the resident desired. 2. Resident #24 was admitted to the facility on [DATE] with diagnoses that included stroke and hemiplegia. Resident #24's care plan that was reviewed and revised on 01/11/23 revealed a focus for activities of daily living (ADL) self-care performance deficit due to general weakness. Interventions included assist of 1 person for personal hygiene. Resident #24's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had moderate cognitive impairment. Resident #24 required extensive assistance with personal hygiene. There were no episodes of behaviors or rejection/refusal of care. An observation and interview with Resident #24 on 03/27/23 at 10:49 AM revealed she had facial hair to her upper lip and chin approximately an 1/2 inch long. Resident #24 stated she did not want the facial hair and if she could, she would want to have it shaved. Resident #24 reported she had been shaved by staff previously but was unable to recall the last time she had been asked by staff or assisted with shaving. An observation and interview of Resident #24 on 03/28/23 at 9:33 AM revealed the facial hair on her chin had been shaved, but the facial hair remained on her upper lip. Resident #24 said she wanted the hair on her upper lip to be shaved as well. Resident #24 reported her chin had been shaved the previous day, but did not say anything about her upper lip to staff. An interview was completed with NA #2 on 03/29/23 at 2:15 PM. NA #2 reported if a resident had facial hair and wanted to be shaved then she would assist them with shaving, even if it was not their scheduled bath day. NA #2 reported Resident #24 received a bed bath this that morning due to the resident not feeling well the previous evening. During the interview with NA #2 an observation was conducted of and Resident #24. NA #2 noted the facial hair to Resident #24's upper lip. Resident #24 informed NA #2 that she wanted to be shaved going forward due to not liking the facial hair. An observation on 03/30/23 at 09:00 AM of Resident #24 revealed facial hair was still visible on her upper lip. An interview with NA #6 was completed on 03/30/23 at 10:25 AM and revealed she had cared for Resident #24 on the 7:00 AM - 3:00 PM shift on 03/28/23. NA #6 reported during ADL care she looked for facial hair on female residents and if the resident reported she wanted to be shaved, the NA would assist with shaving. NA #6 reported residents could be shaved even if it was not during their shower. During this interview with NA #6 an observation was conducted of Resident #24. NA #6 verified there was facial hair on Resident #24's upper lip. Resident #24 told NA #6 that she wanted the facial hair gone. NA #6 verbalized to Resident #24 that she would assist her with shaving. NA #6 reported that she usually cared for Resident #24 and could not recall Resident #24 ever refusing care and was unable to recall seeing the facial hair previously. During an interview with the Director of Nursing (DON) on 03/31/23 at 10:16 AM she revealed the NA's should be checking residents for facial hair during daily care and showers. Refusals of grooming care were to be documented. The DON stated she would like to see all residents asked about their facial hair and would like to see them shaved if that was what the resident desired.

Based on record reviews and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) prior to discharge from Medicare Part A skilled services to 1 of 3 residents reviewed for beneficiary protection notification review (Resident #34). The findings included: Resident #34 was admitted to the facility on [DATE]. A review of Resident 34's admission Minimum Data Set (MDS) dated [DATE] revealed that she was cognitively intact. A review of the medical record revealed a CMS-10123 Notice of Medicare Non-Coverage (NOMNC) letter was issued to Resident #34 which explained Medicare Part A coverage for skilled services would end on 10/26/22 which was signed by Resident #34 on 10/24/22. Resident #34 remained in the facility at the time the survey was being conducted from 3/27/23 through 3/31/23. A review of the medical record revealed a CMS-10055 SNF-ABN (Skilled Nursing Facility Advanced Beneficiary Notice) was not provided to Resident #34 or their Responsible Party. On 3/31/23 at 11:25 am an interview was completed with the Business Office Manager (BOM). The BOM confirmed that the CMS-10123 NOMNC was issued when she was notified Resident #34's Medicare Part A coverage for skilled services was ending. The BOM confirmed that neither Resident #34 nor Resident #34's Responsible Party was issued a CMS-10055 SNF-ABN prior to Medicare Part A services ending. The BOM stated that the social worker was responsible for issuing SNF-ABN but that there had not been a social worker employed at the facility when Resident #34's SNF-ABN should have been issued. The BOM stated the SNF-ABN should have been issued because Resident #34 had 50 benefit days remaining. She revealed that she was responsible for issuing SNF-ABN while there was no social worker, but stated that she must have overlooked Resident #34's. An interview was completed with the Administrator on 3/31/23 at 11:28 am. He revealed that when a resident was coming off Medicare Part A services and the resident had days remaining a SNF-ABN should be issued.

Based on observations, record reviews, resident, staff, Nurse Practitioner and Hospice Nurse interviews, the facility failed to obtain orders for the use of oxygen for 2 of 3 residents reviewed for oxygen use (Resident #4 and Resident #54). The findings included: 1.Resident #4 was originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues), and history of pneumonia. Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident was cognitively intact and used oxygen while at the facility. Resident #4's care plan last updated and reviewed on 03/27/23 showed Resident #4 had impaired gas exchange related to COPD and respiratory failure. The interventions included oxygen as ordered and vital signs as ordered. A review of Resident #4's electronic medical record revealed no physician orders for oxygen use or monitoring of oxygen saturation. Review of electronic medical administration record (eMAR)/treatment administration record (eTAR) showed no documentation about oxygen or monitoring of Resident's oxygen saturation between 02/18/23 and 3/28/23. Vital signs record from February to March 2023 revealed no oxygen saturation documented since 2/17/23 (96% on oxygen via nasal cannula) Observation of Resident #4 on 03/27/23 at 10:00 AM revealed she was receiving oxygen via nasal cannula. Resident was visiting with Hospice Chaplain. Observation and interview with Resident #4 on 03/28/23 at 10:33 AM showed that she was receiving oxygen via nasal cannula at 3 liters per minute. Oxygen tubing was in place and portable oxygen tank was running continuously. Oxygen concentrator was observed in room. Resident #4 had a wet cough that she reported was somewhat productive. She said there was a chest x-ray scheduled for 03/28/23. Resident #4 reported she is supposed to receive oxygen at 3 liters per minute continuously due to having COPD and history of pneumonia. An interview with Nurse #1 on 03/30/23 at 2:06 PM revealed she had worked with Resident #4 on 3/26/23 on the day shift and resident received oxygen at 3 liters per minute on her shift. Nurse #1 could not recall if she had checked Resident #4's oxygen saturation but she stated that Resident #4 had her own pulse oximeter and she used it regularly to check her own oxygen saturation. Nurse #1 stated that there should have been an order in place for oxygen even when Resident #4 came back from the hospital. Nurse #1 stated there should have been an order to monitor Resident #4's oxygen saturation as well. Nurse #1 stated the Unit Manager, or the Director of Nursing usually entered orders in the EMR (electronic medical record) for new admits or re-admits. A phone interview with Nurse #2 on 03/29/23 at 6:11 PM revealed Resident #4 received oxygen for shortness of breath, and she had been using it for at least the past six months that she had taken care of her. Nurse #1 stated she was not sure why there was not a physician's order in place for Resident #4's oxygen. She further stated that Resident #4 was usually on her oxygen concentrator when she was in her room, and she rarely had to change the setting on her oxygen concentrator. On 3/28/23 during the day shift, the physical therapist notified her that Resident #4's oxygen saturation went down to 88-89% but when she checked Resident #4's oxygen saturation, it was around 91% on 3 liters per minute of oxygen. An interview with the Unit Manager on 03/30/23 at 2:21 PM revealed Resident #4 should have an order for oxygen and an order to check her oxygen saturation at least every shift. The Unit Manager confirmed Resident #4 did not have an order in place for oxygen and monitoring of oxygen saturation. He stated that it had not been brought to his attention that Resident #4 did not have a physician's order for oxygen. He further stated the oxygen order must have been missed when Resident #4 came back to the facility from the hospital on 2/21/23 and her admission orders did not include an order for oxygen. An interview with the Nurse Practitioner (NP) on 03/29/23 at 1:30 PM revealed Resident #4 was receiving oxygen because she was on hospice, and it was used for comfort due to her diagnosis of COPD. She was recently diagnosed with pneumonia and was currently being treated with antibiotics. The NP stated that Resident #4 should have an order for oxygen to be given to keep her oxygen saturation greater than 90%. He also stated that the nurses should be monitoring and documenting her oxygen saturation. During an interview with Director of Nursing (DON) on 03/31/23 at 10:16 AM she revealed residents receiving oxygen should have a physician's order in place for oxygen and an order for monitoring oxygen saturation. The DON stated Resident #4's oxygen order was missed because it wasn't included in her admission orders from the hospital when she returned to the facility after her most recent hospitalization . 47696 2. Resident #54 was readmitted to the facility on [DATE]. Review of the resident's cumulative diagnosis did not reveal a diagnosis which would indicate breathing impairment and/or the need for the use of supplemental oxygen. A review of Resident #54's hospital discharge summary dated 3/18/23 revealed that Resident #54 was not receiving oxygen at the time of hospital discharge. Resident #54's admission Minimum Data Set (MDS) dated [DATE] revealed that he was not cognitively intact. He was not coded for the use of oxygen. Resident #54's care plan last updated 3/19/23 revealed Resident #54 was at risk for impaired gas exchange and ineffective airway clearance related to oxygen clearance. Care plan interventions did not include supplemental oxygen. A review of the March 2023 physician orders revealed no order for supplemental oxygen use. A review of the March Medication Administration Record (MAR) revealed documented oxygen saturation data taken while resident was receiving oxygen via nasal canula on 3/18/23, 3/19/23, 3/20/23, 3/22/23 and 3/27/23. Further review revealed no documentation on the MAR to administer the resident oxygen. An observation made on 3/27/23 at 11:57 AM revealed Resident #54 with oxygen in his nares via nasal cannula at 2 liters per minute. An additional observation was made on 3/27/23 at 12:26 PM when Resident #54 was receiving feeding assistance from a staff member in his room. Resident #54 was observed with oxygen in his nares via nasal cannula at 2 liters per minute. An interview was conducted with the Nurse Practitioner (NP) on 3/29/23 at 1:30 PM. The NP stated that he thought that Resident #54 was receiving supplemental oxygen due to diagnosis of obesity and hypoventilation. The NP added that he thought the resident was on supplemental oxygen when he returned from the hospital on 3/18/23. An interview with Nurse #2 on was completed on 3/29/23 at 2:07 PM. Nurse #2 stated Resident #54 wore supplemental oxygen at times. Nurse #2 explained that she knew which residents should be receiving oxygen by looking at the MAR. A follow-up interview and record review were completed with Nurse #2 on 03/30/23 at 10:34 AM. Nurse #2 reviewed Resident #54's March MAR and stated she did not see an order for supplemental oxygen. Nurse #2 stated that she did not know why Resident #54 would be placed on oxygen. During an interview with Director of Nursing (DON) on 3/31/23 at 10:16 AM she revealed residents receiving oxygen should have a physician's order in place for oxygen and an order for monitoring oxygen saturation. An interview with the Administrator was conducted on 3/31/23 at 11:48 AM. The Administrator stated that there should have been an oxygen order in place.

Based on observation and staff interviews, the facility failed to discard an expired medication available for use in 1 of 2 medication carts (200 hall medication cart). The findings included: An observation on 3/30/2023 at 1:47 PM of the 200 hall medication cart with the Unit Manager revealed a large opened bottle of Sodium Bicarbonate (antacid used to relieve heartburn and acid ingestion) which was marked with an expiration date of 1/2023. The bottle contained white round tablets and it was approximately 1/4 full. An interview with the Unit Manager on 3/30/2023 at 2:00 PM revealed that the night shift nurse was responsible for checking the medication carts weekly. The Unit Manager stated that he checked the medication carts whenever there were changes in the medication orders or when a medication was discontinued and needed to be returned to the pharmacy. The Unit Manager also stated he last looked at the 200 hall medication cart a couple of weeks ago. Nurse #1, during a telephone interview on 3/30/2023 at 2:18 PM, indicated that she did not remember giving any Sodium Bicarbonate tablet during the day shift on 3/30/2023. She did not notice the bottle of expired Sodium Bicarbonate on the 200 hall medication cart. An interview with the Director of Nursing on 3/30/2023 at 2:30 PM revealed that the Unit Manager was supposed to check the medication carts weekly for expired medications.

Based on observations and family, Registered Dietician (RD), and staff interviews, and record review, the facility failed to honor food preferences for 1 of 1 sampled resident reviewed for preferences (Resident #41). Resident #41 was admitted to the facility on [DATE] with the diagnoses of stroke and dementia. Resident #41's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had impaired decision making and needed supervision with eating. Review of the RD note dated 03/08/22 showed a physician order for a No added salt with regular texture foods, and fortified foods. No meat, only tuna and baked fish per Resident #41. An observation of the lunch menu for 03/27/23 revealed the following: Honey mustard pork roast Wild rice pilaf Buttered spinach Bread or roll with margarine During the lunch dining room observation on 03/27/23 at 12:10 PM, Resident #41 was observed sitting at the table and not eating. Review of Resident #41's meal ticket revealed a no added salt, regular texture diet with dislikes of pork roast, pork loin, and chicken listed. Resident #41's lunch meal tray consisted of spinach, rice, and pork roast. The observation further revealed the Rehab Manager asking Resident #41 if she wanted something else. The Rehab Manager went to the kitchen and returned with a peanut butter and jelly sandwich. Resident #41 did not eat the sandwich and stated she did not want it. An observation of the lunch menu for 03/28/23 revealed oven fried chicken as the meat for the day. An observation of Resident #41's lunch tray on 03/28/23 at 12:30 PM revealed Resident #41 received mashed potatoes and gravy, mixed vegetables, and a meat patty with gravy. Resident #41's meal was set up in her room and she was observed looking at the food and not eating. Resident #41 was not able to report what type of meat the meat patty was. An observation of the lunch meal on 03/29/23 at 01:09 PM for Resident #41 revealed she had a tray with meatballs and noodles. Resident #41 was observed looking at her food and not eating the meal, however she was observed eating the desert. During an interview via telephone with Resident #41's responsible party (RP) on 03/28/23 at 11:12 AM, the RP revealed Resident #41 was a vegetarian when she admitted to the facility. The RP continued to explain Resident #41 was not a big meat eater but did sometimes prefer fish. An interview was completed on 03/29/23 at 04:07 PM with Rehab Manager regarding the lunch observation on 03/27/23. The Rehab Manager stated Resident #41 told her that she did not like the meal she had so she offered Resident #41 a peanut butter and jelly sandwich because she thought it would be more appealing to Resident #41. An interview was completed on 03/30/23 at 03:08 PM with the Dietary Manager. She revealed she would speak to residents upon admission and weekly about food preferences. The Dietary Manager reported Resident #41 could say what she wanted to eat and ate only baked fish and tuna when she admitted to the facility. The Dietary Manager reported she would speak with Resident #41 and her RP to update food preferences and if needed she could accommodate a diet with more vegetables. An interview was completed via telephone with the Registered Dietician (RD) on 03/30/23 at 04:15 PM. The RD revealed Resident #41's preferences were fish and tuna, and she did not like other meats. The RD further explained Resident #41 mainly ate vegetables and fish. The RD voiced Resident #41 should not have been served pork or chicken if her preferences were fish and tuna. During an interview with the Administrator on 03/31/23 at 10:35 AM he stated residents should be asked about their preferences and the meal tickets match with orders and preferences.

Based on observations, staff interviews and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions the committee put into place following the 2/11/22 annual recertification surveys. This was for F695- Respiratory/Tracheostomy Care and Suctioning. This deficiency was cited again on the annual recertification survey 3/31/23. This continued failure of the facility during two consecutive recertification surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F695- Respiratory/Tracheostomy Care and Suctioning: Based on observations, record reviews, resident, staff, Nurse Practitioner and Hospice Nurse interviews, the facility failed to obtain orders for the use of oxygen for 2 of 3 residents reviewed for oxygen use (Resident #4 and Resident #54). During the recertification survey conducted on 2/11/22 the facility failed to obtain orders for the use of supplemental oxygen for 1 of 3 residents reviewed for oxygen use. During an interview on 3/31/23 at 1:19 PM the Administrator explained a breakdown in the system occurred due to human error. The Administrator continued to explain human error caused the lack of physician order for oxygen use. He stated the facility had implemented standing orders for oxygen use with oxygen saturation monitoring.

Based on observations, review of the daily nursing staff postings, and staff interviews the facility failed to include the resident census information on the daily nursing staff posting for 7 of 9 days reviewed. The findings included: On 3/27/23 at 12:33 PM an observation was made of the facility's daily nurse staffing which was posted on the wall in the hallway across from the nurse's station. There was no census number listed on the nurse staffing sheet. A follow up observation was made on 3/27/23 at 2:59 PM. The census data had not been added. On 3/28/23 at 8:32 AM an observation of the posted nurse staffing sheet revealed no census data. On 3/29/23 at 8:44 AM an observation of the posted nurse staffing sheet revealed no census data. A follow-up observation on 3/29/23 at 11:10 AM revealed that the posted nurse staffing sheet had not been updated to include the resident census. The daily posted nurse staffing sheets were reviewed for 3/23/23 through 3/26/23. The filed daily posted nurse staffing sheets did not include the facility census data. On 3/31/23 at 9:43 AM a phone interview with Nurse #5 was completed. She stated that she worked 11:00 PM through 7:00 AM shift often and worked that shift on 3/28/23. She explained she did not include the resident census when filling out the posted nurse staffing sheet. On 03/31/23 at 12:10 PM a phone interview was completed with Nurse #4. Nurse #4 confirmed she worked the 11:00 PM - 7:00 AM shift and when she filled out the nursing staff posting she did not include the resident census. On 03/31/23 at 11:07 AM an interview was completed with the Director of Nursing (DON). The DON stated that 11:00 PM through 7:00 AM nurse was responsible for filing out the census data on the staffing sheet. An interview was conducted with the Administrator on 03/31/23 at 11:28 AM. He confirmed that the 11:00 PM through 7:00 AM nurse was responsible for posting the census data on posted nurse staffing sheets. He added that the census data should have been updated with any changes in census information throughout the shifts.

Based on Physician and staff interviews, and record review the facility failed to obtain a referral for cataract surgery as ordered by the physician for 1 of 1 resident (Resident #19) reviewed for appointments. Findings included: Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included [CONDITION(S)] and type 2 diabetes mellitus. A review of a physician order dated 5/11/2021 revealed refer for cataract surgery to the ophthalmologist of her choice. A Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was cognitively intact and had adequate vision. A plan of care revised on 1/6/2022 addressed Resident #19's potential for impaired vision. The interventions included monitor for signs and symptoms of acute eye problems, sudden visual loss, blurred or hazy vision. During an interview with Resident #19 on 2/7/2022 at 11:42 am she stated she could barely see out of her left eye. She then stated she knew that she had a left eye cataract when she was admitted to the facility. She stated she had informed the Unit Coordinator and a few nurses (she could not name the nurses) of her vision changes. She further stated nothing was done about her left eye cataract. She was unable to give a time frame of when she reported the vision changes to the unit manager. During an interview with the Unit Coordinator on 2/8/2022 at 11:00 am he stated he did not see in the computer where an appointment was made for Resident #19 to visit an ophthalmologist. He then stated the physician order was before he started working for the facility and he knew nothing about the order. He stated he did not remember Resident #19 telling him about vision changes. On 2/9/2022 at 4:46 pm during a telephone interview with Nurse #1, she stated she put the order for the ophthalmologist referral in the computer and could not remember if she made an appointment or not. She then stated if she made it, it would be in the computer. During an interview with the Director of Nursing on 2/10/2022 at 10:00 am she stated Nurse #1 should have made the appointment according to the order. She then stated normally a nurse was assigned to the desk and would take off orders and make appointments. She further stated she expected the nurses to follow the physician orders as written. The physician stated during a telephone interview on 2/10/2022 at 10:36 am he wrote the order for Resident #19 to see an ophthalmologist for her cataract. He then stated he was not aware that the order had not been followed. He further stated that it was important that Resident #19 see the ophthalmologist. He stated he did not believe any harm occurred to her eye because she did not see the ophthalmologist at that time.

Based on staff interviews and record review the facility failed to provide privacy during a visitation for 1 of 1 resident (Resident #19) reviewed for privacy. Findings included: Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was cognitively intact. The current plan of care revised on 1/6/2022 have a plan that addressed Resident #19's preference. The interventions included encourage the family to continue to visit. A review of a grievance dated 3/3/2021 made by the Resident #19 revealed she voiced concerns that her sister came to visit with her and told her that her younger brother had passed away. Resident #19 stated she was upset, and the Activity Director (AD) had walked her sister to her room and stayed outside the door the whole time her sister visited. Resident #19 stated the Activity Director (AD) told her she was supposed to walk her sister to her room and stay outside the room. Resident #19 stated this violated her privacy and was disrespectful to her and her sister. The documentation of investigation completed by the Director of Nursing (DON) on 3/3/2021 revealed the Administrator discussed the concerns with the resident and explained that compassionate care visitors were supposed to be walked to the room and then escorted back to the exit when leaving. The Administrator did not intend to make her feel disrespected and that her privacy had been violated. The investigation revealed the AD was only doing what was asked of her. During an interview with the Administrator on 2/8/2022 at 4:52 pm she stated during that period of time there were guidelines by the Center for Disease Control (CDC) that compassionate care visitors needed to be escorted to the resident's room and back to the exit when leaving. She stated they did not know at the time that the family member had brought bad news for the resident. She then stated the person did stand outside of the door for the duration of the visit. She stated she spoke with the resident and explained why the AD did what she did which were to follow CDC guidelines. During an interview with Resident #19 on 2/10/2022 at 10:38 am she stated when her sister came to visit her on 12/28/2020 to bring her news of her brother's death, the AD stood outside the room the whole time. She then stated the door was open and she and her sister was crying. She stated she felt like her privacy was invaded and she felt bad because the AD was at the door and heard her crying. During a telephone interview with the AD on 2/10/2022 at 2:00 pm she stated she remembered escorting Resident #19's sister to the room and standing beside the door where the number was on the wall for the duration of the visit. She then stated it had been a long time ago and she could not remember if she heard their conversations or not. She further stated she was told to by the Administrator to wait and escort the sister back to the exit after the visit.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for 3 of 13 resident records reviewed for MDS accuracy (Residents #33, #56, and #32). Findings included: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] and [CONDITION(S)]. Review of Resident #33's quarterly Minimum Data Set (MDS) dated [DATE] indicated she was cognitively intact. Further review of the MDS revealed [CONDITION(S)] was coded as an active diagnosis. Review of Resident #33's medical records which included physician notes, physician history and physical, care plan, and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 2/09/22 at 2:03 PM with the Regional MDS Director revealed she was unable to find a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #33 in the medical record. She stated she did not know why this diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An interview on 2/09/22 at 3:55 PM with the Director of Nursing (DON) revealed Resident #33 did not have documentation for a [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #56 was admitted to the facility on [DATE] with diagnoses which included anxiety and dementia. Review of Resident #56's discharge Minimum Data Set (MDS) dated [DATE] indicated she was discharge to acute hospital with return not anticipated. Review of Resident #56's nurses progress note dated 12/04/21 at 3:54 PM revealed she was discharged home with her family. An interview on 2/09/22 at 4:37 PM with the Director of Nursing (DON) revealed Resident #56 was discharged home with her family and not sent to the hospital. She stated the MDS was not coded accurately and should have been coded as a planned discharge home to the community. 3. Resident #32 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of her annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. The Medication Received section indicated she had received an antipsychotic medication on 7 of the 7 look back days. The Antipsychotic Medication Review section of the assessment indicated Resident #32 did not receive any antipsychotic medications since her last MDS assessment. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/09/2022 at 2:09 PM a telephone interview with the facility's Regional MDS Director indicated the antipsychotic medication review section of Resident #32's 10/22/2021 MDS assessment was completed inaccurately. She stated Resident #32 received [MEDICATION(S)] 15 mg daily and this was an antipsychotic medication. She further indicated Resident #32's 10/22/2021 MDS assessment should have been completed accurately to reflect her receiving this antipsychotic medication on a routine basis.

Based on record review and staff interviews the facility failed to develop a base line care plan which included the use of a high risk anticoagulant medication for 1 of 2 residents (Resident #52) whose baseline care plans were reviewed. Findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of his admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively intact. He received an anticoagulant (blood thinning) medication on 3 of 3 days since his admission. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #52's medical record revealed he received [MEDICATION(S)] 10 mg daily from 01/27/2022 through 01/30/2022. A review of Resident #52's base line care plan initiated on 01/27/2022 revealed it did not include Resident #52's anticoagulant medication use or the associated risk of bleeding. On 02/09/2022 at 8:49 AM an interview with the Director of Nursing (DON) indicated Resident #52's baseline care plan did not address his anticoagulant use. She stated [MEDICATION(S)] was a high risk medication that could cause bleeding side effects. She went on to say this should have been included in Resident #52's baseline care plan. The DON stated either she or the Unit Coordinator (UC) would have been responsible for including this information in Resident #52's baseline care plan when he was admitted . She stated it was missed. On 02/09/2022 at 3:20 PM an interview with the UC indicated Resident #52's baseline care plan did not include his anticoagulant use or the risk of bleeding. He stated nursing would have been responsible for including this information on Resident #52's baseline care plan. He stated it was missed.

Based on observations, record review, staff and Nurse Practitioner interviews, the facility failed to obtain orders for the use of supplemental oxygen for 1 of 3 residents reviewed with oxygen (Resident #33). Findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact and was coded for the use of oxygen. Review of Resident #33's care plan last updated 10/28/21 revealed a focus that resident is on oxygen at two liters per minute continuous via nasal cannula. The care plan interventions included to monitor for respiratory distress and report any shortness of breath. Review of the physician orders revealed no order for supplemental oxygen use. An observation made on 2/07/22 at 4:00 PM revealed Resident #33 had oxygen via nasal cannula at 2 liters per minute. An interview on 2/09/22 at 8:34 AM with the Unit Coordinator confirmed Resident #33 wears supplemental oxygen at times. He confirmed there was no physician's order for oxygen for Resident #33. An interview on 2/09/22 at 9:09 AM with the Nurse Practitioner (NP) revealed Resident #33 should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview on 2/09/22 at 2:22 PM with the Director of Nursing (DON) revealed it was her expectation for all residents receiving supplemental oxygen to have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, record review, and resident, staff, nurse practitioner, physician assistant and physician interview the facility failed to follow a provider's order to discontinue a medication. This was for 1 of 5 residents (Resident #52) reviewed for unnecessary medication. Findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of his admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively intact. He received an anticoagulant (blood thinning) medication on 3 of 3 days since his admission. A provider order from the facility Nurse Practitioner (NP) dated 02/02/2022 revealed Resident #52 was to receive [MEDICATION(S)] (an anticoagulant medication) 105 mg injection subcutaneously (under the skin) twice daily for [CONDITION(S)] and to prevent a [CONDITION(S)] (blood clot). The order further revealed to discontinue the medication once Resident #52's international normalized ratio (INR-a laboratory test evaluating the pathways of anticoagulation) was greater than 2. This order was included on Resident #52's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] The orders to check the INR on 1/31/2022, 2/4/2022 and 2/7/2022 were in facility orders. A review of Resident #52's INR laboratory test results revealed the following: 01/31/2022 INR 1.44 02/04/2022 INR 2.35 02/07/2022 INR 2.04 A review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It further revealed the 9:00 PM dose on 02/06/2022 was documented as held (not given). The medication was discontinued on 02/07/2022 at 3:32 PM. On 02/08/2022 at 8:50 AM an observation of Resident #52 revealed he did not have any bruising or bleeding. An interview with Resident #52 at that time indicated he was receiving blood thinning medication. He stated he had not had any bruising or bleeding. On 02/09/2022 at 4:44 PM a telephone interview with Nurse #1 indicated she administered Resident #52's [MEDICATION(S)] injection on 02/04/2022 at 9:00 PM. She stated she notified the on-call physician of Resident #52's INR result of 2.35 and received an order to continue Resident #52's current [MEDICATION(S)] dosage. She went on to say she did not communicate with the on-call physician about Resident #52's [MEDICATION(S)]. She stated she had not realized there was an order to discontinue the [MEDICATION(S)] when Resident #52's INR was greater than 2. On 02/09/2022 at 8:12 AM an interview with Nurse #4 indicated she administered Resident #52's [MEDICATION(S)] injection on 02/05/2022, 02/06/2022 at 02/07/2022 at 9:00 AM. She stated although she had access to Resident #52's INR results she did not check this before she administered the medication. She stated she had not realized Resident #52 had an order to discontinue the medication when his INR was greater than 2. On 02/09/2022 at 8:19 AM an interview with the Unit Coordinator (UC) indicated he administered Resident #52's [MEDICATION(S)] injection on 02/05/2022 at 9:00 PM. The UC further indicated it was the nurse's responsibility to check the INR level before administering the medication. He stated he did not recall if he checked Resident #52's INR result. He went on to say the medication should have been discontinued on 02/04/2022 when Resident #52's INR was greater than 2. On 02/09/2022 at 8:25 AM an interview with the Director of Nursing (DON) indicated Resident #52 had an order to discontinue his [MEDICATION(S)] when his INR was greater than 2. She stated the nurses should have been checking the INR before administering the medication. She went on to say the medication should have been discontinued when Resident #52's INR was greater than 2 as ordered. On 02/09/2022 at 9:10 AM a telephone interview with Resident #52's NP indicated he ordered Resident #52's [MEDICATION(S)] injection on 02/02/2022. He stated the medication provided Resident #52 with blood thinning protection until his [MEDICATION(S)] resulted in an INR greater than 2. He went on to say the nurses administering Resident #52's [MEDICATION(S)] should have been checking his INR before administration. The NP further indicated Resident #52's [MEDICATION(S)] should have been discontinued when his INR was greater than 2 as per the order. He stated there was always the risk of bruising and bleeding side effects with any anticoagulant medication. He went on to say Resident #52 had not experienced any side effects. On 02/09/2022 at 9:39 AM a telephone interview with Physician #2 indicated it was appropriate for Resident #52 to continue to receive [MEDICATION(S)] although there was an order to discontinue it when Resident #52's INR was greater then 2. He stated that wasn't the best order. He went on to say he preferred to wait until the INR was greater than 2 consistently before discontinuing the [MEDICATION(S)]. He stated Resident #52 had not experienced any bleeding or bruising side effects. He further indicated Resident #52's [MEDICATION(S)] was discontinued on 02/07/2022. On 02/09/2022 at 2:35 PM a telephone interview with Nurse #3 indicated she held Resident #52's [MEDICATION(S)] medication on 02/06/2022 at 9:00 PM. She stated she saw the order to discontinue Resident #52's [MEDICATION(S)] injection when his INR was greater than 2. She stated she checked his INR before administering it. Nurse #3 further indicated because Resident #52's most recent INR was 2.35 on 02/04/2022, she contacted the on-call physician's assistant (PA) for clarification. She stated the PA told her to hold the medication until Resident #52's NP had a chance to review the INR. She further indicated she passed this information on in report to nurse #5 at the end of her shift that evening. On 02/09/2022 at 3:48 PM a telephone interview with the on-call PA indicated on 02/06/2022 she spoke with Nurse #3 regarding Resident #52's [MEDICATION(S)] injection. She stated she gave Nurse #3 an order to hold Resident #52's [MEDICATION(S)] until it could be reviewed by his regular provider. The PA went on to say because Resident #52 was on long term [MEDICATION(S)] therapy and his INR was greater than 2, there was no need for him to continue to receive the [MEDICATION(S)] injection. On 02/10/2022 at 8:33 AM a telephone interview with Nurse #5 indicated he did not recall Nurse #3 reporting to him Resident #52's [MEDICATION(S)] injection was on hold on 02/06/2022.

Based on staff interviews and record review the facility failed to provide a written notification for the reason for transfer to the hospital for 1 of 3 residents (Resident #17) reviewed for hospitalization . This practice affected other residents discharged to the hospital. Findings included: A nursing note written by Nurse #6 dated 12/20/2021 revealed Resident #17 was transferred to the hospital for vomiting. The representative was called about the decision to send the resident to the hospital. A review of the discharge summary dated 12/23/2021 revealed he was discharged from the hospital on 12/23/2021 back to the facility. During an interview with the Social Worker on 2/10/2022 at 2:00 pm she stated she did not send a written transfer notification to Resident #17 or the representative. She further stated she did not know a notification was required to be sent. She then stated she did not know who was responsible for sending out the notifications. On 2/10/2022 at 2:10 pm during an interview with the Admission Coordinator, she stated she did not send out a transfer notification to Resident #17 or his representative. She further stated she had no knowledge of a written transfer notification. On 2/10/2022 at 10:00 am during an interview with the Director of Nursing she stated she did not send out a written transfer notification. She then stated she was not aware that a written transfer notification needed to be sent to the resident or representative after he was transferred to the hospital. She stated they called the representative about the transfer but did not send out a written transfer notification. She further stated the facility did not send out written transfer notifications because they were not aware that it was needed.

Based on staff interviews and record review the facility failed to accurately code the Minimum Data Set (MDS) assessment for the areas of hallucinations and smoking for 2 of 17 sampled residents for MDS accuracy (Resident #33 and Resident #25). Findings included: 1. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing note dated 8/7/19 revealed Resident #33 had several episodes of hallucinations. Resident #33's MDS assessment dated [DATE], an admission assessment revealed he was assessed in section E, question E0100A as not having any hallucinations during the 7-day lookback period of the assessment. During an interview with the MDS nurse on 9/12/19 at 10:08 AM she stated section [NAME] of the MDS assessment was completed by the social worker and she was unsure of the reason Resident #33's hallucinations were not coded on the assessment. An interview was conducted with the social worker on 9/12/19 at 10:15 AM who stated she overlooked the mention of hallucinations in Resident #33's progress notes. The social worker indicated Resident #33's hallucinations should have been coded on the assessment. During an interview with the Administrator on 9/12/19 at 11:23 AM she indicated Resident #33's MDS assessment should have been coded correctly for hallucinations. 2. Resident #25 was admitted to the facility 7/23/19 with [DIAGNOSES REDACTED]. Review of a safe smoking evaluation for Resident #25 with an effective date of 7/23/19 at 2:00 PM indicated Resident #25 was a smoker. Review of an admission progress note dated 7/23/19 at 9:05 PM indicated Resident #25 smoked occasionally. Review of a care plan dated 7/29/19 revealed a focus area of Resident #25 is a safe smoker with a goal of will smoke safely with supervision through next review date and interventions including Resident #25 is oriented to facility's designated smoking areas and times. Review of the 5-day admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 was not a current tobacco user. On 9/9/19 at 4:15 PM Resident #25 was observed smoking at the facility with no safety concerns identified. On 9/11/19 at 4:08 PM interview with the MDS nurse indicated Resident #25's MDS assessment dated [DATE] was not coded correctly for tobacco use. She further indicated a correction request had been submitted on 9/9/19 at 12:36 PM. On 9/12/19 at 10:57 AM interview with the Administrator indicated Resident #25's 5-day admission MDS assessment should have been coded correctly for tobacco use.

Based on record review and physician and staff interviews the facility failed to either limit prn (as needed) [MEDICAL CONDITION] drug use to 14 days or have a prescriber document a rationale in the resident's medical record for extension of use beyond 14 days for 2 of 7 residents reviewed for unnecessary medication. (Residents #25 and #47) Findings included: 1. Resident #25 was admitted to the facility 7/23/19 with [DIAGNOSES REDACTED]. Review of Resident #25's Minimum Data Set assessment dated [DATE] and coded as a 14-day assessment indicated Resident #25 was independent for daily decision making, had no mood symptoms or behaviors, required the limited assistance of 1 person for activities of daily living and received an anti- anxiety medication for 6 of 7 look back days. Review of physician orders [REDACTED]. Review of Resident #25's medication administration records for July, (MONTH) and (MONTH) 2019 indicated [MEDICATION NAME] 0.25 mg by mouth every 12 hours as needed for anxiety had been available to Resident #25 and administered during that time period. Review of a pharmacy consultation report dated 8/1/19 and addressed to Resident #25's prescriber (Physician #1) and the director of nursing (DON) indicated a recommendation for the prescriber to discontinue the prn [MEDICATION NAME] order or to document an indication for use, the intended duration of therapy and a rationale for the extended use in Resident #25's medical record. The report was not acknowledged by the prescriber and no documentation from the prescriber related to the pharmacy recommendation was found in Resident #25's medical record. Review of a pharmacy consultation report dated 9/3/19 and addressed to Resident #25's prescriber (Physician #1) and the director of nursing (DON) indicated a recommendation for the prescriber to discontinue the prn [MEDICATION NAME] order or to document an indication for use, the intended duration of therapy and a rationale for the extended use in Resident #25's medical record. The report was signed on 9/11/19 by Physician #2 with a note to continue the [MEDICATION NAME] 0.25 mg by mouth every 12 hours as needed for anxiety for an additional 2 weeks as Resident #25 received it frequently at night. The note further indicated Physician #2 would review the order again in 2 weeks. On 9/11/19 at 3:17 PM interview with Physician #1 indicated he was familiar with the time limit requirement and the process for prn [MEDICAL CONDITION] medications. He further indicated he expected the prn [MEDICATION NAME] order to be reevaluated within the 14- day time period and either continued with a rationale, discontinued or converted to a routine order. 2. Resident #47 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #47's Minimum Data Set assessment dated [DATE], coded as an admission assessment revealed Resident #47 was cognitively intact, had no mood symptoms or behaviors, required the extensive assistance of one person for activities of daily living and received an anti-anxiety medication for 3 of the 7 look back days. Physician orders [REDACTED]. Review of Resident #47's medication administration records for (MONTH) and (MONTH) 2019 indicated [MEDICATION NAME] 0.25 mg by mouth every 8 hours as needed for anxiety had been available to Resident #47 and administered during that time period. Resident #47 received the medication once in (MONTH) and five times in September. A pharmacy consultation report dated 8/1/19 and addressed to Resident #47's prescriber (Physician #2) and director of nursing (DON) indicated a recommendation for the prescriber to discontinue the prn [MEDICATION NAME] order or to document an indication for use, the intended duration of therapy and rationale for the extended use in Resident #47's medical record. The report was not acknowledged by the prescriber and no documentation from the prescriber related to the pharmacy recommendation was found in Resident #47's medical record. A pharmacy consultation report dated 9/3/19 and addressed to Resident #47's prescriber (Physician #2) and director of nursing (DON) indicated a recommendation for the prescriber to discontinue the prn [MEDICATION NAME] order or to document an indication for use, the intended duration of therapy and rationale for the extended use in Resident #47's medical record. The report was not acknowledged by the prescriber and no documentation from the prescriber related to the pharmacy recommendation was found in Resident #47's medical record. A nurse's progress note dated 9/11/19 indicated the order for prn [MEDICATION NAME] was discontinued by Physician #3. On 9/12/19 at 10:49 AM an interview was conducted with Physician #2 who indicated he was familiar with the time limit requirement and the process for prn [MEDICAL CONDITION] medications. He further indicated he expected the prn [MEDICATION NAME] order to be reevaluated within the required time period and either continued with a rationale, discontinued or converted to a routine order. He further indicated he did not receive the pharmacy consultation reports on 8/1/19 or 9/3/19.

Based on observations, record review and interviews with facility staff, the facility failed to act upon a resident exhibiting signs and symptoms of a urinary tract infection for 1 of 1 sampled resident. (Resident #62). The findings included: The resident was admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) dated 11/29/14 indicated that she had memory problems with short and long term memory. She was coded that she required extensive assistance with one person physical assistance for all of her Activities of Daily Living (ADLs) except eating, which she required set up help only with supervision. She had no impairment with range of motion. Resident #64 was always incontinent with bowel and bladder. Resident was coded as having [DIAGNOSES REDACTED]. Record review of the Care Area assessment dated [DATE] revealed the Resident #62 was admitted from the community hospital needing skilled nursing and rehabilitation. She was status/post fall with fracture requiring surgical replacement of hip. She currently required extensive assistance with bed mobility, walking, locomotion, dressing, and personal hygiene. She was totally dependent on staff at this time for toileting needs. Record review of the Care Plan dated 12/1/14 revealed the following: Problem: Resident had an active infection and was being treated in an attempt to prevent the spread. Is symptomatic and/or has a positive test indicating contagious stage in urine, symptoms include abnormal labs and abnormal cultures. Goals: Resident will have no signs or symptoms of active infection related to urinary tract infection [MEDICAL CONDITION]. Resident ' s active infection will be treated and show signs of improving or resolution. Resident will maintain adequate hydration as evidenced by moist mucous membranes, supple skin turgor, stable laboratory values as treated until resolution of infectious process. Resident will not spread infection to others. Completed 12/8/14. Approaches: Standard universal precautions in place. Offer and encourage intake of fluids. Administer medications as ordered. Temperature every shift until antibiotics/anti-infective completed. Monitor for side effects related to antibiotic therapy and report to physician, rash, itching, nausea/vomiting/diarrhea. Post antibiotic therapy laboratory work as ordered and report results to physician. Report to physician worsening signs and symptoms infection or lack of improvement from treatment. Encourage good clean hygiene techniques to avoid cross contamination, especially hand washing before meals and after bowel movements. Assess need for dietary modification and consult registered dietician as indicated. 12/1/14 [MEDICATION NAME] (an antibiotic) 500 mg (milligram) 1 orally every day for 7 days. Record review of nurse note dated 12/25/14, (7-3 shift). Alert and verbal in early AM (morning) but by 10 AM sleepy and out of it though. VS 98.4, 72, 18, 110/75. Spoke with family member and he said usually when she was like this she had a UTI so will pass it along that needs urine specimen in AM. Record review of nurse notes dated 12/25/14, (3-11 shift). Family reported to nurse that patient is in a beginning phase of possible UTI. Order obtained for UA (urinalysis with culture and sensitivity) C&S. Patient had increased confusion. Record review of the nurse note dated 12/25/14 (3-11 shift). Vital signs, blood pressure 133/72, temperature 98.9, heart rate 76 and respirations were18. Vital signs stable. Sitting up in wheelchair. Had made inappropriate statements through the day. And agitated. Family requested UA done. Order received. Required assistance from staff of two for all ADLs and treatments. Incontinent of bowel and bladder. Record review of the nurse notes dated 12/25/14 (11-7 shift) Temperature was 102.6 and tylenol given for elevated temperature, rechecked 98.8 orally. Resident resting in bed without complaints offered skin warm to touch. Resident takes medications with ease. Alert and oriented, makes needs known. Continued to monitor. Record review of a physician order [REDACTED]. The urinalysis was never collected and sent to the laboratory Record review of the nurse notes dated 12/27/14 (3-11 shift) Vital signs were temperature 101.5, heart rate 80, respirations 20 and blood pressure 123/62. Resident alert and verbal but very weak. Complains of weakness, achiness, and nausea. Resident lungs sounds are clear. Gave tylenol for fever. Checked temperature one half hour later, temperature still at 101. Resident appears to have flu like symptoms. Physician was notified, new order sent to emergency room for flu like symptoms. Family, notified. The Resident Transfer Form dated 12/27/14 revealed the resident was transferred to the community hospital for possible dehydration, flu like symptoms and extreme weakness. Record review of the discharge summary from the hospital dated 1/5/15 revealed that the resident ' s admitting [DIAGNOSES REDACTED]. There was an infectious disease consultant and the resident was ordered an antibiotic through a PICC (Peripherally Inserted Central Catheter). Interview on 1/16/2015 at 11:42 AM with the Director of Nursing (DON) regarding the UA results revealed the nurse called the physician because laboratory was closed for Christmas. The physician was notified. The DON continued that the UA was collected on 12/29/14. The resident was discharged on the 27th of December and the laboratory urine was never collected. No documentation was available at the laboratory or the facility to indicate the urine specimen had been sent out by the facility or been received by laboratory. Interview on 1/16/14 with the Administrator and the Regional Consultant revealed that the expectation was that if the physician's order [REDACTED]. If the physician's order [REDACTED]. The urinary specimen wasn't collected on 12/26/14. The resident was discharged to the hospital on [DATE].

Based on observation, staff interview, record review, the facility failed to prevent tissue injury resulting in traumatic penile injury for 1(Resident # 5) of 5 sampled residents with an indwelling urinary catheter. The facility failed to anchor and secure the indwelling catheter tubing for 1 (Resident # 6) of 5 sampled residents with an indwelling catheter. Findings include: A review of the facility policy titled "Indwelling Urinary Catheter Care" reads "Number 13. Validate the catheter is anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter." 1. Resident #5 was admitted to the facility 3/12/2010 and readmitted [DATE]. Cumulative [DIAGNOSES REDACTED]. Resident's significant change assessment dated [DATE] indicated that Resident #5 had short term and long term memory impairment with poor decision-making. He required total assistance with bathing and transfers. In addition, he was coded as having an indwelling urinary catheter. Physician telephone order on 5/4/2010 8 PM stated "Cleanse penile open area with NS (normal saline) and apply [MEDICATION NAME] qd (daily) til clear." Treatment records for May, 2010 indicated Resident #5 had an open penile area which was treated with [MEDICATION NAME] ointment applied daily. Treatment records for June 2010, July 2010, August 2010 and September 2010 continued daily treatment with normal saline and [MEDICATION NAME] ointment daily to penile open area. physician progress notes [REDACTED]. There were no entries regarding penile erosion or problems noted with the penis. Resident #5's Weekly Skin Check Sheet noted "penis with ulceration around tubing" the first time on 5/4/2010. The Weekly Skin Check Sheet for 8/27/2010 documented, for the second time, treatment continued to open penile area. The weekly skin check entry on 9/17/2010 indicated the penis was split from the foley (urinary catheter). On 9/24/2010, the weekly skin check sheet indicated the skin on penis shaft was split. On 9/21/2010, the Non-Pressure skin condition report sheet for Resident #5 indicated the penis shaft had a 9 cm. (centimeter) length of split and 1 cm. The record indicated it was erosion. Documentation also included that Resident #5 masturbated frequently and caused friction of the area. Nursing notes dated 9/21/2010 at 11:30 AM. indicated Resident #5's attending physician was notified regarding split on penis shaft due to indwelling urinary catheter and a urology consult was ordered. Urology consult dated 9/24/2010 indicated penile erosion from catheter with recommendation for S-P (suprapubic) tube. On 10/5/2010, Resident #5 was seen by a second urologist. Consultation indicated traumatic hypospadius (an abnormality of the penis in which the urethra opens on the underside) secondary to urinary catheter. Wet to dry normal saline dressings were ordered twice daily and catheter tubing was to be taped up on resident's abdomen to prevent further damage. Plan: set up SP tube placement. On 10/12/2010, the Non-Pressure skin condition report sheet completed by the wound care nurse indicated the penile shaft split measured 8 cm. x 1 cm. with a depth of 0.3 cm. The report indicated that staff continued to tape the catheter to the abdomen but Resident #5 continued to masturbate and cause more friction with the catheter. A treatment and dressing change observation was done on 10/14/2010 at 11:30 AM. Resident #5 was lying in bed with incontinent brief in place. He was not wearing any pants or pajama bottoms. Resident #5 was noted to have a split on the underside of the penis extending from the tip of the penis to the scrotal area. The exposed underlying areas of skin were pink/ red in appearance. Yellow liquid material was noted on the dressing. On 10/14/2010 at 11:30 AM, LPN #1 indicated that Resident #5 had been seen by two urologists and was in the process of getting a suprapubic catheter (a bendable rubber tube that is inserted directly from the abdomen into the urinary bladder to drain urine). LPN #1 indicated the split to the base of the penis started approximately one month ago. The catheter tubing was observed taped on the abdomen. On 10/14/2010 at 2:55 PM., LPN #1 indicated the area first started as a little erosion at the head of the penis in May. She indicated treatment, at that time, was saline and [MEDICATION NAME] ointment. Once it started splitting, she indicated it kept splitting day by day. When asked about weekly skin checks, she stated the treatment nurse usually did the weekly skin assessments on days. Nurses on the floor also did skin assessments. Measurements would be indicated on the Non-Pressure Ulcer area sheet. On 10/14/2010 at 4:45 PM., the Director of Nursing indicated that the physician came to the facility every one-two weeks. When asked regarding documentation of the penile area and measurements, she indicated documentation should be on the Non-Pressure ulcer sheet. She indicated the penile erosion should be on the care plan. The care plan for the penile erosion was not found. On 10/14/2010, the MDS (Minimum Data Set) Co-ordinator stated she expected the penile erosion to be on the care plan. She reviewed the care plan and indicated it was not on the care plan. On 10/15/2010 at 10:30 AM., NA #1 indicated that she provided care to Resident #5 about two times weekly. She indicated catheter care was done during morning care and she first noticed Resident #5 had a split at the tip of the penis in May 2010. She stated, in August, the split in the penis area was about 1/3 of the way down the shaft of the penis and had yellow/brown liquid drainage from the area. She indicated she noted this when the nurse was changing the dressing on the penis. She stated the nurse treated the area with ointment and a dressing. She stated Resident #5 masturbated at times and would pull on the catheter tubing. On 10/15/2010 at 11:00AM, RN #1 indicated she noted the split on penis from the head of the penis to the base on 9/17/2010 and informed the wound care nurse and LPN #1. On 10/15/2010 at 11:30 AM., the wound care nurse indicated the order for [MEDICATION NAME] was used to prevent problems such as infection due to Resident #5 masturbating and rubbing the urinary catheter. She stated the penile opening was not red or infected. She stated there was "nothing to measure" in August and the area reported on the weekly skin assessment sheet referred to the opening at the tip of the penis. She stated there was no erosion of the penile opening in August. The wound care nurse indicated the first sign of any problems was in mid-September when the penis shaft split open and was reported to her by RN #1. On 10/15/2010 at 11:45 AM, Resident #5's attending physician indicated that he had not seen the penile erosion but he was aware of it when notified by the facility on 9/21/2010. He indicated he was not a urologist but the weight of the catheter on the urethral penis could cause erosion. He further indicated erosion can happen in different ways and can erode from the inside out. The erosion would not be found out until it split. On 10/15/2010 at 1:30 PM., Resident #5's urologist stated Resident #5 had traumatic hypospadius with a filleted open penis to the scrotum area. He indicated hypospadius did not occur overnight and it was erosion occurring from the tip of the penis. He stated the pressure from the catheter caused erosion and slowly split the urethra and he had never seen it extend all the way to the scrotal area. A suprapubic catheter would be placed and the penile erosion would eventually heal with local wound care. The opening would eventually totally close. He stated, if Resident #5 had been a young, healthy man, he would need advanced reconstruction and many surgeries. On 10/15/2010 at 2:45 PM, NA #1 indicated Resident #5 wore a leg strap in the past and did not remove the strap himself. She did not indicate a leg strap was worn in August. On 10/15/2010 at 3:15 PM, NA #2 indicated Resident #5 wore a leg strap at one time but could not remember if he wore one in August. She stated she had not seen Resident #5 masturbate but he did put his hands in his diaper. On 10/15/2010 at 5:50 PM, the Director of Nursing stated she had full confidence in the wound care nurse and the wound care nurse would have reported it (penile split) if she had seen it earlier than 9/21/2010. On 10/27/2010 at 9:50 AM, LPN #3 indicated she did not recall what the penile area looked like on 8/27/2010 when she completed the Resident weekly skin check sheet. She did not recall if there was a penile split at that time. 2. Resident #6 was admitted to the facility 6/25/2010 and readmitted [DATE]. Cumulative [DIAGNOSES REDACTED]. Resident's significant change assessment dated [DATE] indicated that he had short and long term memory impairment and moderately impaired in decision-making. In addition, it indicated he had an indwelling urinary catheter. An observation on 10/14/2010 at 3:10 PM revealed that Resident #6's urinary catheter tubing was not secured with a leg strap or tape. NA #2 indicated he did not have a leg strap on when she came in for the afternoon shift and did not have one on yesterday evening. NA #1 was also present and indicated she had provided morning care for Resident #6 and he did not have a leg strap on when care was given. She indicated she did not tell anyone that Resident #6 did not have a leg strap. LPN #1 applied a leg strap before Resident #6 was assisted out of bed to his chair. On 10/15/2010 at 2:15 PM, Resident #6 was observed to have the urinary catheter tubing secured with a leg strap.

Based on record review and staff interviews, the facility failed to implement a plan of care for penile erosion for one (Resident #5) of eight sampled residents. Findings included: 1. Resident #5 was admitted to the facility 3/12/2010 and readmitted [DATE]. Cumulative [DIAGNOSES REDACTED]. Resident's significant change assessment dated [DATE] indicated that Resident #5 had short term and long term memory impairment with poor decision-making. He required total assistance with bathing and transfers. In addition, he was coded as having an indwelling urinary catheter. Resident's care plan dated 8/13/2010 indicated Resident #5 had an indwelling urinary catheter secondary to chronic urethral stricture. Approaches included catheter care as ordered, monitor output, monitor for signs and symptoms of infection and privacy bag for dignity. A treatment and dressing change observation was done on 10/14/2010 at 11:30 AM. Resident #5 was noted to have a split on the underside of the penis extending from the tip of the penis to the scrotal area. The exposed underlying areas of skin were pink/ red in appearance. Yellow liquid material was noted on the dressing. On 10/14/2010 at 2:55 PM, LPN #1 indicated the area first started as a little erosion at the head of the penis in May. She indicated treatment, at that time, was saline and [MEDICATION NAME] ointment. Once it started splitting, she indicated it kept splitting day by day. On 10/14/2010 at 4:45 PM, the Director of Nursing, when asked regarding documentation of the penile area and measurements, indicated documentation should be on the Non-Pressure ulcer sheet. She indicated the penile erosion should be on the care plan. She was unable to find the care plan for the penile erosion. On 10/14/2010, the MDS (Minimum Data Set) Coordinator stated she expected the penile erosion to be on the care plan. She reviewed the care plan and indicated it was not on the care plan.

Based on record review and staff interviews, the facility failed to follow the care plan in the use of a lounge (recliner) chair for one (Resident #2) of eight sampled residents. Findings included: Resident #2 was admitted to the facility 5/21/2010. Cumulative [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) dated 8/17/2010 indicated that Resident #2 had short term and long term memory impairment and required reminders, cues and supervision with decision-making. She was non-ambulatory and required total assistance of two persons for transfers. Range of motion was limited in her neck and both arms with partial loss of voluntary movement. Mode of transfer was documented as bedfast all or most of the time. Care plan dated 6/2/2010 and reviewed 8/30/2010 revealed Resident #2 had impaired physical mobility related to end stage liver disease, [MEDICAL CONDITION] and weakness. Approaches included transfer with mechanical lift using two assistants as tolerated to recliner. Her care plan also indicated she was at risk for falls related to [MEDICAL CONDITION] medication, weakness, poor balance and poor decision skills. Approaches included need to use recliner due to weakness, poor balance. A Resident event report sheet dated 9/8/2010 at 11:00 AM. stated Resident #2 was found on the floor in her room. She had been sitting in her wheelchair. A laceration was noted on her forehead above her left eye and she was sent to the emergency room for evaluation and treatment. The LPN who was present at the time of the fall was unable to be interviewed. On 10/15/2010 at 10:15 AM., the Physical therapy manager indicated Resident #2 struggled with therapy. She stated Resident #2 was inconsistent in her ability to perform exercises and therapy tasks and had problems with balance. Therapy had tried to progress resident from a recliner to a wheelchair. She stated therapy recommended a gerichair or reclining high back wheelchair On 10/15/2010 at 11:00 AM., the Director of Nursing indicated she was in the facility on the day of the fall. She stated Resident #2 was in a regular wheelchair and resident's door was not closed. She indicated Resident #2 was alert at that time and, if asked by resident, would have placed her (the resident) in a regular wheelchair. She further indicated there was good communication between nursing staff and therapy. Normally, nursing staff would follow therapy recommendations regarding transfers, use of wheelchair, reclining wheelchair, etc. On 10/15/2010 at 11:35 AM., NA #3 indicated she had provided care for Resident #2 on the day of her fall. She indicated Resident #2 was alert and wanted to get up. She indicated she usually transferred Resident #2 to a recliner. On the day of the fall, Resident #2 had a regular wheelchair folded up by the sink in her bathroom. NA #3 stated the recliner was not in the room. NA #3 said she assumed that therapy had advanced Resident #2 from a recliner to a regular wheelchair. NA #3 indicated therapy had not told her to use a regular wheelchair. On 10/15/2010 at 3:25 PM., the Director of Nursing indicated nursing assistants have care cards in the flow sheet books. They used the cards to record type of transfer, use of wheelchair, reclining wheelchair, etc. She was unable to locate Resident #2 ' s care card.

Based on record review and staff interviews, the facility failed to use a lounge (recliner) chair as recommended by Physical Therapy and noted on the care plan resulting in a fall with injury to one (Resident #2) of three sampled residents. Findings included: Resident #2 was admitted to the facility 5/21/2010. Cumulative [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) 8/17/2010 revealed that Resident #2 had short term and long term memory impairment and required reminders, cues and supervision with decision-making. She was non-ambulatory and required total assistance of two persons for transfers. Range of motion was limited in her neck and both arms with partial loss of voluntary movement. The resident was not able to participate in a sitting balance test without physical help. The resident had a history of [REDACTED]. The Care plan dated 6/2/2010 and reviewed 8/30/2010 indicated Resident #2 had impaired physical mobility related to end stage liver disease, congestive heart failure and weakness. Approaches included transfer with mechanical lift using two assistants as tolerated to recliner. Her care plan also stated she was at risk for falls related to psychotropic medication, weakness, poor balance and poor decision skills. Approaches included need to use recliner due to weakness, and poor balance. Physical therapy progress notes on 9/1/2010 revealed Resident #2 had right lower extremity weakness, bilateral upper extremity weakness with weakness noted greater on the left side. She tolerated sitting up in gerichair (reclining wheelchair) well. Physical therapy notes for the week of 9/2/2010-9/8/2010 indicated Resident #2 continued with weakness, impaired balance and impaired endurance. A resident event report sheet dated 9/8/2010 at 11:00 AM. revealed Resident #2 was found on the floor in her room. She had been sitting in her wheelchair. A laceration was noted on her forehead above her left eye and she was sent to the emergency room (ER) for evaluation and treatment. Review of the physician order [REDACTED]. Bactrium (sp Bactrim)) DS (double strength) tabs (tablets) 10 take (1) po (by mouth) BID (twice day) for (upper) (L) eye wound." On 10/15/2010 at 11:35 AM., NA #3 stated she had provided care for Resident #2 on the day of her fall. She indicated Resident #2 was alert and wanted to get up. NA #3 indicated she usually transferred Resident #2 to a recliner. On the day of the fall, the recliner chair was not in the resident's room. A regular wheelchair was folded up by the sink in the bathroom. NA #3 indicated she assumed physical therapy had switched the resident to a wheelchair. NA #3 indicated therapy had not told her to use a regular wheelchair. NA#3 stated she transferred the resident to the wheelchair and left the room, leaving the door open so staff could keep an eye on her. The NA stated she was down the 200 Hall when she heard a loud fall. The janitor said " lady's on the floor " . The LPN who was present at the time of the fall could not be interviewed. The Physical Therapy Assistant who had been working with Resident #2 for the month of September could not be interviewed. On 10/15/2010 at 10:15 AM., the Physical therapy manager indicated Resident #2 struggled with therapy. She stated Resident #2 was inconsistent in her ability to perform exercises and therapy tasks and had problems with balance. Therapy had tried to progress resident from a recliner to a wheelchair. She stated therapy recommended a gerichair or reclining high back wheelchair. The Physical therapy manager provided treatment to Resident #2 the day before her fall. She indicated Resident #2 stood up but was unable to move her feet. Standing was attempted three times and the resident was returned to bed. The Physical therapy manager stated they did not give any recommendations regarding the use of a regular wheelchair and was using the reclining wheelchair /gerichair at the time of resident's discharge from the facility. The resident was discharged from the facility to the hospital on [DATE]. On 10/15/2010 at 11:00 AM., the Director of Nursing stated she was in the facility on the day of the fall. She stated Resident #2 was in a regular wheelchair and the resident's door was not closed. She indicated Resident #2 was alert at that time and, if asked by the resident, she (the DON) would have placed her (the resident) in a regular wheelchair. She further indicated there was good communication between nursing staff and therapy. Normally, nursing staff would follow therapy recommendations regarding transfers, use of wheelchair, reclining wheelchair, etc. On 10/15/2010 at 3:25 PM., the Director of Nursing indicated nursing assistants have care cards in the flow sheet books. They used the cards to record type of transfer, use of wheelchair, reclining wheelchair, etc. Resident care cards were placed in the permanent chart on resident discharge. She was unable to locate Resident #2's care card.