Every finding on record at Accura Healthcare of Lake City, LLC

Based on observation, facility policy, and the Food and Drug Administration (FDA) food code the facility failed to serve food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness during one of one meal service observed. Facility staff also failed to cover facial hair (beard) while serving food. The facility reported a census of 38 residents. Findings include: Observations revealed the following: a. On 4/20/26 with observation starting at 11:45 AM, the Dietary Manager, without a beard net covering his beard, served the lunch meal for the residents. b. Observation on 4/21/26 from 11:35 AM - 12 PM, Staff A, [NAME] applied gloves and then touched ladle handles, steam table pan lids, and with the same gloved hands placed a hamburger bun on a plate, placed a hamburger on the bun, and touched the bun again to cut the sandwich in half. Staff A proceeded to continue with the same gloves to touch multiple hamburger and hotdog buns and then touch scoop/ladle handles, paper menu slips, pan lids, and the steam table. Staff A proceeded with the same gloves to push her glasses up several times, use a plate to fan herself, and then continued to touch more buns. Facility Food Safety and Sanitation Policy, dated 2021, revealed beard nets are required when facial hair is visible. Facility Employee Sanitary Practices Policy, dated 2021, revealed to use utensils to handle food, disposable gloves are a single use item and should be discarded after each use. Interview on 4/22/26 at 2:30 PM, the Administrator stated her expectation for gloves to be a single use only use utensils to touch food items, and for a beard net to be worn by staff with facial hair when preparing/serving food. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, includes the following requirements: 1) Single-use gloves are to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation, 2) prohibits food employees from bare hand contact with ready-to-eat food (unless washing fruits and vegetables) and requires food employees to wash their hands immediately before engaging in food preparation, including before donning gloves for working with food, in order to prevent cross contamination when changing tasks.

Based on clinical record review, staff interview and policy review the facility failed to develop a care plan to address anticoagulant medication usage, opioid medication usage, antidepressant medication usage and diuretic medication usage and side effects to watch for in 1 out of 12 residents (Resident #6) reviewed for comprehensive care plans . The facility reported a census of 38 residents. Findings include:Resident #6's Minimal Data Set (MDS) assessment dated [DATE] identified a BIMS score of 14, indicating intact cognition. The MDS included diagnoses of chronic pain, anxiety disorder, and hypertension. Review of the MDS dated [DATE] revealed that Resident #6 had taken the following medications in the review period:anticoagulant medication 7 out of the last 7 days opioid medication 7 out of the last 7 daysantidepressant medication 7 out of the last 7 daysdiuretic medication 7 out of the last 7 daysThe Care Plan dated 12/1/25 lacked personalized documentation pertaining to the residents usage and side effects to watch for with anticoagulation medication usage, diuretic medication usage, opioid medication usage, and antidepressant medication usage. The facility policy titled Comprehensive Care Plans dated 12/3/25 documented it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The care plan will be updated in a timely manner to ensure that services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.On 4/23/26 at 4:15 pm the Director of Nursing (DON) acknowledged that the care plans are behind. The DON stated there have been staffing challenges. The DON stated that she would expect the high risk medications to be addressed on the care plan.

Based on observation, record review and staff interview, the facility failed to follow the physician's orders for oxygen for 1 resident (Resident #1), failed to ensure staff used professional standards during med pass, including observing the consumption of medication for 2 of 9 residents (Resident #3 and #4), and infection control practices for 1 of 9 residents reviewed (Resident #8), and failed to store meds properly. The facility reported a census of 41 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 6 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident's diagnoses included chronic obstructive pulmonary disease. The resident received oxygen.The Care Plan revised [DATE] identified Resident #1 had respiratory abnormalities and had Oxygen (O2) at 1.5 liters via nasal cannula.The Medication Administration Record for [DATE] showed Resident #1 had the order for O2 at 1.5 liters per nasal cannula with a start date of [DATE].The Weights and Vitals record documented the resident's O2 saturation on [DATE] at 6:35 a.m. at 97% on 2 liters/minute and [DATE] at 11:43 a.m. 96% at 2 liters/minute.The Progress Notes dated [DATE] at 4:08 a.m. and 6:30 a.m. documented the resident's O2 sat 96% and 97% on O2 at 2 liters.The Progress Notes dated [DATE] at 10:34 a.m. documented the resident's O2 sat 93% on O2 at 2 liters.The Progress Notes dated [DATE] at 2:58 a.m. documented the resident's O2 sat at 97% on O2 at 2 liters.On [DATE] at 9:15 a.m. Resident #1 laid in bed with the head of bed elevated. She had O2 per nasal cannula at 1.5 liters, via the concentrator.At 12:34 p.m. the resident sat in the dining room. She had O2 at 2 liters per nasal cannula via a portable O2 tank.At 1:05 p.m. the Assistant Director of Nursing (ADON) stated she did not think they could put O2 in the weights and vital record in 1/2's. She could not explain why 2 nurses put that in. She did not know who would have taken Resident #2 to the dining room with her O2 at 2 liters. She said they had a concentrator in the DR, they should hook her up to it while she was eating.At 4:40 p.m. the ADON stated an agency Certified Nursing Assistant (CNA) turned the O2 to 2 liters. She had educated the CNA and the nurse, and would educate the rest of the staff. 2) Medication Pass/storage: a. According to the MDS assessment dated [DATE], Resident #3 scored 15 on the BIMS indicating no cognitive impairment. The resident's diagnoses included diabetes, polyneuropathy, and dorsalgia (pain in the back).The Care Plan revised [DATE] identified the resident had actual pain. The interventions included giving medications as ordered.On [DATE] at 11:15 a.m. Staff F Certified Medication Aide (CMA) took an Ibuprofen 200 mg tab to Resident #3. Staff F walked away before Resident #3 swallowed the pill. b. According to the MDS assessment dated [DATE], Resident #4 scored 15 on the BIMS indicating no cognitive impairment. The resident's diagnoses included heart failure, chronic lung disease, and atrial fibrillation.The Care Plan revised [DATE] identified the resident on diuretic therapy. The interventions included administering diuretic medication as ordered.On [DATE] at 11:23 a.m. Staff F CMA took a Coenzyme Q10 and a Lasix (diuretic) 40 mg tab to Resident #4. Staff F walked out of the room before the resident swallowed the pills. c. According to the MDS assessment dated [DATE], Resident #8 scored 15 on the BIMS indicating no cognitive impairment. The resident's diagnoses included atrial fibrillation.On [DATE] at 11:29 a.m. Staff F prepared medication for Resident #8. She took 2 round white tablets from a clear plastic cup, 1/2 full of the tablets, from the top drawer of the med cart. She picked them up with bare fingers and put them into a med cup. When asked what the pills were, she said Tylenol, and picked the cup up to show it had APAP 325 written on it.On [DATE] at 11:30 a.m. the DON, ADON and Administrator agreed staff should observe the residents swallow their medication, the medication should not be touched with bare hands, and medications should be stored in the containers the facility received them in, until ready to administer.The facility Medication Administration policy updated [DATE] documented medications were administered by licensed nurses, or other staff who were legally authorized to do so, as ordered by the physician and in accordance with professional standards of practice, and in a manner to prevent contamination or infection. The procedure included reviewing the Medication Administration Record (MAR) to identify medication to be administered, and compare to the medication source (bubble pack, vial, etc.). Identify the expiration date, and if expired, notify the nurse manager. When removing the medication from the source, taking care not to touch medication with bare hand. The procedure also included observing the resident's consumption of the medication.

Based on record review and staff interview, the facility failed to have sufficient staff to complete restorative as planned for 3 of 3 residents (Resident #4, #5, and #7), and ensure residents received at least 2 baths a week for 3 residents reviewed (Resident #1, #3, and #6). The facility reported a census of 41 residents.Findings include: Restorative: a. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included heart failure, atrial fibrillation, and asthma.The Care Plan revised 9/18/25 identified Resident #4 had limited physical mobility related to arthritis and advanced age. The goals included the resident would be able to perform exercises with staff, and ride the NuStep with staff. Interventions included to see under tasks.The Tasks Tab, POC Response History documented Resident #4's exercises included using the green or blue Thera band or up to 4# weight for bilateral upper extremities, shoulder flexion adduction/abduction, elbow flexion/extension, as tolerated, all planes, 1 time a day, 3-6 days a week. The history documented the restorative completed only 5 times the previous 30 days. b. According to the MDS assessment dated [DATE], Resident #5 scored 9 on the BIMS indicating moderate cognitive impairment. The resident depended on staff for transfers and did not ambulate. The resident's diagnoses included Multiple Sclerosis (MS).The Care Plan revised 6/11/25 identified Resident #5 had limited physical mobility related to disease process. The intervention to see under tasks.The POC Response History documented the resident to have Active Range of Motion, 10 repetitions, cervical extension-tilt head back gently, neck rotation-provide tactile assistance to position shoulder shrugs (scapular elevation), 2 sets times 10 repetitions providing cues and encouraging 5-10 second hold in rotation position. The history documented the restorative only completed 4 times the previous 30 days. c. According to the MDS assessment dated [DATE], Resident #7 scored 9 on the BIMS indicating moderate cognitive impairment. The resident had functional limitation in ROM on 1 side, both upper and lower extremities. The resident's diagnoses included hemiplegia (paralysis of 1 side of the body). The Care Plan revised 9/2/25 identified Resident #7 had limited physical mobility related to disease process. The intervention to see under tasks.The POC Response History documented the resident's exercises included:Active Range of Motion (AROM) upper body using table with cloth or towel. Place right upper extremity on towel. Scapular pro/retraction, horizontal add/abduction, forward/backward, side to side, 3 times 12-15 repetitions, 1 time a day, 3-6 days a week. The POC documented receiving restorative 1 time the weeks of 12/28/25 and 1/3/26, and 1/4/26 to 1/10/26.Passive ROM, circumduction, scapular pro/retraction, bicep flexion/extension, forearm pro/supination, wrist flex/extension, 3 times 12-15 repetitions, 1 time a day, 3-6 days a week. The POC documented receiving restorative 1 time the weeks of 12/28/25 to 1/3/26, and 1/4/26 to 1/10/26.Lower body AROM in all planes and PROM to the right lower extremity in all planes (easier to do so in bed) 10-15 repetitions, 1 time a day, 3-6 days a week. The POC documented receiving restorative 1 time the weeks of 12/28/25 to 1/3/26, and 1/4/26 to 1/10/26.On 1/14/25 at 10:43 a.m. Staff D Certified Nursing Assistant (CNA) stated she strove to get everything done when she worked, and when they were short that was no small task. She said she is the restorative aide and she had been getting pulled off of doing the restorative to work the floor.The facility Restorative Program Process updated 10/26/21 identified it's purpose to ensure their resident(s) achieved and maintained their highest level of function. The licensed nurse would monitor the daily restorative nursing program documentation and follow-up with staff as needed. Baths: a. According to the MDS assessment dated [DATE], Resident #1 scored 6 on the BIMS indicating severe cognitive impairment. The resident required substantial/maximal assist with bathing. The resident's diagnoses included chronic obstructive pulmonary disease.The Care Plan revised 8/26/25 identified Resident #1 had an actual self-care deficit related to osteomyelitis and diabetes with diabetic neuropathy. The interventions included assist of 1-2 with bathing.The POC Response History documented Resident #1 was dependent for baths the past 30 days. The history showed 2 baths/week, with the exception of 1/4/25 to 1/10/25, having only 1 bath. b. According to the MDS assessment dated [DATE], Resident #3 scored 15 on the BIMS indicating no cognitive impairment. The resident required supervision/touching assistance with bathing. The resident's diagnoses included diabetes, muscle weakness, and other abnormalities of gait and mobility.The Care Plan revised 10/8/25 identified Resident #3 had an actual self care deficit related to polyneuropathy, diabetes, muscle weakness and abnormality of gait and mobility. The interventions included bathing assistance of 1.The POC Response History documented Resident #3 needed varying degrees of assistance for baths the past 30 days. The history showed 2 baths/week, with the exception of 12/21/25 to 12/27/25, having only 1 bath. c. According to the MDS assessment dated [DATE], Resident #6 scored 5 on the BIMS indicating severe cognitive impairment. The resident required partial/moderate assistance with bathing. The resident's diagnoses included non-Alzheimer's dementia.The Care Plan revised 5/9/25 identified Resident #6 had a self-care performance deficit related to dementia and limited mobility. The interventions included assist of 1 with bathing.The POC Response History documented Resident #6 needed varying degrees of assistance for baths the past 30 days. The history showed 2 baths/week, with the exception of 12/14/25 to 12/20/25, having only 1 bath.On 1/14/26 at 11:21 a.m. Staff E CNA said they had worked short lately, but she got her baths done. She said sometimes it got pretty hectic. She said most residents were scheduled for baths 2 times a week. She said since they had used more agency, she couldn't say if they were getting them done. On 1/15/26 11:30 a.m. the DON stated they had a staffing crisis and were working through it. Both the DON and Administrator stated they had admitted a new resident this week.

Based on observation, review of menus, and staff interview, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. The facility reported a census of 41 residents.Findings include: a. A review of menus showed the menu starting 12/28/25 had apricot chicken on Wednesday 12/31/25. On 1/14/25 at 9:32 a.m. Staff A Licensed Practical Nurse (LPN) stated about a week and a half ago the residents received undercooked chicken. She said a resident complained about it so she cut the chicken and it was not fully cooked. At 9:36 a.m. the Assistant Director of Nursing (ADON) stated she and 2 other staff went to the kitchen and checked the chicken and it was cooked. She said there is that vein in the meat that can look like blood, and there was a sauce on the chicken also.Staff A reiterated the chicken was not cooked through, the meat inside was still pink/red. On 1/14/25 at 9:48 a.m. Staff B Certified Nursing Assistant (CNA) stated if they put the food in the breakroom for free she would eat it. She said sometimes food was undercooked. On 1/14/25 at 10:10 a.m. Staff C CNA stated in the past couple of weeks they had chicken that was not fully cooked. When you cut into it the meat was still pink/red. On 1/14/25 at 10:43 a.m. Staff D CNA stated the food was not visually appealing. One day the chicken was under cooked. Resident #8 said his was bleeding. Then she checked Resident #7's and it was not done, so she microwaved it. On 1/14/25 at 11:21 a.m. Staff E CNA stated the chicken thighs were raw. She said she was going to take the meat off the bone for a resident and discovered it. She said then they checked others an found the same. She said she microwaved each plate for about 1-1/2 minutes and up to about 185 degrees. She didn't know how many had been served before they caught it, but she knew a few residents said they got bloody chicken and didn't eat it. On 1/15/25 at 12:05 p.m. the Dietary Manager (DM) and Administrator identified the meal served on week 3 on a Wednesday at noon included Apricot Chicken. The Administrator stated they were told they had a concern about the chicken being undercooked. They went to the kitchen and checked the remaining chicken and found the chicken done, but had some veins they may have misinterpreted as blood. She and the DM determined they checked the chicken around 12:30 p.m. at tear down time. Meal service time started at 11:30 a.m. b. On 1/14/25 at 11:59 a.m. the residents in the dining room had been served the noon meal. Dietary staff and nursing staff filled trays to take to residents in their rooms. They used heated plate warmers. They had 2 carts. Staff D took the first cart, and when she reached Resident #10s room, she temped the food with the meat at 130.7 and potatoes 133 degrees. She delivered the tray. Soon after the DS had the 2nd cart and temped the meat at 126 degrees.The facility Policy & Procedure Manual for Food Temperatures documented the temperatures of all hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees.

Based on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 39 residents. Findings include: An initial kitchen tour conducted on 10/29/25 at 10:50 a.m, revealed these observationsThe milk cooler with dried liquid substance down the side of it.The front of the freezer and refrigerator with smudge prints all over them.There were crumbs/food debri on the bottom of both refrigerators and freezers.The steam table had a brown crusty dried substance on it.The warmer had crumbs and food debri on the bottom of it. The following items were observed in the refrigerator without a date on it:A container of ranch salad dressing was open with no date on the container. The following items were observed in the pantry with no open date on them:A package of country gravy with no open date.A package of dried pudding with no open date.A package of ranch dressing seasoning with no open date. Review of facility policy titled Cleaning and Sanitation of Dining and Food Service Areasrevealed, the food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule.1. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department.2. Tasks shall be designated to be the responsibility of specific positions in the department.3. Staff will be trained on the frequency of cleaning, as necessary.4. The methods and guidelines to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned.5. A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. 6. Staff will be held accountable for cleaning assignments. Review of the facility policy titled Food Storage revealed, sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination.All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods.a. Old stock is always used first (first in - first out method). The person designated to manage stock should be trained to rotate it properly.b. Food should be dated as it is placed on the shelves if required by state regulation.c. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS food should be consumed, sold, or discarded.d. Food will be stored and handled to maintain the integrity of the packaging until ready for use. Food stored in bins may be removed from its original packaging.Regarding refrigerated food storage, all foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Interview with Staff A, Certified Dietary Manager (CDM) stated that there are daily, weekly and monthly cleaning schedules for the staff in the kitchen. Staff A stated it is a checklist that they check off when completed. Staff A stated that the expectation is for the staff to complete the checklist prior to them leaving their shift. Staff A stated the expectation is to have staff date the food/package when they open it.

Based on observation, record review and staff interview the facility failed to ensure adequate supervision to prevent elopement for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 38 residents.The facility took action to correct this deficiency prior to the surveyor entrance and is considered past non-compliance.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident wandered daily. The resident demonstrated independence with standing and ambulation. The resident's diagnoses included non-Alzheimer's dementia. The Care Plan revised 5/28/25 identified Resident #1 an elopement risk/wanderer related to impaired safety awareness. Interventions included 1 to 1 as needed, assess for pain, assist resident in making phone calls to her family as desired when she looked for them and verbalized a desire to go see them, distracting the resident from wandering by offering pleasant diversions, structured activities, conversation, television, book, and identifying a pattern of wandering: Was wandering purposeful, aimless, or escapist? Was the resident looking for something? Did it indicate the need for more exercise? Intervene as appropriate. Monitor location as needed, document wandering behavior every shift and attempted diversional interventions in behavior log, offer food/fluids, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. When the resident looked for her eyeglasses, assist her in looking for them and redirect from the doors of the facility. The Progress Notes documented the following:On 8/13/25 at 6:21 p.m. Resident #1 appeared with increased anxiety, more exit seeking, wandering, and pacing back and forth.On 8/23/25 Resident #1 continued to be exit seeking, asking repetitive questions and wandering.On 8/27/25 at 11:09 p.m. Resident #1 had been very anxious, walking hallways frequently looking for staff. She asked about health insurances and family, and at the front entrance x2, but never opened the door due to staff intervening. Difficult to redirect. On 8/30/25 at 9:11 p.m. a Certified Nursing Assistant (CNA) reported to the nurse she walked by the main entrance and saw the resident ringing the doorbell to get let back in the main entrance. The resident told staff she was outside walking around. Safety checks were initiated and all staff were aware to keep a look out on the resident. On 8/30/25 at 9:15 p.m. Staff A CNA notified the nurse she and another CNA, Staff B were walking to the dining room and observed the resident at the main entrance door ringing the door bell to be let back in. Staff A reported that she could not put the door code in to open the door. She checked the box where the switches were, and a switch was turned off. Staff A reported the resident's description to her was that she went for a walk outside to look for her family.On 8/31/25 at 5:04 p.m. report by the night nurse the resident did not sleep and exit seeking a lot during the night. On 9/1/25 at 11:01 a.m. staff heard front door alarm going off. The nurse, a CNA, and housekeeping ran to the front door, and saw Resident #1 in the foyer between the 2 doors. She came back in facility without incident, and cooperated with coming back inside. She denied any complaints, repeatedly stating she just didn't know where everyone was and what she was supposed to be doing. Observations:On 10/21/254:45 p.m. Resident #1 stood in the hall looking around a bit anxious. A staff member told her she could go to the dining room for supper and she took off walking, independent without device, steady gait. She had a bracelet on her left wrist.On 10/22/25 at 9:25 a.m. Resident #1 sat with other residents for activity of exercises. At 9:40 a.m. she actively participated in group exercises. At 10:35 a.m. the resident slept in a chair outside the administrator's office. At 3 p.m. she had been involved in activities for 1-1/2 hours.Staff signed statements:On 08/30/25 Staff A worked as a C.N.A. on the 2-10 shift. At approximately 6:25 p.m. the front doorbell rang. Staff A went toward the door and Staff B also walked toward the door and saw Resident #1. Staff A went to the door and tried a couple of times punching in the door code and it wouldn't give her a green light on the door key pad. She went to the box to check the alarm key, and it was green-meaning it was off. She turned it back on to red and retried the key pad. Then it allowed her to punch in the door code and it turned green. Staff A assisted Resident #1 back into the lobby. She asked Resident #1 what she was doing outside. Resident #1 said she walked around outside. Staff A did not witness Resident #1 walking around outside, that was her statement. Prior to the incident, Staff A saw the resident at supper when she was in the dining room helping with those being assisted around 5:55 p.m Resident #1 did get up many times during supper and would come back and forth. After the dining room, Staff A did other resident cares for approximately 20-30 minutes, the most time that went by from the last she saw Resident #1. Signed by Staff A on 8/31/25. In a follow up statement on 09/03/25, the Administrator did a walk through with Staff A of what occurred when she found Resident #1. Staff A realized that she panicked and likely didn't put the door code in correctly, thus it didn't turn green on the keypad. Staff A didn't realize she could just open the door, she thought she needed the code, and she didn't want the alarm to go off and startle Resident #1.On 8/30/25 Staff B worked as a C.N.A. from 5-9 pm. Staff C came down to the hall to help him with some transfers around 6:15 pm. Approximately 10 minutes later Staff B went back up front to see if anyone remained in the dining room, for maybe a minute and assisted a resident back to her room. When he walked back towards the nurse's station, Staff A and he saw/heard Resident #1 ringing the doorbell. Staff B saw Staff A responding, so Staff B went back to assist the resident with him. Staff B did not see Resident #1 outside, just in the entryway ringing the doorbell. Signed by Staff B on 8/31/25.On 8/30/25 Staff C was the Certified Medication Aide (CMA) on 2-10 p.m. in the front part of the building. Around 3:35 p.m., Resident #1 talked about wanting to go down the hill to see her family. Staff C assisted Resident #1 in calling family around 3:45 p.m. Resident #1 talked to the family member and had a conversation. The family member told her she would be there on Monday. Resident #1 did ask to call the family member approximately 5-10 minutes later and Staff C reminded her they just talked to her and the family member would be there Monday from 4 p.m. until about 615 p.m. The resident followed Staff C (even when in the dining room passing pills) and was anxious. Resident #1 got tearful at one point and thought her family dumped her at the facility. Staff C reminded her that she talked to the family member and reassured her that her family loved her. She said she wished Staff C was her sister because Staff C was so kind to her. Staff C told the resident she could be her family too. Resident #1 constantly rubbed up against Staff C and laid her head on her shoulder and hugged her. A little after 5:10 p.m., she came from the dining room and said she had eaten. Resident #1 sat in the rocking chair by the fire place, right behind Staff C and kept talking to her. Staff C finished her med pass around 5:55 p.m. Resident #1 kept thanking Staff C for helping her. When Staff C pushed her cart to the nurses station Resident #1 followed her there as well. Staff C asked her to go down and use the restroom and she headed down to her room around 6:05 p.m. Resident #1 came back up to the nurse's station and asked for her family member's number. Staff C told her there was a piece of paper in her room and Resident #1 went to look for it (this was usually a good distraction and focus point for her) and Staff D Licensed Practical Nurse (LPN) said to Resident #1 why don't she go look for it. Staff C didn't see Resident #1 return to the desk right away, so at 6:15 p.m. she went down the hall to help with a resident transfer. She learned of Resident #1 (eloping) around 6:45 p.m. They immediately initiated frequency checks. Throughout the shift Staff C used several interventions to assist with Resident #1's wandering and behavior. These included offering food, offering fluids, offering toileting, activity provided, and assessed for pain. Except for at 3:35 p.m. when she asked to go down the hill to see her family, Resident #1 did not display any exit seeking behavior or indications that she wanted to leave. Staff C signed the statement on 8/31/25.During an interview on 10/21/25 at 2:15 p.m. the Administrator stated since the incident on 8/30/25 they had investigated what happened. The door alarm apparently was off when the incident occurred. She had interviewed staff and visitors and was unable to determine who/how the alarm was turned off. They did not feel Resident #1 was outside very long, or if she even went clear outside. Based on the timeline there had only been 10 minutes since she had last been seen.The facility Missing Resident/Elopement Process updated 10/29/24 included when the door alarm sounded, facility staff should: a. Reset the door alarm after they determined by visual check that no resident exited the facility inappropriately or returned to the facility. b. If for any reason, door alarms were turned off, the staff would continually visually monitor the door/doors. c. The nurse, Director of Nursing (DON), or Executive Director would question staff to determine who deactivated the door alarm and reason for doing so.

Based on clinical record review and staff interviews, the facility failed to notify the family or responsible party when a resident had a change of condition for 2 of 15 residents reviewed (Residents #34 and #18). The facility reported a census of 41 residents. Findings include: 1. Resident #34's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #34 was independent with bed mobility, transfers and ambulation. Resident #34's MDS documented diagnoses of hypertension (high blood pressure), atrial fibrillation (irregular heart beat), and hypothyroidism. A Progress Note dated 1/17/25 at 7:17 PM documented Resident #34 reported to the nurse that she had a productive cough with white, thick mucus, runny nose and a sore throat. The note documented Resident #34 had abnormal lung sounds with crackles in the left lower lobe and diminished lung sounds to left upper lobe and right lobes diminishes. Resident #34's temperature was 102.4 degrees Fahrenheit and pulse oximeter (oxygen in the blood) measured 88-90% on room air. The note documented an appointment at the clinic was made for 3:30 PM. The note revealed the facility received a call that Resident #34 had pneumonia and was being admitted to the hospital. The Progress Note lacked documentation Resident #34's niece/POA was notified of the condition change and that she was being admitted to the hospital. A Progress Note dated 1/21/25 at 10:40 AM documented Resident #34's niece/POA called the Social Worker to report she was upset that she had not been notified of Resident #34 being taken to the emergency roiagnom on [DATE]. The note documented that the facility would educate staff moving forward as it was important families are notified of these situations. On 4/3/25 at 9:15 AM, the DON (Director of Nursing) reported it was the first time she was hearing about Resident #34's POA not being notified of the ER transfer/hospitalization . She reported there should have been a grievance form filled out. The DON reported she would expect the POA/responsible party to be notified regarding an ER transfer that resulted in a hospitalization . On 4/3/25 at 9:37 AM, the Administrator provided an education form dated 1/21/25 that documented family notifications need to be completed and it was leadership responsibility to ensure they are done. These would be reviewed during morning clinical meetings. The form was signed by Social Services, ADON, Administrative Assistant, DON and Administrator on 1/22/25. On 4/3/25 at 10AM, the Administrator reported the charge nurses had been educated verbally regarding family notification but she did not have anything documented to prove the education was completed. On 4/3/25 at 10:40 AM, Resident #34 reported she wants her niece/POA to be notified of any condition changes including ER visit/hospitalization . Resident #34 reported that her niece/POA did not know she was hospitalized in January until she came to visit and she told the niece about it. A facility policy titled Notification of Change in Resident Health Status updated 2/8/23 documented the resident's legal representative would be notified of a change in resident status that included a significant change in the resident's physical, mental or psychosocial status for example, a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications. The facility would also notify the resident legal representative of a decision to transfer or discharge the resident from the nursing home. 49056 2. The MDS assessment dated [DATE] for Resident #18 documented diagnosis of non-traumatic brain dysfunction, non-Alzheimer ' s dementia, and hallucinations. The MDS showed the BIMS score of 15, indicating no cognitive impairment. Review of facility Progress Notes noted on 3/8/25 at 2:13 PM, Resident #18's family came to the facility for a visit, when family members arrived Resident #18 was sitting in the commons area. After a couple of hours the family took Resident #18 down to his room and noted there were precaution signs in the room and personal protective equipment outside of the room. Resident #18's family were informed at that time Resident #18 was positive for influenza A. Resident #18's wife was concerned that they had not been informed of the positive result and that if they had known they would not have come to visit him and wanted to know why he was out in the common area. Review of facility Progress Notes revealed on 3/8/25 at 2:23 AM revealed lab called and informed facility Resident #18 was positive for Influenza A. Review of electronic health records lacked documentation of notifying the family Resident #18 was positive for Influenza A. Interview on 4/3/25 at 9:23 AM with the DON revealed the expectation would be to notify families first thing in the morning.

Based on clinical record review, observations, and staff interviews the facility failed to implement care plan interventions to reduce the risk for falls for 1 out of 4 residents (Resident #25) reviewed.The facility reported a census of 41 residents. Findings include: Resident #21's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS identified Resident #21 required partial/moderate assistance with bed mobility and all transfers. Resident #21's MDS documented diagnoses of hypertension (high blood pressure), Cerebrovascular Accident (CVA), non-Alzheimer's dementia, Parkinson's disease, seizure disorder and paroxysmal atrial fibrillation (irregular heart beat). The Care Plan with a target date of 7/8/25 documented Resident #21 was at risk for injury related to falls. The Care Plan and the CNA (certified nursing assistance) Kardex directed the following interventions: -Resident #21 to keep the door ajar so staff can keep a closer eye on him.-8/6/24 -Encourage Resident #21 to leave the room door open.-11/11/24 -Resident #21's bed to be in the lowest position when in bed.-12/31/24 Review of the Care Plan revealed duplicate interventions to keep the door open on 8/6/24 and 11/11/24. Review of the Clinical Record revealed Resident #21 had 7 falls from 11/1/24 to 3/1/25. On 3/31/25 at 1:21 PM observed Resident #21's door to room closed. Upon entering the room, observed Resident #21 lying in bed and bed was not in a low position per the care plan. Resident #21 reported he had had a few falls in the past and had hit his head. On 4/1/25 at 9:35 AM, observed Resident #21's door to room closed. Upon entering the room, observed Resident #21 lying in bed and bed was not in a low position per the care plan. On 4/2/25 at 4:53 PM, the DON (Director of Nursing) reported she expected staff to follow the care plan/kardex. She reported the facility was going to do education as some CNAs do not know what the kardex is. She reported she wanted to get back to the staff carrying a pocket care plan. A facility policy titled Comprehensive Care Plan dated 1/30/24 documented it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy further documented that the qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 2 of 15 residents reviewed (Residents #21 and #23). The facility reported a census of 41 residents. Findings include: 1. Resident #21's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS identified Resident #21 required partial/moderate assistance with bed mobility and all transfers. Resident #21's MDS documented diagnoses of hypertension (high blood pressure), Cerebrovascular Accident (CVA), non-Alzheimer's dementia, Parkinson's disease, seizure disorder and paroxysmal atrial fibrillation (irregular heartbeat). The Care Plan with a target date of 7/8/25 documented Resident #21 was noncompliant with cares/activities of daily living (ADLs) and would get up on his own. The care plan directed staff to increase supervision as needed. In addition, the care plan identified Resident #21 was at risk for injuries related to falls and had Parkinson's disease. The care plan directed staff to contact wife for any falls with known or possible head injuries to see if Resident #21 would like to be seen in the emergency room (ER). The care plan directed staff to administer medications and the diet as ordered by the Physician. A Physician Order dated 4/19/24 directed staff to give Eliquis (anticoagulant) 5 mg (milligrams) twice a day for atrial fibrillation (irregular heartbeat). A Progress Note dated 11/6/24 at 10:15 PM documented Resident #21 was found lying on the floor on his right side between the recliner and the bed. The note documented Resident #21 had an abrasion to the middle of his forehead that measured 5 cm (centimeters) x 4 cm with no active bleeding. A Progress Note dated 11/7/24 at 2:59 PM documented Resident #21 went out to a Dr's appointment and returned without any incident. New orders were received to start APAP (Tylenol) 1000 mg (milligrams) three times a day, oxycodone (opioid pain medication) 5 mg q 6 hours as needed and apply mupirocin ointment to the abrasion to forehead x 7 days. A Progress Note dated 11/8/24 at 5:28 PM documented the radiology department called and insurance approved Resident #21 to have a head CT (computed tomography) scan scheduled for 11/11 at 8 AM. A Progress Note dated 11/11/24 at 5:30 AM documented Resident #21 got up unassisted and fell landing on his right side. Neurological assessment initiated. A Progress Note dated 11/11/24 documented Resident #21 went out of the facility for a CT scan at 7:30 AM and returned to the facility at 8:15 AM. A Progress Note dated 11/11/24 at 11:23 AM documented Resident #21's CT scan results showed a subdural hematoma (pool of blood between the brain and its outermost covering). The note documented Resident #21 had a Dr's appointment at 1 PM and if he had a change in condition prior to the appointment to send him to ER. A Progress Note dated 11/11/24 at 12:50 PM documented Resident #21 went to Dr's appointment regarding the CT scan results. A Progress Note dated 11/11/24 at 3:37 PM documented Resident #21 was admitted to the hospital for observation. A Hospital Progress noted dated 11/11/24 documented Resident #21 had fallen on 11/6/24 and sustained an abrasion to his forehead. The noted revealed Resident #21 was on Eliquis (blood thinner) for anticoagulation due to atrial fibrillation. The CT scan showed a small (0.5 cm) mixed density right subdural hematoma and a small (0.5 cm) subacute left sudural hematoma. The progress note directed to hold the Eliquis medication at this time until follow up CT in 2 weeks. A Progress Note date 11/12/24 at 2:37 PM documented Resident #21 returned to the facility. A facility Physician fax form dated 11/13/24 directed to hold Resident #21's Eliquis anticoagulant medication at least until CT scan was repeated and Resident #21 saw a neurosurgeon as those outcomes would guide further recommendations. Review of the Clinical Record revealed the Eliquis medication was discontinued on 11/12/24. An Incident Report titled unwitnessed fall dated 11/18/24 at 3:57 PM documented Resident #21 was observed lying on the floor between the bed and heating unit on his right side with his right arm under his head and left arm back. The incident report documented Resident #21 had an abrasion to his right forehead. A facility form titled Hawk- Change in Condition dated 11/18/24 documented Resident #21 fell when getting up to close the window that was not open. The condition change form that was faxed to the Physician lacked information that Resident #21 had hit his head during the fall. The form was signed by the Physician on 11/20/24. A Clinic note titled Telephone dated 11/19/24 at 9:22 AM documented the clinic nurse called and spoke to a facility nursing staff member who reported Resident #21 did have an unwitnessed fall hitting his head along with his arm and had some abrasions. The facility staff member reported the facility offered to take Resident #21 to the ER but staff reported that the wife agreed to have nursing staff monitor him closely at the nursing home instead. The facility staff reported Resident #21 was neurologically intact and vitals have been normal. A Clinic note titled Telephone dated 11/19/24 at 11:21 AM documented Resident #21 PCP (Primary Care Physician) medical recommendations continued to be an ER evaluation for any head injury with Resident #21. The Physician documented the last time Resident #21 had a head injury, vitals were fine and neurological assessment intact he had a subdural hematoma. The note documented with the current subdural hematoma, this may have expanded with the recent falll. In addition the note documented if Resident #21 or his wife refused for him to go to the ER, that was one thing but they do need to be clearly aware that was the medical recommendation. Review of the Progress Notes revealed the fall that occurred on 11/18/24 was not documented in the progress notes until 11/19/24 at 1:26 PM. The progress notes lacked documentation the wife or resident offered and refused to go to ER. A facility form titled Education dated 11/21/24 documented if Resident #21 had a fall with head injury or if unknown head injury the facility must call his wife and verify if she would like him to be seen in ER every time. The education form documented if the wife does not want Resident #21 to be seen in ER then a good progress note needs to be completed on the refusal. The education form included nurse signatures and dates acknowledging the education. A Progress Note titled Care Conference note on 11/26/24 at 2:10 PM documented Resident #21 PCP was firm that her medical recommendation was that Resident #21 be seen in ER for a follow up head CT scan for any fall that he does hit his head with. Resident #21's wife was in agreement and would like to be notified when he does have a fall. A facility form titled VAMC SLUMS Examination (screening tool used to assess cognitive function) dated 11/27/24 documented Resident #21 scored a 16. A score 1-20 indicated dementia. A Progress Note dated 12/2/24 documented Resident #21 had a head CT scan completed. A Progress Note dated 12/4/24 documented Resident #21 went and returned from Dr's appointment. The note documented the head CT scan results being forwarded to neurosurgeon for further recommendations. A Clinic Telephone Encounter Note dated 12/5/24 documented Resident #21 had a history of subdural hematoma and the family canceled consulting/management with the neurosurgeon due to difficulty with transportation. The note documented on 12/4/24 the CT scan was faxed to the neurosurgeon's office to see if he could give an opinion on this patient for further management. The neurosurgeon' office reported that they are unable to give an opinion without an office visit/consultation. A facility MD/Nursing Communication form dated 12/4/25 revealed Resident #21 PCP documented a diagnosis of moderate dementia without behavioral or mood disturbance. Review of the Clinical Record after 12/5/25 revealed there was no further follow up on the Eliquis anticoagulant medication on whether to continue to hold the medication, discontinue the medication or restart the medication. An IR titled unwitnessed fall dated 12/31/25 at 4:30 AM revealed staff found Resident #21 lying on his stomach on the floor right next to his bed. Resident #21 denied hitting his head. Review of the Progress Note lacked documentation Resident #21's wife was offered or refused an ER visit due to an unwitnessed fall. An IR titled unwitnessed fall dated 2/3/25 at 6:05 AM revealed staff observed Resident #21 lying on his right side with head facing the wall by his dresser. The note documented Resident #21 had a rug burn to his right temple area and neurological assessment initiated. Review of the Progress Note lacked documentation Resident #21's wife was offered or refused an ER visit due to an unwitnessed fall with head injury. An IR titled unwitnessed fall dated 2/27/25 at 4:40 AM documented staff walked by Resident #21 room and observed him on the floor by his recliner sitting on his bottom with his knees bent up, facing the TV and his arms wrapped around the arm of the chair holding himself upright. His bed was raised almost all the way up. Resident #21 reported he sat up, put his shoes on and started to walk towards his recliner, lost his balance and fell to the floor. The IR documented there were no injuries. The IR lacked documentation on whether Resident #21 was asked if he hit his head or not during the fall. Review of the Progress Note lacked documentation Resident #21's wife was offered or refused an ER visit due to an unwitnessed fall with unknown head injury. A Progress Note dated 3/24/25 at 12:39 PM revealed Resident #21 had been having increased coughing episodes during meal times and when drinking water. The note documented a fax was sent to Resident #21's PCP requesting an order for speech therapy (ST) evaluation and treatment. A Progress Note dated 3/24/25 at 5:07 PM documented a fax was received with a new order for ST evaluation and treatment for diet appropriateness. A Progress Note dated 3/27/25 at 2:01 PM documented ST evaluation completed with recommendations for Resident #21 to have a general diet with thin liquids, no straws. Mechanical soft solids cut into bite sized and ground meat added with moisture. Speech therapy recommended large pills to be cut in half if able and given in pudding/applesauce. A Progress Note dated 3/27/25 at 5:27 PM documented ST recommendations faxed and received back signed by PCP. A facility form titled Rehab Communication for Resident #21 dated 3/27/25 documented ST recommended PO (by mouth) diet of thin liquids with no straws along with mechanical soft solids cut into bit sizes and ground meat with added moisture. ST recommended large pills cut in half if able and given in chocolate pudding. The form had the word yes documented on it and signed by DNP (Doctor of Nursing Practice) on 3/27/25. On 3/31/25 at 1:27 PM, Resident #21 reported his diet changed a couple of days ago because of coughing. He reported the coughing had gotten better with the diet change. Observed a water pitcher with a straw in the pitcher sitting on the bed side table next to the bed. When asked if he could have straws, he said no but that lasted about a day before the straws were given back. Review of the Care Plan with a target date of 7/8/25 and the CNA (certified nursing assistant) Kardex did not address Resident #21 was not to have straws. On 4/1/25 at 7:50 AM, observed Resident #21 sitting at the dining room table eating cereal. The Speech Therapist and a speech therapy student were at the table observing Resident #21 eating. The speech therapist student explained the recommendation for Resident #21 not to have straws. She said when you drink with a straw it requires sucking causing the liquid to shoot back of the throat and could potentially go down the wrong pipe. The speech therapist student reported they had observed Resident #21 would cough when using a straw. Observed Staff A, LPN (Licensed Practice Nurse) bring over a cup of medication in whole forms without applesauce or pudding and a cup of thin liquid with a straw in it. The Speech Therapist told the nurse there was a recommendation for no straws. The Speech Therapist directed the nurse to try giving the pills whole and use the straw to give liquids. Observed Resident #21 take a few pills given on a spoon by the nurse and then take a drink with the straw. Resident #21 had a hard time swallowing the whole pills and did cough when he used the straw. The Speech Therapist directed the nurse to try giving the whole meds without using the straw. Observed Resident #21 take whole pills on a spoon from the nurse, take a drink from the cup without the straw and he was able to swallow the pills without difficulty and did not cough. The Speech therapist and the nurse both told Resident #21 that he does better without the straw. The Speech therapist told Resident #21 that she knew he had a preference for straws but the straw was causing him to cough. On 4/1/25 at 7:59 AM observed straw in the water pitcher in Resident #21's room. On 4/1/25 at 9:35 AM, observed Resident #21 lying in bed with a water pitcher on the bed side table with straw in it. Resident #21 reported the water pitcher was delivered that way with a straw in it. When asked if he was using the straw he said yes. On 4/1/15 at 10:04 AM, the DON (Director of Nursing) reported she had talked to Resident #21's wife regarding his diet change and she did not want to do a shared negotiated risk. She reported Resident #21 had been educated about the types of food he was able to eat but was not sure if he had been educated regarding not using a straw. The DON was informed Resident #21 had a straw yesterday and today in his water pitcher. The DON acknowledged the concern and reported she would follow up. A Speech Therapy Encounter Note dated 4/1/25 at 11:03 AM documented Resident #21 was seen in the dining room to complete dysphagia therapy. The note documented nursing came to administer medication, where straw was present in thin liquid. Nursing then administered three pills at a time via spoon, where Resident #21 tried thin liquids via straw. Moderate oral holding of about 20 seconds noted before initiation of the swallow. Resident #21 then took three more pills with thin liquids via cup rim with no oral holding noted and immediate initiation of the swallow. Speech therapy will continue to recommend intake of medications with pureed consistencies, however will continue trial with thin liquids via cup rim and no straws. On 4/1/25 at 2:08 PM, the Nurse Consultant reported the facility completed immediate education with the staff regarding straw usage so it should not happen again. On 4/1/25 at 3:04 PM, the Nurse Consultant reported she would expect staff to follow therapy recommendations and physician orders. 4/1/15 at 2:00 PM, the Nurse Consultant verified she could not locate any additional documentation or follow up regarding the Eliquis after 12/5/24. On 4/2/25 at 10:45 AM, the Nurse Consultant reported her expectation after a fall with a head injury or suspected head injury and the resident was taking anticoagulant was to complete neurological assessments according to the Risk Management Policy and if there was a deviation from the neurological assessments to follow up with the Physician for further direction. The Nurse Consultant reported Resident #21's Physician would be rounding on 4/2/25 to address the Eliquis medication. She reported she did not think the Pharmacist reviewed the Eliquis medication during pharmacy reviews as the Eliquis was discontinued and was not put on hold so the Eliquis was not on Resident #21's medication list. The Nurse Consultant reported she would expect staff to follow physician orders and that the facility follows the regulations/standards of care. On 4/2/25 at 12:00 PM, the Nurse Consultant reported falls on 12/31/24, 2/3/25 and 2/27/25 were unwitnessed falls and required neurological assessments. She acknowledged the clinical record lacked documentation that the facility contacted wife regarding an evaluation in the emergency room and that the facility did not follow the care plan or Physician recommendations. On 4/2/25 at 12:37 PM, the Nurse Consultant acknowledged the condition change form from 11/18/24 did not address Resident #21 had hit his head. On 4/2/25 at 12:42 PM, the Administrator reported the facility does not have a policy that addresses anticoagulant medications. The Administrator reported the facility follows regulations and standards of care related to following Physician orders. A facility policy titled Notification of Change in Resident Health status updated 2/8/23 documented the resident's physician and resident's legal representative will be notified of a change in resident status when an accident involving the resident results in injury and has the potential for requiring physician intervention. 2. Resident #23's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS identified Resident #23 required supervision/touching assistance with bed mobility and transfers. Resident #23's MDS documented diagnoses of hypertension (high blood pressure), anemia, heart failure, diabetes mellitus, and arthritis. The Care Plan with target date 7/29/25 revealed Resident #23 had bladder incontinence and directed staff to monitor/document for signs and symptoms of a urinary tract infection (UTI). A Progress Note titled Transfer to Hospital Summary dated 2/28/25 at 2:25 AM documented Resident #23 was being admitted to the hospital for a UTI and IV (intravenous) antibiotics. A Progress Note titled Admission Summary dated 3/2/25 at 1:20 PM documented Resident #23 returned to the facility. The March 2025 Medication Administration Record (MAR) for Resident #23 directed staff to administer Cefdinir 300 mg (milligrams) 1 capsule two times a day for 5 days for acute cystitis with hematuria (bladder infection). A Physician fax form dated 3/11/25 directed staff to obtain a UA (urinalysis) with C&S (culture and sensitivity) related to fatigue and status post UTI. A Progress Note dated 3/12/25 documented the UA was collected and sent with labs. A Progress Note dated 3/13/25 documented a fax was received regarding UA and waiting for final C&S results prior to treatment. Review of the final culture results dated 3/16/25 documented >100,00 CFU (colony forming unit) per ml (milliter) of yeast sensitivity. The form documented the culture results were faxed to the facility on [DATE]. A new physician order for Macrobid (antibiotic) 100 mg twice a day for 5 days was documented on the form and signed by the DNP and dated 3/19/25. Review of the form revealed a note was written on the bottom of the form to the pharmacy to start the Macrobid on 3/20/25 at supper. The results and physician order for Macrobid were double noted by two facility nurses on 3/19/25. Review of the Progress Notes lacked documentation the facility received the final culture results or that the results were faxed to the Physician for review. The Progress Notes lacked any documentation regarding follow up or phone calls to the Physician regarding the results or need for treatment. The March 2025 MAR revealed the Macrobid medication was not started until the evening of 3/20/25. On 4/3/25 at 9:00 AM, the DON (Director of Nursing) reported the laboratory fax the results to the facility and then the nurses fax the results to the Physician. She reported she would expect documentation in the progress notes to reflect when the facility received the culture results and notified the Physician of the results. The DON verified the facility received the culture results on 3/17/24 by the timestamp on the fax. She reported she would expect the nurses to follow up with the Physician if there had not been a response and document the follow up in the progress notes. She reported she was working with the nurses regarding timely responses and documentation with the faxes. She reported she would expect the antibiotic to be started the day the antibiotic was ordered. She said if the fax was received the afternoon of the 19th she would expect the order to be started that evening. She reported the facility had an E-kit (emergency kit) so if the pharmacy was not able to deliver the medication the nurses could take the medication from there. She acknowledged the order for Macrobid was BID and was not started until the evening the following day after the order was received. On 4/3/25 at 10:00 AM, the DON verified Macrobid medication was available in the Ekit. A facility policy titled Notifying Clinicians of Lab Results updated 10/19/22 documented the facility must promptly notify the ordering physician and/or designee results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the order physician ' s orders. The policy further documented labs or diagnostic results that are outside the normal range, the facility to do the following: a. Notify the physician via phone or fax of the abnormal lab results. b. If the physician had not responded by the next day a phone is made to the physician office for response. c. If the physician still has not answered the DON is notified to attempt to get a response or notify the Medical Director for a response.

Based on clinical record review, staff interview and policy review the facility failed to provide bathing assistance for 2 of 2 residents reviewed for bathing (Residents #1 and #13). The facility reported a census of 41 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS did not document or code how much assistance Resident #1 required for bathing. Resident #1's MDS included diagnoses of peripheral vascular disease, diabetes mellitus, non-alzheimer's dementia, and an unstageable pressure ulcer to buttocks. The Care Plan with a target date of 8/12/25 documented Resident #1 required assistance of one staff member with bathing or showering. The facility form titled Bath Schedule documented Resident #1 was scheduled for a bath on Monday and Wednesday. The facility electronic from titled Shower/Bath Self for the last 30 days documented Resident #1 received a bath/shower on 3/12, 3/17, 3/24, 3/26 and 3/31. The form documented the response not applicable on 3/5 and 3/10. The form lacked documentation Resident #1 had refused any baths or showers. According to the documentation Resident #1 did not receive a bath/shower from 3/1 through 3/11. The Clinical Record lacked documentation of any other attempts to offer or encourage Resident #1 to shower or bathe. On 3/31/25 at 3:34 PM, Resident #1 reported she only gets one bath per week and she was supposed to have two baths a week. She reported the facility does not have enough staff at times so she does not get her bath. On 4/2/25 at 2:49 PM, the Corporate Nurse acknowledged the lack of documentation regarding bathing for Resident #1. She reported she could not locate any other documentation that baths/showers were completed in the last 30 days. 2. Resident #13's MDS dated [DATE] assessment identified a BIMS score of 15, indicating intact cognition. The MDS documented Resident #13 required substantial/maximal assistance for bathing and was dependent on staff for tub/shower transfer. Resident #13's MDS included diagnoses of diabetes mellitus, cerebrovascular accident (stroke), Psychotic disorder, anxiety and depression. The Care Plan with a target date of 8/5/25 documented Resident #13 required assistance of two staff members with bathing. The care plan directed staff to give a whirlpool bath on Wednesday and Saturdays and if Resident #13 refused the bath to tell him his sister wanted him to get in the bath. The care plan documented Resident #13 frequently refused his baths. The care plan directed staff to encourage Resident #13 to take baths. The facility form titled Bath Schedule documented Resident #13 was scheduled for a bath on Monday and Wednesday. The facility electronic from titled Shower/Bath Self for the last 30 days documented Resident #13 received a bath on 3/10, 3/17, 3/24, 3/31. The form documented Resident #13 refused a bath on 3/12 and the response not applicable was documented on 3/5 and 3/26. According to the documentation Resident #13 did not receive a bath from 3/1 through 3/9 and had only received 4 baths in the last 30 days. The Clinical Record lacked documentation of any other attempts to offer or encourage Resident #13 to bathe or attempts to reapproach when Resident #13 refused to bathe. On 3/31/25 at 1:57 PM, Resident #13 reported he has only been getting baths once a week. When asked if this was his preference he said no. He reported he has told the staff about not getting his baths but nothing has changed. On 4/2/25 at 2:49 PM, the Corporate Nurse acknowledged the lack of documentation regarding bathing for Resident #13. She reported she could not locate any other documentation that baths were completed in the last 30 days. She reported she could not locate any documentation in the progress notes regarding refusals. She reported she would expect staff to offer baths according to resident preference. She reported the facility does not have a bathing policy. She reported the facility follows the regulations and standard of practice. On 4/2/25 at 3:24 PM, the Administrator reported Resident #13 refused care and bathing often and the care plan reflected this. The Administrator acknowledged the concern with bathing, will educate staff and start the plan of correction. On 4/3/25 at 3:30 PM, the DON (Director of Nursing) reported she did not know what non applicable meant when it was documented on the bathing forms. She said it could mean that there was a mix up between the facility bath list/schedule and what was documented in the electronic medical record.

Based on record review, staff interviews and facility policy the facility failed to put proper interventions in place to prevent a stage 2 pressure ulcer to the right heel consistent with professional standards of practice for 1 of 1 residents reviewed (Resident #38). The facility reported a census of 41 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The Minimum Data Set (MDS) assessment dated [DATE], for Resident #38 documented diagnoses that included hip fracture, peripheral vascular disease, and renal insufficiency. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified the resident as at risk for pressure ulcers and also identified the facility had placed a pressure reducing device for the bed. The MDS indicated Resident #38 needed substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with sit to lye, lye to sitting on side of bed, sit to stand, chair/bed to chair transfers and toilet transfers. Review of Resident #38's baseline Care Plan dated 9/20/24 revealed Resident #38 needed assistance from 1 staff member with repositioning and bed mobility. The baseline Care Plan failed to identify any interventions in place to prevent pressure ulcers. Review of facility provided skin sheet dated 10/5/25 revealed Resident #38 with an area to his right heel measuring 2.5 centimeters(cm) x 2.5cm indicated a Stage 2 pressure ulcer. The facility policy named Pressure Injury Prevention Guidelines dated 2024 revealed to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment(moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). The goal and preferences of the resident and/or authorized representative will be included in the plan of care. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders. Prevention devices will be utilized in accordance with manufacturer recommendations(heel flotation devices, cushions, mattresses). Guidelines for prevention may be utilized in obtaining physician orders. The facility may use facility specific guidelines or see Pressure Injury Prevention Guidelines below. Interventions will be documented in the care plan and communicated to all relevant staff. Compliance with interventions will be documented in the medical record The effectiveness of interventions will be monitored through ongoing assessments of the resident and/or wound. Interview with the DON on 4/3/25 at 1:10 PM stated there were no indications to put interventions in place, Resident #38 had a low braden score and was working with therapy. The DON stated Resident #38 did have a pressure reducing mattress to his bed. The DON stated there was no risk management or incident completed on this area and could not find a root cause analysis, the facility thought this area happened from his shoe. Interview with the DON on 4/3/25 at 3:30 PM revealed the expectation is to review the resident's information during the admission's process and put interventions in place based on that information.

Based on clinical record reviews, staff interviews and policy review, the facility failed to put effective interventions in place and provide adequate nursing supervision to prevent accident and injuries from falls for 1 of 1 residents reviewed (Resident #18). Resident #18 had a risk for falls with a history of repeated falls. Resident #18 had his thirteenth fall on 3/5/25 in a three-month period of time. On 1/9/25 Resident #18 had an unwitnessed fall in his room, resulting in a fracture to his left hand. Findings include: Resident #18's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS listed Resident #18 as independent with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfers. The MDS listed Resident #18 as supervision for toileting. The MDS described Resident #18 as frequently incontinent of urine. Resident #18's MDS included diagnoses of non-traumatic brain dysfunction, non-Alzheimer's dementia, and hallucinations. The Facility Incident Reports (IR) documented from 12/26/25 to 3/5/25 revealed Resident #18 fell on [DATE], 12/30/24, 1/7/25, 1/9/25 x2, 1/26/25, 2/4/25, 2/6/25, 2/10/25, 2/18/25 x 2, 3/5/25 x 2. The Care Plan with a target date of 1/6/25 revealed Resident #18 had a risk for falls related to encephalopathy. Resident #18 tends to place himself on the floor when looking for objects or tinkering with items. Resident #18 also tends to walk without a walker. The interventions directed the following: 12/26/25 Medication reviewed and changes made. 1/7/25 Gripper socks on at bedtime as resident allows. 1/9/25 Has had recent medication changes, will have primary care physician review medications. 1/10/25 Re-eval with physical therapy. 1/26/25 Encourage Resident #18 to wear proper footwear at all times. 2/6/25 Staff to encourage Resident #18 to utilize a walker when appearing unsteady. 2/10/25 Medication review by primary care physician for possible insomnia. 2/18/25 Recliner replaced with straight back chair in resident's room. 3/5/25 All regular socks removed from room and only gripper socks added to room. 3/5/25 Assessment and treatment for acute illness. Review of the Progress Notes on 12/30/24 at 11:07 AM revealed Resident #18 was found on the floor in the dining room, with his walker on the floor with him. Intervention to put a sign on the walker directing Resident #18 to utilize the walker. The facility failed to complete an Incident Report and a Root Cause Analysis to identify the reason for the fall. An IR dated 12/30/25 at 9:30 PM identified an unwitness fall in his room. The IR indicated Resident #18 was found lying on his right side in front of closet, Resident #18 had a drawer at the bottom of the closet open and taking out the items. Resident #18 denied falling and put himself down on the floor, Resident #18 reported he was fixing the drawer with nails. The IR for 12/30/25 stated assessment not needed as care plan updated that Resident #18 placed himself on the floor. An IR dated 1/7/25 3:30 AM identified an unwitnessed fall in his room. The IR indicated staff heard a noise coming from Resident #18's room, staff found Resident #18 on his knees leaning against the recliner. Resident #18 stated I think I fell right here. Intervention to have gripper socks on at bedtime as Resident #18 will allow. An IR dated 1/9/25 at 3:00 AM identified an unwitnessed fall in his room. The IR indicated staff went to check on Resident #18 due to on 15 minute safety checks, Resident #18 was found lying flat on his back on the floor next to bed. Resident #18 did receive a bruising to the palm and back of his left hand and his left wrist. Intervention is a medication review. The facility failed to put any additional interventions in place until the medication review was completed. Review of facility Progress Notes revealed the facility updated the primary care physician on the swelling and bruising to the left hand/wrist, and continued complaints of right shoulder pain. Appointment scheduled for 1/9/25 at 2:00 PM. Review of the x ray results of the left wrist and hand dated 1/9/25 at 2:27 PM revealed Resident #18 had a minimally displaced oblique fracture(bone is broken at an angle and the broken ends are slightly out of alignment) of the third metacarpal (middle finder that connects the palm to the hand) mid/proximal diaphysis (the area of the shaft of a long bone that is near the proximal end). An IR dated 1/9/25 at 11:15 PM identified an unwitnessed fall in his room. The IR indicated staff entered room to find Resident #18 laying on his left side facing dresser, left arm under his head, right arm at side, legs partly bent. When nurse entered room, Resident #18 was on his knees leaning on the bed. The certified nursing assistant (CNA) stated he wouldn't wait to be assessed. Resident #18 continued to have a splint on left hand, lower arm in place. RCA: Medication changes taking time to get out of the system. Intervention: physical therapy to re-evaluate need for walker. The facility failed to put any additional interventions in place until physical therapy could see Resident #18. Information provided by the Administrator on 4/3/25 revealed physical therapy saw Resident #18 on 1/13/25. An IR dated 1/26/25 at 2:10 PM identified an unwitnessed fall in the hallway. The IR indicated Resident #18 was found on the floor with a rug burn noted to the right knee. Resident #18 unsure of how it happened. Intervention: Encourage Resident #18 to wear proper footwear at all times. An IR dated 2/4/25 at 10:58 AM identified an unwitnessed fall in his room. The IR indicated Resident #18 was found laying on the floor and yelling for help. Upon entering room, Resident #18 was laying on left hip with legs extended and propping himself up with arms. Resident #18 stated he slid out of his recliner. Intervention: dycem applied between cushion and chair. An IR dated 2/6/25 at 6:50 PM indicated Resident #18 had a witnessed fall in his room. The IR indicated staff was assisting Resident #18 to get ready for bed. Staff asked Resident #18 to sit down into his chair so his legs can rest, when the CNA turned around, Resident #18 stepped towards the door to leave his room and tripped over his feet and fell to the floor. Intervention: Encourage Resident #18 to use a walker when appearing unsteady. An IR dated 2/10/25 at 7:35 AM indicated Resident #18 had an unwitnessed fall in his room. The IR indicated Resident #18 was found on the floor between his dresser and the wall with his head in the corner, lying on his left side. Resident #18 fully dressed with gripper socks on and brief is dry. Resident #18 stated I was trying to get that worm as he pointed to a piece of yarn on the floor. Resident #18 noted to have skin tear to left forearm and some bruising to his left elbow and left ear. Intervention: Facility will have Resident #18 seen by primary care physician for medication review due to reported by night nurses that Resident #18 is not sleeping at night. The facility failed to put any additional interventions in place until the medication review could be completed. An IR dated 2/18/25 at 4:35 AM indicated Resident #18 had an unwitnessed fall in his room. The IR indicated Resident #18 was yelling for help, when staff entered the room he was lying on the ground in front of the recliner. Resident #18 stated I slipped off the damn thing. Intervention: Dycem placed underneath the recliner to prevent from sliding backwards. An IR dated 2/18/25 at 1:45 PM indicated Resident #18 had an unwitnessed fall in his room. The IR indicated Resident #18 was found next to the recliner between the wall and recliner and feet out toward the center of the floor facing toward the west wall. When Resident #18 was asked what he was doing, he was not able to answer stating he doesn't know what's going on and said he is waiting for some woman. Intervention: Recliner removed from room and replaced with straight back chair. Resident #18 sent to the emergency room per primary care physician due to his decline with respiratory status and increased confusion. An IR dated 3/5/25 at 00:00 AM indicated Resident #18 had an unwitnessed fall in his bathroom. The IR indicated that Resident #18 was found on the floor of his bathroom in front of toilet sitting on buttocks. Resident #18 had bottom pants off and was sitting on the floor. Resident #18 had regular socks on no gripper socks. Intervention: to make sure Resident #18 had gripper socks on at all times. All regular socks removed from the room; only gripper socks in room. An IR dated 3/5/25 at 3:05 AM indicated Resident #18 had an unwitnessed fall in his room. The IR indicated staff checked on Resident #18 on the floor laying on his left side next to bed. Resident #18 stated I don't know how I got myself in this predicament. Resident #18 had taken non-skid socks off so a new pair applied. Intervention: Assessment and treatment for acute illness. The facility failed to put any additional interventions in place until acute illness resides. Interview with the DON on 4/3/25 at 3:30 PM revealed the expectation regarding falls/interventions for the nursing staff is to fill out the risk management and put interventions in place immediately. DON stated that she is going to implement Risk Management binders at the nurse's station to help with implementations of interventions and to notify her if they need help with an intervention. Review of facility Progress Notes dated 1/1/25 at 00:35 AM revealed Resident #18 was found in bed with a female resident in her room. Resident #18 was found naked from the waist down and his pants and brief were on the floor by the bed. Staff assisted Resident #18 out of the bed and back to his room. Intervention at this time to initiate one on one. The facility failed to fill out an Incident Report and root cause analysis with this incident. Interview on 4/1/25 at 12:54 pm interview with Staff C, Licensed Practical Nurse (LPN) revealed Resident #18 hadn't been in his room and they were looking for him and found him in another room, in the resident's bed with no clothes on from waist down. Staff C stated she got him out of bed and dressed him. Staff C stated Resident #18 told her he was going to bed. Staff C stated the other resident was asleep. Staff C stated she didn't know if the other resident knew he was there, the resident wasn't awake and she still had her clothes on. When Staff C was asked about frequent check, Staff C stated that we just checked on him frequently, Resident #18 was always going in another resident's room. Staff C stated if she documented frequent checks she doesn't remember or if they had implemented the fifteen minute visual checks. Staff C stated we just did frequent ones because he was a wanderer and we would do them every so often, we didn't have a formal place to document the frequent checks. Interview on 4/1/25 at 4:00 PM with Staff B, Certified Nursing Assistant (CNA), revealed that it is day by day with what Resident #18 wears to bed, sometimes he just wears a brief and sometimes he wears sweatpants. Staff B stated that she had never known him to sleep naked. Review of facility Progress Notes dated on 1/22/25 at 10:40 AM revealed Resident #18 was found sitting at the end of the bed with no pants/brief on, his pants were at his ankles and the other Resident (whose room this was) was in bed with eyes closed and did not appear to be aware that this Resident was even in there. Staff assisted Resident #18 pulled his pants up and walked him out of the room. Per Administrator on 4/3/25 stated they tried to identify patterns of wandering, stating he was typically looking for the bathroom, so a sign was placed on the bathroom door. The facility failed to fill out an Incident Report and root cause analysis with this incident. Review of the facility's policy named Risk Management dated 9/27/24 revealed all accidents/incidents involving residents will be reported, investigated and reviewed through the facilities Quality Assurance and Performance Improvement (QAPI) Process to ensure residents receive the highest quality of care. The nurse identifying an incident (see all incident types below) will be responsible for completing the incident report in the electronic health record. Incident Reports: a) All incident reports are located under the clinical tab under the dropdown box under care management and choose risk management and click on active. Under active click on the new button tab. This will open a new incident report window and enter resident specifics and location. b) Select the appropriate type of Incident: 1) Witness or Unwitnessed Fall 2) New Skin Issue 3) Elopement 4) Medication Error 5) Resident to Resident incident 6) Abuse 7) Unusual event 8) Smoking injury, Burns Completion of Incident Reports: a) Fill out completely all tabs of incident report, be very specific. b) Details: 1) incident description 2) resident ' s description 3) immediate action taken, assessment at time of incident and intervention initiated (care plan intervention). c) Injuries: 1) Injuries, select from drop down type and location 2) Level of pain 3) Level of Consciousness, Mobility, and Mental Status 4) Note section: any supporting note ( increased confusion, increased pain or new pain, refusal of pain medication, gait disturbance new or unusual, etc). d) Factors: 1) Predisposing Environmental factors, select all that apply. 2) Predisposing Physiological factors, select all that apply. 3) Predisposing Situation, select all that apply. 4) Other information, additional information as needed (resident has a urinary tract infection (UTI) and is more confused,things that may have contributed to the incident). e) Witnesses 1) Only list first and last name of those staff that actually witnessed the incident. f) Actions: 1) Agencies/People notified (emergency department, director of nursing, physician, family and law enforcement as appropriate). 2) Progress Notes, this note will populate to the resident ' s chart. 3) Triggered user-defined assessments (UDA) will prepopulate as required and appropriate and complete before moving to next step. g) Notes: close out the incident by charting about your interdisciplinary team (IDT) reviewing the incident report, what the root cause was, and all interventions related to this incident. h) Signature, sign when completed. Witness statements: a) These will be completed on facility ' s investigation statement form by the witness, only document name of witness in risk management. b) Sign incident as completed by the end of shift. c) All investigation assessments are located under the resident ' s chart and are due by the end of the nurses shift that incident occurred. Neurological Assessment: a) Must be completed with every unwitnessed fall or a fall with possible head injury. b) Neuro checks must be completed in the following time frames: 1) Every 15 minutes x 4 2) Every 30 minutes x 2 3) Every hour x 2 4) Every 4 hours x 3 5) Every shift x 3 All Incidents Reports and investigations will be completed by the end of your shift. DON, MDS and ED will review risk management Monday through Friday to identify new incidents. a) Incident dashboard indicates incidents occurred in the last 7 days. b) Incident analysis located on dashboard. c) Review all active incident reports daily. d) Huddle/Stand-up review all new incidents. e) Monitor UDA portal for any UDA ' s were not initiated or completed (under in progress), in both Clinical and Admin. f) Ensure intervention is appropriate and care planned. g) Once reviewed, report will be signed by the DON, ED and MDS within 48 hours. h) Review all residents who have had 2 or more incidents in 30 days for trending and need for further interventions to prevent incidents.

Based on clinical record review, staff interview and facility policy review, the facility failed to complete a gradual dose reduction (GDR) for 2 out of 5 residents reviewed for unnecessary medications. (Residents #5 and #19). The facility reported a census of 41 residents. Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. The MDS identified Resident #5 was dependent on staff for bed mobility, and transfers. Resident #5's MDS included diagnoses of Alzheimer's disease, Non-Alzheimer's disease, multiple sclerosis and depression. The MDS documented Resident #5 was taking antipsychotic and antidepressant medications during the 7 day look back period. The Care Plan with a target date 7/15/25 documented Resident #5 was at risk for adverse effects from antipsychotic and antidepressant medications. The Care Plan directed staff to attempt GDR (gradual dose reduction) per physician orders. A Consultant Pharmacist Communication to Prescriber form dated 10/28/24 documented Resident #5 was taking Sertraline (antidepressant) 150 mg (milligrams) daily, Trazadone (antidepressant) 100 mg at HS (bedtime) and Aripiprazole 2 mg daily for explosive disorder and major depressive disorder since admission in February 2024. The Behavioral Health ARNP (Advanced Registered Nurse Practitioner) documented on the form on 11/21/24 that it was ok to trial decrease Sertraline to 125 mg daily if okay with the patient. The Behavioral Health ARNP did not address the Trazadone or Aripiprazole medications on the form and did not provide a clinical rationale on why the medications were not adjusted or a GDR done. A Progress Note dated 11/21/24 documented Psych faxed back ok to trial decrease of Sertraline to 125 mg daily if okay with patient. The note revealed Resident #5 stated no he did not want to decrease the medication. The Progress Note lacked documentation regarding a GDR for the Trazadone or Aripiprazole medication and lacked a clinical rationale for not completing a GDR. On 4/2/25 at 2:38 PM, the DON (Director of Nursing) reported she acknowledged the concern with the GDRs. She reported her expectation was for a GDR to be completed two separate quarters the first year with a month in between and then annually after. A facility policy titled Medication Regimen Review Policy updated 10/19/22 documented the consultant pharmacist would review the resident medication regiment including the resident chart at least once a month. The consultant pharmacist will report in writing in recommendations and irregularities to the Attending Physician, the community Medical Director and DON and if appropriate to the Administrator. 2. The MDS assessment dated [DATE] for Resident #19 documented diagnoses of hemiplegia, seizure disorder, depression, and aphasia. The MDS showed the BIMS score of 9, indicating moderate cognitive impairment. Review of facility provided document titled Consultation Pharmacist Communication to Prescriber dated 9/24/24 revealed Resident #19 was on Sertraline 25 milligrams (mg) since March 2024 and Trazodone 50mg daily since admission in May 2022. The Sertraline was due for a gradual dose reduction in March 2025. The facility failed to complete the gradual dose reduction.

Based on record review and staff interview, the facility failed to provide adequate supervision to ensure timely intervention during a choking incident for 1 resident (Resident #1) and failed to ensure appropriately trained staff supervised and fed residents at risk for choking for 2 of 2 residents (Resident #1 and #3). On [DATE], while at supper in the assisted area, Staff A, Noncertified Nurse Aide (NCNA), assisted Resident #3 eat and observed Resident #1. Resident #1 choked. At the time, the only people in the assisted dining room were Staff A and the 2 residents. Staff A couldn't do the Heimlich and the walkie talkie failed to work to summon help timely. Staff A yelled for help. After hearing Staff A, Staff D Dietary Aide responded and learned they needed assistance. Staff D left the dining room to find additional staff to assist Resident #1. Staff A provided back thrusts without success. Once the nurse arrived, they managed to dislodge a piece of bread which allowed the resident to resume breathing. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 46 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began on [DATE] on [DATE] at 4:30 p.m. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: On [DATE], the Administrator initiated staff education to ensure all nursing staff are carrying a functioning walkie talkie during their shift. All nursing staff will be educated on [DATE] or prior to the start of their next shift. On [DATE], the Administrator and DON were educated by the VP of Operations on the requirement to ensure licensed nurses or certified nurse aides are the only staff assisting residents during meals. As of [DATE], there are no uncertified nurse aides on the nursing schedule. Staff A is no longer employed at the facility. Last date of employment was [DATE]. The DON/Administrator and/or designee will audit staff for compliance with walkie talkie usage at random during their shift. The DON/Administrator and/or designee will also audit the nursing daily schedule sheets at random to ensure licensed/certified staff are scheduled. Any concerns will be reported to the Administrator immediately and addressed in facility QA. The scope lowered from a J to a G at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required supervision or touching assistance with eating. The resident had diagnoses including diabetes. The Care Plan initiated [DATE] identified Resident #1 had a recent swallow study with recommended mechanical soft with ground meat diet and honey thick liquids. The resident declined. Resident #1 and his family were aware of the risks per a managed or negotiated shared risk agreement. 2) According to the MDS assessment dated [DATE] Resident #3 scored 7 on the BIMS indicating severe cognitive impairment. The resident required substantial/maximal assistance with eating. The resident had diagnoses including non-Alzheimer's dementia and multiple sclerosis. The Care Plan initiated [DATE] identified Resident #3 had a swallowing problem related to dsyphagia. Interventions included all staff informed of special dietary and safety needs, alternate small bites and sips, check mouth after a meal for pocketed food and debris, remove and report as needed. The resident had oral/dental health problems related to poor oral hygiene. He did not have his own teeth. Interventions included diet as ordered. Consult with the dietician and change if chewing/swallowing problems. In a statement dated [DATE] Staff A signed on [DATE] she was in the dining room at the end of supper feeding another resident (Resident #3) around 6:15 p.m. Resident #1 sat across the table from her. Staff A saw Resident #1 take a bite of his sandwich. He chewed and swallowed it and then made a gasping/muffled whistling noise. He picked up a glass of water and took a drink and kept gasping. No liquid ran out of his mouth. Staff A went behind him and tried to put her arms around him for the Heimlich, but couldn't fit her arms around him. She called for help and the walkie talkie didn't work. Staff A pounded on Resident #1's back to see if something would lodge loose. Staff D Dietary Aide (DA) heard Staff A yelling and ran to get help. Resident #1 never lost consciousness. Resident #1 kept trying to take drinks and Staff A had to take the cup out of his hand as he kept trying. Time lapse between when he started choking and when the nurse's arrived, approximately 3 minutes. The Progress Notes dated [DATE] at 7 p.m. documented Staff C Licensed Practical Nurse (LPN) was giving on coming nurse Staff B LPN report at approximately 6:20 p.m. when Staff D came running, stating a resident choked in the dining room. Staff B ran to the dining room while Staff C looked up code status and grabbed vital sign equipment and ran to the dining room. When Staff C entered the dining room a NCNA said Resident #1 started choking. Resident #1 could not talk or cough. His lips were blue and teeth were clenched together. Staff B started thrusts while this nurse called 911 at approximately 6:23 p.m. while running for the crash cart. When Staff C reentered the dining room, Staff B stated she got a small chunk of food to come up. Resident #1 still did not cough and Oxygen (O2) read low at 50%. O2 applied via a mask. The Ambulance arrived and took over. The Progress Notes dated [DATE] at 9:01 p.m. documented at approximately 6:20 p.m. Staff B Licensed Practical Nurse (LPN) was getting shift report at the nursing station when Staff D came and notified her Resident #1 choked in the dining room. Staff B and Staff C ran to the dining area. Staff A was in the dining area helping Resident #1 lean forward and encouraging him to cough. Resident #1 was awake, but unable to speak or cough. The resident noted to have blueish purple lips. Back blows given while the resident sat forward then abdominal thrusts performed by Staff B while Staff C called 911 at 6:23 p.m. and obtained the emergency cart. Resident #1 able to dislodge a piece of bread after multiple thrusts, then resident gasped and had some air movement. Resident #1 had his teeth clenched and had a whistle when breathing with fast shallow respirations. No secretions noted and lips appeared less blue in color. Helped Resident #1 sit forward and encouraged him to cough. He didn't cough, but made a growl noise. Abdominal thrusts done again to see if there were anymore food that could be dislodged, but none did. Resident #1 continued to clench his teeth so unable to look inside of his mouth. Resident #1 remained awake, Oxygen (O2) applied via mask. When pulse oximetry checked it read 51%-60% (normal ,d+[DATE]%). Emergency Medical Technicians (EMTs) arrived and took over and applied their oxygen source. Resident #1 transferred to a cot then left the facility. The ambulance Prehospitalization Care Report dated [DATE] documented Resident #1's primary impression of esophageal obstruction and secondary hypoxemia (low level of O2 in the blood). Resident #1 visibly tried to breathe and cough with no success. He had cyanosis of the face, head, hands, and arms (deep purple dark blue in color) and lethargy. Resident #1 had his jaw clenched closed with his lips open. EMS used a suction device on the patient, one attempt. Unable to see inside due to his jaw being clenched and nothing seen inside the cheeks. The resident's color improved to red in color with some cyanosis present (lighter blue purple) and he had grunting/gasping sounds present and breathing labored. Oxygen increased to 8 liters and his 02 saturation improving. The hospital report dated [DATE] at 6:42 p.m. documented Resident #1 presented per EMS from the facility with complaints of choking at supper. The Heimlich attempted with a small amount of bread expelled. EMS tried the manual vac device with no output retrieved. He struggled to breath with 15 L non-re breather on per EMS with oxygen saturations at 68%. When placed on BiPAP he improved to 86% oxygenation. His family was called and was at the bedside. A physical exam revealed Resident #1 in acute distress. He showed tachypnea (rapid, shallow breathing), accessory muscle usage (the use of muscles other than primary respiratory muscles to assist with breathing), respiratory distress and retractions present. Decreased air movement, wheezing, rhonchi and rales present. Mottling (skin developing a patchy or marbled appearance, often with shades of red, purple or blue) up to the residents umbilicus (navel). Resident #1 unable to voice concerns or needs due to condition. Final diagnoses included: Choking due to food in larynx, Parkinson's disease, Aspiration pneumonia of both lungs due to regurgitated food, Acute respiratory failure with hypoxia, End of life care. Resident #1 remained on BIPAP until all of his family arrived. Time of death: [DATE] at 10:40 p.m. from cardiac arrest due to acute respiratory failure and a choking incident from Parkinson's disease. On [DATE] at 12:25 p.m. Staff A said she sat in the assisted area with Resident #1 and one other resident, Resident #3. Staff A sat by Resident #3 because he needed more assistance. Resident #1 took a bite of his tenderloin sandwich and Staff A heard him make a gasp. She looked over and Resident #1 tried to get a hold of his water and got it up to his mouth, but he really couldn't take any in. Staff A went over and told Resident #1 to cough but he wasn't able to do that so she tried to put her arms around him and do the Heimlich maneuver, but she couldn't get her arms around him and the wheelchair arms. While she did some back blows Staff A said she used her walkie to try to call for help, but she didn't get any response, so she started yelling that she needed help. Staff D from the kitchen came out and asked what she needed, and she told her a resident choked and she needed the nurse. Staff D ran to get her. Staff A thought Resident #1 was getting some air but not a lot. When the nurse came, she took over. Staff A said she was not certified as a nurse aide. She had worked in an assisted living previously, and didn't have to be certified to work in that area. The Administrator was willing to give her a shot at being an aide and they were going to set her up with testing out so she could be a certified aid, but with the holidays it was hard to get a date. She has since then moved and no longer working at the facility. Staff A said she had not been certified in CPR, but she knew how to do it and the Heimlich maneuver, and in fact had performed CPR on someone previously. On [DATE] at 1:35 p.m. Staff C stated she thought the event with Resident #1 went as well as they could have expected. She said the NCNA, Staff A said she had been trying to call over the walkie for help. Staff C was giving the night nurse report when the dietary staff (Staff D) came and told them she needed help. They had heard nothing over the walkie. She said Staff B took off running while she got vital sign equipment and checked code status. She said they did things as quick as they could. She said the only delay was not getting the message over the walkie. She said they never heard any call for help come over the walkie. On [DATE] at 7:45 a.m. Staff B LPN stated as soon as Staff D came running and said they needed help she went to the dining room. And when she got to the dining room she started working with Resident #1. She said the only thing that she could think of that would have gotten them there quicker would be a call over the walkie. She said they never heard any call for help over the walkie. She said Staff A's walkie wasn't working later either because she had call lights on and Staff B told her they had been on too long. Staff A said she didn't have any call lights on. Her walkie had either died or wasn't working because she didn't get her call lights. In a statement signed and dated [DATE], Staff D was in the middle of the dining room picking up dishes and the aide was over in the back helping residents. Staff D heard the aide ask if one of the residents in the assisted dining was ok. Directly after that Staff D heard her yell hey he is choking go get help. Staff D dropped what she was doing and ran down the halls looking for someone. She did not see anyone in the halls, nobody was at the nurse's station either. Staff D ran down a hall and did not see anyone in the rooms, but saw some people at the other station. Staff D told them they had someone choking in the dining room. One of them took off running to the dining room and the other messaged people on the walkie. Staff D did not see or hear the aide using a walkie talkie. Staff D heard her yell to go get help so she did. On [DATE] at 12:45 p.m. the Administrator stated nurse aides could work for up to 4 months if they had the skills and competencies with a Registered Nurse (RN). Staff A had that with the Director of Nursing (DON) at a previous facility. That facility closed and they all transferred to this facility. An application dated [DATE] showed Staff A worked as a Training CNA from ,d+[DATE] to ,d+[DATE] at another facility training to take the CNA test. From ,d+[DATE] to ,d+[DATE] she worked in a restaurant where she served customers food and beverages. Staff A signed the job description for a Certified Nursing Assistant (CNA). A CNA/Nurse Aide-Skills and Competency checklist with a date of hire [DATE] (at previous facility) and had items dated and checked under met objectives. The facility Job Description: Aide in Training (CNA Scholarship) revised [DATE] documented the facility would enroll a candidate directly into a state certified Certified Nursing Assistant (CNA) course, either prior to joining their team, or request a candidate join their team in a non-certified capacity for a predetermined allotted time, prior to their investment in a CNA course and testing. As a non-certified aide in training, they would play a vital role in providing direct resident care and assisting the nursing and medical staff in delivering high quality healthcare services. Essential job functions included performing all duties and responsibilities under the direct supervision of the nursing staff.

Based on observation, and staff and resident interview, the facility failed to maintain an effective pest control program. The facility reported a census of 46 residents. Findings include: On 1/6/24 at 1:50 p.m. Resident #2 sat in her room in her wheelchair. She said the first time she saw a mouse in her room was sometime in November and she got up and went to her top drawer dresser and opened it. There was a mouse sitting on top of her underwear. It startled her and she fell . She said the second time she saw a mouse in her room is when it came in and got into a sticky trap. Then one of the staff members took it out of the room for her. She didn't know what they did with it and she didn't care. She just couldn't stand the idea of having a mouse in her room. On 1/7/25 at 9:40 a.m. Staff E Certified Nursing Assistant (CNA) stated they have had a mouse infestation. Residents and family had brought it up. She said they had to clean out drawers with mouse droppings in them. It didn't seem to be getting any better. On 1/9/25 7:45 a.m. Staff B Licensed Practical Nurse (LPN) stated there were mice, and a staff member saw one the previous day. It had been going on for awhile. On 1/9/25 at 8:08 a.m. Resident #5 stated she had just seen a mouse this past week. She was looking down and saw a mouse. If she had not been looking down she would not have seen it. She thought she had seen something before, but couldn't quite look quick enough. They have put out sticky traps. The Maintenance Man came in Resident #5's room and stated the pest control person had just been there and sent pictures of areas mice may be getting in. He brought some sealant for an area by the register in Resident #5's room. On 1/9/25 at 11:05 a.m. Resident #2's family member stated they have had mice for awhile. Resident #2 had been startled by a mouse in her dresser drawer, and they had to clean the drawers several times due to their droppings, and they chewed on things. He said the pest control person came this week and found a mouse in one of the sticky traps in Resident #2's room. He took it and said he would take care of it. A pest control report dated 1/7/25 documented all conditions were still active and observable during the inspection. Added conditions pertaining to rooms inspected due to increased rodent activity. Mice were reported in 9 rooms. Four rooms had potential points of entry needing sealed. On 1/9/25 at 1:50 p.m. the Administrator confirmed awareness of the mouse infestation and there had been a change in pest control companies.

Based on personnel file review and staff interview the facility failed to ensure sufficient nursing staff with appropriate training to provide supervision during a meal for 1 of 2 staff reviewed (Staff A). The facility reported a census of 46 residents. Findings include: Staff A's personnel file contained an application dated 9/17/24 showing Staff A worked as a Training Certified Nursing Assistant (CNA) from 8/2024 to 9/2024 at another facility, training to take the CNA test. From 7/2021 to 7/2024 Staff A worked in a restaurant where she served customers food and beverages. Staff A signed the job description for a CNA. A CNA/Nurse Aide-Skills and Competency checklist with a date of hire 8/28/24 (at previous facility) had items dated and checked under met objectives dated 8/31 or 9/3/24. The observer signature identified as the Director of Nursing (DON). The personnel file lacked training by a state approved program or enrollment in a CNA class. In a statement dated 12/5/24 Staff A signed on 12/4/24 she was in the dining room at the end of supper feeding another resident (Resident #3) around 6:15 p.m. Resident #1 sat across the table from her. Staff A saw Resident #1 take a bite of his sandwich. He chewed and swallowed it and then made a gasping/muffled whistling noise. He picked up a glass of water and took a drink and kept gasping. No liquid ran out of his mouth. Staff A went behind him and tried to put her arms around him for the Heimlich, but couldn't fit her arms around him. She called for help and the walkie talkie didn't work. Staff A pounded on Resident #1's back to see if something would lodge loose. Staff D Dietary Aide (DA) heard Staff A yelling and ran to get help. Resident #1 never lost consciousness. Resident #1 kept trying to take drinks and Staff A had to take the cup out of his hand as he kept trying. Time lapse between when he started choking and when the nurse's arrived, approximately 3 minutes. On 1/7/25 at 12:45 p.m. the Administrator stated nurse aides could work for up to 4 months if they had the skills and competencies with a Registered Nurse (RN). Staff A had that with the Director of Nursing (DON) at a previous facility. That facility closed and they all transferred to this facility. The facility Job Description: Aide in Training (CNA Scholarship) revised 3/14/24 documented the facility would enroll a candidate directly into a state certified Certified Nursing Assistant (CNA) course, either prior to joining their team, or request a candidate join their team in a non-certified capacity for a predetermined allotted time, prior to their investment in a CNA course and testing. As a non-certified aide in training, they would play a vital role in providing direct resident care and assisting the nursing and medical staff in delivering high quality healthcare services. Essential job functions included performing all duties and responsibilities under the direct supervision of the nursing staff.

Based on personnel file review and staff interview, the facility failed to ensure an individual applying for a position as a nurse aide could prove that he or she had recently successfully completed a training and competency evaluation program, or was a full time employee in a training and competency program approved by the State for 1 of 2 staff reviewed (Staff A). The facility reported a census of 46 residents. Findings include: Staff A's personnel file contained an application dated 9/17/24 showing Staff A worked as a Training CNA from 8/2024 to 9/2024 at another facility, training to take the CNA test. From 7/2021 to 7/2024 she worked in a restaurant where she served customers food and beverages. Staff A signed the job description for a Certified Nursing Assistant (CNA). A CNA/Nurse Aide-Skills and Competency checklist with a date of hire 8/28/24 (at previous facility) had items dated and checked met objectives dated 8/31 or 9/3/24. The observer signature identified as the Director of Nursing (DON). The personnel file lacked training by a state approved program or enrollment in a CNA class. On 1/7/25 at 12:45 p.m. the Administrator stated nurse aides could work for up to 4 months if they had the skills and competencies with a Registered Nurse (RN). Staff A had that with the Director of Nursing (DON) at a previous facility. That facility closed and they all transferred to this facility. The facility Job Description: Aide in Training (CNA Scholarship) revised 3/14/24 documented the facility would enroll a candidate directly into a state certified Certified Nursing Assistant (CNA) course, either prior to joining their team, or request a candidate join their team in a non-certified capacity for a predetermined allotted time, prior to their investment in a CNA course and testing. As a non-certified aide in training, they would play a vital role in providing direct resident care and assisting the nursing and medical staff in delivering high quality healthcare services. Essential job functions included performing all duties and responsibilities under the direct supervision of the nursing staff.

Based on record review and staff interview, the facility failed maintain a system of drug reconciliation to identify disposition of a missing pill for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 46 residents. Findings include: The Progress Notes dated 9/27/24 at 8 a.m. documented staff reported Resident #4 had a missing Methadone 1/2 tab to equal 2.5 mg. A Self Report documented on 9/27/24 at approximately 6:45 a.m. the Administrator in Training (AIT) received notification from Staff F Registered Nurse (RN) that during narcotic count they noted a discrepancy in Methadone count for Resident #4 of a 2.5 mg tablet of Methadone missing. At Approximately 6 a.m. oncoming Certified Medication Assistant (CMA), Staff G began count of the narcotics in one of the carts and noticed the incorrect count of Methadone for Resident #4. There were only 15 tablets of Methadone, but should have been 16. As of 10 p.m. on 9/26/24 all of the narcotic count was correct and signed off by the off going CMA and oncoming Staff H Licensed Practical Nurse (LPN). A narcotic count completed by the Director of Nursing (DON) and the AlT on 9/27/24 at approximately 5 p.m. revealed all other controlled substances were accounted for per nursing documentation. The internal investigation determined the missing medication could not be found. The medication was a scheduled narcotic to be given at approximately 8 a.m. and 8 p.m. per the electronic health record. At 10 p.m. all controlled substances were accounted for and at 6 a.m. 1 pill missing during count. The overnight nurse Staff H, per her statement, indicated she did not know where the medication went and she was the only one with access to the medication cart during that time. Staff H sent her statement via email. She wrote she arrived to her scheduled shift at 10 p.m. They had one nurse and two CMA's working from both med carts passing meds. The nurse and the CMA mentioned it had been a really busy, chaotic night. Staff H asked how she could help and the nurse and CMA instructed her in a few things they still needed done and Staff H did those tasks. When it came time to count narcotics Staff I CMA and Staff H counted one of the two carts together. All of the narcotics were removed from the drawers and set on the cart. Staff I had the narcotic count sheet and Staff H had the narcotics. Staff H did not visualize the narcotic count sheet as they counted. Staff H visualized the narcotics and counted them in the cassettes and relayed the number to Staff I and she then confirmed the number was correct. Staff H then counted the other cart with the nurse. It was med change over and Staff H was very busy changing out the medications and it took a good portion of her shift. As Staff H finished that around 4:30 a.m. she then signed off the narcotic check book, trying to be proactive and get things ready for the on coming shift. Around 5:30 a.m. or so one of the CMA's came in and took the keys for one of the carts and Staff H passed early a.m. medications. Another CMA came on shift and counted the cart with the other CMA that came in at 5:30. The CMA then stated the count was off for a medication. A Staff Investigation Questionnaire dated 9/27/24 documented the Director of Nursing investigated the missing medication and a CMA did not follow facility policy to count with off going staff. She counted by herself and found medication missing. The Controlled Drug Count Record for September 2024 showed missing signatures/initials on 9/1, 6, 7, 8, 13, 16, and 20/24. Education given to nurses and CMAs on the controlled substance procedure on 9/27/24 and 9/30/32 by the AlT. Staff H taken off the schedule pending investigation. The facility Controlled Substance updated 10/29/22 identified the purpose included to complete a physical inventory of narcotics at each change of shift by 2 nurses to identify discrepancies and need for reconciliation and accountability, to assure controlled drugs were handled, stored and disposed of properly, and to assure proper record keeping for controlled drugs. The procedure for controlled substance count included one authorized person was responsible for narcotics utilization every shift Going off duty and coming on duty, authorized persons must count and validate accuracy of narcotics supply for every resident at the change of every shift. Narcotic records are reconciled by a physical count of the remaining narcotic supply at the change of each shift by the oncoming and outgoing licensed nurse/designee. After the supply is counted and justified each nurse must record the date and his/her signature to verify the count was correct. The nurse going off duty surrenders the narcotics key to the oncoming nurse after the narcotics count was reconciled.

Based on clinical record review and staff interviews, the facility failed to assess and provide interventions necessary for the care and services, to maintain the residents' highest practical physical well- being for 1 of 3 residents reviewed (Resident #3). The facility failed to assess and document fall and neurological assessments after an unwitnessed fall for Resident #3. The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) for Resident #3 dated 2/28/24 documented a Brief Interview for Mental Status (BIMS) score of 09, indicating moderately impaired cognition. The MDS identified Resident #3 required partial/moderate assistance with bed mobility, and substantial/maximal assistance with chair/bed to chair transfers. Resident #3 ' s MDS included diagnoses of coronary artery disease, heart failure (heart does not pump blood well), Hypertension (high blood pressure), and renal (kidney) disease. An Incident Report (IR) dated 5/10/24 at 6:30 AM revealed Resident #3 had an unwitnessed fall in her room. The IR documented Resident #3 was sitting on the floor in front of the recliner with legs bent in front of her. Resident #3 stated, I was just sitting down on the floor, I did not fall and I ' m not hurt either. The IR documented Resident #3 had no injuries noted and a neurological check was initiated. Resident #3's clinical record lacked documentation related to her fall on 5/10/24 including follow up falls assessments and neurological checks. A facility electronic form titled Neurological Assessment directed staff to complete neurological assessments every 15 minutes x4, every 30 minutes x2, every hour x2, every 4 hours x3 and every 8 hour x1. On 5/30/24 at 8:20 AM, the Director of Nursing (DON) reported a late entry was made in the Progress Notes on 5/29/24 for Resident #3's fall that occurred on 5/10/24. The DON reported she would expect a fall to be documented in the progress notes. The DON stated she would expect neurological assessments to be completed on a neurological assessment form with an unwitnessed fall or when a resident hits their head. On 5/30/24 at 11:27 AM, The DON reported the facility does not have a neurological policy and the facility follows standards of care. The DON reported she would expect staff to complete neurological assessments according to the assessment form. On 5/30/24 at 11:45 AM, the DON reported Resident #3's fall on 5/10/24 was not added to the hot charting which resulted in the followup fall and neurological assessments not being completed.

Based on clinical record reviews, wound center record review and staff interviews the facility failed to assure that a resident with a pressure ulcer received treatment and services, consistent with professional standards of practice, to promote healing of a stage three pressure ulcer for 1 of 1 resident reviewed (Resident #2). The facility reported a census of 34 residents. Finding include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, with slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III is full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) which may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound. Other staging consideration include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent skin. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #2 ' s Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 08, indicating moderately impaired cognition. The MDS identified Resident #2 required extensive assistance of two persons with bed mobility, transfers and toilet use. The MDS identified walking did not occur. The MDS included diagnoses of heart failure (heart doesn ' t pump blood), hypertension, anemia, coronary artery disease, and pneumonia. The MDS documented Resident #2 was at risk for developing pressure ulcers. Resident ' s 2 ' s Care Plan revised 12/19/22 contained the following information: a. Resident #2 could not transfer independently due to abnormal gait and mobility. The care plan directed that Resident #2 required assistance of one person, gait belt and front forward walker for transfers and ambulation in the room. Resident #2 used a wheelchair for longer distances. b. Resident #2 was at risk for skin impairment related to self care deficit. The care plan documented Resident #2 had actual skin impairment due to dry areas to bilateral lower extremities requiring treatment. The care plan directed staff to: -Dietician to evaluate resident nutrition PRN (as needed). -Float heels using pillows or off loading boots PRN. -Keep nails trimmed and filed, encourage not to scratch PRN. -Pressure relieving devices to chair and bed at all times. -Provide peri care after each incontinent episode. -Report any denuded (loss of skin due to moisture) or discolored areas PRN. - Teach about risk factors for development of pressure ulcers PRN. - Try to identify skin allergies and avoid them; process of elimination PRN. -Use caution during transfers and bed mobility to prevent striking extremities against sharp or hard surfaces. -Utilize turn sheets PRN. -Weekly and PRN skin monitoring by a professional nurse. The Braden Scale assessments (tool used to evaluate risk of development of a pressure ulcer) documented a score of 10-12 indicated that the resident had a high risk for pressure sore development, 13-14 meant the resident had a moderate risk, and 15-18 meant the resident had a risk for pressure ulcer development. The review of the Braden Scale assessments completed for Resident #2 documented scores on the following dates: 12/18/23= 17 2/14/23=15 A Progress Note titled Skin/Wound Note dated 2/6/23 at 3:36 AM documented an aide reported to the nurse that Resident #2 had a blister on the right heel. The note documented the blister was intact without drainage and measured 0.75 Length x 0.5 width. The note documented the area was reddened and Resident #2 denied pain. According to the note, it appeared the area to be from back of a shoe rubbing on Resident #2 ' s heel. The Clinical Record lacked documentation from 2/6/23 to 2/9/23 regarding an intervention or treatment for the blister to the right heel, family notification and Physician notification. The facility was not able to provide an incident report or a skin condition record for the blister area to the right heel. A facility form titled Physician Visit/Communication Form dated 2/9/23 at 10:45 AM documented Resident #2 ' s Physician was notified of the blister to the right heel. The form documented the area blanched when touched and a boot was applied to keep the area from developing a pressure area. The Physician acknowledged on the form by documenting ok and directed to see wound care or podiatry the following week. A Progress Note dated 2/10/23 at 3:04 PM documented Resident #2 was admitted to the hospital. A Physician Transfer Order Report dated 2/14/23 revealed Resident #2 was hospitalized for pneumonia to both lungs. A Progress Note dated 2/14/23 at 1:35 PM documented Resident #2 returned from the hospital. The admission Progress Note lacked documentation, assessment or intervention for the right heel. A facility form titled Physician Visit/Communication Form dated 2/15/23 at 1:21 PM documented upon readmit, Resident #2 had an abrasion to back, and slightly above right heel that measured 2.1 cm (centimeters) x 2.3 cm with scant amount of serous (clear to yellow) drainage. The note documented a mepilex border dressing (foam dressing) was applied. The communication form requested an order for the mepilex dressing and to change the dressing every 3 days and PRN. The communication form was signed by a Physician and dated on 2/15/23. A Progress Note dated 2/15/23 at 4:53 PM documented Resident #2 had an open area to the back of the right heel that measured 2.1 cm x 2.3 cm. The note documented an order was received to apply mepliex border dressing every 3 days and PRN. Resident #2 ' s daughter updated. The Clinical Record revealed daily skilled assessments completed in the Progress Notes that documented no changes in skin integrity on 2/16, 2/17, 2/18, 2/19, 2/21, 2/23, 2/24, 2/25, 2/26, 2/28, 3/1, 3/2, 3/3 and 3/5. The daily notes lacked a specific assessment related to the right heel ulcer regarding measurements of the wound and characteristics of the wound such as odor, drainage (type/color), wound bed (slough/eschar), surrounding skin, pain, and signs and symptoms of infection. A Progress Note dated 2/18/23 at 11:34 AM documented Resident #2 complained of the right heel hurting. The note documented a mepliex dressing was applied and right foot elevated. A Progress Note dated 2/26/23 at 4:10 PM documented Resident #2 ' s right heel did not appear to be getting better. The note documented the right heel had some bleeding, leakage and appeared to be breaking down further. The note documented the area was cleansed, vaseline gauze, some regular gauze and a tegaderm (transparent/film dressing) applied to the area to help give more cushion. The note documented staff would continue to monitor the area. The note lacked documentation regarding physician or family notification. The Clinical Record lacked a Physician order for the dressing that was applied to Resident #2 ' s right heel on 2/26/23. A facility form titled Physician Visit/Communication form dated 2/27/23 at 4:32 PM documented Resident #2 had a wound to the right heel that was initially presented as a blister. The note documented the wound had worsened with the mepilex border dressing and the daughter had requested Resident #2 to be seen at the wound clinic. The Physician's response was OK. A Progress Note dated 2/27/23 at 7:11 PM documented a fax was received from the Physician okaying Resident #2 to be seen at the wound clinic for a worsening wound to the right heel. The Clinical Record lacked any additional skin interventions implemented for the right heel when the area declined on 2/26/23 until 3/7/23 when Resident #2 was evaluated in the wound center. A Progress Note dated 3/4/23 at 3:00 PM documented Resident #2 reported his heel was sore and he was trying to keep pressure off of it. The note documented the dressing on his heel was changed using mepilex with minimal drainage noted. The note documented wound bed had improved since 2/27/23. A Progress Note dated 3/5/23 at 12:45 PM documented Resident #2 was watching television in his reclining chair. The note documented his shoes were taken off so his heel had less friction. A Progress Note dated 3/7/23 at 3:59 PM documented Resident #2 went to a wound care appointment. The note documented Resident #2 returned with new orders to cleanse the wound with normal saline, pat dry, apply silvercel to the wound and cover with a foam dressing 3 times per week. Resident #2 to return for a follow up appointment on 3/14/23 at 10:30 AM. Resident #2 to continue to wear a heel protector and keep weight off the affected area/limb at all times. Resident #2 ' s daughter updated. A Visit Discharge Instruction Details form dated 3/7/23 directed the facility to keep weight off the affected area/limb at all times and apply heel protector to the right foot. The right heel was diagnosed as a chronic stage 3 pressure ulcer. A facility form titled Physical Therapy Treatment Note documented on 3/13/23 Staff F, Physical Therapy assistant (PTA) was approached by staff regarding making Resident #2 assistance of one person with transfers. The note documented Staff F assisted staff and Resident #2 with a transfer from the recliner with moderate assistance of one person with time allowed. The note documented Resident #2 ambulated 79 feet with front wheeled walker and moderate assistance of one person and a second person to assist with wheelchair following. The note further documented Staff F did make Resident #2 assistance of one person with pivot transfer and when ambulating assistance of two persons as needed. A Progress Note titled therapy note dated 3/13/23 at 7:01 PM documented Resident #2 required assistance of one staff member with gait belt and front forward walker with pivot transfers only and assistance of two staff members for ambulation. A Progress note dated 3/14/23 at 11:54 AM documented Resident #2 returned from the wound center. Resident #2 to return on 3/21/23 at 10:30 AM. A Visit Discharge Instruction Details form dated 3/14/23 directed the facility to keep weight off the affected area/limb at all times and apply heel protector to the right foot. The discharge instructions directed staff to cleanse the wound with normal saline, pat dry, apply silvercel to the wound then cover with foam dressing 3 times per week. A facility form titled Physical Therapy Treatment Note documented on 3/14/23 Staff F, PTA was going to walk with Resident #2 with staff after appointment, but Resident #2 wanted to wait until after lunch. The note documented during lunch, nursing staff received paperwork from the wound clinic and Resident #2 status change to non weight bearing on right heel due to wound not healing. The note further documented that Staff F assisted nursing with explaining situation and Resident #2 stated he felt so blue now. A Progress Note dated 3/21/23 at 12:50 PM documented Resident return from wound center and dressing change completed at the clinic. The note documented the facility received new treatment orders to apply xeroform (non-adherent dressing) 3 times per week and cover with foam dressing. Follow up appointment on 3/28/23 at 10:30 AM A Progress Note titled Social Services dated 3/14/23 at 3:55 PM documented Resident #2 to be a full body lift with assistance of two staff members due to non-weight bearing status on the right heel. A Visit Discharge Instruction Details form dated 3/21/23 directed the facility to keep weight off the affected area/limb at all times and apply heel protector to the right foot. The discharge instructions directed staff to cleanse the wound with normal saline, pat dry, apply xeroform to the wound then cover with foam dressing 3 times per week. A Progress Note dated 3/25/23 at 1:59 PM documented that the dressing change was completed on the right heel. No dressing was present initially as the dressing came off frequently. The note documented the wound appeared to be closed but still needed some protection. A Progress Note dated 3/28/23 at 12:45 PM documented Resident #2 's dressing change was held due to the dressing change to be done at the wound clinic. The clinical record lacked documentation that Resident #2 went to the wound center for a follow up appointment on 3/28/23. A Progress Note dated 4/4/23 at 11:17 AM documented Resident #2 returned from the wound center with new orders. The note documented the following new orders: 1- May shower, cleanse with soap and water, pat dry. 2- Continue to apply foam pad dressing for 2 weeks and then discontinue. 3- No ambulation restrictions related to wound care. May wear shoes at all times. Should wear a heel protector when in bed. May return to ambulating with a walker. 4- Treatment completed at wound center and does not need to return. Resident 2 's Non Pressure Skin Condition records revealed the following information: -2/6/23: no skin condition record completed for the blister to the right heel. -2/9/23: Blister area to the right heel that measured (length x Width x Depth) 2cm x 2.5cm x 0cm. Blister intact with no drainage. Surrounding skin was reddened. Boot applied to the right heel and Physician notified. -2/14/23: Abrasion above right heel that measured 2.1cm x 2.3cm, partial thickness with scant amount of serous drainage. Wound bed was dark pink/red tissue. Surrounding skin was normal. Description documented mepilex border dressing, change every 3 days and as needed. -3/3/23: Blister looking area to right heel, area is open and slightly painful. No measurements documented. No drainage, wound bed normal for skin and surrounding skin normal. Area looked better. -3/11/23: Open area to right heel that measured 2cm x 2cm. Area improving. No redness or drainage noted. -3/26/23: Wound to right heel, initially a blister on back of heel that had deteriorated to an open area. Assessment documented wound was closed, to continue foam dressing and using foot boot to keep pressure off of the area to continue to let the area heal. The clinical record lacked wound evaluations/assessments completed for the following weeks: February 21st February 28th- On 2/26 a partial skin assessment was completed in the Progress Note that documented the wound had declined. A non-pressure skin report was not completed on 2/26 or 2/28. A non-pressure skin report was partially completed on 3/3 with no wound measurements documented. March 7th- Resident #2 went to the wound center. The facility did not complete an assessment. The facility completed measurements on 3/11. March 14th- Resident # 2 went to the wound center. The facility did not complete an assessment. March 21st- Resident #2 went to the wound center. The facility did not complete an assessment. The clinical record revealed the facility continued to document periodically on a non- pressure skin condition record even though the area to the right heel was diagnosed as a stage 3 pressure ulcer on 3/7/23. The clinical record lacked a dietician assessment and that nutritional interventions were reviewed related to the right heel pressure ulcer. Review of Resident #2' s wound center notes revealed the following information: An initial evaluation on 3/7/23 documented Resident #2 had a chronic stage 3 pressure injury/ulcer to the right heel that measured 1.5cm length x 1cm width x 0.2cm depth. Adipose (fat) tissue was exposed. No tunneling, sinus tract or undermining had been noted. There was a moderate amount of drainage. The wound bed had slough (dead tissue) present. The periwound skin color, texture, moisture and temperature was normal and without signs and symptoms of infection. Local Pulse was normal. A skin/subcutaneous tissue level excisional/surgical debridement was performed by the Physician. Dermis, epidermis, and subcutaneous tissue were removed along with devitalized tissue: biofilm and slough. A minimal amount of bleeding was controlled with pressure. Post debridement measurements 1.7cm x 1.1cm x 0.2cm. Wound Center appointment on 3/14/23 documented chronic stage 3 pressure injury/ulcer to the right heel that measured 1.0cm x 0.8cm x 0.2cm. Adipose (fat) tissue was exposed. No tunneling, sinus tract or undermining had been noted. There was a moderate amount of drainage. The wound bed had slough (dead tissue) present. The periwound skin color, texture, moisture and temperature was normal and without signs and symptoms of infection. Local Pulse was normal. A non-selective mechanical debridement was performed. Non-viable tissue was removed. Post debridement measurements 1.0cm x 0.8cm x 0.2cm. Wound Center appointment on 3/21/23 documented chronic stage 3 pressure injury/ulcer to the right heel that measured 0.9cm x 0.3cm x 0.1cm. Adipose (fat) tissue was exposed. No tunneling, sinus tract or undermining had been noted. There was a small amount of drainage. The wound bed had slough (dead tissue) present. The periwound skin color, texture, moisture and temperature was normal and without signs and symptoms of infection. Local Pulse was normal. A skin/subcutaneous tissue level excisional/surgical debridement was performed by the Physician. Dermis, epidermis, and subcutaneous tissue were removed along with devitalized tissue: biofilm and slough. A minimal amount of bleeding was controlled with pressure. Post debridement measurements 1.0cm x 0.3cm x 0.2cm. Wound Center appointment on 4/4/23 documented the chronic stage 3 pressure injury/ulcer had healed with 0cm x 0cm x 0cm. Resident #2 ' s wound had healed, continue with foam protector for 2 weeks, no restrictions, return as needed. On 9/11/23 at 12:00 PM, the Director of Nursing (DON) reported that her expectation was for a wound to be assessed each week. She acknowledged and verified Resident #2 did not have consistent weekly skin assessments for his pressure area to the right heel. She also acknowledged and verified Resident #2 did not have a dietician assessment after the pressure ulcer developed. The DON verified she could not locate family notification or Dr notification regarding the pressure ulcer on 2-6-23. The DON reported a heel protector was added to the right foot on 2-7-23 according to her QAPI notes which is not part of the clinical record. The DON stated the boot was already on the care plan as PRN so the facility did not change any interventions on the care plan. On 9/12/23 at 12:00PM, the Administrator reported the facility did not have a pressure ulcer policy. The Administrator reported for skins, the facility follows regulations and best practices. On 9/12/23 at 3:56 PM, the Hospital Health Information reported Resident #2 was not seen at the wound clinic on 3/28. On 9/12/23 at 4:39 PM, Staff G, Registered Nurse (RN) reported she recalled Resident #2 had a blister to his right heel due to shoes being too tight. Staff G stated the staff were trying to keep shoes off of Resident #2 and cushion the area. Staff G stated it was difficult as Resident #2 would wheel himself around in his wheelchair and put weight on the wound. Staff G stated Resident #2 did not have a good memory so it took awhile for the area to heal. Staff G stated a family friend was present in the room on 2/26/23 when she applied the dressing to the right heel. Staff G stated she was concerned about how the wound looked and so was the friend. Staff G stated she did not recall if she had faxed the Dr or not regarding the decline in the wound. On 9/12/23 at 6:23 PM, the Administrator acknowledged the facility did not have an incident report for the blister on 2/6/23.

Based on observation, clinical record review, resident and staff interview, a physician interview and facility policy review the facility failed to provide the necessary assessment and interventions for a resident who started to present with respiratory distress, a change in skin color (cyanosis), and a loss of consciousness. The resident passed away at the facility within 50 minutes of the first coughing episode on [DATE]. (Resident #1) This failure put the facility into an Immediate Jeopardy to the health, safety, and security of the resident. The facility identified a census of 32 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of February 21, 2023 at approximately 4:45 P.M. The Facility Staff removed the Immediate Jeopardy on [DATE] through the following actions: a. All staff education on acute condition changes-clinical protocols The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 32 residents. There were 3 residents included in the sample size. Findings Include: Resident #1 ' s Minimum Data Set (MDS) assessment dated ,d+[DATE]/.23 included diagnoses of disorientation, pharyngeal phase dysphagia, oropharyngeal phase dysphagia and dementia. The MDS identified that Resident #1 had short and long-term memory deficits with severely impaired cognitive skills. The MDS indicated that Resident #1 required extensive assistance from staff with eating. The assessment failed to address the resident's swallowing difficulties. A Care Plan included the following focus area and approaches: Problem: At risk for potential impaired nutritional status due to dementia/confusion. Edema bilateral lower legs. Created [DATE] Goal Resident #1 will have adequate intake to avoid significant weight loss Target date: [DATE] Interventions 1. Diet as ordered. (initiated 11.29.22) 2. Dine in the assisted dining room. Allow adequate time to ingest meals and offer assistance as needed. (initiated 5.12.21) 3. Encourage Resident #1 to drink if pocketing her food. (initiated 10.13.22) 4. All staff informed of special dietary and safety needs (initiated 1.31.18) Problem: Potential for complications related to diabetes, date initiated: [DATE] Goal: Blood sugars will be within normal range through the next review date. Target date [DATE]. Intervention General, liberal, pureed diet with thin liquids, date initiated [DATE]. An undated Clinical Resident Profile form included the following staff directives: Comfort Measures Only - Administration of medications by any route, positioning, wound care and other measures to relieve pain and suffering. Utilization of oxygen, suction, and manual treatment of airway obstruction as needed for comfort. The patient preferred no transfer to hospital for life-sustaining treatment but to transfer if comfort needs could not have been met at the current location. A Progress Notes entry dated [DATE] at 6:16 p.m. included the following documentation: At 5:20 p.m. the staff alerted the Registered Nurse (RN) that Resident #1 had been coughing with difficulty expecting any food and/or phlegm. The staff encouraged Resident #1 to cough and could hear phlegm as she coughed. The staff stayed with Resident #1 and alerted the RN when her color changed to blue. The staff took the unresponsive resident to her room via a wheelchair. When the staff called the resident's name she opened her eyes wide in response. Two (2) staff members assisted her into bed as she could stand at first. The staff positioned Resident #1 in bed with her head up. Resident #1 continued to experience a weak cough with little result. The RN phoned Resident #1 ' s family, who arrived to see Resident #1 who passed away at 6:10 p.m. On [DATE] at 9:30 a.m. observed the hospital right next door to the facility with a driveway to each entity. During an interview on [DATE] at 12:51 p.m. Staff A, RN, confirmed that she worked at the facility for [AGE] years. Staff A indicated on [DATE] at 5 ish in the afternoon, she had been at the nurse's desk and then went to the assisted dining room. While in there she saw two CNA's at a table informed her Resident #1 exhibited a coughing spell. Staff A reported that she approached Resident #1, stood on her left side, bent over, and looked at Resident #1 as she returned. Staff A reported that she directed Resident #1 to cough more as she followed the request. Resident #1's cough seemed to ease up a bit, meaning not coughing as much so Staff A returned to the nurse's desk. As she spoke on the telephone she observed the two CNA's as they propelled Resident #1 by the nurse's station in a wheelchair due to the continued coughing in the dining room. Staff A explained that she hung up the phone and followed them right down the hall. Staff A and one of the CNA's transferred Resident #1 out of her wheelchair and into bed as she continued to cough. Staff A observed a piece of a fry on the resident's tongue so she used a washcloth and removed the fry. Staff A described the fry as ,d+[DATE] centimeters (cm) long. At that time Staff A added that she failed to look further into Resident #1's mouth because she had already removed the fry and the breath sounds the resident exhibited sounded like phlegm. Staff A confirmed that through the entire process Resident #1 experienced audible phlegm in the throat region. Resident #1 coughed some clear phlegm up but not in big chunks. Staff A confirmed that the entire time from when the staff propelled Resident #1 by the nurse's station and into her room, she appeared blue (cyanotic) around the lips and fingertips. Once positioned on the edge of the bed, Resident #1 continued to cough but exhibited air exchange throughout the process to that point. Staff A indicated that they laid Resident #1 in bed with the head of the bed elevated around ,d+[DATE] degrees as she still tried to cough but with decreased oomph power to move the phlegm. Staff A left the room and the two CNA's stayed with Resident #1. Staff A called Resident #1's family and updated them. The family stated they would be right out and arrived within ,d+[DATE] minutes at the facility. Staff A added that she was not in the room when Resident #1 passed away, however, she had been present when the family arrived. At that point the staff member told the family she planned to return to the nurse's station to give someone insulin. Staff A told the family to call her if things changed and she did not get back to Resident #1 ' s room. Staff A explained that it all happened so fast. During the interview, Staff A confirmed the following: 1. Resident #1 was known to cough frequently. 2. She had no knowledge as to why she did not look further into Resident #1's mouth. Staff A explained that she knew she still coughed. 3. Staff A failed to suction Resident #1, even though phlegm had been audible in her throat because Resident #1 requested comfort measures. 4. Staff A did not know why she failed to apply oxygen, rather she stated it happened to darn fast. 5. Staff A left Resident #1's room to call her family and returned in approximately ,d+[DATE] minutes. When she returned to the room Resident #1 appeared unresponsive, Staff A could hear gurgling, Resident #1 appeared not as cyanotic, she could hear phlegm but not as much and Resident #1 exchanged air. 6. Staff A confirmed that she failed to assess Resident #1's vital signs such as her blood pressure, pulse, respirations, oxygen saturation rate, temperature, and lung sounds. When asked if she would have done anything differently, the staff member said I would not have changed anything I did. The staff member stated suctioning never came to her mind, the oxygen placement did when the family got there but the resident appeared less blue. It just happened so fast. During an interview [DATE] at 11:15 a.m. the Director of Nursing (DON) confirmed the facility had a crash cart located in the nurse's supply room which included a suction machine, an oxygen e-tank and all the supplies required for usage, such as tubing. The DON indicated that when she spoke with Staff A the nurse felt she removed all of the food from the resident's mouth so she identified the Heimlich maneuver as not necessary. During an interview [DATE] at 1:42 p.m. the DON felt the staff focused on the resident's DNR (do not resuscitate) which did not apply until a resident did not have a pulse. The facility conducted a staff meeting following the incident and reviewed suctioning, oxygen (O2), vitals expectations, and the proper usage of the crash cart as a means to trigger staff thought processes. The DON agreed that Staff A should have assessed vitals, applied oxygen, and suctioned the resident. During an interview [DATE] at a time unknown, Staff B, Health Information Manager, confirmed she worked on [DATE] at the time of the incident she processed a new resident admission in her office. She heard the hubbub of what went on and heard Staff C, CNA, as she encouraged Resident #1 to cough it up as her voice became more anxious. When Staff B arrived Staff C stood to one side of Resident #1 as Staff D, CNA, stood on the other side. Staff C stated they got everything out and that Resident #1 just had a phlegm in her mouth. Staff B pushed Resident #1 forward and patted her back. Staff B noticed that Resident #1 turned colors further described as purplish. Staff B requested Staff D go and get Staff A. Staff A told Staff D to take Resident #1 to her room. Staff D brought a wheelchair and Staff B assisted Staff C with the transfer to the wheelchair but at that point the resident drooled out of her mouth, appeared droopy on her right side, became unresponsive, appearing to have a fixed look on her face and unable to move easily due to stiffness. Upon completion of the transfer process Staff B returned to her office. Staff B confirmed that she participated in in-services and in fact she conducted the in-service in February 2022 at which time they reviewed the location of the crash cart and AED during a visual tour and how to use it. During an interview on [DATE] at 2:06 p.m. Resident #1 ' s family member confirmed that Staff A called him to update him on her condition. Staff A explained that Resident #1 ate supper and struggled to breath. Staff A explained that the family needed to come to the facility right away and/or the staff member would have called with an update later. The family left right away. As they arrived Staff A and two aides stayed with Resident #1. Resident #1 ' s Family Member described Resident #1 as unresponsive and struggled to breath as the family heard phlegm in her mouth which bubbled out of the resident's mouth however Resident #1 did not appear cyanotic (blue in color). Due to Staff D being out of the country, no interview was conducted. During an interview [DATE] at 2:17 p.m. Staff E, CNA, stated that on [DATE] she served Resident #1 her meal which consisted of cheeseburger soup and french fries. Staff E confirmed that Resident #1 could feed herself but that she required supervision. After she served the food, the nurse and medication aide said she just needed to cough up the phlegm so the staff watched Resident #1. Resident #1 probably coughed for five minutes as she tried to get the phlegm up but she kept swallowing it. Staff D went to get a glove on her hand and a kleenex in her hand as she encouraged Resident #1 to spit it out. Resident #1 stopped coughing and her lips turned a bluish, purple color as her face turned pale and gray. Staff D told Staff C to get Staff A because Resident #1 stopped coughing. Staff C returned with Staff B, a wheelchair, and scooped up Resident #1 taking her to her bedroom. From that time until Staff A directed her to get a gown she did know what happened. Staff E went to get a gown and went into Resident #1's room where she observed her in bed with the head of the bed all the way up but she looked deceased . Staff E confirmed that no one performed the Heimlich maneuver, suctioning, or applied oxygen to Resident #1. Staff E indicated that she did not know the facility had a suction machine or anything, as she did not get educated on the suction machine or crash cart nor did she know the location of the crash cart. During an interview on [DATE] at 3:20 p.m. the Physical Therapy Assistant (PTA) indicated that she did not know the location of the crash cart. During an interview on [DATE] at 3:36 p.m. the family member indicated Staff A never offered to send the resident to the hospital either on the telephone or when they arrived at the facility. During an interview on [DATE] at 3:49 p.m. the family member indicated they probably would not have sent the resident to the hospital. According to an email dated [DATE] at 3:59 p.m. the DON described the distance from the facility's door to the hospital's emergency room as 600 feet. According to an email dated [DATE] at 4:04 p.m. the DON described the distance from the facility's front door to the clinic entrance as 335 feet. During an interview on [DATE] at 11:42 a.m. Resident #1's physician indicated it would have been hard to tell if the outcome would have been different had the nurse appropriately intervened. The physician offered that the family refused a pureed diet as suggested by Speech Therapy. Without a direct observation of what actually transpired he knew that if she choked with complete airway obstruction, she would have passed out in ,d+[DATE] minutes so that led him to believe the problem had been a build up of phlegm not choking. The physician described oxygen administration and suctioning as overrated unless a resident presented foaming at the mouth then suctioning would have been appropriate. The physician stated he failed to agree with government agencies and he described them, including the Department of Inspections and Appeals as entities that always say coulda, woulda and shoulda. The physician described himself over how nursing facilities have been treated since the pandemic and described it as a shit show. The physician hoped the nurse terminated had not been a good nurse because they are hard to find. Review of the facilities Oronasopharyngeal Suctioning policy revised [DATE] included the following documentation under the tab labeled Introduction: Oronasophaeyngeal suctioning removes secretions from the pharynx with a suction catheter inserted through the mouth or nostril. Used to maintain a patent airway, this procedure helped patients who could not effectively clear the airway through coughing and expectoration, such as unconscious or severely debilitated patients.

Based on observations, clinical record reviews, staff, and provider clinic staff interviews the facility failed to provide an accurate and timely assessment with an intervention after a fall for 1 of 3 residents reviewed (Resident #11). On 5/18/22 Resident #11 reported that she fell on [DATE] around 10:15 PM and that the nurse helped her up. The clinical record lacked an assessment, provider notification, or description of the fall until 5/18/22. After learning of Resident #11's fall and complaint of ankle pain, the facility notified the provider via fax. The interviews determined that the provider did not typically work in the office on that day of the week. The facility waited until 5/19/22 before receiving a response for additional testing at the office, which determined an ankle fracture. The facility reported a census of 28 residents. Findings include: Resident #11's Minimum Data Set (MDS) assessment dated [DATE] listed her as independent with all activities of daily living (ADLs). A Significant Change MDS assessment dated [DATE] identified that she required extensive assistance from one person for bed mobility and transfers while requiring total assistance from staff for locomotion. Resident #11's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed that she required extensive assistance from one person for transfers and walking. On 2/6/23 at 12:57 PM observed Resident #11 dressed in her wheelchair. She reported that she broke her ankle a while back when her knees gave out and said that she went down to the floor. She explained that she walked independently before the fall but she couldn't remember the details of the fall. The Care Plan Focus dated 9/22/21 indicated that Resident #11 had a self-care performance deficit related to weakness. In addition, Resident #11 had the potential for falls related to impaired balance and advanced age. The Incident Audit Report for the incident dated 5/17/22 at 10:15 PM created by Staff I, Licensed Practical Nurse (LPN) on 5/19/22 at 1:15 PM indicated that Staff I took a statement from the Staff J present at the time of the fall. The nurse stated via telephone that they answered Resident #11's call light per her usual routine of requiring assistance with post-toileting perineal (peri) care. The nurse reported that she walked Resident #11 towards her bed from the bathroom. At approximately the middle of Resident #11's bedroom, her knees became weak and the nurse lowered her to the floor. Resident #11 had no pain at the time and could pull herself to a standing position using a walker with the nurse holding the gait belt. The nurse then assisted Resident #11 to the wheelchair then over to her bed where she pivot (the person bears at least some weight on one or both legs and spins to move their bottom from one surface to another) transfers her to bed. The Un-witnessed Incident Report dated 5/17/22 at 10:15 PM prepared by Staff I indicated that no immediate action occurred at the time of the fall. Resident #11 went to the clinic and received x-rays of her right ankle on 5/19/22. The Witness Statements included the following a. Staff G, Registered Nurse (RN), reported that Staff J stated in the morning report of 5/18/22 reported Resident #11 as being weak and utilizing a wheelchair. In the evening report Staff J reported that Resident #11 did not fall, that he kept her from falling. b. Staff J, RN, on 5/19/22 reported via telephone call that he answered Resident #11's call light per her usual routine of needing assistance with peri care post toileting. Staff J assisted Resident #11 with her care and walked with her towards the bed from the bathroom. In approximately the middle of Resident #11's bedroom her knees became weak so Staff J lowered her to the floor. Resident #11 reported no pain at that time and could pull herself to a standing position using a walker with Staff J holding the gait belt. Staff J then assisted Resident #11 to the wheelchair to the bed and pivot transferred her to bed. Resident #11 continued to not have pain with no visible injuries noted. c. Staff K, Certified Nurse Aide (CNA), on 5/19/22 explained that Resident #11's call light sounded after 11:00 PM. Staff J came from Resident #11's room for a gait belt stating her knees were weak. Later Staff J instructed the staff that Resident #11 should use a call light due to her knees giving out. Staff K stated that she answered one call light for Resident #11 after Staff J directed them to use a gait belt where she assisted her with the remote to her T.V. Staff K reinforced education to Resident #11 to use a call light for the rest of the night shift. Resident #11 did not have any complaints at that time. The Nursing Note dated 5/17/22 at 10:58 PM indicated that Resident #11 reported that her knees felt like they wouldn't support her. She felt like she could fall all the time. Resident appeared hunched over with a weak gait (walk) clinging to her walker. Resident #11 barely able to transfer to her bed. The nurse instructed Resident #11 to not transfer herself as they would use a wheelchair for safety concerns. The Nurse Shift Report dated 5/18/22 for the 6 AM to 6 PM shift listed Resident #11 as very unsteady as her knees would not support her, staff to use a wheelchair for all transfers. The Physical Therapy (PT) Daily Treatment Noted for 5/18/22 at 12:06PM indicated that a supervisory visit for reason for Resident #11's treatment that day. Resident #11 reported that she fell the night before and hurt her right ankle. Resident #11 expressed no pain at rest or with active range of motion (ROM) but explained that it hurt with weight-bearing. Resident #11 limited herself to pivot transfers only. Resident #11 reported that a nurse planned to assess it and considered getting an x-ray. Resident #11 did not remember how or why she fell , only that it happened fast and in her room. Upon assessment, Resident #11 had no limitation in dorsiflexion (DF, bending up)/ or plantar flexion (PF, bending down), but reported mild discomfort upon inversion (movement so that soles face towards the body)/eversion (movement so that soles face away from body). The PT determined the ankle had no bruising but appeared swollen in malleoli (bony portion of the ankle). Resident #11 could complete pivot transfers with heavy support on grab bar in the bathroom or with a front wheeled walker (FWW), placing approximately 50% weight during standing and pivot turn with a minimum assistance of one. Resident #11 reported that her pain increased during that movement. Resident #11 reported that she waited for assistance all day due to pain. The PT reported that they notified the nurse. The Provider Note dated 5/18/22 at 12:17 PM indicated that Resident #11 reported that she fell the previous night at bedtime, at approximately 10:15 PM. She stated that she hurt her ankle and the PT staff assessed her ankle and found no bruising but some swelling. Resident #11 did not want to bear weight on that ankle. Resident #11 would only pivot transfer and use a wheelchair at the time, but could walk independently before. The nurse sent Resident #11's provider a fax requesting an order for x-ray. The Physician Visit/Communication form dated 5/18/22 at 12:12 PM indicated that Resident #11 reported that she fell at bedtime, at approximately 10:15 PM and hurt her ankle. The PT staff reported that they looked at her ankle and observed no bruising but did note some swelling. Resident #11 did not want to put weight on it and would only complete a pivot transfer or use a wheelchair. Prior to the injury Resident #11 walked independently with a walker. The nurse added, would an x-ray be in order or any additional orders? - The facility received the provider's response on 5/19/23 at 10:13 AM indicating that they would see. The Nursing Note dated 5/18/22 at 2:20 PM labeled Late Entry created on 5/19/22 at 2:21 PM by Staff I indicated that Resident #11 asked the nurse (not caring for her at the time) to assess her right ankle. Staff I assessed Resident #11's ankle and observed swelling with small linear (line) ecchymosis (discoloration similar to bruising) noted to her right lateral (side) ankle. Staff I asked Resident #11 what happened. Resident #11 reported that she could not recall where it happened either in her bedroom or bathroom or what she was doing at the time when her knees gave out causing her to fall. Resident #11 explained that the Staff J came and she would not have been able to stand without him. Resident #11 could not remember what surface she fell on . Resident #11 reported that no assistive devices were used to assist her with standing. Resident #11 requested that Staff I ask the Staff J for more details as she could not remember. Staff I reported notifying the events to the charge nurse. The Nursing Note dated 5/19/22 at 8:30 AM indicated that Resident #11 asked the nurse when she could go to the clinic for an x-ray. Resident #11 reported that she fell the evening of 5/17/22 but could not tell the nurse how or what happened. She could only remember being in her room and that the night nurse assisted her from off the floor. Resident #11 continued to complain of right ankle discomfort. On examination Resident #11's right ankle and foot appear swollen with the outer ankle slightly red and warm to the touch. The nurse called the provider's office and made an appointment for that day at 11 AM. The nurse notified Resident #11's son. The Nursing Note dated 5/19/22 at 1:30 PM indicated that Staff I took a statement from the Staff J present at the time of the fall. The nurse explained via telephone call that they answered Resident #11's call light per her usual routine of needing assistance with peri care post toileting. The nurse assisted Resident #11 with care and walked with her towards the bed from the bathroom, with an assistive device. Resident #11 wore her bedtime clothing and gripper socks. The nurse had not yet given her night time medications. Approximately in the middle of Resident #11's bedroom her knees became weak and the nurse lowered her to the floor. Resident #11 reported no pain at that time and could pull herself to a standing position using the walker with the nurse holding the gait belt. The nurse then assisted Resident #11 to a wheelchair to her bed and then pivot transferred her to bed. Resident #11 continued to not have pain with no visible injuries noted. The nurse reported that Resident #11 had no prior issues with dizziness, weakness, or any other complaints. Resident #11's chart lacked documentation of an assessment following her incident on 5/17/22 until the PT assessed her on 5/18/22. On 2/7/23 at 1:44 PM, the Director of Nursing (DON) said that she called Staff J because he worked at the time of the fall to get the details because he hadn't filled out an incident report. On 2/7/23 at 1:47 PM attempted to contact Staff J via telephone, but he did not answer or return the call. On 2/7/23 at 1:54 PM Staff G, said that she worked as the morning nurse on 5/18/22 and she remembered that Staff J told her that he had lifted Resident #11 off of the floor by himself after he lowered her to the floor. She said that he told her that the resident was complaining of ankle pain and she assumed that he would have completed a full assessment, but she was not sure. On 2/8/23 at 9:03 AM Staff H, PT, said that Resident #11 participated in therapy three times a week before the ankle break. A couple of weeks prior to her fall Resident #11 had some injections in her knees at the beginning of May. She pointed out that Resident #11 complained of pain in her right ankle when standing on 5/18/22. On 2/9/23 at 10:24 AM the Provider Clinic's Nurse (PCN) said that they did not keep all the faxes that come into the office from facilities. Due to that the PCN said she did not know when the 5/18/22 fax actually came into the office. She said that the doctor did not work in the office on Wednesdays and the 18th was a Wednesday. The PCN expected someone to call the on-call doctor to get an order for an x-ray. On 2/9/23 at 11:51 AM the DON stated that she would expect that Staff J to complete an incident report, do a nursing assessment, and call the on-call doctor on the night of the fall on 5/17/22. She said that the staff know that the doctor is not in the office on Wednesdays so she would expect the staff to call the on-call doctor for an x-ray when a resident is having pain. The form titled Fall Documentation dated March 2017 directed the staff to a. Complete an assessment of the resident with vital signs. b. Complete entry in progress notes and document the presence or absence of external rotation of lower extremities in every fall assessment progress note entry. Do not chart FALL. c. A fall huddle will be performed immediately after the resident is stabilized, all team members working in the neighborhood should participate. d. Complete the Fall Scene Investigation (FSI) report (to be completed by the charge nurse). Give the completed FSI to the DON or designee. e. Complete the Quality Assurance (QA) Reader Incident Report form. f. Complete the Physician Visit/Communication user defined assessment (UDA) to update the physician. g. Notify the responsible party. h. Fill out Nursing to Therapy Communication Form/Screen Request on EVERY fall. i. Assess/document every shift for 72 hours, including vital signs as follow-up from fall. j. Notify leadership as per facility process.

Based on observation, record review and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 4 residents reviewed. Resident #3 lost consciousness and chicken winged during a transfer with the stand lift on 10/22/15 with immediate complaints of pain. The resident continued to experience pain and the facility failed to provide pain medication. The facility also failed to follow the facility bowel elimination policy. Facility census was sixty-eight (68) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 7/31/15, assessed Resident #3 with a brief interview for mental status (BIMS) score of 15 (no cognitive impairment). The resident required extensive staff assistance with bed mobility, transfers, ambulation and toileting. The resident was frequently incontinent of bladder and continent of bowel. The resident had [DIAGNOSES REDACTED]. The MDS pain assessment revealed no presence of pain. The resident had one fall without injury since the previous assessment. The resident admitted to the facility 1/29/13. The PT (physical therapy) Daily Treatment Note dated 10/22/15 at 1 p.m. documented the following: attempted to stand Resident for Ambulation at beginning of PT session. Resident unable to attain standing positon with the assist of 2 due to weakness and significant increased LBP with transitional movements. Took resident to therapy room for pain management. After the e-stim treatment, returned resident to room to attempt a pivot transfer. Resident was again unable to stand. Requested assistance from CNA to transfer resident to bed using EZ Stand. Transferred from wheelchair to bed with EZ stand and assist of 2. Later in the day nursing reports that while using the EZ stand with resident he/she became unresponsive while up in the lift. (PT) instructed nursing to not use EZ Stand. This therapist measured resident for sling size and when the therapist approached the resident for measuring, he/she woke up and had right sided facial droop, sluggish and unclear speech, resident alert and oriented times one (only). (Therapist) notified nursing and resident transferred from recliner to bed using a Hoyer lift and medium sling with assist of three (3) staff. (PT Therapist) notified nursing to transfer resident with a Hoyer lift only. PT assessed the resident prior, during, and after e-stim treatment with improvement in the resident ' s lower lumbar pain from 5-6/10 (out ten) to 0/10 (the higher number represented more pain). Interdisciplinary progress notes dated 10/22/15 at 12 p.m. revealed staff called Staff C (licensed practical nurse) charge nurse to the resident's room. Staff informed the charge nurse that the resident passed out during a transfer with the sit/stand lift. When Staff C got to the room, she found the resident alert and with complaints of back pain. The nurse aides stated the resident chicken winged in the lift and complained of back pain so they sat the resident in the recliner. Staff Interviews: On 11/17/15 at 12:37 p.m. Staff D (certified nurse aide) stated she and Staff E (agency certified nurse aide) had the resident in the EZ stand. She stated the resident's back hurt and his/her legs gave out and the resident was hanging in the lift by his/her arms. They hurried and got the resident into a recliner. Staff D stated they went to check and change the resident and when they pulled the resident's slacks down, the resident's legs gave out. Staff D stated the resident's pain was not as bad once they seated the resident. The resident's face turned red after they put the resident down. According to Staff D, putting the resident down relieved the pressure on the resident's back. The resident did not complain of pain earlier. On 11/17/15 at 12:29 p.m. Staff E (agency certified nurse aide) stated they had the resident hooked into the EZ stand when the resident lost consciousness and chicken winged. They set the resident down in the recliner. Staff E stated she couldn't recall but she didn't think the resident's knees buckled. She didn't recall if the resident complained of pain before the transfer. Staff E stated the resident didn't complain of pain afterward and didn't recall what happened. On 11/17/15 at 11:50 a.m. Staff C ( licensed practical nurse) stated staff called her to the resident's room. The nurse aides informed her the resident lost consciousness in the lift and was not coherent. When Staff C arrived at the room she took the resident's vitals and the resident said his/her back felt sore. Staff C stated every once-in-awhile the resident complained of chronic back pain before that incident. Staff C stated it was 3 days without a bowel movement for the resident so she thought it could have been a vagal response (brief loss of consciousness). Interdisciplinary progress notes dated 10/22/15 at 9:45 p.m. revealed the resident had severe back pain. The resident became overcome with pain when staff raised the head of the bed. The resident hyperventilated, had tears and his/her face turned red. The facility faxed the physician who directed staff to bring the resident to the clinic in the morning. Record review showed the Interdisciplinary notes did not contain any documentation from 10/22/15 the 10 p.m. to the 6 a.m. shift on 10/23/15. Review of the resident's Medication Administration Records and interdisciplinary notes revealed staff did not administer pain medication from 10/22/15 at noon until 10/23/15 at 8:30 a.m. even though the resident experienced and reported severe pain. Interdisciplinary notes dated 10/23/15 at 8:15 a.m. revealed staff summoned the charge nurse to the resident's room. The resident complained of low back/right shoulder/right abdominal pain. The resident's face got red and the resident cried with movement from side to side and elevating and lowering the bed. At 8:30 a.m. staff administered Tylenol ([MEDICATION NAME] for pain) 650 milligrams (mg.). The resident's abdomen was form with hypoactive bowel sounds. Interdisciplinary progress notes identified the resident transported to the physician on 10/23/15 at 9:20 a.m. and returned to the facility at 11:45 a.m. with orders for Tylenol #3 (narcotic [MEDICATION NAME]) one tablet every 4 hours for pain as needed. Review of x-rays performed on 10/23/15 failed to identify a back x-ray was done at the physician visit. Interdisciplinary progress notes following the order identified the Tylenol #3 seemed effective for the pain until 10/24/15 at 11:45 a.m. when the resident yelled and cried with back pain that occurred with any movement. Staff called 911 and the resident transferred to the hospital for examination. Interdisciplinary progress notes dated 10/24/15 at 3 p.m. revealed the hospital called and identified the resident admitted to the hospital for compression fractures. The resident returned to the facility on [DATE] at 12 p.m. with [DIAGNOSES REDACTED]. The radiology report dated 10/24/15 documented the resident had [MEDICAL CONDITION] changes noted throughout the spine. The compression deformity at T12 (and possibly L1) was new compared to prior study. (The radiology report from 6/24/14 documented the resident had compression deformity at T12 which was mild and compression deformity at L1 is unchanged.) Observation: On 11/12/15 at 11:52 a.m. the resident laid in bed. The resident denied hurting his/her back. The resident fell asleep while interviewed. On the same date at 1:22 p.m. 2 staff put the resident to bed from the wheelchair via the mechanical lift. When asked if he/she had pain, the resident stated he/she just wanted to sleep. 2.) Review of Resident #3 ' s bowel records for September 2015 identified the following: The resident had a medium BM on 9/2/15. The Medication Administration Record [REDACTED]. The resident had a large BM on 9/24/15. The MAR indicated [REDACTED]. Review of Resident #3 ' s bowel records for October 2015 identified the following: The resident had a medium BM on 10/18/15 and did not have a BM until 10/23/15. Interdisciplinary progress notes dated 10/24/15 at 10:15 a.m. revealed the resident stated his/her bowels moved at the physician office visit yesterday. The MAR indicated [REDACTED]. The resident had a medium BM on 10/27/15 and did not have a BM until 10/31/15. The MAR indicated [REDACTED]. Review of Resident #3 ' s bowel records for November 2015 identified the following: The resident had a large BM on 11/1/15 and did not have a BM until 11/4/15. The MAR indicated [REDACTED]. The resident had a small BM on 11/6/15 and did not have a BM until 11/10/15. The MAR indicated [REDACTED]. The resident had a medium BM on 11/11/15 and did not have a BM until 11/16/15. The MAR indicated [REDACTED]. The facility policy titled Elimination Protocol revealed the following: a. Day 1 without a bowel movement (BM), staff would offer 4 ounces of prune juice or natural laxative and document in intervention column. b. Day 2 without a BM staff should administer 30 cc Milk of Magnesia (MOM) (or whatever PRN as needed laxative the physician ordered). c. Day 3 without a BM, the charge nurse to assess bowel sounds, palpate and document assessment results. The day nurse should conduct the bowel assessment and again by the evening nurse prior to administration of suppository. Staff should also document if the resident was uncomfortable. Then give [MEDICATION NAME] or [MEDICATION NAME] suppository as ordered on PRN order. d. Day 4 without a bowel movement if interventions were not successful, advance to enema and continue bowel assessments every shift until resolved. Staff should notify the attending physician as appropriate.

Based on observation, record review and staff interview, the facility failed to provide adequate supervision to protect a resident from hazards. Resident #11 fell and sustained a fracture when the 2 staff working on the unit assisted residents they could not leave. The day room was unattended by staff. The resident also had multiple other falls that fall investigation reports did not identify if interventions were in place. The facility census was sixty-eight (68) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 7/24/15, assessed Resident #11 with a brief interview score of 5 (severe cognitive impairment). The resident required limited staff assistance with transfers and ambulation and extensive staff assistance with dressing, toileting, personal hygiene and bathing. A balance during transitions and walking test identified the resident with a score of 1 in all areas of testing. A score of 1 identified the resident as not steady but able to stabilize without staff assistance. The resident was frequently incontinent of urine. The resident had [DIAGNOSES REDACTED]. The resident had 2 falls without injury since the previous assessment. Fall History: 1. An unusual occurrence report dated 6/13/15 at 3 p.m., identified staff found the resident on the dayroom/dining room floor. The report identified the resident exhibited restlessness that shift. A fall scene investigation revealed the resident was alone and unattended and attempted to self transfer. The pressure alarm sounded when the incident occurred. A fall huddle identified less staff available when the incident occurred. The resident did not sustain injury. The care plan dated 5/12/15 contained an addendum dated 6/15/15 that directed staff to offer to ambulate the resident if restless. An unusual occurrence report dated 6/24/15 at 6 a.m. identified staff found the resident on the floor of the resident's room at the foot of the bed. The fall scene investigation identified the alarm did not sound when the incident occurred and staff found the resident when they passed ice water. The resident held the string alarm in his/her hand. The pressure alarm was not plugged in and observation showed it in the window sill. The resident was wet with urine. Staff did not complete nurse aide rounds at end of shift. A new intervention was for staff to change the bed alarm to one that did not contain a shut off switch. The resident did not sustain injury. An unusual occurrence report dated 6/29/15 at 2:25 p.m. identified staff observed the resident on the floor of the resident's room. The resident identified self as getting up and rolling out of bed. The intervention after the incident was: place the bed against the wall. The resident did not sustain injury. The report did not identify last toileting or if the alarm sounded when the fall occurred. An unusual occurrence report dated 7/3/15 at 10:30 p.m. identified staff observed the resident on the floor of the resident's room. The resident identified self as going to the bathroom and slipped. The alarm worked properly. The report did not identify when staff last toileted the resident. The intervention following the incident was: a laser alarm on the bed. The resident did not sustain injury. A therapy note to nursing revealed therapy informed staff the resident could ambulate independently as of 7/20/15. An unusual occurrence report dated 7/26/15 at 10:30 p.m. identified staff observed the resident on the floor of the resident's room. The report did not identify if alarms sounded, when staff last toileted the resident or what caused the incident. The resident did not sustain injury. The intervention following the incident was: bed and chair alarms An unusual occurrence report dated 8/14/15 at 4:15 a.m. identified staff observed the resident on the floor of the resident's room in front of the bathroom door. The report did not identify if alarms sounded or when staff last toileted the resident. The resident did not sustain injury. The intervention was: motion sensor in room. An unusual occurrence report dated 8/15/15 at 3 p.m. identified staff observed the resident on the floor of the resident's room. The resident slid of the bed and could not voice what he/she planned to do. The resident wore TED hose on feet. The report did not identify when staff last toileted the resident. The new intervention was: Wear gripper socks when not wearing shoes. A facsimile dated 8/16/15 revealed the resident received a 5.6 centimeter (cm.) by 2.4 cm. bruise to the right anterior wrist from the 8/15/15 fall. An unusual occurrence report dated 8/20/15 at 6:30 a.m. revealed staff lowered the resident to the ground without injury. The unusual occurrence report did not identify a new intervention following this incident. The care plan dated 7/23/15 did not identify a new intervention following this incident. An unusual occurrence report dated 8/28/15 at 10:45 p.m. revealed staff observed the resident on the floor in his/her room. Alarms worked properly. The resident did not sustain injury. The new intervention was: body pillow to outside of bed. The report did not identify when staff last toileted the resident. Fracture Incident: An unusual occurrence report dated 8/30/15 at 8 p.m. revealed staff saw the resident fall in the dining room. The resident had shortening and rotation of the right hip and transported to the hospital for examination. The report identified that the resident did not remember the directive not to get up per self. admission orders [REDACTED]. A transfer communication sheet from the hospital to the facility dated 9/11/15, identified hospital staff removed staples from the right hip prior to discharge back to the facility. The resident could pivot transfer with 2 staff if oriented enough to follow directions. Staff Interviews regarding 8/30/15 incident: On 11/12/15 at 2:16 p.m. Staff A (registered nurse) stated she was the nurse in the CCDI (chronic confusion and dementing illness) unit where Resident #11 resided. She stated she heard the resident's alarm but she had a resident on the toilet that she couldn't leave. She identified no staff present in the dining/dayroom area where Resident #1 fell . She identified 2 staff working on the unit at the time and both staff were busy. Staff A was one of the 2 staff. She stated the alarm sounded for a couple minutes. She identified other occasions when alarms activated and while staff worked in rooms. She stated staff got there in time before residents fell on those occasions. On 11/12/15 at 1:15 p.m. Staff B (certified medication aide) identified self as the other staff working on the CCDI unit when Resident #1 fell . Staff B stated she was in the shower room giving a shower and didn't hear the alarm until she turned the shower jets off. She looked out of the shower room as soon as she could and saw Resident #1 fall to the ground. She stated Staff A was way down at the end of the hall with a resident she could not leave. On 11/17/15 at 2:30 p.m. Staff B measured the distance from the resident's wheelchair to where the resident fell on [DATE]. Staff B measured 9 feet. Falls After Fracture: An unusual occurrence report dated 9/12/15 at 8:30 p.m. revealed staff observed the resident on the floor of the resident's room The resident needed to use the bathroom. The report did not identify when the staff last toileted the resident or if alarms functioned. The resident did not sustain injury. Following this incident, the report revealed staff obtained a urinalysis. An unusual occurrence report dated 9/19/15 at 9 p.m. revealed staff observed the resident on the floor of the resident's room. The resident was unable to tell staff why he/she got up. The report did not identify when the staff last toileted the resident or if alarms functioned. The resident did not sustain injury. On 11/17/15 at 4:05 p.m. Staff A stated she worked in the CCDI unit with one other staff. The alarms sounded but neither staff could get to the resident right away because they worked with residents they could not leave. The report identified staff placed the resident's bed in low after the incident. An incident report dated 9/30/15 at 11:55 p.m. revealed the motion sensor sounded and staff found the resident on his/her knees. The resident stated he/she rolled out of bed. The resident did not sustain injury. The report did not identify if the bed was in low. Interdisciplinary progress notes dated 10/1/15 at 12:15 a.m. revealed the resident was incontinent and staff took the resident to the bathroom after the fall. The resident became more relaxed after toileting. The care plan dated 9/16/15 revealed staff initiated a toileting plan after this incident. An incident report dated 10/7/15 at 12:30 p.m. revealed a nurse aide went in the resident's room and found the resident on knees with feet under the bed. The report stated the resident's roommate turned the motion sensor off, brought the resident a sandwich and tried to get the resident up. The report did not identify if the bed was in low and if the bed alarm functioned. The new intervention listed on the 9/16/15 care plan was dated 10/7/15 and directed staff to divert the roommate's attention when staff saw him/her attempt to help the resident. An incident report dated 10/10/15 at 11:30 p.m. revealed staff heard the motion sensor and found the resident on his/her knees next to the bed. The bed was in low positon. The care plan dated 9/16/15 contained an addendum to reposition the bed in the room. On 11/17/15 at 2:25 p.m. observation showed the resident in a wheelchair with alarm in place. At that time, the resident attempted to stand and the alarm sounded. A nurse aide immediately went to the resident and asked the resident if he/she wanted to go somewhere. The resident stated yes he/she wanted to go across the river to his/her cousin's house. On 11/24/15 at 9:59 a.m. the Director of Nursing emailed the surveyor and confirmed 2 staff on the unit when the 9/19/15 fall occurred. She wrote that the facility implemented 3 staff on the unit from 6 a.m. to 10 p.m. as of 9/30/15.

Based on observation, record review and staff interviews, the facility failed to plan for and direct nursing services to ensure one (1) of sixteen (16) residents received adequate supervision. Resident #1 fell from a rocking chair to the floor and reopened his/her prior left hip incision. Record review and staff interviews identified Resident #1's safety interventions intended to alert staff of his/her supervision needs were not implemented at the time of the fall. The onsite observation identified care plan interventions were not in place. The director of nursing and or the facility failed to ensure care plan interventions intended to prevent falls were implemented. The facility reported a census of seventy three (73) residents. Findings include: Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed he/she had [DIAGNOSES REDACTED]. The MDS revealed the resident had short and long term memory loss and his/her cognitive skills for daily decision making were severely impaired. According to the MDS assessment of 6/24/11, the resident required limited assistance of 1-2 staff for ambulation and extensive assistance of 1-2 staff for transfers. The MDS documented the resident had 1 fall with no injury. Resident #1's Care Plan dated 5/23/09 (with the review date of 12/23/11) identified a potential for falls related to his/her [DIAGNOSES REDACTED]. prevent independent ambulation; apply seat belt during high anxiety periods; transfer with 2 staff; a noodle on outside of bed; and ensure the resident wore non-skid shoes or socks. Review of the Fall Risk Assessments revealed: a. On 7/22/11 the resident scored 24 on the assessment; a score of 10 or greater identified the resident as a high risk for falls. b. On 8/30/11, the resident had a score of 24. c. On 9/27/11 the resident had a score of 22. Review of the Unusual Occurrence Reports for Resident and Visitor revealed: a. On 4/9/11 at 4:15 PM, a Certified Nursing Assistant (CNA) entered the resident's room and found the resident on the floor. The document indicted the alarms were in place but failed to go off until the resident was already on the floor. The resident had no injury. According to the Unusual Occurrence Investigation Form; Quality Assurance for Individual Resident, dated 4/9/11 revealed interventions currently in place for fall prevention included a low bed, bed sit/stand alarm, chair sit/stand alarm and noodle on bed. b. On 7/14/11 at 3:50 PM, the resident attempted to transfer by him/her(self) and the alarms sounded to alert staff of his/her supervision needs. The resident sustained [REDACTED]. c. On 8/30/11 at 2:15 PM, Resident #1 had been sitting up in a rocking chair in the dining room later, staff found Resident #1 on the floor, laying on his/her left side with his/her glasses bent and forehead bleeding. The report identified the chair alarm in place, but not turned on. The sit/stand alarm could not be found on the chair or the resident at the time of the fall. The resident obtained 2 lacerations to the forehead measuring 1.5 centimeter (cm) and 2 cm in length. The resident's left hip incision site had broken open, measuring approximately 10 cm in length. According to the emergency room Note dated 8/30/11, Resident #1's developed a 4 cm opening to his/her prior hip incision which required 7 sutures. The ER note documented the nursing home staff informed them there was substantial amount of bleeding from the resident's hip after the fall. While at the ER, the resident experienced pain and had been given medication to address his/her pain and restlessness. Since Resident #1 lesion happened on the floor, the physician started him/her on antibiotic care to prevent site infection. The resident also had 2 abrasions to the left eyelid, one measuring 1 cm and the second measuring 1.5 cm which required Dermabond to close the eye abrasions. The resident had no loss of consciousness, and the CT of the resident's head showed no intracranial lesion or evidence of hemorrhage. Observation on 11/29/11 at 10:45 am revealed the resident sitting in a rocking chair. The resident appeared anxious. Staff A, CNA transferred Resident #1 from the rocking chair to a wheelchair with a gait belt. The resident's sit/stand alarm or the chair alarm did not sound when he/she stood up from the chair. Interview with Staff B CNA/Certified Medication Aide (CMA) on 11/29/11 at 2:55 PM revealed she stated when the resident fell in August, she had been in another room providing care to a resident and did not remember alarms sounding prior to the resident's fall. Staff B stated she heard the resident's left hip incision site re-opened when he/she fell . Interview with Staff C, Registered Nurse (RN) on 11/29/11 at 2:45 PM revealed at the time of the August fall, she and a second staff were in the shower room. According to Staff C, when she came out of the shower room, she found the resident on the floor. Resident #1 had previously been sitting in the rocking chair before she entered the shower room. Staff C stated 2 staff were working the 2-10 shift and no other staff were in the dining room area at the time of the incident. Staff C stated according to the documentation, the chair alarm was not turned on and the sit/stand alarm was not on the resident or the chair. Staff C stated alarms are checked when staff put them on the resident. Staff C stated she did not check the alarms, only the CNAs did. She also stated they do not have a daily schedule to check the alarms. Interview with the Director of Nursing on 11/29/11 at 11:28 AM revealed she had been present in the Memory Support Household (MSH) at the time of the resident's fall. The resident sat at the table and she could not recall if the resident's safety alarms sounded. The DON stated the facility did not have a set schedule to check safety alarms on a daily basis. The DON stated the alarms were to be checked when staff put the alarms on the resident. The DON revealed staff did not document anywhere when they did check the alarms.