Every finding on record at Abbey Delray South

Based on the observations, interviews and record review, the facility failed to ensure accurate and complete Level I PASARR (Preadmission Screening and Resident Review) assessment for 3 of 3 residents reviewed for PASARR (Resident #34, Resident #20 and Resident #5). The findings included: Review of the facility's policy titled, admission Criteria, revised February 2024, included the following: Our communities only admit residents whose medical and nursing care needs can be met.Policy Interpretation and Implementation: 8. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. 1) Record review for Resident #34 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Depression, Bipolar Disorder, Anxiety Disorder and Mild Dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #34 had a Brief Interview for Mental Status (BIMS) of 12, which indicated moderate cognitive impairment. Record review of Resident #34's electronic medical chart documented the most recent PASARR Level I screening was conducted on 06/30/26 and revealed in section I: PASARR Screen Decision-Making, sub-section A for Diagnosis (check all that apply): none of the above diagnoses were checked. Review of the psychiatry consultation note dated 07/07/26, documented Resident #34 has a history of anxiety, insomnia, and bipolar disorder. It stated collateral information was obtained from his family member, who reports that Resident #34 was diagnosed with bipolar disorder approximately 40 years ago and reports a psychiatric hospitalization several years ago for mood stabilization. During an interview conducted on 07/22/26 at 1:21 PM with Social Services Manager (SSM), she stated she has worked at the facility for 4 months. She stated the PASARR and hospital documentation are reviewed upon admission by the team in clinical meetings. If there is any conflict with behavior or something wrong with the PASARR, it is immediately brought up to the admissions staff to contact the hospital to see if they can correct the PASARR. On 07/22/26 at 1:31 PM an interview was conducted with the Assistant Director of Nursing (ADON). She stated they hold psych meetings, unsure how often, however, the PASARR is reviewed by Social Services and if necessary, the DON has access to redo the form. During an interview conducted on 07/23/26 at 9:33 AM with the DON, who stated during the morning team meetings all admissions are reviewed, including PASARR. She stated if she is notified that there is a concern, the initial plan is to have the hospital redo the PASARR during real time. The facility keeps the original PASARR and scans the updated copy into the electronic medical chart. The DON acknowledged that she is the one responsible for redoing a PASARR and she stated that she has changed a few. When asked if a resident has a medical diagnosis that is not checked on the PASARR would that be considered incomplete, she responded yes. 2) Record review for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Depression, and Anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. Record review of Resident #20's electronic medical chart documented the most recent PASARR Level I screening was conducted on 06/24/26, and revealed in section I: PASRR Screen Decision-Making, sub-section A for Diagnosis (check all that apply): none of the above diagnosis were checked. Review of the psychiatry consultation note dated 07/07/26, documented Resident #20 has a long-standing history of depression, ADHD (Attention Deficit Hyperactive Disorder), and anxiety. 3) Record review for Resident #5 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Depression and Anxiety Disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. Record review of Resident #5's electronic medical chart documented the most recent PASARR Level I screening was conducted on 05/13/26, and revealed in section I: PASRR Screen Decision-Making, sub-section A for Diagnosis (check all that apply): none of the above diagnosis were checked. Review of the psychiatry consultation note dated 06/16/26, documented Resident #5 has a history of anxiety, and depression.

Based on one of two observations and interview, the facility failed to ensure a clean and sanitary kitchen.The findings included: An observation of the kitchen was made on 07/20/26 beginning at 8:54 AM with the Director of Culinary Services and the Certified Dietary Manager. Upon entering the kitchen, the breakfast service was completed, the kitchen had been cleaned after the meal, and staff were in the process of doing the breakfast dishes. The following concerns were noted and confirmed by managerial staff.The air conditioning unit in the walk-in refrigerator had dust on the black insulation around the PVC piping.A pot with handles and cover, was noted to have what appeared to be rust, was stored with other clean serving pans.Two unlabeled frozen plastic water bottles were inside the freezer.An unlabeled plastic jug with dark liquid approximately 25% full was on the lower shelf of a utility table.A bin with clean utensils included two serving utensils that appeared to be rusted and damaged.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions and to ensure the prevention of foodborne illnesses for 2 of 2 visits to the central kitchen. Facility failed to store resident's food in the appropriate temperature during 1 of 2 dining observations for Resident #648. The findings included: In a tour conducted on 02/17/25 at 10:00 AM, in the main kitchen, the following were noted: 1. Staff A, Dietary Aid, did not have facial hair restraints while in the food production area. 2. Staff B, Chef, did not have facial hair restraints while in the food production area. 3. A round garbage bin in the food production area is noted to have food debris and is not covered by the lid. 4. A square garbage bin in the food production area was noted to have food debris and was not covered. 5. The walk-in refrigerator was noted with the following: 6. A large metal container with slices of raw fish with today's date of 02/15/25 and used by date of 02/20/25. 7. A large metal container of cooked shrimps with today's date of 02/15/25 and used by date of 02/19/25. 8. Eight (8) -10 pounds rolls of raw ground meat not dated or labeled with a red bloody drainage on the bottom enough to cover the entire bottom of the container. 9. A large metal container with chunks of filet [NAME] dated 02/14/25 to 02/20/25. 10. Four large pieces of unidentified raw meat that were not labeled or dated. 11. Two large boxes of raw chicken that were opened and exposed to the air. 12. A large box of raw Pork was noted with a sign of use or freeze by 03/13/25. 13. The walk-in freezer was noted to have condensation above the food, and food boxes exposed. 14. In a tour conducted on 02/19/25 at 11:15 AM in the Satellite kitchen, the following were noted: Staff N, Dietary Aide, was observed wearing round earrings that were about 2 inches long while handling prepared foods on the tray line. While on the tray line, she was observed dumping the water and the chemicals in the red sanitation bucket and using it to scoop the hot water from the tray line. She then proceeded to handle the prepared foods without changing her gloves first. 41837 Review of the facility's policy titled, Foods Brought by Family/Visitors with a revised date of March 2022 included in part the following: Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from the facility-prepared food .Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. Record review for Resident #648 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cognitive Communication Deficit and Parkinsonism. The Minimum Data Set for Resident #648 dated 02/04/25 documented in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. On 02/17/25 at 11:00 AM, an observation was made of Resident #648 sitting in the wheelchair next to the bed, on the overbed table in front of the resident was an opened container of cut up mango with no label from facility, with manufacturer label keep refrigerated, a closed container of egg salad with label dated 02/14/25 and a use by date of 02/17/25, and a closed container of fish with a label dated 02/15/25. During an interview conducted on 02/17/25 at 11:05 AM with Resident #648 who stated the food is brought in by relatives and he keeps Kosher and they are Kosher foods. The resident stated the food has been on his table all weekend long. When asked if staff had offered to put his perishable food items in the refrigerator for him, he said no. During an interview conducted on 02/17/25 at 11:10 AM with Staff H, Registered Nurse who stated she has worked at the facility for just over a year. When asked about food brought in from the outside, she said it needs to be labeled and dated. When asked about the food on Resident #648's overbed table, she acknowledged it should have been in the refrigerator. Staff H stated the items were probably no longer any good since they have not been refrigerated and should be thrown out.

Based on interviews and record reviews, the facility failed to maintain an effective system to obtain and use of feedback and input from (Minimum Data Set (MDS) Department and ensure an effective QAPI/PIP (Quality Assurance Performance Improvement/Performance Improvement Plan) to ensure MDS assessments were completed timely with the potential to affect 70 out of 70 residents. The findings included: . Review of the facility's policy titled, Quality Assurance and Performance Improvement Program Plan with a revised and reviewed date of 08/31/22 indicated in part the following: Each facility's Administrator will be accountable for leadership and will provide coordination of the overall health center QAPI program. Together with members of the QAPI Committee, the Administrator will be responsible for planning, designing, implementing, and coordinating care and services and selecting QAPI activities to meet the needs of residents. Guidelines for Performance Improvement Projects: The facility will have a plan for conducting PIPs to improve care and services. This will be accomplished by: PIPs will be identified by the department representative as discovered in conversation, complaints, observations for opportunities for improvement, improved practices, new standards, new rules or as recommended among the team. The facility will monitor all PIPs within the organization. Communication of QAPI: By conveying the message that nay and every team member is expected to raise quality concerns and to think about how we can improve our systems, and that it is safe for team members to raise quality concerns and issues. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI efforts that serve to identify, report, investigate, analyze, and prevent adverse events. Documentation will reflect the development, implementation, and evaluation of corrective actions or performance improvement initiatives. In order to maintain an effective QAPI plan, the plan will include all team members, all departments and all services provided and specific to each facility. QAPI will be adequately resourced. Review of the PIP titled, Late MDS Assessments with an initiated date of 12/12/24 with Staff R -MDS Coordinator and it included in part the following: Priority: Medium Problem or Opportunity for Improvement: Late assessments averaging 55% in last month. Root Cause Analysis: Turnover in IDT and high volume of admissions and discharges. Goals: Reduce the number of assessments that are completed late on a monthly basis by 5%. Meetings: 12/19/24 assessments late 61.73% 12/26/24 continue with late assessments 70.49% 01/02/25 continue with late assessments 47.62% 01/09/25 assessments completed for month end late 61.54% 01/16/25 continue with schedule late 50% 01/23/25 assessments continue to fall behind (no percentage documented) 01/30/25 continue with late assessments 61.8% 02/06/25 assistance provided from support team to assist with late assessments 78.% 02/13/25 assessments remain late 72% Review of the QAPI Committee Meeting sign - in sheet for 12/20/24 indicated the Attendees included the Administrator, the Director of Nursing and Staff R, MDS Coordinator. When asked about MDS assessments still listed as in progress, Staff R stated that they have been having problems closing MDS assessment due to change in staff. Some areas of the assessments performed by other departments were not done timely. When asked when this was identified and if she notified anyone, she stated it was identified in December of 2024 and at the time she notified the Administrator, DON (Director of Nursing), and the Regional MDS Director. Staff R also added that it was discussed in QAPI and the PIP was initiated by her. Staff R showed the PIP to the surveyor which was initiated on 12/12/24. Staff R stated they discuss the action plan at the weekly IDT meeting, and she discussed which resident assessments were due and which ones are late. When asked if it is one particular department that is late on doing their assessments and entering their information in the MDS assessments she stated it is predominately the Social Services Department. During an interview conducted on 02/19/25 at 9:15 AM with the Administrator who was asked about care plans for advanced directives, he said they would be completed by a social worker, but they identified an issue last week of the Social Services Department not having completed care plans, evaluations and BIMS evaluations in a timely manner due to high volume of admissions and discharges as well as only having 1 full time Social Worker. When they identified this issue last week, they put a PIP in place for the Social Services Documentation on 02/12/25. During an interview conducted on 02/19/25 at 12:15 PM with the Administrator who was asked if he was made aware of the MDS assessments not being completed in a timely manner, he said he was aware of the issue in January 2025. When asked if there was a PIP in place for the MDS assessments not being completed timely, he said yes he believed Staff R MDS Coordinator started a PIP in January 2025. When asked if the PIP has been effective, he said he is not really sure, but they are working on it. When asked if he has reviewed the PIP, he said he believed he did not. The Administrator said he thinks they talked about it in QAPI at the end of January 2025. During an interview conducted on 02/20/25 at 12:30 PM with the Administrator who was asked about the Late MDS Assessments PIP he stated at the QAPI meeting held on 12/20/24, the MDS Coordinator was not present at the meeting, and he was not aware or told that she started a PIP on 12/12/24 and this was something that she started on her own and not everything is brought to his attention. When asked if any other staff member was involved in the PIP, he said maybe her Regional Supervisor, but he was not sure. During an interview conducted on 02/20/25 at 1:50 PM with the Social Service Director who was asked when Staff R, MDS Coordinator informed her the MDS assessments were late, she said it has been going on for a while at least several weeks. When asked if she attends monthly QAPI meetings, she stated yes she does. When asked if it has ever been brought up at QAPI meetings about the MDS assessments being late, she stated yes she believes it was the Administrator who brought it up but did not go into much detail about it.

Based on observations, interviews and record review, the facility failed to follow the care plan's interventions to prevent falls for 2 of 2 resident reviewed for accidents (Resident #69 and Resident #64). The findings included: 1.) A review of the facility's policy titled, Comprehensive Care Plan, revised on 09/06/2022, revealed the following: The resident care plan will include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and will be developed and implemented for each resident. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met, c. When the resident has been readmitted to the facility from a hospital stay. A review of the facility's policy titled, Fall Prevention and Management Program revised on 09/23/2019 showed the following: Post-fall: there are two key elements of the post-fall response and management: Initial post fall evaluation, documentations and follow-up include ongoing monitoring for resident changes in condition where medically indicated, and the care plan will be reviewed and updated as indicated. 2.) A record review showed that Resident #69 was readmitted to the facility on [DATE], had a fall on 09/23/24, and was transferred to the hospital. On 10/3/24, Resident #69 returned to the facility with a diagnosis of a right hip fracture, Dementia and General Anxiety. The significant change Minimum Data Set (MDS) assessment completed on 10/11/24 showed that Resident #69 had a Brief Interview Mental Status (BIMS) score of 03, which indicated the resident was cognitively impaired. She required extensive assistance of two people with transfer and bed mobility. A review of the Quarterly MDS dated [DATE] showed the following: for chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair), Resident #69 was coded for substantial with maximum assistance. The helper does more than half the effort, lifts or holds trunks or limbs and provides more than half the effort. This did not show that Resident #69 needed two person assist with transfer and bed mobility. In an observation conducted on 02/17/25 at 11:10 AM, Resident #69 was noted in bed with the bed in a low position and a fall mat noted on the right side of the bed. No fall mat was noted on the left side of the bed. In an observation conducted on 02/18/25 at 11:10 AM, Resident #69 was noted in bed with the bed in a low position and a fall mat noted on the right side of the bed. No fall mat was noted on the left side of the bed. In an observation conducted on 02/19/25 at 3:45 PM, Resident #69 was noted in her bed. A floor mat was noted on the right side of her bed, folded against her drawers, and no floor mat was noted on the left side of the bed. A review of the medical record did not show that a post fall assessment was completed for Resident #69 after her fall on 09/23/24. The care plan initiated on 10/4/24, after Resident #69 came back from the hospital, showed keeping the bed in the lowest position when resident in bed, keeping the room and floor free from spills and clutter, and floor safety mats. For transfers, it showed that Resident #69 needs extensive assistance from one staff member to move between surfaces. The Care plan initiated on 02/19/25 revealed that Resident #69 had a fall and is at risk for additional falls related to history of falls, Impaired mobility, Increased muscle weakness, Poor safety awareness, Refusal for assistance with mobility. An interview conducted on 02/19/25 at 3:06 PM with the Director of Nursing ( DON) stated that Resident #69 did not have a post-fall evaluation since they went to the hospital and were not in the building, but she would have expected staff to complete a post-fall assessment. The DON reported that the care plan needs to be reviewed and updated after a fall. She further said that if the care plan says mats, then the expectation is to have two-floor mats on each side of the bed. In an interview conducted on 02/19/25 at 3:36 PM with Staff M, a Certified Nursing Assistant, stated that Resident #69 was at risk for falls. She must make sure that the call light is within reach and that she has a floor mattress on each side of the bed. In an interview conducted on 2/19/25 at 3:40 PM with Staff C, the Registered Nurse stated that Resident #69 is at risk for falls. She conducts frequent rounds and ensures that there are mats on each side of the bed. Staff C said that Resident #69 tried to get out of bed at times and that she is coded for one-person assistance. A post-fall evaluation is always completed after a fall, even if the resident is transferred to the hospital. 51137 3.) Review of the Record revealed Resident #64 was admitted to the facility 06/16/23 with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #64 had a Brief Interview for Mental Status (BIMS) score of 3, on a 0 to 15 scale, indicating the resident had severe cognitive impairment. Review of the fall risk assessment evaluation created on 02/16/24 revealed Resident #64 had a fall risk score of 11. This same assessment documented, Upon admission and quarterly, at a minimum, thereafter, observe the resident status in the 11 clinical condition parameters listed below by assigning the corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered at high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Review of the Care Plan dated 01/13/25 documented Resident is at risk for falls related to impaired cognition, impaired mobility. This same care plan revealed interventions such as Keep bed in lowest position while resident is in bed, keep call light within reach and encourage resident to use for assistance as needed, and keep personal items within reach. During an observation on 02/17/25 at 11:15 AM, a fall mat was observed placed behind the Resident's recliner against the wall, photographic evidence obtained. Resident #64's personal belongings were not observed within reach and her bedside table was placed by the Resident's recliner in front of the fall mat on the wall. On a follow up observation on 02/17/25 at 2:57 PM, the fall mat was still observed against the wall. Review of the active orders on 02/17/2025 revealed there were no orders for a fall mat. Review of the active orders on 02/18/2025 revealed a new order floor mat as need. During an observation on 02/18/25 at 11:13 AM, the floor mat was observed on the left side of Resident's bed; the Resident's belongings and call light were not within reach. During an observation on 02/19/25 at 11:42 AM, the Resident was observed in bed in a high position approximately 36 inches from the floor and the call light and personal belongings were not within reach. The resident's spouse walked in the room at approximately 12:00 PM. There were no staff present in the room with the Resident for over 25 minutes. On 02/19/25 at 12:08 PM, an interview was conducted with Staff O, Registered Nurse (RN.) When asked why Resident #64's bed was left in a high position for over 25 minutes with no staff present in the room, she stated the Certified Nursing Assistants (CNA)s usually leave the bed in the lowest position when they leave the room. She stated that during mealtimes, the Resident's spouse requests for the bed to be up high while he is present in the room. Staff O was made aware that the husband was not present in the room during the majority of the observation and that he entered towards the last couple of minutes of the observation. When asked if Resident #64 was at risk for falls, Staff O stated that she did not believe they were a fall risk because they hadn't fallen or tried to get out of bed. When asked if her mental status and diagnoses could play a role in her being a fall risk, she repeated The resident has not fallen and stays in bed. When asked why the floor mat was not on the floor on Monday, Staff O stated that she did see it in the room on Monday up against the wall. When asked why it was on the wall and not the floor she stated, maybe they were cleaning and left it like that. During an interview on 02/19/25 at 12:42 PM, the Director of Nursing (DON) was made aware of the observations made throughout the week regarding Resident #64. The (DON) agreed with the findings and stated it should not have happened since the Resident was identified as at risk for falls. She stated that if a floor mat was already in the room prior to having an order in place for it, it should have been placed back on the ground.

Based on observation, interviews and record review, the facility failed to provide assistance during dining for 1 of 2 residents reviewed for nutrition (Resident #12). The findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses of Dementia, Osteoporosis, and Hemiplegia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #12 has a Brief Interview of Mental Status (BIMS) score of 13, which is cognitively intact. Section GG of this MDS showed that for eating, Resident #12 was coded for supervision or touching assistance only. A review of the Physicians' orders revealed an order for assistance with feeding with every meal-careful oral assisted feeding by hand every shift dated 2/11/25. In an interview conducted on 02/17/25 at 11:15 AM with Resident #12, she stated that she eats as much as she can and has lost some weight, but she is not sure how much. She is given Ensure Supplements and has tried to drink them when they are provided. In an observation conducted on 02/17/25 at 1:03 PM, Resident #12 was eating her lunch with no staff noted in the room. Continued observation at 1:25 PM showed that Resident #12 ate about 50% of her meal. In an observation conducted on 02/18/25 at 9:07 AM, Resident #12 was eating her breakfast meal with no staff noted in the room. A nutrition dietary progress note dated 2/12/25 showed that Resident #12 had 9.6% weight loss in 3 months and that she is receiving Ensure supplements 3 times a day. Her meal intake varies mostly between 25% and 75%. It further showed that a new order was placed to assist with feeding with every meal. A review of the care plan dated 02/19/24 showed the following: Resident #12 is at nutritional/dehydration risk related to mechanically altered diet, dementia, use of laxatives, and history of significant weight change. It showed staff to provide the necessary assistance with meals. In an interview conducted on 02/19/25 at 1:30 PM, Resident 12 stated that she needed assistance during dining. She stated that in the past, she was able to eat on her own, but now she needs more help during meals. An interview conducted on 02/19/25 at 1:40 PM with Staff L, a Certified Nursing Assistant, stated that Resident #12 can eat on her own and that she only needs assistance with setting up meals and opening containers.

Based on observations, interviews and record review, the facility failed to acquire a Physician order for a urinary catheter and failed to initiate a urinary catheter Care Plan for 1 of 2 sampled residents, Resident # 502; and failed to keep the urinary catheter anchored for 1 of the 2 residents, Resident #69. The findings included: A review of a facility policy titled, Indwelling Catheter Use and Removal dated 01/06/25, revealed under the Compliance Guidelines that if an indwelling catheter is in use, the community will provide appropriate care for the catheter in accordance with current professional standards of practice, will identify and document clinical indications for use of the catheter, and will keep the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral dislodgement of the catheter. 1) A record review for Resident #502 revealed the resident was admitted on [DATE] with diagnoses including Malignant Neoplasm of Cervix, Acute Cystitis, and Urinary Tract Infection. A review of the admission Minimum Data Set (MDS) assessment for Resident #502 dated 02/14/25, revealed resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating slightly impaired mental cognition. A review of Section H revealed a no for indwelling urinary catheter. A review of Section V revealed the triggering condition of an occasional urinary incontinence. A record review of Physician orders for Resident #502 dated 02/17/25, revealed no urinary catheter care and maintenance, urinary catheter size, and indication for insertion of urinary catheter. A review of the Care plans for Resident #502 dated 02/16/25 did not indicate the focus, plan and interventions for urinary catheter for Resident #502. In an observation conducted on 02/18/25 at 11:00 AM, Resident #502 was in her room trying to use her phone. When asked where she was yesterday, she responded, I had to see my doctor. This resident was observed with a urinary bag strapped on her right leg. When asked if she is comfortable wearing the urinary bag on her leg, she responded, Yes. She added, Staff empty the urinary bag before it gets full. During an interview conducted on 02/19/25 at 9:00 AM, with Staff T, Certified Nursing Assistant (CNA), who when asked if she had emptied the urinary bag of the resident, she responded, The other CNA did it. In an interview conducted on 02/19/25 at 2:30 PM with the Staff G, Admission Registered Nurse (RN), when requested to have the Resident #502's orders printed, she responded, Is it alright, I just put the order for the urinary catheter today? When asked how long the resident had had the urinary catheter, she did not respond. 41837 2) Record review for Resident #69 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on 10/03/24 with diagnoses that included in part the following: Other Obstructive and Reflux Uropathy, Neuromuscular Dysfunction of Bladder, and Dementia. Review of the Minimum Data Set for Resident #69 dated 01/11/25 documented in Section C a Brief Interview of Mental Status score of 2 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #69 revealed an order dated 10/03/24 for Catheter: Foley, Size:16 FR, Balloon Size:10 CC Diagnosis: Neurogenic Bladder. Review of the Physician's Orders for Resident #69 revealed an order dated 10/03/24 to secure catheter to leg. Be Sure to Keep Bag Off Floor. Catheter Size:16 FR, Reason: Neurogenic bladder. Review of the Medication Administration Record and the Treatment Administration Record for Resident #69 from 02/01/25 to 02/19/25 revealed no documentation of securing the catheter to the leg. Review of the Nursing Progress Notes for Resident #69 from 02/01/25 to 02/19/25 revealed no documentation of securing the catheter to the leg. Review of the Tasks for Resident #69 from 02/01/25 to 02/19/25 revealed no documentation of securing the catheter to the leg. Review of the Care Plan for Resident #69 dated 05/10/23 indicated a focus of the resident having an urinary catheter for Neurogenic Bladder and Obstructive Uropathy. She has recurrent UTI (Urinary Tract Infection) secondary to indwelling catheter. Collaboration with hospice services. The goal was for the Resident to be/remain free from catheter-related trauma and/or complications through next review date. The interventions included in part the following: Secure catheter to leg when up to avoid tension on urinary meatus. On 02/19/25 at 10:00 AM, an observation was conducted of the catheter care being performed for Resident #69 by Staff P, Certified Nursing Assistant (CNA) and assisted by Staff Q, Certified Nursing Assistant (CNA). The resident was lying in bed with the indwelling urinary catheter not secured to her leg. The catheter care was performed with good technique and staff wore appropriate Personal Protective Equipment. When Staff P and Staff Q were finished with the care for the resident they did not secure the indwelling urinary catheter to the resident's leg. During an interview conducted on 02/19/25 at 10:30 AM with Staff P and Staff Q, who were asked if they secure the indwelling urinary catheter, they said no. They have seen some residents with a leg strap to secure the catheter, but they acknowledged Resident #69 did not have a leg strap. During an interview conducted on 02/19/25 at 10:40 AM with the Director of Nursing who was asked about indwelling urinary catheters being anchored, she said it is best practice for the catheter to be anchored.

Based on observations, interviews and record review, the facility failed to meet the nutritional needs and provided the correct nutritional supplement for 1 of 2 residents reviewed for nutrition (Resident #47). The findings included: A record review revealed that Resident #47 was admitted to the facility on [DATE] with diagnoses of Cerebral infarction and Dementia. The quarterly 10/29/24 Minimum Data Set (MDS) showed that Resident #47 had a Brief Interview of Mental Status (BIMS) score of 02, which is cognitively impaired. In an interview conducted on 02/17/25 at 1:00 PM, Resident 47's family stated that Resident #47 had lost some weight and that he used to be around 180 pounds. He receives Ensure supplements twice a day and drinks them all. In this interview, a bottle of Ensure original was noted on the side table near Resident #47. In an observation conducted on 02/18/25 at 9:07 AM, Resident #47 was eating his breakfast. Staff were in the room setting up the breakfast meal for Resident #47. At 9:13 AM, Resident #47 was in the room, eating with no staff present. At 9:20 AM, Resident #47 only ate the eggs on the breakfast plate. A review of the weight log showed the following weights for Resident #47: 08/08/24, a weight of 180.2 pounds was recorded. 09/06/24, a weight of 159.8 pounds was recorded. 09/13/24 a weight of 160.9 pounds recorded. 09/25/24, a weight of 151.8 pounds was recorded. On 11/7/24, a weight of 152.8 pounds was recorded. On 12/2/24, a weight of 157.8 pounds was recorded. On 1/13/25, a weight of 156.0 pounds was recorded. On 2/3/25, a weight of 155.0 pounds was recorded. A review of the nutrition follow-up note dated 09/12/24 showed that Resident #47 had recently lost 11.3% of weight in one month. Ensure high-protein nutritional supplements are recommended twice a day. This note documented that Resident #47 was eating between 50% and 75% of meals. The follow-up nutritional note dated 09/26/24 showed that the Ensure high protein twice a day provided 1060 calories and 44 grams of protein. A nutrition note dated 11/25/24 showed that the Ensure high protein supplement was decreased from two times a day to one time a day and that Resident #47 was eating between 50% to 75% of his needs. The quarterly nutritional assessment dated [DATE] revealed that Resident #47's estimated nutritional needs were 1914 to 2340 calories a day. A review of the Certified Nursing Assistants documentation showed that between 02/5/25 and 02/17/25, Resident #47 ate between 47% and 71% of his meals. A review of the weekly nutrient summary revealed that Resident #47 was provided with an average of 2130 calories a day. This showed that Resident #47's intake of meals with the one bottle of Ensure original (250 calories a bottle), was only around 1123 calories to 1762 calories. This was meeting 65% of his lower end estimated needs and 75% of his higher end of estimated needs. In an interview conducted on 02/18/25 at 10:45 AM, Staff D, a Certified Nursing Assistant, stated that she oversees ordering nutritional supplements. The Registered Dietitian will let her know of any supplements that need ordering. She said that the last time she ordered Ensure High Protein was last year, but she was not sure when last year. In an interview conducted on 02/18/25 at 10:50 AM with Staff E, Registered Dietitian, she stated that for a resident with a supplement they do not have in-house, she would ask to order the supplement or change it to another type of supplement with similar nutritive value. Resident #47 should not have been given Ensure original instead of Ensure high protein. Staff E then went to the storage room to show this Surveyor what they had in stock. The storage room did not have Ensure high protein in stock, and Staff E was not sure when the last time they had this supplement was in-house. She further acknowledged that the diet order with the Ensure original once a day was not meeting Resident #47's nutritional needs. An interview conducted on 02/18/25 at 11:12 AM with Staff F, Licensed Practical Nurse, stated that Resident #47 had an order for Ensure High Protein, which she did not give this morning. She left a message for the doctor to change the order for Ensure Original, which they have in-house. She cared for Resident #47 last week and was unsure what type of Ensure was given. According to her, they get different kinds of Ensure supplements, and they have to go back and forth between them. In an interview conducted on 02/18/25 at 11:20 AM with Staff C, the Registered Nurse stated that she has been giving Ensure Original to all residents. She said they had not had Ensure High Protein for some time and could not remember the last time they had it in-house.

Based on observations, interview and record review, the facility failed to have an order for oxygen for 1 of 1 sampled residents, Resident #501. The findings included: A record review of a facility policy titled,Oxygen Administration with a revision date of 10/2010, revealed to verify that there is a physician's order for oxygen administration. A record review for Resident #501 revealed the resident was admitted on [DATE] with diagnoses that included Displaced Intertrochanteric Fracture of Right Femur, Chronic Obstructive Pulmonary Disease (COPD), and Chronic Systolic Congestive Heart Failure. A review of the Minimum Data Set (MDS) assessment for Resident #501 dated 02/18/25 revealed it was blank for the Brief Interview for Mental Status (BIMS) score. A review of Section I revealed a yes response to Asthma. A review of Section O was blank for oxygen therapy. A review of Physician Orders for Resident #501 revealed there was no order for oxygen indication, administration, care and management. A record review of the Care Plan for Resident #501 initiated on 02/16/25, and with the target date of 05/16/25, revealed a focus on COPD related to smoking. The goals were Resident will be free of signs and symptoms of respiratory infections through next review date. The interventions included: Give aerosol or bronchodilators as ordered; Monitor/document any side effects and effectiveness; Monitor for difficulty breathing (Dyspnea) on exertion; Monitor for signs and symptoms of acute respiratory insufficiency; Oxygen setting at 2 Liters via nasal prong as ordered. During an observation conducted on 02/17/25 at 10:53 AM, Resident #501 was asleep with the oxygen nasal cannulae on both nares, and a portable oxygen tank next to the bed, set at 2 Liters (L) per minute mark. There was no date tag observed on the oxygen tubing. During another observation conducted on 02/18/25 at 10:00 AM, there was a red oxygen sign posted on the door of Resident #501's room. The resident was able to answer questions. She was wearing the the oxygen nasal cannulae on both nares. There was no tag on the oxygen tubing and the meter flow was set at 2 L per minute on the portable oxygen tank. In an interview conducted with Resident #501 on 02/18/25 at 10:08 AM, when asked if the oxygen is helping her breath better, she responded Yes.

Based on observations, interviews, and record review, the facility failed to ensure that psychotropic medication PRN (as needed) orders were limited to 14 days for 1 of 5 residents reviewed for Unnecessary Medication (Resident #17). The findings included: A review of the policy titled, Medication Utilization and Prescribing-Clinical Protocol, revised in April 2018, showed the following: As part of the overall review, the Physician and staff will evaluate the rationale for existing medications that lack a clear indication or are being used intermittently on a PRN. The Physician will provide and or document rationale when the indication, dose, duration, or frequency of a prescribed medication is more significant than commonly accepted practice. The Consultant Pharmacist can help by reviewing facility medication usage patterns and trends and by intensifying medication reviews of individuals taking medications that present clinically significant risks. Resident #17 was admitted to the facility on [DATE] with diagnoses of bipolar disorder and major depressive disorder. The admission Minimum Data Set (MDS), dated [DATE], showed that Resident #17 had a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. A review of the Physician's order revealed an order for Lorazepam 0.5 milligrams, given one tablet by mouth every 8 hours as needed for anxiety for 30 days, dated 01/30/25. In a Pharmacy review conducted on 02/4/25 (five days later), the Consultant Pharmacist reviewed all medications for Resident #17. In this review, he wrote no irregularities and did not address the 30-day PRN medication of Lorazepam. In an interview with the Director of Nursing (DON) on 02/19/25 at 12:30 PM, she stated that for any psychotropic medication that has been PRN for the past 14 days, the nurse and the pharmacist will contact the prescribing Physician to discuss the necessity of the medication. In a phone interview conducted on 02/20/25 at 9:16 AM with the Consultant Pharmacist, he stated that for any psychotropic medication that is PRN past 14 days, he will recommend discontinuing the medication and will contact the Physician. The pharmacy recommendations always go to the Doctor for further review. In an interview conducted on 02/20/25 at 1:00 PM with the DON, she acknowledged all findings.

Based on observations, interviews, and record review, the facility failed to monitor behaviors and side effects for 2 of 5 residents on antipsychotic medication (Resident #17 and Resident #501). The findings included: A review of the policy titled, Medication Utilization and Prescribing-Clinical Protocol revised in April 2018, showed the following: The staff and Physician will monitor the progress of anyone with a probable adverse drug reaction and anyone for whom the medications has been adjusted because of the probability of an adverse drug interaction. 1.) Resident #17 was admitted to the facility on [DATE] with diagnoses of bipolar disorder and major depressive disorder. The admission Minimum Data Set (MDS) dated [DATE], showed that Resident #17 had a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. A review of the Physician's order revealed an order for Rexulti (antipsychotic medication), 4 milligrams given 1 tablet by mouth at bedtime for bipolar disorder, dated 01/22/25. Further review did not show any orders to monitor the medication's side effects or behaviors. A review of the Medication Administrator Record (MAR) for February 2025 did not show that the side effects and behaviors of the antipsychotic medication have been documented. A review of the care plan initiated on 02/05/25 showed the following: The resident has a mood problem diagnosis of anxiety, depression, and bipolar disorder. Monitor and document for side effects and effectiveness. The resident uses psychotropic medication related to depression, which was initiated on 01/20/25. Monitor, document, and report any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. In an interview conducted on 02/19/25 at 11:50 AM with Staff I, a Licensed Practical Nurse, the Surveyor asked if Resident #17 was on any antipsychotic medication. She did not know. She proceeded to look in the electronic system and stated that Resident #17 was on antidepressants and antianxiety medications but did not see any antipsychotic medication for Resident #17. The Surveyor said that Resident #17 was receiving Rexulti oral tablet 4 milligrams give 1 tablet by mouth at bedtime for bipolar disorder dated 01/22/25, which was an antipsychotic medication. When asked if Resident #17 was monitored for side effects or behaviors of the Rexulti medication, she said yes. Staff I reported that it is documented in the Medication Administration Record and attempted to show the Surveyor in the electronic system but was unable to show documentation. Then, said, We need to update the orders. 50370 2.) A record review revealed Resident #501 was admitted on [DATE] with diagnoses including Displaced Intertrochanteric Fracture of Right Femur, Type 2 Diabetes Mellitus, and Anxiety Disorder. A record review of the Minimum Data Set (MDS) assessment for Resident #501 dated 02/18/25 revealed it is in progress. Section C for Brief Interview for Mental Status score was blank. Section I revealed, yes responses to anxiety and depression. A record review of Physician Orders dated 02/16/25 revealed Escitalopram Oxalate (Anti-depressant) 10 MG (milligram), to give by mouth one time a day for depression. An additional review of Physician Orders for Resident #501 revealed to monitor for signs and symptoms of depression and to include the following numerical codes : 0-None, 1-Isolation, 2-Sadness, 3-Withdrawn, 4-Lack of interest, 5-Crying, 6-Other, see nurses note, every day and night shift, and document the corresponding number(s) reflecting any sign and symptom of depression. A further review of the Medication Administration Record (MAR) revealed that the medication Escitalopram 10 MG was administered on 02/17/25 at 9:00 AM. The MAR box for the medication revealed no statement to monitor for signs and symptoms of depression including the numerical codes. Additional review of MAR revealed no anti-depressant side effects were monitored after the administration of Escitalopram. A review of the Care Plan revealed no goal, plan or interventions related to the resident's depression. During observation on 02/17/25 at 10:53 AM, Resident #501 was asleep. During an interview conducted on 02/18/25 at 11 AM, Resident #501 was able to respond to questions. She stated she was not happy in the facility. In an interview conducted on 02/19/25 at 12:30 PM with Staff G, Admission Registered Nurse (RN), when asked regarding Resident #501's discharge instructions regarding the antidepressant and antianxiety medications, she responded she talked with the Psychiatry Nurse Practioner and was told that the antianxiety, anti-psychotic, and anti-depressant medications were all ordered by the resident's Cardiologist. When asked if the facility staff perform behavior monitoring related to the medications, she responded behavior monitoring is always done, with the PCC drop down menu, and staff may add this indicator in the MAR. When asked regarding depression monitoring, she stated, depression monitoring is numbered from 1 to 6 and recorded in the MAR. The anti-depressant side effects are also monitored with numbers from 1 to 19 and recorded in MAR. When asked if there would be instances when a staff nurse might forget to put the behavior monitoring and side effects monitoring for anti-depressant medications, she added that all the staff nurses know how to put an order. During an interview conducted with Staff C, RN, when asked about antidepressant medications monitoring, she responded, Yes, the staff monitor the behavior when residents are receiving anti-depressants. The behaviors are represented by numbers. Nurses document the residents' behaviors in the MAR. She added that staff nurses always put the behavior in the MAR as proof of documentation before giving anti-depressant medications. When asked if staff nurses monitor the side effects of anti-depressant medications, she responded, she is not sure and will get back to this surveyor. Until the end of the survey, Staff C, RN did not provide an answer.

Based on observations, interviews and record review, the facility failed to ensure medications were secured at the bedside for 1 of 22 sampled residents (Resident #645). The findings included: Review of the facility's policy titled, Medication Labeling and Storage with a revised date of February 2023 included in part the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Review of the facility's policy titled, Self-Administration of Medications with a revised date of February 2021 included in part the following: As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: The resident is able to safely and securely store the medication. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. Record review for Resident #645 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Acute Myocardial Infarction, Personal History of Malignant Neoplasm of Tongue. Review of Resident #645's record revealed no documentation of a Brief Interview of Mental Status having been attempted or completed. Review of the resident's record revealed no evaluation of self-administering medications. On 02/17/25 at 10:49 AM, an observation was made of Resident #645 sitting up in bed and on the nightstand next to the bed was a clear plastic bag with ChapStick and Nystatin ointment 100,000 units per gram. On 02/18/25 at 9:05 AM, an observation was made of Resident #645 sitting up in the bed with the overbed table in front of him, and on the overbed table next to his breakfast was a clear plastic bag with ChapStick and Nystatin ointment 100,000 units per gram. During an interview conducted on 02/18/25 at 9:05 AM with Resident #645 who was asked about the Nystatin ointment in the bag on the overbed table, he stated that is his denture adhesive and he puts it on his gums daily. During an interview conducted on 02/18/25 at 9:15 AM with Staff P, Certified Nursing Assistant (CNA) who entered Resident #645's room and acknowledged the Nystatin ointment at the bedside and said medications are not supposed to be at the bedside and removed the medication to give to the Director of Nursing. During an interview conducted on 02/18/25 at 9:55 AM with Staff H, Registered Nurse (RN) who was asked if residents can have medications at the bedside, she said no the residents cannot have medications at the bedside and acknowledged the resident was not evaluated for self-administration of medications.

Based on observations, interviews, and record review, the facility failed to provide water consistent with resident needs for 1 of 3 residents on thickened liquids (Resident #645). The findings included: Review of the facility's policy titled, Menus and Therapeutic Diets with a revised date of 04/14/20 that included in part the following: Nectar, honey and pudding thickened liquids are offered as ordered by the physician. Record review for Resident #645 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Acute Myocardial Infarction, Personal History of Malignant Neoplasm of Tongue. Review of Resident #645's record revealed no documentation of a Brief Interview of Mental Status having been completed. Review of the Physician's orders for Resident #645 revealed an order dated 02/13/25 for NAS (No Added Salt) diet Mechanical Soft texture, Nectar Thick Liquids consistency, and was discontinued on 02/18/25. Review of the Physician's orders for Resident #645 revealed an order dated 02/18/25 NAS diet Pureed Diet texture, Nectar Thick Liquids consistency. Review of the Care Plan for Resident #645 revealed no care plan for nutrition or hydration. On 02/17/25 at 10:49 AM, an observation was made of Resident #645 sitting up in chair at bedside, with overbed table in front of him with a full 20 ounce Styrofoam cup of ice water with straw. Thickener packets were located on the nightstand next to bed on the opposite side of the bed from where Resident #645 was sitting. During a side-by-side observation conducted on 02/17/25 at 11:10 AM with Staff H, Registered Nurse (RN) in Resident #645's room, the resident was sitting up in bed and in front of the resident was a full 20 ounce Styrofoam cup of ice water with a straw. Staff H acknowledged the resident was on nectar thickened liquids and should not have regular water at the bedside. Staff H immediately removed the water. When asked when water is passed to the residents she said it would have been at the end of the previous shift or at the beginning of the shift for today. During an interview conducted at Resident #645's bedside with the Speech Therapist (ST) who was asked about the liquid consistency and straws for the resident, the ST stated the resident is on nectar thickened liquids and it is okay for the resident to use a straw. The ST stated the resident had tongue cancer and has an issue with using his tongue but has no problem swallowing the nectar thickened liquids with a straw. When asked why she was seeing the resident today, she stated the resident had difficulty with his mechanical soft diet this morning and the Resident #645's son was present, and the son had requested his diet be changed to pureed. During an interview conducted on 02/20/25 at 9:15 AM with Staff P, Certified Nursing Assistant (CNA) who was asked how often water is provided to residents, she stated they provide water to residents once or twice a shift and as needed. When asked if a resident is on thickened liquids how she would know, she said the nurse will tell them. When asked how they provide thickened water to residents who are on thickened liquids, she said they are provided with containers of water or juice that are kept in a cooler at the bedside. When asked what the shifts for Certified Nursing Assistants are, she said 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM.

Based on observations, interviews and record reviews, the facility failed to maintain an effective Infection Prevention and Control Program, for 3 sampled residents, as evidenced by staff failed to wear Personal Protective Equipment (PPE) while providing direct care for residents on Enhanced Barrier Precaution (EBP) for Resident #545 and Resident #38; and failed to have an order and care plan for EBP for Resident #501. The findings included: The Center for Disease Control and Prevention (CDC) Enhanced Barrier Precautions included the following: Everyone must clean their hands, when entering and leaving the room. Providers and Staff must also wear gloves and a gown for the following: High-contact care resident care activities - dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound care with any skin opening requiring a dressing. https://www.cdc.gov/long-term-care facilities/media/pdfs/ A review of the facility policy titled, Enhanced Barrier Precaution, with a revision date of 04/05/24, revealed the facility adheres to the CDC recommendation on implementing EBP in their health care center. The policy explained that EBP will be implemented for the following: indwelling medical devices (e.g. central line, urinary catheter, feeding tube); chronic wounds including pressure ulcer, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers. It also stated that all team members will wear appropriate PPE (gown and gloves) for high contact resident care but not limited to peri-care, device care (urinary catheter and feeding tube), and wound care. 1) Record review of Resident #545 revealed the resident was admitted to the facility on [DATE], with diagnoses that included Cachexia, Adult Failure to Thrive, Malignant Neoplasm of the Esophagus, Percutaneous Endoscopic Gastrostomy (PEG) tube, and Sacral Pressure Ulcer. A review of the Minimum Data Set (MDS) assessment for Resident #545 dated 02/12/25 revealed a blank space in Section C for the Brief Interview for Mental Status (BIMS) score. Record review of Physician Orders for Resident #545 dated 02/11/25 revealed an order for EBP: gown and gloves should be worn while providing high-contact resident care (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting), every day and night shift for percutaneous endoscopic gastrostomy (PEG) tube. A further review of Physician Orders for Resident #545 revealed an order for wound care dated 02/15/25, Wound: sacrum- cleanse with Normal Saline, apply Medi honey, apply Calcium alginate, cover with foam dressing every day shift for pressure injury. During an observation conducted on 02/18/25 at 3:20 PM, Staff K, Certified Nursing Assistant (CNA) entered a room with an EBP sign without performing hand hygiene. She donned gloves, drew the privacy curtain and stood by the foot of bed. Then Staff C, Registered Nurse (RN) came in and told the resident that she would change the dressing on the left buttock and Staff K would assist. Staff C went inside the bathroom and performed hand washing, donned on gloves, yellow gown and asked for the resident to turn to his right side. She opened the left side of the resident's brief and proceeded with the wound care without any concerns. After she completed the wound care, Staff C, RN asked Staff K, CNA to change the resident's brief. Staff K obtained a brief and approached Resident #545, wearing only a pair of gloves and no gown. She proceeded to change the resident's brief, with her blue uniform touching the resident's bed linens. In an interview conducted on 02/18/25 at 3:32 PM with Staff C, RN, when asked why Staff K, CNA was not wearing a gown while assisting with wound care and changing of the resident's briefs, she responded, I reminded her. When asked if all facility staff receive training and in-services for EBP, she responded yes. In an interview conducted with Staff K, CNA on 02/18/25 at 4:14 PM, when asked why she did not put on gown, she responded, I was just asked to help the nurse. I did not look at the EBP sign on the door. When she was shown the EBP sign on resident's door, she responded, I should have put on gown. 2) A record review of Resident #501 revealed he was admitted on [DATE] with the diagnoses that included Displaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Type 2 Diabetes Mellitus, and Right Heel Pressure Ulcer. A review of the Minimum Data Set (MDS) assessment for Resident #501 dated 02/18/25 revealed it was blank for the Brief Interview for Mental Status (BIMS) score. A review of Physician Orders dated 02/16/25 revealed that there was no EBP order related to the right heel pressure ulcer. A further review of the care plan revealed there was no EBP focus, plan or interventions related to Resident #501's right heel pressure ulcer. In an interview conducted with Staff J, CNA on 02/18/25 at 3:42 PM regarding the EBP sign on the resident's door, she stated, Staff must wear mask and gloves when providing care to resident such as during the changing of briefs and bed linens. When asked if she needed to wear a gown, she responded no, gown is only used for very contagious diseases like COVID and C. difficile. 51137 3) Review of Record revealed Resident #38 was admitted to the facility 01/09/25. He was admitted with a primary diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation Other diagnoses included: respiratory failure with hypoxia (low levels of oxygen in your body tissues), metapneumovirus pneumonia(a lung infection caused by the human metapneumovirus virus), and hypoxemia (a condition where there is an abnormally low level of oxygen in the blood.) Review of the active orders revealed there was an Enhanced Barrier Precaution (EBP) order, Gown and Gloves should be worn while providing high-contact resident care (Dressing, Bathing/showering, Transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting.) Further review revealed an active order for a midline catheter to the right arm (a thin, flexible tube inserted into a vein in the upper arm, typically near the elbow or just below the armpit) for intravenous administration of antibiotics due to a pneumonia diagnosis. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #38 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, which indicated the resident was cognitively intact. This same MDS also documented the Resident required continuous oxygen therapy. During an initial observation and interview on 02/17/25 at 11:53 AM, Resident #38 was observed wearing a nasal cannula and had a midline catheter to the right upper arm. When asked how care was, the Resident stated they've had an issue with her maintaining normal oxygen levels. Resident #38 stated she had acquired several respiratory infections over a short period of time that required her to be on antibiotic therapy. A medication administration observation was conducted on Resident #38 on 02/18/25 at 09:32 AM with Staff I, Licensed Practical Nurse (LPN). The medication administration included oral medications, intranasal spray, a medication patch and a respiratory nebulizer treatment. Upon entering the Resident's room an (EBP) sign was observed by the Resident's door and another one on the wall in front of the Resident's bed. Staff I performed hand hygiene and donned gloves; she stated she had already completed vital signs on the Resident. Staff I proceeded with the administration of the medications while the resident was in her wheelchair; no additional Personal Protective Equipment (PPE) was donned. Staff I performed a respiratory assessment and listened to Resident #38's lungs with her stethoscope and afterwards the Resident requested to complete her treatment in bed. Staff I assisted to transfer the Resident from the wheelchair into bed; she then helped position her up in bed to a comfortable position. Staff I performed hand hygiene and donned new gloves; she then placed the nebulizer solution into the mask and placed it on the Resident. At the end of the respiratory treatment she performed another respiratory assessment. During an interview on 02/18/25 at 10:16 AM, when asked if Resident #38 was on (EBP), Staff I stated yes for direct care. When asked if giving the multiple types of medications and transferring the resident would be considered direct care, she stated she was unsure and asked the surveyor if she should of wore a gown. When asked what education was provided by the facility on residents requiring (EBP), she began to read the sign placed by Resident #38's door. Staff I was still unsure and stated, I probably should have worn it. An infection prevention interview was conducted on 02/19/25 at 10:00 AM with the Director of Nursing (DON) who was filling in for the Infection Preventionist for the week. The (DON) was made aware of the observations regarding Resident #38 and agreed that it was best practice to wear (PPE) for all direct contact activities especially if the Resident was transferred during the process.

Based on observations and interviews the facility failed to ensure a homelike environment with overbed lights having pull cords attached for 2 out of 70 occupied beds. The findings included: On 02/17/25 at 10:49 AM, an observation was made in room [ROOM NUMBER]-B of overbed light located on the wall above the head of the bed with no pull cord attached. On 02/17/25 10:56 AM, an observation was made of room [ROOM NUMBER]-B of overbed light located on wall above the head of the bed with no pull cord attached. On 02/18/25 at 9:05 AM, an observation was made in room [ROOM NUMBER]-B of overbed light located on the wall above the head of the bed with no pull cord attached. During a side by side observation conducted on 02/18/25 from 10:15 AM to 10:30 AM with the Maintenance Supervisor who acknowledged the pull cords for the overbed lights were missing in rooms 22-B and 28-B. During an interview conducted on 02/18/25 at 10:30 AM with the Maintenance Supervisor who stated each overbed light should have a pull cord long enough for each resident to be able to turn the overbed light on and off themselves.

Based on review of policy and procedure, record review and interview, the facility failed to ensure that it followed through in processing a physician's order, in a timely manner for 1 of 5 sampled residents reviewed, Resident #1. The findings included: Review of the facility policy and procedure, titled, Medication Administration provided by the Director of Nursing (DON) revised 12/01/21 documented in the Procedure Statement: The administration of medications will be performed only in accordance with written and signed orders from the client's physician. All orders, as appropriate, shall include: Complete name of client, complete name of medication, strength of the medication, dosage to be given, frequency of administration, route of administration .Controlled Substances .The Comprehensive Drug Abuse Prevention Control Act .requires that the nurse understand her responsibility in the administration, handling, and record keeping of controlled substances .A controlled substance may be given only with a physician's order Resident #1 was admitted to the facility on [DATE] with diagnoses which included Arthritis due to Bacteria right knee, Muscle Wasting and Atrophy, Cognitive Communication Deficit, Methicillin Susceptible Staphylococcus Aureus (MRSA) Infection, pain in right knee, Atherosclerotic Heart Disease and Hypertension. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). On 03/12/24 the physician's order dated 03/12/24 documented generic Oxycodone with Acetaminophen Oral Tablet 5-325 mg to be given one (1) tablet by mouth every six (6) hours (PRN) as needed for Pain, as ordered by Resident #1's primary care physician (PCP). On 03/13/24 the resident's care plan documented---Focus: potential alteration in comfort related to Septic Arthritis right knee, decreased mobility, generalized discomfort. Intervention: Administer analgesia as per orders. Goal: The resident will not have an interruption in normal activities due to pain through the review date. On 03/19/24 the Physical Medicine physician's progress note documented .resident with right knee pain 6/10. He wants pain medication . Percocet Oral Tablet 5-325 mg to be given one (1) tablet by mouth every six (6) hours (PRN) as needed for Pain. Record review of the Medication Administration Record (MAR) revealed that from 03/15/24 until 03/26/24, Resident #1 was administered only generic Oxycodone with Acetaminophen Oral Tablet 5-325 mg give one (1) tablet by mouth every six (6) hours (PRN) as needed for Pain, as evidenced by the nurses' initials and resident pain level recorded for each day. And, between the dates of 03/12/24 through 03/31/24 Resident #1's pain level range was recorded as: 0-7/10. Further record review of the facility's two (2) computerized Controlled Substance Utilization Record/Narcotic sign-off sheets only contained nurse signature-offs from 03/13/24 until 03/26/24 for only the generic Oxycodone with Acetaminophen Oral Tablet dosage 5-325 mg to be given one (1) tablet by mouth every six (6) hours (PRN) as needed for Pain, which was received by the facility on 03/13/24 and 03/23/24. In contrast, record review of the (MAR) reflected that from 03/21/24 until 03/26/24, facility staff nurses documented as if Resident #1 was administered Percocet/generic Oxycodone with Acetaminophen oral tablet 7.5/325 mg give one (1) tablet by mouth one time a day for pain one (1) hour prior to Physical Therapy (PT). However, there was no current Orthopedic Surgeon's order in place signifying an increase for the Percocet to 7.5/325mg. Neither were there any corresponding Controlled Substance Utilization Record/Narcotic sign-off sheets to match or reflect those particular dates of service. It was noted that Resident #1 had two (2) scheduled visits in which he was seen by his Orthopedic surgeon: 1) Wednesday March 20th and 2) again on Wednesday March 27th. During a subsequent computerized record review of Resident #1's uploaded facility documentation, it was noted that there was an un-dated prescription from Resident #1's Orthopedic Surgeon for Percocet 7.5/325 mg one (1) tablet by mouth three times (TID) (PRN) as needed, non-acute pain which had not been uploaded by the facility until 03/26/24. On 07/11/24 at 3:20 PM, during an interview with Staff A, a Registered Nurse (RN), she revealed that she contacted Resident #1's PCP first, and she said that she was directed by the PCP to contact Resident #1's Orthopedic Surgeon to have him to write a prescription for an increase in the resident's Percocet pain management order. Staff A then explained that she then followed-up and called the Orthopedic Surgeon's office, prior to ending her work shift and she spoke with the office nurse there. She then proceeded to give the Orthopedic Surgeon's office nurse the facility's fax number. Next, Staff A said that she was told by the office that they would fax over the new increased Percocet pain medication order. Staff A stated that when she returned to work on the 25th that she did call the Orthopedic Surgeon's office again about the prescription. But, Staff A also admitted to this Surveyor that she did not follow-through to ensure that a prescription had been received back from Resident #1's Orthopedic Surgeon office. Staff A said that she had indicated, with a #9 indicator in the facility's MAR, that a nurses' note was written referencing the status of Resident #1's Percocet 7.5-325 mg tablet for that day. However, a side-by-side computerized record review conducted by Staff A and this Surveyor of the nurses' notes, did not reflect any entries pertaining to the Percocet 7.5-325mg tablet. Staff A ultimately acknowledged that she did not document any prior communication or conversation in the record, with Resident #1's PCP regarding the Percocet 7.5-325mg increase. There was no documentation in any of the facility's nurses' progress notes to indicate that a physician's order was ever obtained or secured from the Orthopedic Surgeon by Resident #1's nurse. On 07/11/24 at 3:43 PM an interview was conducted with Staff B, an RN, in which she acknowledged that she was following what had been previously recorded in the resident's MAR and she also said that she had indicated with a #9 that a nurses' note was written with regard to the Percocet 7.5-325mg tablet that day on the MAR, however, side-by-side computerized record review of the nurses' notes, did not reflect any entries pertaining to the Percocet 7.5-325mg tablet. Neither Staff C, an RN, nor Staff D, an RN were available for interview. But, during a side-by-side computerized record review with the DON, it was revealed that both nurses had signed off the MAR on Friday 22nd and Sunday the 24th of March in error with the resident not having been administered the Percocet 7.5-325mg tablet either day. In summary, there was no Controlled Substance Utilization Record for the dates-of-service (DOS) March 21st through March 26th due to the fact that there was no physician's order obtained, nor was there any documentation in the associated physician progress notes identifying an increase Percocet 7.5/325; this medication was not received according to the Narcotic sheet until March 26th. The DON further recognized and acknowledged after reviewing the MAR that on 07/12/24 at 4:20 PM there was a PCP order, but no prescription order from Resident #1's Orthopedic Surgeon to validate the increase in the Percocet dosage and further the Percocet 7.5-325mg tablet had been signed off as administered on both days by the nursing staff, when in fact, it should not have been.

Based on interviews and records review, the facility failed to treat in a dignified manner 1 of 3 sampled residents (Resident #110). The findings included: On 10/09/23 at 11:13 AM, Resident #110 said that she recently was admitted to the facility after undergoing hip surgery. Upon her admission to the facility, she had requested a commode, because the toilet seat in her room was too low, for her to use. Resident #110 said although different staff members promised to bring the commode, they did supply it. She reiterated that since the toilet bowl in her bathroom was too low and she could not use it, she ended up urinating on her sanitary briefs. She said that wearing a brief was not the primary problem, the main issue was that they did not provide the requested commode. That situation left her with no choice but to urinate on herself. Resident #110 ensued and stated that she had reported the issue to Employee (H) daily, last week or since her admission to the facility. Last Wednesday, 10/4/2023, Resident #110 said she spoke to Employee (H)'s Assistant, Employee (I), and Employee (I) told her that she would be moved to another room, because many residents would be discharged , however, as of 10/9/2023, she was still in the same room. Those events, she said makes me feel old, helpless like a piece of meat. The reason they did not move her from the room was because they said, there was no room available. The Social Worker (SW) reported on 10/10/23 at 2:15 PM, that she received an email from Employee (H) informing her that the resident had requested to be moved to a private room. She went and spoke to Resident #110 about her concerns that same morning to let her know that there would not be a bed available until Friday 10/13/2023. The SW also said that Resident #110 told her that she needed a commode in the room. The SW added that today was the first day she heard about her needing a commode in the room. So, she provided the commode to her today 10/10/23 at 11:44 AM. She also initiated a grievance about it. The SW also said that Resident #110 informed her that she had already discussed this matter with Employee (H) and Employee (I), but they did not do anything. The SW worker stated that she was aware that Resident #110 was waiting to be transferred to a private room the second day after her admission. During that waiting period about eight residents who were in private rooms were discharged . The SW also stated that she was not sure why the resident was not placed in one of those rooms, as she was promised. The Admissions Director (AD) said on 10/10/23 at 2:33 PM, that she was not the one who recruited the resident to come to this facility. She said that a Contractor was the person who first met with the resident. She said that she was on leave for a few days. When she returned, she met with the resident in her room. The AD said that the resident told her that she was happy to be back at the facility. She told the AD I know you give good care, that is why I am happy to be back. The AD said that she met with the Resident probably on the 5th of October. She said the resident did not make any request then. On 10/9/2023, I met with her and she told me when you have a private room in Cypress, I would like to move there. She said that Resident #110 did not make any other request. She did not ask her for a commode. She just wanted to move to Cypress because she was there before. I told her that when I find a private room, I will accommodate her, the SW said. On 10/10/23 at 2:48 PM, Employee (I) said that Resident #110 told her on the day of admission that she wanted a private room. She told Employee (I) that she did not get along with the roommate. Employee (I) said that Employee (H) told her that she had a private room the last time she was here and she would like to get a private room, in Cypress again. Employee (I) said that she relayed the information to the Contractor who recruited Resident #110 who, at that time, was acting as the Admission Director. The Contractor said OKAY but, I am not sure what she did with that information. She said that the resident did not ask her for a commode or a recliner. I am not sure she spoke to the resident because she is mostly in the field. Employee (I) said that she told Resident #110 that residents leave the facility throughout the week, so it is likely that she could find another room. Employee (I) said that there were no private rooms available when she spoke to the Resident. An interview with the Consultant on 10/11/23 at 09:16 AM revealed that she spoke to the Resident at the hospital and did not make any promises, such as a private room. She said that knowing that there are but a few private rooms, she never promises or guarantees private room access to anyone, unless they need to be isolated. She said that she did not discuss recliner or commode with the resident. She said the need for a recliner or commode probably came after her admission to the facility. The interview with Employee (J) a Physical Therapist (PT) on 10/11/23 at 12:20 PM revealed that she had completed the initial PT assessment for the resident. Resident #110 had a fall and fractured her left Femur on 8/18/2023. She underwent surgery. On 9/27/2023 she fell at home and had a hip fracture revision. Resident #110 was admitted to the facility with partial 50% weight bearing. Resident #110 could not ambulate and required Moderate to Maximum assistance. Which meant that the resident required more than minimum assistance. Because she was non-weight bearing. She said that she did not discuss with the resident the need for using a commode. An interview with the Certified Occupational Therapy Assistant (COTA) Employee (K) on 10/11/23 at 12:29 PM revealed that she had completed the initial OT assessment for the resident and had made the recommendation for a commode on 10/4/2023 for the resident. Employee K said that she attempted to provide the commode because her Manager was not available, but she could not find one. Employee (L) a Physical Therapy Assistant (PTA) informed on 10/11/23 at 12:34 PM, that on Friday the 5th of October 2023, she discussed Resident #110's need to use a commode with the Resident's Nurse. She said that she was not sure who the nurse was. Employee (L) said that she also discussed with the Maintenance Director on Monday 10/4/2023; yet, they did not provide the commode. Review of the Minimum Data Set (MDS) showed that Resident #110 obtained a score of 15/15 on the brief interview for mental status (BIMS). This signifies that Resident #110's cognitive status was intact. She could make her needs known. Review of the Nursing Care Plan (CP) revealed the following: Potential alteration in comfort related to depression, fracture left hip, decreased mobility. o The resident will not have an interruption in normal activities due to pain through the review date. o To show minimal/no side effects of medications taken The resident is at risk for constipation related to decreased mobility, pain [Bowel/Bladder]. o The resident will have a normal bowel movement at least every three days through the review date o Encourage Resident to sit on toilet to evacuate bowels if possible. o Follow facility bowel protocol for bowel management. The resident has an ADL self-care performance deficit r/t decreased mobility, Left Hip Fracture. [ADLs/Mobility] o The resident will improve the current level of function in ADL's through the review date. In all, although Resident # 110 had requested a commode and the facility, as evidence by interviews with three employees, was fully aware of the Resident's need to use one, it was not provided. The findings were discussed with the Administrator on 10/10/2023 and he informed that a commode would be immediately provided to Resident #110.

Based on interviews and records review, it was determined that Residents' rights were not discussed and 3 of 3 sampled Residents (Residents # 4, 14, & 19) were not reminded of their rights during Resident Council meetings. The findings included: On 10/12/23 at 11:10 AM an interview was conducted with the Resident Council President, Resident #43. She said that she was not sure whether she was the President. If they say that I am the President, then I must be. She could not recall whether they met monthly. The Activity Director, Employee (M) reported on 10/12/23 at 11:23 AM, that he has been working at this facility since January 2023. He said that he assists in setting up the Resident Council meeting every month and help facilitate the meeting. He reported that they did not discuss Residents' rights during the meeting. Review of the Resident Council minutes documented no Residents rights items discussed. The Minutes of the meetings documented that the Management team informed the resident council about the renovation that was happening in the building, from January 2023 to September 2023. This information was documented every month as old business. Resident #14 said on 10/12/23 at 11:45 AM, she attended Resident Council meeting monthly, but she did not recall residents' rights being discussed. Resident #4 informed on 10/12/23 at 11:58 AM that he did not recall residents' rights being discussed during Resident Council meetings. Resident #19 also said on 10/12/23 at 12:38 PM that he could not confirm or refute whether residents' rights were ever discussed. The findings were discussed with the Administration on 10/12/2023 and they informed that the situation will be remediated.

Based on records review and interviews, the facility failed to file a federal report for an allegation of injury of unknown origin immediately to the State Agency for 1 of 1 sampled resident (Resident #108). The findings included: Review of an incident report dated 6/26/2023 revealed that on 06/08/2023, on the 6:00 AM to 2:00 PM shift, Resident #108 sustained an injury which origin the facility could not explicitly determine. The record revealed that Resident #108 was diagnosed with: Unspecified Dementia; Unspecified Anxiety Disorder; Other recurrent Depressive Disorder; Poly Osteoarthritis; Glaucoma and Edema, among others. Review of the Minimum Data Set (MDS) documented that Resident #108 obtained a score of 3 out of 15 which is indicative of significant cognitive deficit. Further records review showed that Resident #108 was impulsive and used the bathroom for her toileting needs without using her call lights and waiting for assistance. Consequently, on 6/08/2023 while using the bathroom, Resident #108 sustained bodily injuries reported by the facility as follows: Per Supervisor's statement, while making rounds, she entered room [ROOM NUMBER]A and observed the Certified Nursing Assistant (CNA) changing soiled bed linens, resident noted on the toilet at this time on 6/8/23, 7am - 7pm shift. The Nurse reported no concerns voiced by resident, no events reported by floor staff and noted that resident often tries to self-transfer and independently propel herself to the nurse's station and to self-toilet without asking for assistance. Resident would also independently change her incontinent brief with available supplies in the room without activating the call light or asking for assistance. On 6/9/23, 6am - 2pm shift: Per CNA statement, while making rounds she observed resident with dark area to the left arm and discoloration to the left cheek. Observations were immediately reported to the nurse. On 6/9/23, 7am - 7pm shift: Per nurse's note; nurse was called to the room by assigned CNA, upon arrival resident noted with discoloration to left arm and slight discoloration to her left cheek. Resident denied any fall at that time, no other resident concerns were noted. Nurse notified MD and responsible party. Orders received to send resident to the local hospital for further evaluation and treatment. 6/10/23 PM Shift: Resident returned to facility. 6/11/23 AM Shift: Xray results reviewed- 2mm depressed minimally displaced fracture of left orbital floor. Facial bones are otherwise intact and in anatomic alignment. The Executive Director (ED) of the facility reported on 10/12/2023 at 3:13 PM, that he had investigated this incident to determine its root cause. The ED said that he interviewed the staff assigned to the resident the date of the incident. The assigned staff (Employee N) had reported that she was getting ready to provide morning care when she had found the resident in her wheelchair, at the beginning of her shift on 6/9/2023 with bruises on her left arm and discoloration on her cheek. Employee N said that she had immediately contacted the shift-nurse to report the incident. The Shift-Nurse (Employee O) reported on 6/9/2023 during the 7:00 AM-7:00 PM shift that she found the resident fully dressed and sat in her wheelchair fully dressed. Resident had a large hematoma on her left arm, which was hard on palpation, dark and grayish in color. She was also noted small skin discoloration on the left side of the Resident's eye. The Nurse documented that Resident #108 denied any fall, any pain, and any physical abuse. Interviews conducted with the employees assigned to care for the resident the day before the resident's injuries were identified on 6/9/2023 @ around 7:15 AM yielded no positive knowledge of an incident involving Resident #108. No employees reported having noted any bruises or facial discoloration on Resident 108 on 6/8/2023. However, despite the inconclusive investigative report, the facility did not submit the federal report for an allegation of an injury of unknown origin to the State Agency. The findings of the complaint investigation were discussed with the Administrator on 10/12/2023 and he acknowledged the result.

Based on record review and interview the facility failed to accurately document a resident's discharge status for 1 of 3 residents reviewed for discharges (Resident #56). Findings included: Record review noted that Resident #56 was not hospitalized as per discharge assessment, but was discharged home. Resident #56 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had mild cognitive impairment and limited 1 person assist for activities of daily. A review of Resident #56's progress notes revealed a discharge summary dated 07/28/23 at 12:55 PM that documented the resident was discharged home with home health. A review of Resident #56's discharge assessment dated [DATE] documented the resident was discharged to hospital. An interview was conducted on 10/12/23 at 1:20 PM, with the MDS coordinator. The coordinator stated Resident #56 was discharged to home on 7/28/23, not transferred to the hospital, and the discharge assessment was coded wrong.

Based on interviews and record review, the facility failed to provide supervision to prevent a fall with major injury in the bathroom ([MEDICAL CONDITION]), and failed to thoroughly investigate the circumstances on how it occurred, for 1 of 5 residents reviewed for accidents (Resident #70). The findings included: Resident #70 was admitted to the facility on [DATE] with [MEDICAL CONDITIONS] exacerbation. She was admitted to the facility to receive physical therapy and speech therapy. During the initial pool process on 07/22/19 at 1:30 PM, an observation and interview was conducted with Resident #70. The resident was observed as having a purple-green colored bruise to her right upper cheek. During the interview with the resident, she revealed that she had a fall a few weeks ago. The resident has [DIAGNOSES REDACTED]. The resident has a brief interview for mental status (BIMS) score of 13 according to the minimum data set (MDS) done on 07/06/19. This indicates that the resident is cognitively intact. A review of the resident's medical record and the report for a fall on 06/06/19 reveals the resident was found on the floor at 1:28 AM on 06/06/19. The report reveals that the resident was found by Staff B, a certified nursing assistant, on the floor in a sitting position. There is no comment from Staff B on the report. An interview was conducted with Staff B via telephone on 07/25/19 at 5:40 AM which revealed that she responded to a call light in resident #70's bathroom on 06/06/19 and found her on the floor. She was not the aide assigned to her care that night but she answers call lights for all residents. Staff B was asked if she knew how to care for resident #70 and she responded that the resident is known to get up during the night and go to the bathroom on her own. She pulls the call light when she is done but by the time the aides get to her she is already up walking back to bed. Staff B states that this was well known on nights. Staff B also stated that she overheard the resident making a statement to the nurse (Staff A) saying the aide was with her when she walked back to bed and couldn't stop her from falling. Staff B states that is not true. An interview was conducted with Staff A via telephone on 07/25/19 at 3:51 PM. The interview revealed that he was called to resident #70's room by Staff B. He states that he quickly did the assessment on the resident while she was on the bathroom floor. The resident complained of pain with range of motion of her legs. Staff B stated to him that she was not with the resident when she fell . Staff A cannot confirm whether or not the call light was on. He can't remember what the resident had on her feet at the time of the fall. Discussed with Staff A the inconsistency with the report regarding the resident stating that the aide was assisting her when she fell versus the report stating that there were no witnesses to the fall. Staff A revealed that these were the two statements that he got and even though he knew that they were conflicting, he put both statements in the report. A review of the report dated 06/06/19 was conducted side by side with the DON on 07/25/19 at 11:40 AM. Upon review of the report the DON realized that this fall on 06/06/19 resulted in the right [MEDICAL CONDITION] which was after the resident was admitted to the facility on [DATE]. The resident was taken to the emergency room , evaluated, admitted and surgery was done on 6/6/19. On 06/09/19, the resident returned to the facility. On 07/25/19 at 12:41 PM another review of the report dated 06/06/19 was conducted with the DON and the administrator. The day shift charge nurse signed off on the report. The administrator was asked if he knew how long the call light was on before it was answered. He replied that he did not know because they have no system in place to see that yet. The resident's care plan was reviewed with the DON and the administrator also at this time. The care plan for activities of daily living self care performance initiated on 05/12/19 and revised on 05/22/19 reveals that the resident requires extensive assist by 1 staff for toileting and moving between surfaces. A care plan for falls initiated on 05/22/19 and revised on 06/05/19 reveals an intervention to ensure that the resident is wearing appropriate footwear when ambulating or up in wheelchair. The DON and administrator could not answer if the resident was wearing proper footwear or was being assisted by staff at the time of the fall because the report did not answer those questions. The DON and the administrator could not state the circumstances at the time of the fall due to the lack of information on the report.