Every finding on record at Ararat Nursing Facility

Based on observation, interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) by failing to maintain complete and accurate documentation when Resident 1's care plan did not correctly indicate the correct year of the fall. This failure resulted in Resident 1's medical records containing inaccurate information, which had the potential to negatively affect Resident 1's care in the facility. Findings: During a review of Resident 1's admission Record, the admission Records indicated the facility admitted the resident on 4/5/2024 with diagnoses including hypertension (elevated blood pressure), atherosclerotic cardiovascular disease (ASCVD - condition caused by plaque buildup in the blood vessels which reduces blood flow to the heart, brain, and body), degenerative joint disease (DJD - a wear and tear condition where the protective cartilage cushioning your bones breaks down over time, causing pain, stiffness, and bones to rub together), and recent fracture (break in bone) of nasal bones. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/10/2026, the MDS indicated the resident had intact cognition (process of how the brain handles information, primarily thinking, learning, and remembering). During a review of the Interdisciplinary Team (IDT - a group of different health workers, including nurses, doctors, and therapists, who talk to each other to care for residents) Interdisciplinary Care Conference, dated 6/2/2026, the document indicated Resident 1, on 6/1/2026 at approximately 11:30 a.m., the resident was observed sitting on the floor next to his walker . according to the resident's wife, the resident was ambulating [walking or moving from one place to place] to the bathroom when he bent down to retrieve a tissue from the floor and gently lowered himself to the floor while holding onto his walker. During a concurrent interview and record review on 7/23/2026 at 9:18 a.m. with the Risk Management Nurse (RMN), Resident 1's Care Plan Report, dated 6/2/2026, was reviewed. The document indicated, Resident 1 had a Witnessed Fall on 6/01/25. The RMN stated, the care plan report was not correct due to the incorrect date. The RMN stated, the care plan is the guide for a resident's overall care and when it is not entered accurately, the risk is that the care provided could not be ensured to be safe or without medical errors. During a review of the facility's policy and procedure (P&P) titled, Documentation - Nursing, last reviewed 1/26/2026, the P&P indicated the nursing documentation will be concise, clear, pertinent, and accurate.

Based on observation, interview, and record review, the facility failed to prevent a fall and injury for one of four sampled residents (Resident 1), who had severely impaired cognition (resident had lost the ability to think, learn, remember, or make decisions to the point that resident cannot live independently and require full-time supervision or help with daily tasks like eating and dressing), identified as high risk for falls, and had history of falls. The facility failed to ensure two or more nursing staff assisted Resident 1 when turning in bed from one side to the other side during resident care.As a result, on 6/26/2026 at 4:10 p.m., Resident 1 fell off the bed while Certified Nursing Assistant (CNA) 1 was changing Resident 1's disposable brief (a single-use undergarment designed to manage incontinence [the accidental loss of bladder or bowel control, leading to an unwanted leak of urine or stool]). CNA 1 turned Resident 1 by herself towards her (CNA 1) opposite side while Resident 1 allegedly reached for his (Resident 1) eyeglasses located on top of the bedside table. Resident 1's head hit the corner of the bedside table when the resident fell off the bed which resulted in a one centimeter (cm - unit of measurement) length and one cm in width laceration (a jagged tear or cut in the skin and soft tissues caused by a blunt impact against a rough surface) on the top of the scalp (the skin and tissue covering the top and back of the head). Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 6/26/2026 and was diagnosed with bilateral cerebral convexity acute on chronic subdural hematomas (a collection of blood trapped between the brain (body's main control center) and the skull [the bony framework of the head], where a new bleed had occurred on top of an older, pre-existing collection, on both sides of the head following a head injury or trauma).Findings:During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted Resident 1 on 5/24/2017 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities that interfere with daily life), age-related osteoporosis (a condition where bones become brittle, weak, and highly porous [full of tiny holes] as a person gets older), sarcopenia (age-related progressive loss of muscle mass, strength, and function), and history of falling.During a review of Resident 1's MD (Medical Doctor) - History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings) Nursing Facility form, dated 12/15/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 1/7/2026, the MDS indicated Resident 1 had severe impaired cognitive skills (a profound and persistent decline in memory, reasoning, language, and judgment that makes it impossible for a person to manage daily life without substantial help) for daily decision making and was dependent (helper does all of the effort and resident does none of the efforts to complete the activity) with toileting, showers, lower and upper body dressing, oral, and personal hygiene.During a review of Resident 1's Order Review History Report, dated from 6/1/2026 to 6/30/26, the Order Review History Report indicated a physician order for Eliquis oral tablet (a medication, taken by mouth, that reduces and prevents blood clotting) 2.5 milligrams (mg - a unit of measurement) two times a day with an order date of 1/14/2026.During a review of Resident 1's Fall Risk Assessment, dated 6/4/2026, the Fall Risk Assessment indicated Resident 1 had a total score of 16 (score breakdown not indicated) and indicated Resident 1 was at high risk for falls. The Fall Risk Assessment indicated Resident 1 had decreased muscular coordination (the body's ability to use the nerves, muscles, and joints together to perform movements smoothly and accurately).During a review of Resident 1's Change in Condition Evaluation (COC - when there is a sudden change in a resident's condition that requires assessment, often prompting a revision of the care plan) Evaluation, dated 6/26/2026, the COC Evaluation indicated on 6/26/2026 at 4:10 p.m., Registered Nurse 1 (RN 1) was notified of Resident 1's witnessed fall. The COC Evaluation indicated Resident 1 reached for his (Resident 1) glasses and fell (off the bed) while being changed. Resident 1 hit his head in the nightstand (bedside table) that caused a skin tear and laceration on the scalp measuring a length of one cm and a width of one cm (1 cm x 1 cm). The COC Evaluation indicated on 6/26/2026 at 4:50 p.m. the facility transferred Resident 1 to GACH 1.During a review of Resident 1's Progress Notes, dated 6/26/2026 and timed at 4:10 p.m., the Progress Notes indicated that RN 3 received a call (name of caller not specified) that Resident 1 was on the floor. The Progress Notes indicated that when RN 3 went to Resident 1's room, she (RN 3) observed Resident 1 was lying on the floor next to the bed on the left side of the bed. The Progress Note indicated that MD was notified on 6/26/2026 at 4:11 p.m. and order was received to transfer Resident 1 to GACH 1 via 911 (universal emergency telephone number) for further evaluation. During a review of Resident 1's Physician Order, dated 6/26/2026, the Physician Order indicated to transfer Resident 1 to GACH 1 via ambulance (a specially equipped vehicle used to transport sick or injured people to a hospital, usually for emergency medical care) due to the fall.During a review of Resident 1's GACH 1 H&P note, the H&P note's computed tomography scan (CT scan - a medical imaging test that uses X-rays [shoot invisible energy beams through the body onto a digital detector] and a computer to make detailed, slice-by-slice pictures of the inside of the body) without contrast (a special substance [dye] used during scan to make organs stand out clearly) report, dated 6/26/2026, indicated Resident 1 had bilateral cerebral convexity acute or chronic subdural hematomas. The H&P note indicated Resident 1's subdural hematomas measured 11 millimeters (mm - a unit of measurement) on the left side and 7 mm on the right side.During an interview on 7/9/2026 at 9:32 a.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 1 was dependent on staff and required two-person assistance on activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily) and mobility.During an interview on 7/9/2026 at 10:39 a.m. with the Director of Staff Development (DSD), the DSD stated CNA 1 was on leave and went home to her country. CNA 1 did not answer the telephone calls.During an interview on 7/9/2026 at 10:59 a.m. with CNA 2, CNA 2 stated Resident 1 could not turn without staff assistance. CNA 2 stated Resident 1 was dependent on staff in performing ADLs and mobility. CNA 2 stated he (CNA 2) changes Resident 1's clothes and disposable brief without another staff assistance. CNA 2 stated he used his one arm to push and hold Resident 1 in side lying position while he changes the brief with the other hand. CNA 2 stated then he would go to the opposite side of the bed and again push and hold the Resident 1 with resident back facing him then clean resident and change the briefs.During a concurrent observation and interview on 7/9/2026 at 1:26 p.m. with Registered Nurse (RN) 3, in Resident 1's room, observed CNA 2 and RNA 2 turn Resident 1 in bed with CNA 2 standing on the right side of the resident and RNA 2 standing on the left side of the resident. Observed CNA 2 and RNA 2 holding Resident 1's position while the resident was turned on the side. Resident 2's face was observed close to the bedside table when the resident was turned towards the left side. Resident 2's body was observed to be in a stiff and straight position. RN 3 acknowledged and stated that Resident 3 did not help while being turned.During a follow up interview and record review on 7/9/2026 at 1:55 p.m. with RN 3, Resident 1's Care Plan (CP - a comprehensive health document that outlines resident's specific medical needs, treatments, and goals) Report for Falls, initiated on 4/26/2024, were reviewed. RN 3 stated Resident 1's CP indicated Resident 1 was at risk for falls secondary to impairment of upper and lower extremities on both sides, has history of falls, sarcopenia, antihypertensive medication (medications to lower blood pressure [the force of person's blood pushing against the walls of arteries as heart pumps it throughout the body]), presence of left artificial hip joint (a medical implant used to replace damaged, worn-out, or fractured hip joint), and left hip fracture (broken bone) status post (after) hemiarthroplasty (partial joint replacement). RN 3 stated RN 1 reported that Resident 1 had a fall. RN 3 observed Resident 1 lying on the floor on the left side of the resident's bed. RN 3 stated CNA 1 reported that she (CNA 1) was standing on the right side of Resident 1's bed and turned the resident towards the left side, opposite CNA 1's location. RN 3 stated CNA 1 reported that Resident 1 reached for his glasses on the bedside table which caused Resident 1 to slide down the bed. RN 3 stated that CNA 1 reported that Resident 1's head hit the bedside table as the resident was sliding down the bed. RN 3 stated CNA 1 performed the task on Resident 1 without assistance from other staff. RN 3 stated Resident 1's body was stiff and the resident (Resident 1) does not help with turning, therefore, Resident 1 required two-person assistance for resident's safety. RN 3 stated Resident 1 was on an anticoagulant (a medication that slows down the body's process of making blood clots) that could cause the resident to bleed following a fall.During a concurrent interview and record review on 7/10/2026 at 1:10 p.m. with MDS Nurse (MDSN) 1, Resident 1's MDS, dated [DATE], was reviewed. MDSN 1 stated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. The MDS indicated Resident 1 was dependent on facility staff to dress and undress the upper and lower body, oral (mouth) hygiene, toileting hygiene, and personal hygiene. MDSN 1 stated the MDS indicated Resident 1 was dependent on facility staff for mobility (movement) activities, including rolling to the left and to the right side. MDSN 1 stated Resident 1 was dependent on staff when providing care and required two or more staff members actively assisting for resident safety.During a concurrent observation and follow up interview on 7/10/2026 at 1:45 p.m. with RN 3, in Resident 1's room, RN 3 raised Resident 1's bed to the height the bed was on during Resident 1's fall. RN 3 measured the height from the top of Resident 1's bed mattress to the floor. RN 3 stated Resident 1's bed was 24 inches (a unit of measurement) high. During an interview on 7/10/2026 at 3:07 p.m. with the DSD, the DSD stated residents that were dependent on staff to provide care including turning from one side to the other side, required two people to complete the task for resident and staff safety. The DSD stated CNAs were trained to ask for assistance from another nursing staff before providing care to dependent residents to prevent accidents such as resident fall which could result in an injury.During an interview on 7/10/2026 at 3:19 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was a high risk for falls. The DON stated Resident 1 was dependent on staff for ADLs and mobility including turning from side to side and should be assisted by two facility staff for resident safety. The DON stated Resident 1 was on anticoagulant medication that increased the resident's risk for bleeding. The DON stated CNA 1 provided care to Resident 1 by herself when the resident fell, therefore, Resident 1's bed was not in the lowest position during the fall because CNA 1 was providing care. The DON stated not asking for assistance from another nursing staff before providing care to Resident 1 placed Resident 1 at increased risk for falls and injury. The DON acknowledged and stated that the facility failed to identify Resident 1's need for two-person assistance while ADLs and mobility activities were provided.During a review of the facility's policy and procedure (PnP) titled, Fall Management Program, last reviewed on 1/26/2026, the PnP indicated the purpose of the PnP is to prevent resident falls and minimize complications (anything that makes a situation, process, or condition more difficult to understand, manage, or deal with) associated with falls through the development of a fall management program. The PnP indicated . upon completion of the resident care assessment upon admission, quarterly, with significant change in condition, and as needed, MDS nurse will assess how many persons assist is needed for the resident based on an RN assessment and staff interviews. The PnP indicated based on the information gathered from the history and assessment of the resident, the nursing staff, and the interdisciplinary team (IDT - a collaborative group of professionals from different disciplines - such as physicians, nurses, therapists, and social workers - who work together to create and implement a single, unified care plan for a resident), with input from the Attending Physician, will identify and implement interventions to reduce the risk of falls. The Care Planning section of the PnP indicated the nursing staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls.

Based on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of four sampled residents (Resident 2). The facility failed to ensure that Resident 2's witnessed fall on 5/25/2026, which resulted in a subarachnoid hemorrhage (a serious type of brain bleed), was reported to the State Survey Agency (SSA) within 24 hours as required by the facility's policy and procedure, titled Unusual Occurrence Reporting.This deficient practice had the potential for delayed oversight, inadequate monitoring, and potential unmet resident medical needs following a serious injury.Findings:During a review of Resident 2's undated admission Record, the admission Record indicated the facility admitted Resident 2 on 5/28/2021 with diagnoses including Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to perform simple tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and age-related osteoporosis (a condition where bones become brittle, weak, and highly porous as a person gets older). During a review of Resident 2's MD (Medical Doctor)-History and Physical Nursing Facility (H&P), the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 5/6/2026, the MDS indicated Resident 2's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was moderately impaired. The MDS indicated Resident 2 required supervision (assistance may be provided throughout the activity or intermittently) on walking 10 to 50 feet with two turns. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) for toileting, shower, and lower body dressing. During a review of Resident 2's Situation Background Assessment Recommendation (SBAR - a standardized tool used by healthcare professionals to share critical patient information clearly and accurately) Communication Form, dated 5/25/2026, the SBAR Communication Form indicated Resident 2 had a fall that resulted in Resident 2's hitting her head in the floor. During a review of Resident 2's facility-provided computed tomography scan (CT scan - a medical imaging test that creates cross-sectional images of the inside of a person's body) report, dated 5/25/2026, the CT scan result indicated Resident 2 had a subarachnoid hemorrhage (a life-threatening type of stroke [happens when blood vessels in the brain bursts or leaks, spilling blood into or around the brain] caused by bleeding into the slim area between the brain and the thin tissues that cover it) in the bilateral vertex (both sides of the top part of the brain). During an interview on 7/9/2026 at 4:25 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 2 was walking in the hallway when the resident fell backwards. CNA 4 stated Resident 2's head hit the ground. During an interview on 7/10/2026 at 2:33 p.m. with Registered Nurse (RN) 2, RN 2 stated Resident 2 sustained a subarachnoid hemorrhage following a fall on 5/25/2026. RN 2 stated on 7/8/2026, the nursing staff checked the documentation of the residents who had fall to ensure the reporting process was followed. Resident 2's fall with injury was not reported to SSA. RN 2 stated the Director of Nursing (DON) reported Resident 2's fall to the SSA on 7/8/2026. During a concurrent interview and record review on 7/10/2026 at 3:19 p.m. with the DON, the facility's policy and procedure (PnP) titled, Unusual Occurrence Reporting, last reviewed on 1/26/2026, was reviewed. The DON stated the PnP indicated the facility reports the following events. other occurrences that interfere with facility operations and affect the welfare, safety, or health of resident, employees, or visitors. The PnP indicated unusual occurrences are reported to the appropriate agency within 24 hours . The DON stated Resident 2's injury following a witnessed fall should be reported to the SSA as unusual occurrence. The DON acknowledged and stated the facility failed to report the outcome of Resident 2's fall to the SSA within 24 hours.

Based on interview and record review, the facility failed to ensure the medical records for one of four sampled residents (Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure licensed nurses documented the correct change in condition (COC - when there is a sudden change in a resident's condition) date on Resident 3's medical record. This deficient practice resulted in inaccurate information on Residents 3's medical records and had the potential for delayed and inaccurate medical interventions.Findings: During a review of Resident 3's undated admission Record, the admission Record indicated the facility admitted Resident 3 on 1/19/2024 with diagnoses including chronic systolic heart failure (a condition when the heart muscle had become too weak to squeeze blood forcefully enough to the rest of the body), dizziness and giddiness, and age-related osteoporosis (a condition where bones become brittle, weak, and highly porous as a person gets older). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/16/2026, the MDS indicated Resident 3's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact. During a concurrent interview and record review on 7/9/2026 at 2:20 p.m. with Registered Nurse (RN) 3, Resident 3's Situation Background Assessment Recommendation (SBAR - a standardized tool used by healthcare professionals to share critical patient information clearly and accurately) Communication Form, dated 7/6/2026, was reviewed. RN 3 stated Resident 3's SBAR Communication Form indicated that Resident 3 had a fall which resulted in a laceration (a tear in the skin) on the resident's right eyebrow. SBAR Communication Form indicated Resident 3's change in condition of fall started on 9/5/2026, which is two months in the future. RN 1 stated the date on Resident 3's SBAR Communication Form was inaccurate. RN 3 stated that inaccurate documentation could cause miscommunication and confusion among the healthcare team. During an interview on 7/9/2026 at 4:40 p.m. with the Director of Nursing (DON), the DON stated the licensed nurses should ensure the correct date for Resident 3's COC was documented in the resident's medical records. The DON stated the COC date for Resident 3's fall was inaccurate and could result in confusion among the healthcare team. The DON acknowledged and stated the facility failed to ensure documentation in Resident 3's medical records was complete and accurate. During review of the facility's policy and procedures (PnP) titled, Documentation - Nursing, last reviewed on 1/26/2026, the PnP indicated nursing documentation will be concise, clear, pertinent, and accurate. The PnP indicated nurse's notes are dated, timed, and signed when written. During review of the facility's PnP titled, Change of Condition Notification, last reviewed on 1/26/2026, the Documentation section of the PnP indicated a licensed nurse will document the following: date, time, and pertinent details of the incident.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication error (one which causes the resident discomfort or jeopardizes his or her health and safety) when Registered Nurse (RN) 1 failed to resume Resident 1's apixaban (a generic name of a blood thinner medication used to prevent blood clots) on 5/28/2026 as ordered by the Medical Doctor (MD). On 5/27/2026, the MD gave an order to RN 1 to hold Resident 1's apixaban on that night (5/27/2026) because of nose bleeding but to resume it the next day (5/28/2026). Resident 1 did not receive the apixaban medication from 5/28/2026 through 6/1/2026. As a result, on 6/1/2026 at around 8 a.m., Resident 1 experienced a significant change of condition (COC - a major decline in a resident's status), including new onset left-sided weakness, left side facial drooping (a noticeable loss of muscle tone on one side of the face), and slurred speech requiring further medical evaluation and intervention. The facility transferred Resident 1 to the General Acute Care Hospital (GACH) on 6/1/2026 at 8:30 a.m. where Resident 1 was diagnosed with acute ischemic stroke (a life-threatening medical emergency when there is a sudden interruption of blood flow to part of the brain) due to occlusion (blockage) of right middle cerebral artery (a major blood vessel that supplies oxygenated blood to the right side of the brain and primarily controls movement and sensation on the left side of the body).Findings:During a review of Resident 1's undated admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/27/2025 with diagnoses including congestive heart failure (CHF - a heart disorder which causes the heart not to pump the blood efficiently, sometimes resulting in leg swelling), chronic atrial fibrillation (an irregular heartbeat that can lead to blood clots), presence of prosthetic heart valve (replacing and implanting heart valve in the body), and respiratory failure (when not enough oxygen passes from the lungs to the blood).During a review of Resident 1's GACH Skilled Nursing Facility Transfer Orders, dated 5/27/2026, the Skilled Nursing Facility Transfer Orders indicated an order for apixaban 2.5 milligram (mg - a metric unit of measurement, used for medication dosage and/or amount) tablet with the instruction to take one tablet by mouth two times daily. The Skilled Nursing Facility Transfer's Medication List indicated the last time apixaban was given to Resident 1 was on 5/27/2026 at 9 a.m.During a review of Resident 1's Progress Notes, dated 5/27/2026 at 11:59 p.m., the Progress Notes indicated a late entry documentation note for 5/27/2026. The Progress Notes indicated medications were reviewed with the MD which included apixaban (Eliquis is the brand name) 2.5 mg. The Progress Notes indicated that RN 3 reported to the MD that Resident 1's nose was bleeding. The Progress Notes indicated a pack of gauze was applied to control the bleeding. The Progress Notes indicated the MD ordered for Resident 1 to skip tonight, on 5/27/2026, the resident's Apixaban 2.5 mg medication.A review of Resident 1's MD-History and Physical (H&P) Nursing Facility, dated 5/28/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Progress Notes, dated 5/28/2026 at 4:53 p.m., the Progress notes indicated a late entry. The Progress Notes indicated Licensed Vocational Nurse (LVN) 2 looked through Resident 1's medications and noticed apixaban medication was not in the list and LVN 2 documented that it was no longer there. During a review of Resident 1's Medication Administration Record (MAR - a log used to track a resident's prescribed medications), dated 5/27/2026 to 5/31/2026, the MAR did not have an order for the medication Apixaban 2.5 mg by mouth twice a day. The MAR did not indicate that apixaban was held on 5/27/2026 (one dose) and there was no order to continue the medication.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 1 had severely impaired cognitive functioning (the ability to think, learn, remember, use judgment and make decisions). The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort. Helper lifts and supports trunk or limbs and provides more than half the effort) with oral hygiene, toilet hygiene, upper body dressing, and with putting on and taking off footwear.During a review of Resident 1's COC, dated 6/1/2026 at 8:30 a.m., the COC indicated that at 8:30 a.m., Certified Nurse Assistant (CNA) 1 reported that when she (CNA 1) transferred Resident 1 from bed with the sit-to-stand machine (a mobility device designated to help individuals safely transition from sitting to standing), she noted that Resident 1 was leaning on her left side so a RN (name not specified) was called to further evaluate Resident 1. The COC indicated Resident 1 was transferred to bed with two licensed staff (names not specified). The COC indicated that upon RN's assessment Resident 1 was noted with left side facial drooping, left side weakness, and slurred speech. The COC indicated the facility called 911 (number to call for emergency services) and transferred Resident 1 to the GACH.During a review of Resident 1's Emergency Department (ED - emergency room in the hospital) Provider Notes from the GACH, dated 6/1/2026 at 9:40 a.m., the ED Provider Notes indicated Resident 1 presented to the ED for evaluation of left-sided weakness approximately one hour and with the chief complaint of facial drooping and weakness. The ED Provider Notes indicated Resident 1 was brought to the ED as a code stroke (an urgent hospital emergency protocol activated when a patient inside the hospital or arriving through ambulance shows immediate signs of having a fresh stroke) and CAT Scan (CT - Computed Tomography, a medical test used first in a stroke emergency) showed right M2 occlusion (a physical blockage [blood clot] in the second segment of the right middle cerebral artery). The ED Provider Note's Diagnoses/Clinical Impression indicated Resident 1 had an acute ischemic stroke due to occlusion of right middle cerebral artery.During a review of Resident 1's Magnetic Resonance Imaging Brain Without Contrast (MRI - a non-invasive medical imaging test to create detailed pictures of the brain structure without injecting any special dye into the person's veins) Notes from the GACH, dated 6/2/2026 at 2:54 p.m., the Impression indicated Resident 1 had multiple scattered foci of cortical and subcortical acute infarct (several distinct, small areas of brand-new brain tissue damage caused by a sudden loss of blood flow) throughout the right middle cerebral artery territory involving the right frontal and parietal lobes (two large, interconnected regions located on the right side of the brain) and posterior insula (a deeply hidden region.During an interview with the MD on 6/10/2026 at 2:30 p.m., the MD stated he (MD) received a call from a nurse (RN 1) on 5/27/2026 that Resident 1's nose was bleeding, and he (MD) gave orders to hold the dose for apixaban that night (5/27/2026). The MD stated he (MD) did not discontinue Resident 1's medication. The MD stated this medication (apixaban) is used to prevent blood clots and stopping the medication may lead to a stroke.During an interview with the Assistant Director of Nursing (ADON) on 6/10/2026 at 1:15 p.m., the ADON stated that she was working on 6/1/2026 and an LVN (name not specified) notified her that at around 8 a.m. Resident 1 was experiencing left-sided weakness and left mouth drooping. The ADON stated she went in with another RN (name not specified) and they assessed Resident 1. The ADON stated they took Resident 1's vital signs (are essential measurements of the body's most basic functions) and she (ADON) called 911. The ADON stated she called the MD, and he (MD) informed her (ADON) that on 5/27/2026 he received a call from a nurse (RN 1) stating that Resident 1 had a nosebleed, and he ordered to hold the dose for the night on 5/27/20206 and to resume the medication the next day. The ADON stated that Resident 1's Family Member called the MD to notify him that the facility was not administering Resident 1's apixaban. The ADON stated apixaban is an anticoagulant medication, and it is used to prevent blood clots. The ADON stated that not administering this medication (apixaban) can lead to a stroke.During an interview with RN 1 on 6/12/2026 at 11:20 a.m., RN 1 stated that he (RN 1) admitted Resident 1 to the facility and while he was working on Resident 1's admission, another nurse called him to let him know that Resident 1 was having a nosebleed. RN 1 stated he notified the MD and MD gave him orders to hold apixaban for the night (of 5/27/2026) and then to resume the medication the next day. RN 1 stated he must have forgotten to put in the apixaban order for Resident 1. RN 1 stated that not administering the medication apixaban can lead to Resident 1 having a stroke.During a review of the facility's Policy and Procedure (P&P) titled, Physician Orders, dated 5/1/2019, the P&P indicated the facility will ensure that all physician orders are complete and accurate. The P&P indicated the medical records department will verify that physician orders are complete, accurate and clarified as necessary. Medication/treatment orders will be transcribed into the appropriate resident administration record.

Based on interview and record review, the facility failed to ensure professional standards of practice were followed for one of three sampled residents (Resident 3) when Certified Nurse Assistant (CNA) 1 found Resident 3 on her knees next to her roommate's bed on 5/15/2025. The facility failed to: 1. Complete Resident 3's Change of Condition (COC) assessment. 2. Monitor Resident 3 for 72 hours after the fall. 3. Conduct neuro checks on Resident 3. 4. Implement interventions to prevent Resident 3 from further falls. These failures had the potential to result in delayed care and services following Resident 3's fall. Findings: During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), repeated falls, and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 3's Minimum Data Set [MDS)] resident assessment tool), dated 4/9/2026, the MDS indicated Resident 3 had impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making and needed dependent assistance (helper does all of the efforts) for toileting hygiene, showers, lower body dressing and putting on/taking off footwear. During a review of Resident 3's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 1/31/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During an interview on 5/29/2026 at 10:14 a.m. with Licensed Nurse (LVN) 1, LVN 1 stated that on 5/15/2025 around 9 p.m., CNA 1 called for assistance in Resident 3's room. LVN 1 stated that she went into Resident 3's room immediately and observed Resident 3 kneeling on the floor next to her roommate's bed. LVN 1 stated that they assisted Resident 3 into a seated position and called Registered Nurse (RN) 1 to assist Resident 3 back into bed. LVN 1 stated that she did not know how Resident 3 got out of bed because she had never seen Resident 3 ambulate. LVN 1 further stated that Resident 3 had a fall but did not investigate the fall because she focused on immediately separating Resident 3 from her roommate. During an interview on 5/29/2026 at 11:05 a.m. with CNA 1, CNA 1 stated that on 5/15/2026 at approximately 8:30 p.m., CNA 1 heard a voice coming from Resident 3's room. CNA 1 stated that she immediately entered Resident 3's room and saw Resident 3 kneeling beside her roommate's bed. CNA 1 stated that she called for help, and LVN 1 arrived in the room right away. CNA 1 stated that LVN 1 assisted Resident 3 to a sitting position on the floor mat. CNA 1 stated that LVN 1 and RN 1 assisted Resident 3 back to bed. CNA 1 stated that they did not know how Resident 3 ended up on the floor since CNA 1 had put Resident 3 in bed prior to finding Resident 3 on the floor. During an interview on 5/29/2026 at 2:13 p.m. with Risk Management (RM) nurse, the RM stated that after the facility completed the investigation regarding Resident 3's physical altercation the CNA 1 stated that Resident 3 was on her knees on the floor. RM stated that resident had an unwitnessed fall on 5/15/2026 and the facility did not complete a COC because the staff was focused on separating Resident 3 from her roommate. RM stated that Resident 3 was not monitored for the unwitnessed fall and staff should have completed a COC evaluation and monitored Resident 3 for 72 hours after the fall. During an interview on 5/29/2026 at 3:27 p.m. with Assistant Director of Nursing (ADON), the ADON stated that Resident 3 was found on her knees by CNA 1 on 5/15/2026. The ADON stated that Resident 3 had an unwitnessed fall and that the facility's policy (P&P) titled, Fall Management Program was not followed when the licensed nurse did not complete an incident report and a post fall assessment within 24 hours. The ADON stated that Resident 3 did not receive high quality of care after the unwitnessed fall because there was no documentation indicating that Resident 3 was monitored for 72 hours after the fall, no neuro checks were done, and no interventions were implemented to prevent Resident 3 from falls. During a review of the facility's P&P titled, Fall Management Program dated 4/6/2026, the P&P indicated, Following a resident's fall, the licensed nurse will complete an incident report and a Post-Fall Assessment & Investigation within 24 hours or as soon as practicable. Nursing staff will document the resident's response to interventions being utilized in the resident's medical record.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for four of nine sampled residents (Residents 3, 4, 6, and 8) by failing to:1. Implement Resident 3's care plan on risk of anti-hypertensive medication (medications used to treat hypertension [HTN-high blood pressure]).2. Develop a care plan for Resident 4's use of hydrogel (promotes wound healing by maintaining a moist environment, cooling the skin, and softening dead tissue to allow the body to naturally clear it away).3. Implement Resident 6's care plan on enhanced barrier precaution (EBP- an infection control method used in nursing homes to prevent the spread of hard-to-treat germs, like antibiotic-resistant bacteria).4. Develop a care plan for Resident 8's right heel deep tissue injury (DTI-a serious form of pressure sore where the soft tissue under intact skin is damaged).These failures had the potential for delays in the delivery of necessary care and services and could place Resident 3 at risk for HTN, Residents 4 and 8 at risk for worsening of pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence,) and Resident 6 at risk for infection. Findings:a. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 8/13/2025, with diagnoses that included essential HTN.During a review of Resident 3's Care Plan, dated 8/14/2025, on antihypertensive medication, the Care Plan indicated the following interventions:1. Hold metoprolol (medication used to lower HTN) for systolic blood pressure (sbp- measures the maximum pressure inside your arteries when your heart beats and pushes blood out into your body) less than 120 millimeters mercury (mmHg-a standard unit of measurement for pressure).2. Administer medications as ordered per given parameters (specific, measurable conditions, limits, or guidelines set by a doctor that direct nurses or caregivers on how and when to administer a treatment or medication).During a review of Resident 3's Order Audit Report, dated 4/20/2026, the Order Audit Report indicated metoprolol tartrate tablet 12.5 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for HTN, hold for sbp less than 120 mmHg.During a review of Resident 3's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/21/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.During a review of Resident 3's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 5/2026, the MAR indicated metoprolol was administered on the following dates:1. Licensed Vocational Nurse 4 (LVN 4) administered on 5/1/2026, at 5 p.m. with a blood pressure of 119/76 mmHg,2. LVN 4 administered on 5/2/2026, at 5 p.m. with a blood pressure of 115/69 mmHg.3. LVN 4 administered on 5/5/2026, at 5 p.m. with a blood pressure of 117/79 mmHg.4. LVN 5 administered on 5/7/2026, at 9 a.m. with a blood pressure of 115/75 mmHg.During an interview on 5/19/2026, at 11:29 a.m., with LVN 5, LVN 5 stated he (LVN 5) should have held the metoprolol as per physician order. LVN 5 stated Resident 3's care plan was not followed.During an interview on 5/21/2026, at 12:05 p.m., with the Risk Management Nurse (RMN), the RMN stated Resident 3's care plan for HTN was not followed. The RMN stated care plans are guides on how to care for the residents. The RMN stated if care plan is not followed, Resident 3 would be at risk for hypotension (low blood pressure).b. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 3/13/2026, with diagnoses that included unspecified (unconfirmed) respiratory failure (occurs when the lungs cannot get enough oxygen into the blood or fail to remove excess carbon dioxide), unspecified dementia (a progressive state of decline in mental abilities) and generalized muscle weakness.During a review of Resident 4's H&P, dated 3/14/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decisions were intact.During a review of Resident 4's Order Recap Report, dated 5/6/2026, the Order Recap Report indicated zinc oxide (a medicated cream, ointment or paste that treats or prevents skin irritation like cuts, burns or diaper rash) ointment 10 percent (%-for every 100) to left buttocks stage two pressure ulcer (partial-thickness loss of skin, presenting as a shallow open sore or wound) twice a day.During a review of Resident 4's Progress Notes, dated 5/11/2026, the Progress Notes indicated the Wound Care Provider (WCP) came and assessed Resident 4's pressure ulcer. The Progress Notes indicated the treatment for stage two left buttocks was changed to hydrogel daily.During a review of Resident 4's Treatment Administration Record (TAR), dated 5/2026, the TAR indicated the Treatment Nurses (TNs) applied zinc oxide to Resident 4's left buttocks twice a day from 5/11/2026, to 5/14/2026.During a concurrent observation on 5/19/2026, at 9:20 a.m., with TN 1, at Resident 4's bedside, TN 1 applied zinc oxide to Resident 4's left buttocks pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence).During a concurrent interview and record review on 5/19/2026, at 10:42 a.m. with TN 1, Resident 4's WCP Progress Notes, dated 5/11/2026, was reviewed. TN 1 stated she (TN 1) had applied zinc oxide to Resident 4's left buttocks stage two pressure injury. TN 1 stated she (TN 1) should have used hydrogel as per WCP order since 5/11/2026. TN 1 stated using medication not ordered by the WCP can slow the healing process of Resident 4's pressure injury.During a concurrent interview and record review on 5/19/2026, at 12:14 p.m., with Care Planner 1 (CP 1), CP 1 stated there was no care plan developed for use of hydrogel because the hydrogel was not transcribed as a physician order.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated care plan should reflect treatment orders that should be provided to residents. The RMN stated hydrogel should have been transcribed in the physician order, treatment should have been initiated, and CPs should have been notified so they (CP) could have developed a care plan for the use of hydrogel. The RMN stated that without the care plan for the use of hydrogel, there was no appropriate treatment for Resident 4's stage two pressure injury and could worsen the pressure injury.c. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 3/31/2025, with diagnoses that included chronic respiratory failure, and history of fall.During a review of Resident 6's H&P, dated 9/22/2025, the H&P indicated Resident 6 had fluctuating capacity to understand and make decisions.During a review of Resident 6's Care Plan, dated 10/28/2025, on EBP, the Care Plan indicated an intervention to use gown and gloves during high contact resident care activities (dressing, bathing, transfers, hygiene, toileting, brief changes, changing linens, device care, wound care).During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 6 was dependent on staff for ADL. The MDS indicated Resident 6 had one stage two pressure ulcers, and three unstageable pressure ulcers (a severe full-thickness skin and tissue loss where the true depth of the damage cannot be assessed).During an observation on 5/15/2026, at 1:37 p.m., outside of Resident 6's room, an EBP signage posted by the door and an isolation cart with gloves, gown and mask observed. Resident 6's door was open and curtain was pulled close.During an observation on 5/15/2026, at 1:38 p.m., inside Resident 6's room, Resident 6 lying in bed with urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) hanging to the right side of the bed covered with a dignity bag. Observed CNA 1 standing on the left side of Resident 6 providing bed bath.During a concurrent observation and interview on 5/15/2026, at 1:39 p.m. with CNA 1 at Resident 6 bedside. CNA 1 stated she (CNA 1) provided bed bath to Resident 6 who had a urinary catheter. CNA 1 stated she (CNA 1) did not wear a gown and should have worn a gown before providing bed bath.During a concurrent interview and record review on 5/19/2026, at 12:14 p.m., with CP 1, Resident 6's care plans were reviewed. CP 1 stated the Care Plan, dated 10/28/2025, for EBP indicated an intervention to use gown and gloves during high contact resident care activities. CP 1 stated care plan for EBP was not followed if CNA did not wear a gown while providing bed bath.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated care plans are guides that nurses should follow to prevent spread of infection.d. During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 2/20/2026, with diagnoses that included metabolic encephalopathy (when the brain temporarily stops working properly because of a chemical problem or imbalance in the rest of your body) and right heel stage three pressure injury (Full-thickness loss of skin. Dead and black tissue may be visible).During a review of Resident 8's H&P, dated 2/20/2026, the H&P indicated Resident 8 did not have the capacity to understand and make decisions.During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 8 had one stage three pressure injury.During a review of Resident 8's Progress Notes, dated 5/11/2026, the Progress Notes indicated the WCP assessed and documented Resident 8 with unstageable upper mid back and right heel DTI.During a concurrent interview and record review on 5/19/2026, at 12:14 p.m., with CP 1, Resident 8's Progress Notes, dated 5/11/2026, and Care Plans were reviewed. CP 1 stated the WCP assess Resident 8 on 5/11/2026 and documented right heel DTI. CP 1 stated the WCP notes were not relayed to CPs reason why no care plan was developed for right heel DTI.During an interview on 5/20/2026, at 11:29 a.m., with Registered Nurse 1 (RN 1), RN 1 stated care plan should have been developed for Resident 8's right heel DTI.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated no care plan was developed for Resident 8 after the WCP reclassified right heel from stage three to DTI. The RMN stated care plan should have been developed to treat Resident 8's current pressure injury.During a review of facility's policy and procedure (P&P), titled, Wound Management, dated 11/1/2017, and last reviewed on 1/26/2026, the P&P indicated, If the Wound Monitoring Record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans.Implement a wound treatment per physician's order. A Licensed Nurse will develop a Care Plan for the resident based on recommendations from Dietary, Rehabilitation and the Attending Physician. Update the resident's Care Plan as necessary.During a review of facility's P&P, titled, Care Planning, dated 3/7/2025, and last reviewed on 1/26/2026, the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.2. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.3. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an ass needed bases.9. Each resident's Comprehensive Care Plan will describe the following:A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.During a review of facility's P&P, titled, Pressure Ulcer Prevention, dated 2/1/2015, and last reviewed on 1/26/2026, the P&P indicated, The Care Plan will be revised as indicated.

Based on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for two of nine sampled residents (Residents 1 and 9) by failing to:1. Ensure the Physician was notified of Resident 1's blood sugar over 250 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) per deciliter (dl- a metric unit of volume equal to one-tenth of a liter) on 4/17/2026, to 4/19/2026, as per physician order.2. Ensure Resident 9's fluid restriction of one liter per day was followed as per physician order.These failures had the potential to place Resident 1 at risk for hyperglycemia (high blood sugar) and for Resident 9 at risk for fluid overload.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/20/2026, with diagnoses that included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities).During a review of Resident 1's Order Summary Report, dated 1/20/2026, the Order Summary Report indicated fasting blood sugar fingerstick check (FBS- using a small, portable device to check a resident's current blood glucose level by pricking their fingertip) two times a day, notify the physician if blood sugar is less than 70 mg/dl or more than 250 mg/dl.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/21/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 1/27/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 4/2026, the MAR indicated the following:1. 4/17/2026, at 7 a.m.- 275 mg/dl2. 4/18/2026, at 5 p.m.- 285 mg/dl3. 4/19/2026, at 7 a.m.- 254 mg/dlDuring a review of Resident 1's Progress Notes, dated 4/17/2026, to 4/19/2026, the Progress Notes did not indicate documentation of physician notification for blood sugar over 250 mg/dl.During an interview on 5/19/2026, at 1:27 a.m., with Assistant Director of Staff Development 1 (ADSD 1), ADSD 1 stated he (ADSD 1) might have forgotten to document physician notification of elevated blood sugar on 4/17/2026, at 7 a.m. ADSD 1 stated if no documentation it means physician was not notified. ADSD 1 stated 275 mg/dl is a high blood sugar and the physician should have been notified to prevent episode of hyperglycemia.During an interview on 5/20/2026, at 10:42 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated if there was no documentation of physician notification, it means physician was not notified of Resident 1's elevated blood sugar of over 250 mg/dl. LVN 1 stated it is important to notify the physician accordingly to modify the plan of care and for immediate action to prevent hyperglycemia.During a concurrent interview and record review on 5/20/2026, at 11:29 a.m., with Registered Nurse 1 (RN 1), Resident 1's Physician Order, dated 1/20/2026, MAR, and Progress Notes, dated 4/17/2026 to 4/19/2026, were reviewed. RN 1 stated if ADSD 1, LVN 1 and LVN 2 had called the physician they should have documented in the Progress Notes. RN 1 stated ADSD 1, LVN 1 and LVN 2 should have followed the physician order to notify if Resident 1's blood sugar was over 250 mg/dl to prevent hyperglycemia that could result in uncontrolled blood sugar. During an interview on 5/21/2026, at 12:05 p.m., with the Risk Management Nurse (RMN), the RMN stated ADSD 1, LVN 1 and LVN 2 should have notified the physician according to physician order. The RMN stated if physician not notified, Resident 1 would not receive appropriate medication to lower the blood sugar. The RMN stated Resident 1 could experience hyperglycemia.During a review of facility's policy and procedure (P&P) titled, Diabetic Care, dated 8/1/2014,and last reviewed on 1/26/2026, the P&P indicated, In any case where the resident's blood sugar is less than 70 or greater than 350, the Attending Physician must be notified; unless otherwise noted on the Physician's order.Document the episode in the resident's medical record including: .D. Physician notification.b. During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 4/5/2023, with diagnoses that included chronic combined congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic kidney disease stage 4 (kidneys are severely damaged and operating at 15 percent [%] to 29% capacity. It is the final stage before kidney failure), and unspecified pulmonary hypertension (high blood pressure in the blood vessels that supply the lungs). During a review of Resident 9's Physician Order, dated 6/15/2024, the Physician Order indicated 1,000 milliliters (ml- a metric unit of volume equal to one-thousandth of a liter) daily fluid restriction.During a review of Resident 9's H&P, dated 3/20/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions.During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decisions were intact. The MDS indicated Resident 9 was on diuretic (sometimes called water pills, help remove extra fluid from the body).During a review of Resident 9's Order Review History Report, dated 4/9/2026, the Order Review History Report indicated the following orders:1. Bumetanide (medication used to eliminate excess fluid buildup in the body) tablet 2 mg, give one tablet by mouth daily for fluid retention.2. Metolazone (medication used to eliminate excess fluid buildup in the body) tablet 2.5 mg, give one tablet by mouth daily for water retention. During a review of Resident 9's MAR, dated 4/2026, the MAR indicated the following daily fluid intake:1. 4/1/26, 1300 ml2. 4/5/26, 1300 ml3. 4/9/26, 1100 ml4. 4/10/26, 1300 ml5. 4/11/26, 1100 ml6. 4/14/26, 1300 ml7. 4/16/26, 1300 ml8. 4/18/26, 1500 ml9. 4/19/26, 1300 ml10. 4/20/26, 1200 ml11. 4/21/26, 1200 mlDuring a concurrent interview and record review on 5/20/2026, at 11:29 a.m., with RN 1, Resident 9's Physician Order, dated 6/15/2024, and MAR, dated 4/2026, were reviewed. RN 1 stated bumetanide and metolazone are both diuretics and Resident 9was on fluid restriction of 1,000 ml a day. RN 1 stated there were 11 days in Resident 9's MAR, dated 4/2026, that Resident 9 received more than 1,000 ml a day. RN 1 stated nurses should follow the physician order. RN 1 stated Resident 9 could have pulmonary edema (a dangerous buildup of fluid in the lungs) from excess fluid intake.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated nurses should have documented accurately and follow the physician order. The RMN stated Resident 9 could have fluid overload.During a review of facility's policy and procedure (P&P) titled, Physician Orders, dated 5/1/2019, and last reviewed on 1/26,2026, the P&P indicated, Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order.

Based on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice to prevent pressure injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence) for three of nine sampled residents (Residents 3, 4, and 6) by failing to:1. Ensure Treatment Nurse 1 (TN 1) provided wound treatment to Resident 3's pressure injuries on 5/14/2026.2. Ensure TN 1 assessed Resident 3's skin accurately on 5/10/2026.3. Ensure accurate treatment was provided to Resident 4 from 5/11/2026, when the physician changed the treatment from zinc oxide (a medicated cream, ointment or paste that treats or prevents skin irritation like cuts, burns or diaper rash) to hydrogel (promotes wound healing by maintaining a moist environment, cooling the skin, and softening dead tissue to allow the body to naturally clear it away).4. Ensure TN 2 assessed Resident 4's skin accurately on 5/7/2026.5. Ensure TN 1 assessed Resident 4's skin weekly and documented on 5/14/2026.6. Ensure TN 1 provided wound treatment to Resident 6's pressure injuries on 5/14/2026.These failures had the potential for the development and worsening of Residents 3, 4 and 6's pressure injuries.Findings:a. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 8/13/2025, with diagnoses that included vascular (having to do with the blood vessels and circulation) dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial weakness, heaviness, or numbness on just one entire side of your body) following cerebral infarction (a critical medical emergency caused by a blocked or narrowed blood vessel in the brain).During a review of Resident 3's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/21/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 3 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 3's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 5/2/2026, the COC indicated unstageable (a severe full-thickness skin and tissue loss where the true depth of the damage cannot be assessed) right heel pressure injury and the physician ordered Santyl (medication used to remove dead tissue from chronic skin ulcers [open, crater-like sores that develop when the skin breaks down and underlying tissue is exposed] and severe burns) ointment 250 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount) daily.During a review of Resident 3's Order Recap Report (Physician Order), dated 5/8/2026, the Order Recap Report indicated the following orders:1. Hydrogel wound dressing to sacral-coccyx (tailbone) right buttocks topically (applying something directly to the surface of the body), daily and as needed for excoriation (a scrape or scratch to the skin).2. Santyl external ointment 250 units per gram, apply to left inner knee topically daily for unstageable pressure injury and cover with collagen dressing (an advanced medical bandage made from natural proteins that promotes wound healing).During a review of Resident 3's Treatment Administration Record (TAR- flowsheet that indicates treatment given to a resident), dated 5/2026, the TAR indicated on 5/14/2026, treatment for right heel, right buttocks and left inner knee were left blank.During a concurrent interview and record review on 5/19/2026, at 10:26 a.m., with TN 1, Resident 3's TAR, dated 5/2026, were reviewed. The TAR indicated blank treatment on 5/14/2026. TN 1 stated if TAR was left blank it means treatment was not provided. TN 1 stated she (TN 1) was the assigned TN to Resident 3 on 5/14/2026.During an interview on 5/20/2026, at 11:29 p.m., with Registered Nurse 1 (RN 1), RN 1 stated if TAR was left blank it means treatment was not provided. RN 1 stated if treatment is not provided a pressure injury can worsen.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated TNs should provide the treatment according to the physician order and document that treatment was provided. The RMN stated if left blank it means TNs did not change the residents dressing. The RMN stated residents' pressure injuries can worsen.b. During a review of Resident 3's COC, dated 5/8/2026, the COC indicated unstageable pressure injury to left inner knee and left buttocks.During a review of Resident 3's Skin Check, dated 5/10/2026, the Skin Check only indicated right heel unstageable pressure injury.During a concurrent interview and record review on 5/21/2026, at 11:20 a.m., with TN 1, Resident 3's COC, dated 5/8/2026, and Skin Check, dated 5/10/2026, were reviewed. TN 1 stated she (TN 1) did not include the unstageable pressure injury on the left inner knee and left buttocks from the 5/8/2026 COC to the Skin Check, dated 5/10/2026. TN 1 she (TN 1) should have completely documented all pressure injuries to show that skin assessment was done thoroughly. TN 1 stated it resulted in Resident 3's inaccurate skin assessment. During an interview on 5/21/2026, at 12:05 p.m. with the RMN, the RMN stated TNs should do a weekly skin check to assess residents' skin for any new and ongoing skin issues. The RMN stated that because Resident 3's skin was not accurately assessed, Resident 3's pressure injury can worsen.c. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 3/13/2026, with diagnoses that included unspecified (unconfirmed) respiratory failure, unspecified dementia and generalized muscle weakness.During a review of Resident 4's H&P, dated 3/14/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decisions were intact.During a review of Resident 4's Order Recap Report, dated 5/6/2026, the Order Recap Report indicated zinc oxide ointment 10 percent (%-for every 100) to stage two left buttocks pressure injury twice a day.During a review of Resident 4's Progress Notes, dated 5/11/2026, the Progress Notes indicated the Wound Care Provider (WCP) came and assessed Resident 4's pressure injury. The Progress Notes indicated the treatment for stage two left buttocks was changed to hydrogel daily.During a review of Resident 4's TAR, dated 5/2026, the TAR indicated zinc oxide applied to left buttocks twice a day from 5/11/2026 to 5/14/2026.During a concurrent observation and interview on 5/19/2026, at 9:20 a.m., with TN 1, at Resident 4's bedside, TN 1 was standing on Resident 4's right side while Registered Nurse 1 (RN 1) on the left side of Resident 4, assisting TN 1 with dressing change. Observed TN 1 cleansed Resident 4's stage two left buttocks pressure injury with saline (salt water) wet gauze, then TN 1 removed her (TN 1) gloves, used alcohol-based hand rub (often called hand sanitizer-is a liquid or gel used to quickly kill germs on your hands), don (put on) gloves, and dry wound with gauze. Observed TN 1 removed gloves, took a tongue depressor (a medical instrument made of wood), and used to apply zinc oxide to Resident 4's left buttocks pressure injury and applied a new foam dressing with no gloves.During a concurrent interview and record review on 5/19/2026, at 10:42 a.m. with TN 1, Resident 4's WCP Progress Notes, dated 5/11/2026, was reviewed. TN 1 stated she (TN 1) had applied zinc oxide to Resident 4's left buttocks stage two pressure injury. TN 1 stated she (TN 1) should have used hydrogel as per WCP order since 5/11/2026. TN 1 stated using medication not ordered by the WCP can slow the healing process of Resident 4's pressure injury.During an interview on 5/20/2026, at 11:29 a.m., with RN 1, RN 1 stated TNs should read the wound care notes and carry out the new orders. RN 1 stated hydrogel should have been applied to Resident 4's left buttocks since 5/11/2026, as per physician order.During an interview on 5/21/2026, at 12:05 p.m. with the RMN, the RMN stated TNs should check the WCP Progress Notes. The RMN stated not using the ordered treatment can result in Resident 4's wound regressing (to return to a former, usually less developed or worse) instead of improving.d. During a review of Resident 4's COC, dated 5/6/2026, the COC indicated stage two pressure injury to left buttocks.During a review of Resident 4's Skin Check, dated 5/7/2026, the Skin Check indicated below left elbow bruising. During a concurrent interview and record review on 5/21/2026, at 8:33 a.m., with TN 2, Resident 4's COC, dated 5/6/2026, and Skin check, dated 5/7/2026, were reviewed. TN 2 stated Skin Check on 5/7/2026, should include the COC on 5/6/2026, that Resident 4 had stage two pressure injury on the left buttocks. TN 2 stated Skin Check on 5/7/2026 was not complete. TN 2 stated Resident 4 had incomplete skin assessment on 5/7/2026.During an interview on 5/21/2026, at 12:05 p.m. with RMN, the RMN stated TNs should assess Resident 4 's skin weekly and document in the Skin Check. The RMN stated incomplete Skin Check indicated incomplete skin assessment. The RMN stated that incomplete skin assessment could potentially result in worsening of pressure injury.e. During a concurrent interview and record review on 5/21/2026, at 8:33 a.m., with TN 2, Resident 4's Skin Checks, dated 5/2026, were reviewed. TN 2 stated weekly skin check was performed to keep track of resident's skin, identify problem areas and notify the physician to obtain treatment. TN 2 stated latest documented Skin Check for Resident 4 was on 5/7/2026. TN 2 stated TN 1 was the assigned TN for Resident 4 on 5/14/2026, when Skin Check was not done. TN 2 stated there was no documented Skin Check on 5/14/2026. TN 2 stated there was a glitch (a brief, unexpected malfunction or temporary fault in a system) in the computer documentation that took out the skin check schedule.During an interview on 5/21/2026, at 9:45 a.m., with Information System (IS) staff, the IS stated Resident 4 was not affected by the glitch in skin check schedule.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated TNs should assess residents' skin weekly and document findings. The RMN stated not doing a weekly skin check could potentially result in unidentified skin problems and could worsen pressure injury.f. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 3/31/2025, with diagnoses that included chronic respiratory failure, and history of fall.During a review of Resident 6's H&P, dated 9/22/2025, the H&P indicated Resident 6 had fluctuating capacity to understand and make decisions.During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 6 was dependent on staff for ADL. The MDS indicated Resident 6 had one stage two pressure injuries, and three unstageable pressure injuries.During a review of Resident 6's Order Review History Report, dated 4/20/2026, the Order Review History Report indicated cleanse coccyx stage two pressure injury with normal saline, gently pat dry, apply nickel thick Santyl ointment, then cover with foam dressing daily.During a review of Resident 6's Order Review History Report, dated 4/25/2026, the Order Review History Report indicated cleanse right buttocks unstageable pressure injury with normal saline, pat dry, apply Santyl and cover with foam dressing.During a review of Resident 6's Order Review History Report, dated 5/6/2026, the Order Review History Report indicated applying silver sulfadiazine (a prescription topical antibiotic primarily used to prevent and treat infections in severe second- and third-degree burns) cream one percent (%) to buttocks skin tear daily.During a review of Resident 6's Order Review History Report, dated 5/6/2026, the Order Review History Report indicated cleanse left heel deep tissue injury (DTI-a serious form of pressure sore where the soft tissue under intact skin is damaged) with normal saline, pat dry, paint betadine (used on the skin to treat or prevent skin infection in minor cuts, scrapes, or burns) 10% and cover with dry dressing and secure with tape.During a review of Resident 6's Order Review History Report, dated 5/13/2026, the Order Review History Report indicated cleanse left heel with normal saline, pat dry, apply Santyl, cover with foam dressing topically daily for unstageable pressure injury.During a review of Resident 6's TAR, dated 5/2026, the TAR indicated the treatment for following pressure injuries were left blank on 5/14/2026.1. coccyx stage two pressure injury with Santyl.2. left heel unstageable pressure injury with Santyl3. left heel DTI with betadine4. right buttocks unstageable with Santyl.5. left buttocks skin tear with silver sulfadiazineDuring a concurrent interview and record review on 5/19/2026, at 10:26 a.m., with TN 1, Resident 6's Physician Orders, dated 4/20/2026, 4/25/2026, 5/6/2026 and 5/13/2026, and TAR, dated 5/2026, were reviewed. TN 1 stated treatment for Resident 6's skin issues were left blank on 5/14/2026. TN 1 stated blank means treatment not provided since it was not documented.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated a blank TAR indicated treatment was not provided. The RMN stated TN should provide the treatment per physician order and document. The RMN stated if treatment is not done, Resident 6's wounds can worsen.During a review of facility's policy and procedure (P&P) titled, Wound Management, dated 11/1/2017, and last reviewed on 1/26/2026, the P&P indicated, To provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers. A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing.1. AssessmentA. A Licensed Nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident.C. Implement a wound treatment per physician's order.2. Wound Management.Per Attending Physician order, the Nursing Staff will initiate treatment and utilize interventions for pressure redistribution and wound management.3. Documentation.B. Wound documentation will occur at a minimum of weekly until the wound is healed.During a review of facility's P&P titled, Pressure Ulcer Prevention, dated 2/1/2015, and last reviewed on 1/26/2026, the P&P indicated, The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development.1. Risk Identification and Assessment: .B. The Licensed Nurse will conduct a skin assessment for a resident upon admission, readmission, weekly, and as needed. Results of the weekly skin assessment will be documented in the medical record.During a review of facility's P&P titled, Medication Administration, dated 7/1/2016, and last reviewed on 1/26/2026, the P&P indicated, If the Attending Physician increases or changes a medication order, this is an automatic stop or discontinue order for the original order.XIX. Documentation.B. Recording will include the date, the time and the dosage of the medication or type of treatment.

Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for one of four sampled residents (Resident 9) by failing to ensure nurses administer hydrocodone (medication used to treat severe and persistent pain) and morphine (a strong pain-relief medicine that can cause life-threatening breathing problems) for severe pain level as per physician order.These failures had the potential to result in Resident 9's sedation (state of calmness, relaxation, or sleepiness caused by certain drugs) that could lead to slow and shallow breathing.Findings:During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 4/5/2023, with diagnoses that included generalized muscle weakness and unspecified (unconfirmed) polyarthritis (inflammation affecting five or more joints simultaneously. It causes joint pain, swelling, and stiffness). During a review of Resident 9's Order Review History Report, dated 6/4/2023, the Order Review History Report indicated the following orders:1. Tylenol (medication used to treat pain and fever) oral tablet 325 milligram (mg-metric unit of measurement, used for medication dosage and/or amount), give two tablets by mouth every four hours as needed for mild (pain level from 1 to 3 out of 10) pain or general discomfort.2. Acetaminophen (medication used to treat pain and fever) suppository (a medication designed to be inserted into the anus) 650 mg, insert one suppository rectally (giving a medication through the anus) every four hours as needed for mild pain or general discomfort if unable to tolerate by mouth.During a review of Resident 9's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/20/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS-a resident assessment tool), dated 4/1/2026, the MDS indicated Resident 9's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 9's Order Review History Report, dated 4/18/2026, the Order Review History Report indicated hydrocodone-acetaminophen oral tablet 5-325 mg, give one tablet by mouth every four hours as needed for severe pain (pain level between seven to ten out of 10 pain) for one month.During a review of Resident 9's Order Review History Report, dated 4/21/2026, the Order Review History Report indicated morphine sulfate solution 20 mg/ milliliter (ml- a metric unit of volume equal to one-thousandth of a liter), give 0.25 ml by mouth every two hours as needed for severe pain.During a review of Resident 9's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 4/2026, the MAR indicated nurses administered morphine on the following dates and time:1. on 4/22/2026 at 6:57 p.m., with a pain level of 3/10.2. on 4/24/2026 at 3:33 a.m., with a pain level of 5/103. on 4/23/2026 at 8:47 p.m., with a pain level of 6/104. on 4/24/2026 at 6:50 a.m., with a pain level of 6/10.5. on 4/24/2026 at 6:38 p.m., with a pain level of 6/10. During a review of Resident 9's MAR, dated 4/2026, the MAR indicated the following:1. Nurses administered hydrocodone to Resident 9 who had a pain level of 0/10 (no pain) on 4/9/2026 at 6:52 p.m.2. Nurses administered hydrocodone to Resident 9 who had a pain level of 4/10 on the following dates and times: -4/3/2026, at 10:11 a.m. -4/9/2026, at 10:51 p.m. -4/10/2026, at 6:02 a.m. -4/10/2026, at 3:51 p.m. -4/11/2026, at 1 a.m. -4/11/2026, at 8:39 p.m. - 418/2026, at 6:27 a.m.3. Nurses administered hydrocodone to Resident 9 who had a pain level of 5/10 on the following dates and times: -4/5/2026, at 9 p.m. -4/6/2026, at 2:11 a.m. -4/7/2026, at 3:44 a.m. - 4/8/2026, at 8:30 p.m. -4/9/2026, at 5:48 a.m. -4/11/2026, at 6:37 a.m. -4/12/2026, at 10:41 a.m. -4/15/2026, at 9:30 p.m.4. Nurses administered hydrocodone to Resident 9 who had a pain level of 6/10 on: - 4/17/2026, at 9:55 a.m.During a concurrent interview and record review on 5/20/2026, at 11:29 a.m. with RN 1, Resident 9's Physician Order, dated 6/4/2023, 4/18/2026, 4/21/2026, and MAR, dated 4/2026, were reviewed. RN 1 stated severe pain is a pain level from 7 to 10. RN 1 stated a pain level of 0/10 means no pain and LVN 2 should have not administered hydrocodone to Resident 9 on 4/9/2026, at 6:52 p.m. RN 1 stated pain level of 4/10 to 6/10 were moderate pain and the nurses should have called and obtain an order from the physician for pain medication to address moderate pain since Resident 9 did not have any pain medication for moderate pain. RN 1 stated nurses administered pain medication not for Resident 9's pain level. RN 1 stated that giving stronger pain medication can cause dizziness and could cause poor appetite.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated severe pain is from level 7 to 10 out of 10. The RMN stated LVN 2 should not administer hydrocodone which is for severe pain as per physician order if Resident 9 had 0/10 pain. The RMN stated nurses should have clarified the orders. The RMN stated nurses must follow the physicians order and administer pain medication according to Resident 9's pain level. The RMN stated that receiving stronger pain medication more than Resident 9's pain could cause sleepiness resulting in less food intake and might slow Resident 9's respiration.During a review of facility's policy and procedure (P&P) titled, Pain Management, dated 8/1/2024, and last reviewed on 1/26/2026, the P&P indicated, To ensure accurate assessment and management of the resident's pain. A Licensed Nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain.II. Pain ManagementA. The Licensed Nurse will administer pain medication as ordered and document all medication administered on the Medication Administration Record (MAR).

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for three of five sampled residents (Residents 3, 5, and 6) by failing to:1. Ensure Licensed Vocational Nurse 4 (LVN 4) and LVN 5 follow physician order to hold (to temporarily pause or skip a dose as instructed by a healthcare professional) metoprolol (medication used to treat hypertension [HTN- high blood pressure]) for Resident 3's systolic blood pressure (sbp- the top or first number in a blood pressure reading. It measures the maximum pressure the blood exerts against the artery walls when the heart beats and pumps blood throughout the body) below 120-millimeters of mercury (mmHg-standard unit of measurement for pressure).2. Ensure LVN 6 follow physician order to hold amlodipine (medication used to treat HTN) and metoprolol for Resident 5's sbp below 110 mmHg.3. Ensure LVN 7 follow physician order to hold midodrine (medication used to treat low blood pressure) for Resident 6's sbp above 120 mmHg. These failures had the potential to result in medication errors and could result in Resident 3 and 5's hypotension (low blood pressure) and Resident 6's HTN.Findings:a. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 8/13/2025, with diagnoses that included essential HTN.During a review of Resident 3's Order Audit Report, dated 4/20/2026, the Order Audit Report indicated metoprolol tartrate tablet, given 12.5 milligram (mg-metric unit of measurement, used for medication dosage and/or amount) by mouth twice a day for HTN, hold for sbp less than 120 mmHg.During a review of Resident 3's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/21/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a review of Resident 3's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 5/2026, the MAR indicated the following:1. LVN 5 administered metoprolol on 5/7/2026, at 9 a.m., with a blood pressure of 115/75 mmHg.2. LVN 4 administered metoprolol on 5/1/2026, at 5 p.m. with a blood pressure of 119/76 mmHg.3. LVN 4 administered metoprolol on 5/2/2026, at 5 p.m., with a blood pressure of 115/69 mmHg. 4. LVN 4 administered metoprolol on 5/5/2026, at 5 p.m. with a blood pressure of 117/79 mmHg.During an interview on 5/19/2026, at 11:29 a.m., with LVN 5, LVN 5 stated he (LVN 5) should have held the metoprolol as per physician order. LVN 5 stated Resident 3 could possibly get dizzy and fall because blood pressure was low.During an interview on 5/20/2026, at 10:49 a.m., with LVN 4, LVN 4 stated usually the physician's parameter (set of specific clinical guidelines that dictate how a treatment or medication should be administered) was to hold blood pressure medication below 110 mmHg. LVN 4 stated the physician might have changed the order to hold metoprolol below 120 mmHg. LVN 4 stated she (LVN 4) had given the metoprolol because she (LVN 4) had documented it was given. LVN 4 stated she (LVN 4) should have checked the physician order first. LVN 4 stated Resident 3 could develop hypotension. During an interview on 5/20/2026, at 11:29 a.m., with Registered Nurse 1 (RN 1), RN 1 stated LVN 4 and LVN 5 should have read the physician order before medication administration. RN 1 stated that because blood pressure medication was administered to Resident 3, below the blood pressure parameter, Resident 3 could experience hypotension.During an interview on 5/21/2026, at 12:05 p.m., with the Risk Management Nurse (RMN), the RMN stated LVN 4 and LVN 5 should have validated the physician order and held the metoprolol if sbp is below 120 mmHg. The RMN stated Resident 3's blood pressure could drop and cause hypotension.b. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 10/2/2018, with diagnoses that included congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 5's Order Review History Report, dated 10/9/2025, the Order Review History Report indicated the following order:1. metoprolol tartrate tablet 25 mg, give half a tablet via gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) in the morning and at bedtime, hold for sbp less than 110 mmHg.2. amlodipine besylate tablet five mg, give one tablet via g-tube daily for HTN, hold for sbp less than 110 mmHg.During a review of Resident 5's H&P, dated 10/10/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decisions were severely impaired.During a review of Resident 5's MAR, dated 5/2026, the MAR indicated on 5/4/2026, at 9 a.m., LVN 6 administered amlodipine and metoprolol to Resident 5 who had a blood pressure of 97/54 mmHg.During a concurrent interview and record review on 5/20/2026, at 11:29 a.m., with RN 1, Resident 5's Physician Order, dated 10/9/2025, and MAR, dated 5/4/2026, were reviewed. RN 1 stated LVN 6 documented that she (LVN 6) administered amlodipine and metoprolol to Resident 5 on 5/4/2026, at 9 a.m., with a blood pressure of 97/54 mmHg. RN 1 stated Resident 5's blood pressure can drop and cause hypotension.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated the physician ordered to hold the amlodipine and metoprolol if blood pressure is below 110 mmHg. The RMN stated LVN 6 should have held the medications to prevent hypotension.c. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 3/31/2025, with diagnoses that included unspecified hypotension and history of falling.During a review of Resident 6's Order Review History Report, dated 9/19/2025, the Order Review History Report indicated an order for midodrine hydrochloride tablet 10 mg, give one tablet by mouth three times a day for hypotension, hold for sbp greater than 120 mmHg.During a review of Resident 6's H&P, dated 9/22/2025, the H&P indicated Resident 6 had fluctuating capacity to understand and make decisions.During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decisions were moderately impaired.During a review of Resident 6's MAR, dated 5/2026, the MAR indicated on 5/10/2026, at 1 p.m., LVN 7 administered midodrine to Resident 6 at the following times:1. 9 a.m., with blood pressure of 122/62 mmHg.2. 1 p.m., with a blood pressure of 126/68 mmHg.During a concurrent interview and record review on 5/20/2026, at 11:29 a.m., with RN 1, Resident 6's Physician Order, dated 9/19/2025, and MAR, dated 5/10/2026, were reviewed. RN 1 stated LVN 7 should have followed the physician order and held the midodrine. RN 1 stated Resident 6 could have elevated blood pressure because physician order was not followed.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated LVN 7 should have held the midodrine per physician order to prevent HTN.During a review of facility's policy and procedure (P&P) titled, Medication Administration, dated 7/1/2016, and last reviewed on 1/26/2026, the P&P indicated, To provide practice standards for safe administration of medications for residents in the Facility.I. Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner.VI. Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required and the results recorded.VII. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record (blood pressure, pulse, finger stick blood glucose monitoring).

Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for four of nine sampled residents (Residents 4, 6, 10, and 11) during treatment cart storage observation by failing to:1. Ensure Resident 4's nystatin cream (medication used to treat skin infections caused by yeast) was labeled with an open date.2. Ensure Resident 6's Silver Silvadene cream (medication used to prevent, manage, and treat burn wound infections) was labeled with an open date.3. Ensure Resident 10's Santyl (medication used to clean dead, damaged tissue from severe burns and chronic skin ulcers [a small open sore or wound generally found in the stomach or on the skin]) was labeled with an open date.4. Ensure Resident 11's Dakins solution (diluted bleach used to kill germs without hurting a healing wound) was labeled with an open date.These failures had the potential to cause medication errors and could possibly lead to unsafe medication administration affecting Residents 4, 6, 10, and 11.Findings:During an interview on 5/15/2026, at 11:47 a.m., with Treatment Nurse (TN) 4, TN 4 stated the facilities treatment cart was not organized and medications had no written open dates.During a concurrent observation and interview on 5/19/2026, at 8:50 a.m., with TN 1, facility's treatment cart for station A was reviewed. TN 1 stated the following medications did not have an open date written on the medication. TN 1 stated each medication once opened should have a written open date.1. Resident 4's nystatin-triamcinolone cream.2. Resident 6's Silver Silvadene cream one percent (%)3. Resident 10's Santyl external ointment 250 unit per gram4. Resident 11's Dakins solution.During an interview on 5/20/2026, at 11:29 a.m. with Registered Nurse 1 (RN 1), RN 1 stated nurses should write the open date on the multidose medications when they open the medication so it can be discarded timely before the 30th day.During an interview on 5/21/2026, at 12:05 p.m., with the Risk management Nurse (RMN), the RMN stated it is important to write the open date on multidose medication to know when it should be discarded. The RMN stated it is the facility's policy to write the open date on the medication container.During a review of facility's policy and procedure (P&P), titled, Specific Medication Administration Procedures, dated 4/2008, and last reviewed on 1/26/2026, the P&P indicated, To administer medications in a safe and effective manner.E. Check expiration date on package/container. When opening a multi-dose container, place the date on the container.

Based on interview and record review, the facility failed to maintain accurate and complete medical record for three of nine sampled residents (Residents 3, 8, and 9) by failing to:1. Ensure accurate documentation of Resident 3's location of pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) on 5/8/2026.2. Ensure accurate documentation of Resident 8's location of pressure ulcer in the weekly Skin Checks on 4/23/2026, 4/30/2026, and 5/7/2026.3. Ensure accurate documentation of Resident 8's right heel deep tissue injury (DTI-purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) on 5/2026 Treatment Administration Record (TAR).4. Ensure accurate documentation of Resident 9's weekly Skin Check on 4/16/2026.These failures had the potential to cause confusion in the care and the medical records containing inaccurate documentation for Residents 3, 8, and 9.Findings:a. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 8/13/2025, with diagnoses that included vascular (having to do with the blood vessels and circulation) dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (partial weakness, heaviness, or numbness on just one entire side of your body) following cerebral infarction (a critical medical emergency caused by a blocked or narrowed blood vessel in the brain).During a review of Resident 3's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/21/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.During a review of Resident 8's Change in Condition (CIC), dated 5/8/2026, the CIC indicated Resident 3 had unstageable pressure ulcer (a severe wound where the true depth and severity cannot be seen because it is completely obscured by dead tissue) to left inner knee and left buttocks. The CIC indicated Treatment Nurse 1 (TN 1) obtained an order of Santyl (medicine that removes dead tissue from wounds so they can start to heal) for unstageable pressure ulcer to left inner knee and hydrogel (medication used to promote wound healing, deliver medications and hydrate skin) for right buttocks excoriation (a scrape or scratch to the skin).During a concurrent interview and record review on 5/19/2026, at 10:26 a.m., with TN 1, Resident 3's CIC dated 5/8/2026, was reviewed. TN 1 stated Resident 3 had excoriation to right buttocks and not the left buttocks as indicated in the 5/8/2026 CIC. TN 1 stated she (TN 1) documented the wrong location of excoriation.During an interview on 5/20/2026, at 11:29 a.m., with Registered Nurse 1 (RN 1), RN 1 stated TN 1 made an incorrect documentation. RN 1 stated Resident 3 had excoriation on the right buttocks. RN 1 stated TN 1 should document accurately.During an interview on 5/21/2026, at 12:05 p.m., with the Risk Management Nurse (RMN), the RMN stated TN 1 made an inaccurate documentation in Resident 3's CIC on 5/8/2026. The RMN stated TN 1 should document accurately. The RMN stated inaccurate documentation of location of wound could result in inaccurate treatment provided.b. During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 2/20/2026, with diagnoses that included stage three right heel pressure ulcer (full-thickness loss of skin. Dead and black tissue may be visible) and generalized weakness.During a review of Resident 8's H&P, dated 2/20/2026, the H&P indicated Resident 8 did not have the capacity to understand and make decisions.During a review of Resident 8's Care Plan, dated 2/25/2026, the Care Plan indicated stage three right heel pressure ulcerDuring a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 8 had one stage three pressure ulcer.During a review of Resident 8's Progress Notes, dated 4/19/2026, the Progress Notes indicated Resident 8 had stage three pressure ulcer to right heel.During a review of Resident 8's Skin Check, dated 4/23/2026, the Skin Check indicated TN 4, documented left heel stage three pressure ulcer.During a review of Resident 8's Skin Check, dated 4/30/2026, the Skin Check indicated TN 4 documented left heel stage three pressure ulcer.During a review of Resident 8's Skin Check, dated 5/7/2026, the Skin Check indicated TN 2 documented left heel stage three pressure ulcer.During an interview on 5/19/2026, at 10:42 a.m., with TN 1, TN 1 stated Resident 8 had no pressure ulcer to the left heel only in the right heel.During an interview on 5/19/2026, at 1:30 p.m., with TN 2, TN 2 stated Resident 8 had right heel pressure ulcer and not in left heel. TN 2 stated he (TN 2) should have documented accurately the correct location of stage three pressure ulcer.During an interview on 5/20/2026, at 11:29 a.m., with RN 1, RN 1 stated TN 2 documented the wrong site of pressure ulcer. RN 1 stated TN 2 should have documented pressure ulcer to right heel instead of the left heel.During an interview on 5/21/2026, at 12:05 p.m., with the RMN, the RMN stated TN 2 should assess Resident 8's skin weekly and document accurately in the Skin Check to prevent confusion in care.c. During a review of Resident 8's Progress Notes, dated 5/4/2026, the Progress Notes indicated the Wound Care Provider (WCP) assessed Resident 8 with unstageable pressure ulcer to upper mid back and DTI to right heel.During a review of Resident 8's Order Audit Report, dated 5/7/2026, the Order Audit Report indicated TN 2 obtained an order to clean right heel stage three pressure ulcer with normal saline (salt water) and paint with betadine (powerful, dark-brown liquid or ointment used to kill germs on the skin, clean minor cuts and scrapes, and prevent infections) daily.During a review of Resident 8's TAR, dated 5/2026, the TAR indicated daily treatment was provided to Resident 8's right heel stage three pressure ulcer with betadine.During a concurrent interview and record review on 5/19/2026, at 10:42 a.m., with TN 1, Resident 8's Progress Notes, dated 5/4/2026, and TAR dated 5/2026, were reviewed. TN 1 stated the WCP came on 5/4/2026 and assessed Resident 8 with right heel DTI. TN 1 stated TAR for right heel had a wrong documentation of the stage of pressure ulcer as it still indicated right heel stage three instead of DTI, but the treatment was already correct with betadine.During an interview on 5/20/2026, at 11:29 a.m., with RN 1, RN 1 stated the treatment record had incorrect pressure ulcer staging. RN 1 stated TAR should reflect the accurate stage of pressure ulcer. RN 1 stated TNs should have seen and corrected the stage of pressure ulcer since they (TNs) provide daily treatment to Resident 8.During an interview on 5/20/2026, at 12:05 p.m., with the RMN, the RMN stated the TAR should match the physician order. The RMN stated the TAR should have been updated to ensure accurate documentation.d. During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 4/5/2023, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and generalized muscle weakness.During a review of Resident 9's H&P, dated 3/20/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions.During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decisions were intact.During a review of Resident 9's Progress Notes, dated 4/10/2026 timed at 11:29 a.m., the Progress Notes indicated Resident 9 had right shin (front part of your lower leg, specifically the area between your knee and your ankle) fluid filled blisters (a small, fluid-filled bubble or pocket that forms just under the top layer of your skin).During a review of Resident 9's Progress Notes, dated 4/10/2026, timed at 11:38 a.m. the Progress Notes indicated Resident 9 had a change in condition of multiple ruptured blisters.During a review of Resident 9's Skin Check dated 4/16/2026, the Skin Check indicated left medical foot (near the second knuckle) scab and left medial foot (near the big toe knuckle) blister.During a concurrent interview and record review on 5/19/2026, at 11:04 a.m., with TN 1, Resident 9's, COC, dated 4/10/2026, and Skin Check dated 4/16/2026, were reviewed. TN 1 stated Resident 9 had a change in condition and had blisters on the right shin. TN 1 stated the right shin did not reflect in the 4/16/2026, Skin Check. TN 1 stated whoever the TN did not document accurately. TN 1 stated it is important to conduct weekly skin check and document accurately.During an interview on 5/20/2026, at 11:29 a.m., with RN 1, RN 1 stated Resident 9 had ruptured blisters on both legs. RN 1 stated TNs did not make an accurate documentation of the skin assessment. RN 1 stated TNs should do a thorough skin assessment weekly and should make an accurate documentation of what was observed.During an interview on 5/21/2026, at 12:05 p.m. with the RMN, the RMN stated TNs should have assessed and documented accurately. The RMN stated documentation in residents medical record should be complete and accurate.During a review of facility's policy and procedure (P&P) titled, Wound Management, dated 11/1/2017, and last reviewed on 1/26/2026, the P&P indicated, Documentation will include: .i. Location of wound.During a review of facility's P&P, titled, Documentation-Nursing, dated 1/1/2016, and last reviewed on 1/26/2026, the P&P indicated, Nursing documentation will be concise, clear, pertinent, and accurate.

Based on observation, interview, and record review, the facility failed to implement its infection control measures for two of seven sampled residents (Residents 4 and 6) by failing to:1. Ensure Resident 4's oxygen tubing (flexible tubing that carries oxygen from an oxygen source to the user) was not touching the floor.2. Ensure Treatment Nurse 1 (TN 1) wore gloves when applying new foam dressing to Resident 4's stage two pressure injury (Partial-thickness loss of skin, presenting as a shallow open sore or wound).3. Ensure Certified Nursing Assistant 1 (CNA 1) wore gown when providing bed bath to Resident 6 who was on enhanced barrier precaution (EBP- an infection control method used in nursing homes to prevent the spread of hard-to-treat germs, like antibiotic-resistant bacteria).These failures had the potential to spread and expose other residents to infection.Findings:a. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 3/13/2026, with diagnoses that included unspecified (unconfirmed) respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide), unspecified dementia (a progressive state of decline in mental abilities) and generalized weakness.During a review of Resident 4's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/14/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Set (MDS-a resident assessment tool), dated 4/22/2026, the MDS indicated Resident 4's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 4's Order Recap Report, dated 5/6/2026, the Order Recap Report indicated oxygen at three liters per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continuously for shortness of breath.During an observation on 5/15/2026, at 1:46 p.m., inside Resident 4's room, Resident 4's oxygen tubing touching the floor.During a concurrent observation and interview on 5/15/2026, at 1:49 p.m., with Licensed Vocational Nurse 3 (LVN 3), at Resident 4's bedside, LVN 3 stated Resident 4's oxygen tubing was touching the floor. LVN 3 stated oxygen tubing should not touch the floor for infection control.During an interview on 5/19/2026, at 12:45 p.m., with the Infection Preventionist (IP), the IP stated oxygen tubing should not touch the floor because it could be contaminated (something is made dirty or unsafe) and cause a spread of infection.b. During a concurrent observation and interview on 5/19/2026, at 9:19 a.m., with Registered Nurse 1 (RN 1), RN 1 stated Resident 4 was on EBP.During an observation on 5/19/2026, at 9:20 a.m., with TN 1, at Resident 4's bedside, TN 1 was standing on Resident 4's right side while Registered Nurse 1 (RN 1) on the left side of Resident 4, assisting TN 1 with dressing change. Observed TN 1 cleanse Resident 4's stage two left buttocks pressure ulcer with saline (salt water) wet gauze, then TN 1 removed her (TN 1) gloves, used alcohol-based hand rub (often called hand sanitizer-is a liquid or gel used to quickly kill germs on your hands), don (put on) gloves, and dry wound with gauze. Observed TN 1 removed gloves, took a tongue depressor (a medical instrument made of wood), and applied zinc oxide (a medicated cream, ointment or paste that treats or prevents skin irritation like cuts, burns or diaper rash) to Resident 4's left buttocks pressure injury and applied a new foam dressing with no gloves.During an interview on 5/19/2026, at 12:45 p.m., with the IP, the IP stated TN 1 should have worn gloves when applying a dressing since Resident 4 was on EBP. The IP stated wearing gloves prevents the spread of infection like multidrug resistance organism (MDRO- refers to germs that have developed resistance to three or more classes of antibiotic [medication used to treat infection]).c. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 3/31/2025, with diagnoses that included chronic respiratory failure (a long-term condition that happens when your lungs cannot get enough oxygen into your blood) and urinary tract infection (UTI- an infection in the bladder/urinary tract) with urinary device.During a review of Resident 6's Order Review History Report, dated 9/19/2025, the Order Review History Report indicated urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) to gravity, drain every shift.During a review of Resident 6's H&P, dated 9/22/2025, the H&P indicated Resident 6 had fluctuating capacity to understand and make decisions.During a review of Resident 6's Order Review History Report, dated 4/20/2026, the Order Review History Report indicated to cleanse coccyx (tailbone) stage two pressure injury (partial-thickness loss of skin, presenting as a shallow open sore or wound) with normal saline, pat dry, apply nickel thick Santyl (medication used to remove damaged tissue from chronic skin ulcers and severely burned areas) ointment then cover with foam dressing.During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 6 had a urinary catheter.During an observation on 5/15/2026, at 1:37 p.m., outside of Resident 6's room, an EBP signage posted by the door and an isolation cart with gloves, gown and mask observed. Resident 6's door was open and curtain was pulled close.During an observation on 5/15/2026, at 1:38 p.m., inside Resident 6's room, Resident 6 laying in bed with urinary catheter hanging to the right side of the bed covered with a dignity bag. Observed CNA 1 standing on the left side of Resident 6 providing bed bath.During a concurrent observation and interview on 5/15/2026, at 1:39 p.m. with CNA 1 at Resident 6 bedside. CNA 1 stated she (CNA 1) was providing bed bath to Resident 6 who had a urinary catheter. CNA 1 stated she (CNA 1) did not wear a gown and should have worn a gown before providing bed bath.During a concurrent observation and interview on 5/15/2026, at 1:41 p.m., with Assistant Director of Staff Development 2 (ADSD 2), outside of Resident 6's room. ADSD 2 stated Resident 6 had an EBP signage posted by the door that should remind staff to wear personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when providing care like bed bath. ADSD 2 went inside the room and stayed with Resident 6.During a concurrent observation and interview on 5/15/2026, at 1:43 p.m., with CNA 1 outside of Resident 6's room, CNA 1 came out of Resident 6 room without gloves. CNA 1 stated she (CNA 1) had forgotten to wear a gown before giving bed bath, CNA 1 stated she (CNA 1) had to wear a gown to protect Resident 6 from infection. Observed CNA 1 used ABHR, don gloves and gown and went back inside the room.During an interview on 5/15/2026, at 1:44 p.m. with ADSD 2, ADSD 2 stated CNA 1 did not wear a gown when providing bed bath to Resident 6 who was on EBP. ADSD 2 stated CNA 1 should have worn a gown for infection control.During an interview on 5/19/2026, at 12:45 p.m. with the IP, the IP stated CNA 1 should have worn a gown before entering the room of Residents 6 who was on EBP since she (CNA 1) knows she (CNA 1) will give a bed bath to Resident 6 and to prevent Resident 6 from MDRO.During a review of facility's policy and procedure (P&P) titled, Standard and Enhanced Precautions, dated 4/1/2024, and last reviewed on 1/26/2026, the P&P indicated, Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization (means that bacteria, fungi, or viruses are living and multiplying on or in the body, but they are not causing any harm or illness) when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (like urinary catheter.) and wounds or presence of unhealed pressure ulcers.B. Glovesi. Gloves (clean, non-sterile) are worn when direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material is anticipated.D. Gownsi. A gown is worn to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing.V. Enhanced Barrier PrecautionsB. For residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities: .i. Dressing,ii. Bathing/showering.viii. Wound care: any skin opening requiring a dressing

Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) was maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:1. Ensure Registered Nurse (RN) 1 documented the level of care provided to Resident 1 while the resident was in the facility. RN 1 documented the level of care and assessment she provided to Resident 1 on 2/10/2026. Resident 1 had a change of condition (COC) on 2/9/2026.2. Ensure social service staff documented the level of care provided to Resident 1 while the resident was in the facility. Social service staff documented Resident 1 was transferred to the General Acute Care Hospital (GACH) 1 on 2/9/2026. Resident 1 was transferred to GACH 1 on 2/10/2026. 3. Ensure Licensed Vocational Nurse (LVN) 1 documented the Tylenol oral tablet (a medication taken by mouth used to temporarily relieve minor aches, pain, and reduce fever) 650 milligrams (mg - unit of measurement) given to Resident 1 in the resident's medication administration record (MAR).These deficient practices resulted in incomplete and inaccurate information on Resident 1's medical records and had the potential for delayed medical interventions.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 3/3/2025 with diagnoses including age-related osteoporosis (a disease that makes bones thin, weak, and brittle, increasing the risk of fractures [broken bones]), unspecified dementia (a decline in brain function including memory, language, reasoning, and behavior severe enough to interfere with daily life but the specific type had not been identified), and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 1's Physician Orders, dated 3/3/2025, the Physician Orders indicated Tylenol oral tablet 325 mg, give two tablets every four hours as needed for mild pain or general discomfort. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired. During a review of Resident 1's COC Evaluation, dated 2/9/2026, the COC Evaluation indicated Resident 1 complained of right hip pain. The COC Evaluation indicated Resident 1 was given Tylenol for the right hip pain. The COC Evaluation indicated on 2/9/2026 at 2:45 p.m., Resident 1's Attending Physician (MD) 1 was notified and ordered a right hip x-ray (a medical imaging that uses radiation to take pictures of the inside of a body). During a review of Resident 1's COC Evaluation, dated 2/10/2026, the COC Evaluation indicated the facility received Resident 1's x-ray results. The COC Evaluation indicated on 2/10/2026 at 8:05 a.m., Resident 1's Attending Physician (MD) 1 was notified and ordered to transfer the resident to GACH 1. During an interview on 2/24/2026 at 3:15 p.m., and concurrent record review of Resident 1's Progress Notes, dated 2/9/2026 to 2/10/2026, reviewed with RN 1, RN 1 stated she assessed Resident 1 after the resident's COC on 2/9/2026. RN 1 stated Resident 1's Progress Notes indicated she documented her assessment of the resident's COC on 2/10/2026. RN 1 stated Resident 1's Progress Notes did not indicate the assessment documented on 2/10/2026 was a late entry for the assessment done on 2/9/2026. RN 1 stated the documented assessment on Resident 1's Progress Notes was not timely and was not accurate. RN 1 stated Resident 1's Progress Notes, dated 2/10/2026, indicated social services documented the resident was transferred to GACH 1 on 2/9/2026. RN 1 stated Resident 1 was transferred to GACH 1 on 2/10/2026. RN 1 stated the social services documentation on Resident 1's transfer to GACH 1 was inaccurate. RN 1 stated on 2/9/2026, she witnessed LVN 1 giving Resident 1 two tablets of Tylenol 325 mg. RN 1 stated there was no documented evidence on Resident 1's MAR, dated 2/1/2026 to 2/28/2026, that Resident 1 received two tablets of Tylenol 325 mg on 2/9/2026. During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated RN 1 did not timely document Resident 1's assessment after the COC on 2/9/2026. The DON stated Resident 1's Progress Notes, dated 2/10/2026, should indicate RN 1's documented assessment was a late entry for 2/9/2026. The DON stated Resident 1 was transferred to GACH 1 on 2/10/2026. The DON stated the social services documentation should indicate the correct date of Resident 1's transfer to GACH 1. The DON stated inaccurate documentation had the potential to cause confusion amongst the care team that may negatively affect resident care. The DON stated inaccurate documentation of Resident 1's transfer to GACH 1 had the potential to cause confusion on the resident's 7-day bed hold. The DON stated Resident 1's MAR did not indicate the two tablets of Tylenol 325 mg were given to Resident 1 on 2/9/2026. The DON stated another licensed nurse may give another dose of Tylenol that may potentially cause Resident 1 to overdose. The DON stated the facility failed to provide safe care to Resident 1 by failing to document the resident assessment timely. The DON stated the facility failed to document accurately the date Resident 1 was transferred to GACH 1. The DON stated the facility failed to ensure the pain medication given to Resident 1 was documented in the resident's MAR. During a review of the facility's policy and procedure (PnP) titled, Documentation - Nursing, last reviewed on 1/26/2026, the PnP indicated the purpose to provide documentation of resident status and care given by nursing staff. The PnP indicated . F. nurse's notes are dated, timed, and signed when written. H. medication administration records and treatment administration records are completed with each medication or treatment completed. K. documentation will be completed by the end of the assigned shift. During a review of the facility's PnP titled, Medication - Administration, last reviewed on 1/26/2026, the PnP indicated the purpose to provide standards for safe administration of medications for residents in the facility. The PnP indicated the time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment. During a review of the facility's PnP titled, Completion & Correction, last reviewed on 1/26/2026, the PnP indicated the purpose to ensure that medical records are complete and accurate. The PnP indicated . II. entries will be recorded promptly as the events or observations occur, III. Entries will be complete, legible, descriptive and accurate. V. when adding an entry at a later date, the entry is to be clearly identified as a late entry, late entries should be documented as soon as possible. VII. Documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner.

Based on observation, interview, and record review, the facility failed to ensure confidential personal information for one of four sampled residents (Resident 4) was protected. The medical records of Resident 4 were left unattended on the medication cart computer. This deficient practice had the potential to violate Resident 4's rights for privacy and confidentiality of personal and medical records.Findings: During a review of Resident 4's admission Record (undated), the admission Record indicated the facility admitted the resident on 2/19/2026 with diagnoses including atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), gastroesophageal reflux disease (a condition in which the stomach contents leak backward from the stomach into the esophagus [the tube connecting the mouth and stomach]), and age-related osteoporosis (a disease that makes bones thin, weak, and brittle, increasing the risk of fractures [broken bones]). During an observation on 2/25/2026 at 9:58 a.m., observed the medication cart computer at nurse station 1 was open with Resident 4's medical record on the computer screen. Resident 4's visible medical records included the resident's name, picture, and medication list. Observed facility staff walked past the medication cart computer with Resident 4's medical information on it. During a concurrent observation and interview on 2/25/2026 at 10:02 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 4's medical records were observed on the medication cart computer. LVN 2 stated she did not lock the medication cart computer before she left to assist another resident. LVN 2 stated Resident 4's medical information was visible to the people walking on station 1 hallway. LVN 2 stated Resident 4's medical records left unattended had the potential to violate resident confidentiality. During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated Resident 4's medical records should not be left unattended. The DON stated facility staff not involved in Resident 4's care, other residents, and visitors had the potential for unauthorized access to Resident 4's medical records. The DON stated the facility failed to ensure private information in Resident 4's medical records was safe from unauthorized access. During a record review of the facility's policy and procedure (PnP) titled, General Provisions, last reviewed on 1/26/2026, the PnP indicated protected health information contained in the record is confidential and will only be released accordance with the facility's HIPPA policies. The PnP indicated active records are to be located in an area not accessible to unauthorized persons.

Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented. The facility failed to develop and implement an individualized care plan with interventions addressing Resident 1's change of condition (COC) on 2/9/2026. This deficient practice had placed Resident 1 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition such as worsening of Resident 1's right hip fracture and pain.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 3/3/2025 with diagnoses including age-related osteoporosis (a disease that makes bones thin, weak, and brittle, increasing the risk of fractures [broken bones]), unspecified dementia (a decline in brain function including memory, language, reasoning, and behavior severe enough to interfere with daily life but the specific type had not been identified), and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired. During a review of Resident 1's COC Evaluation, dated 2/9/2026, the COC Evaluation indicated Resident 1 complained of right hip pain. The COC Evaluation indicated Resident 1 was given Tylenol for the right hip pain. The COC Evaluation indicated on 2/9/2026 at 2:45 p.m., Resident 1's Attending Physician (MD) 1 was notified and ordered a right hip x-ray (a medical imaging that uses radiation to take pictures of the inside of a body). During an interview on 2/24/2026 at 3:15 p.m., and concurrent record review of Resident 1's Care Plans, reviewed with Registered Nurse (RN) 1, RN 1 stated Resident 1 complained of right hip pain on 2/9/2026. RN 1 stated there was no care plan created for Resident 1's COC on 2/9/2026. RN 1 stated a care plan should be initiated to address Resident 1's right hip pain. RN 1 stated if Resident 1's care plan was not created, the facility staff will not be aware of the interventions to address the resident's COC. During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated a care plan was a list of care and services to be provided for the residents. The DON stated a care plan should be created after Resident 1's COC on 2/9/2026. The DON stated Resident 1 did not have a care plan that included Resident 1's right hip pain. The DON stated Resident 1's care had the potential to lack interventions to prevent further injuries and manage the resident's pain. The DON stated the facility failed to ensure Resident 1 had a care plan after the resident's COC on 2/9/2026 that addressed the resident's right hip pain. During a review of the facility's policy and procedure (PnP) titled, Care Planning, last reviewed on 1/26/2026, the PnP indicated the purpose to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The PnP indicated each resident's comprehensive care plan will describe the. services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. During a review of the facility's PnP titled, Change of Condition Notification, last reviewed on 1/26/2026, the PnP indicated a licensed nurse will. update the Care Plan to reflect the resident's current status.

Based on interview and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1) by failing to:1. Ensure licensed nurses monitored Resident 1's medical status after the resident's change of condition (COC) on 2/9/2026. Resident 1's COC status was not monitored on 2/9/2026, 11 p.m. to 7 a.m. shift.2. Ensure Registered Nurse (RN) 1 assessed Resident 1's right lower extremity after the resident complained of right hip pain. These deficient practices had the potential to place Resident 1 at risk for undetected and worsening medical conditions which could negatively impact the residents' health and safety.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 3/3/2025 with diagnoses including age-related osteoporosis (a disease that makes bones thin, weak, and brittle, increasing the risk of fractures [broken bones]), unspecified dementia (a decline in brain function including memory, language, reasoning, and behavior severe enough to interfere with daily life but the specific type had not been identified), and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired. During a review of Resident 1's COC Evaluation, dated 2/9/2026, the COC Evaluation indicated Resident 1 complained of right hip pain. The COC Evaluation indicated Resident 1 was given Tylenol for the right hip pain. The COC Evaluation indicated on 2/9/2026 at 2:45 p.m., Resident 1's Attending Physician (MD) 1 was notified and ordered a right hip x-ray (a medical imaging that uses radiation to take pictures of the inside of a body). During an interview on 2/24/2026 at 3:15 p.m., and concurrent record review of Resident 1's medical records, reviewed with RN 1, RN 1 stated Resident 1's COC Evaluation, dated 2/9/2026, indicated on 2/9/2026 at 2:40 p.m., Resident 1 complained of right hip pain. RN 1 stated Resident 1's COC should be monitored every shift for 72 hours. RN 1 stated Resident 1's Progress Notes indicated there was no documented evidence that the resident was monitored on 2/9/2026 (11 p.m. to 7 a.m. shift). RN 1 stated she did not document her full assessment of Resident 1's right lower extremity on the resident's Progress Notes. RN 1 stated a resident care that was not documented was considered as not done. RN 1 stated incomplete documentation of Resident 1's health status had the potential for the resident's health condition to worsen. During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated Resident 1 should be monitored every shift for at least 72 hours after the resident's COC. The DON stated there was no documented evidence that Resident 1 was monitored on 2/9/2026, 11 p.m. to 7 a.m. shift. The DON stated RN 1 did not document the assessment done on Resident 1's lower extremities that included pain on palpation and the appearance of the right lower extremity. The DON stated that if resident care was not documented it meant the resident care was not done. The DON stated not assessing and monitoring the resident after a COC had the potential for the resident's progress or decline to be missed. The DON stated the facility failed to provide safe resident care by failing to ensure Resident 1 was assessed and monitored after a COC. During a review of the facility's policy and procedure (PnP) titled, Change of Condition Notification, last reviewed on 1/26/2026, the PnP indicated the licensed nurse will assess the resident's change of condition and document the observations and symptoms. The PnP indicated a licensed nurse will document the. date, time, and pertinent details of the incident and the subsequent assessment in the nursing notes. The PnP indicated a licensed nurse will document each shift for at least seventy-two (72) hours.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a history of multiple falls in the facility (12/20/2024 and 9/30/2025) and required partial/moderate assistance (helper does less than half the effort) from facility staff with bed mobility (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), remained free from accidents by failing to:1. Initiate the facility's Falling Star Program (a resident safety initiative that uses a visual symbol, like a falling star, to identify residents at high risk for falls in healthcare settings) on 6/24/2025 when Resident 1 was identified as being at higher risk for falls following a fall incident on 12/20/2024. A fall risk assessment was completed for Resident 1 on 12/20/2024, however Resident 1 was not added to the facility's Falling Star Program until 11/1/2025 (nearly one year later).2. Ensure Certified Nurse Assistant (CNA) 1 requested additional support from another facility staff when providing morning care (changing bed linens and resident's incontinence briefs (disposable, underwear designed for managing bladder or bowel incontinence [having no or insufficient voluntary control over urination or defecation]) to Resident 1 on 11/1/2025. These deficient practices resulted to Resident 1's fall on 11/1/2025 at 6:15 a.m., during morning care, when CNA 1 rolled Resident 1 to her (Resident 1) left side of the bed and Resident 1, unable to hold self (Resident 1) on the side of her bed, fell to the floor. Resident 1 sustained a laceration (a deep cut or tear in the skin) on the left eyebrow, skin tear (wounds caused by friction or shear that separates skin layers) on the left forehead, skin tear on the left wrist, and bleeding. Registered Nurse (RN) 4 cleaned the laceration site with normal saline (a sterile solution used to clean and treat wounds) and applied a dressing (a pad or cover applied to an injury or wound to protect it, promote healing and prevent infection) to control the bleeding. Resident 1 complained of headache with level of three (mild pain) out of 10 on the numeric pain rating scale (a pain assessment tool that uses a scale ranging from zero [0 - no pain] to 10 [worst pain imaginable], to quantify pain intensity). RN 4 administered Tylenol (a brand of medication used to treat mild to moderate aches and pains) 325 milligrams (mg - unit of measurement) two (2) tablets to Resident 1 on 11/1/2025 at 6:15 a.m. On 11/1/2026 at 7:19 a.m., the facility transferred Resident 1 to the General Acute Care Hospital (GACH) for further evaluation due to head injury where Resident 1 received seven (7) sutures (sterile medical devices (threads and needles) used to hold body tissues together after injury) on the left eyebrow laceration. 3. Ensure Resident 1's bilateral floor mats (high-impact, shock-absorbing pads placed beside beds to minimize injury from falls, fractures, and head trauma) were placed next to Resident 1's bed.4. Ensure facility staff completed Resident 1's Fall Risk Assessment after Resident 1 had an episode of fall on 11/1/2025. 5. Ensure Resident 1's Care Plan was revised after Resident 1's fall incident on 12/20/2025. These deficient practices had the potential to increase the chances of Resident 1 incurring accidents such as falls with injury.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 6/27/2019 and readmitted on [DATE] with diagnoses including chronic diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), right shoulder rotator cuff tear or rupture (damage to the muscles/tendons, causing pain, weakness, and limited motion), wedge compression fracture (a type of spinal injury where the front part of a vertebra [the individual bones of the spine] collapses while the back remains intact, causing the bone to take on a wedge shape) of T11-T12 vertebra sequela (the long-term or lasting effects resulting from a previous injury to the eleventh [11th] and twelfth [12th] thoracic vertebrae), and muscle weakness. During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 7/1/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Fall Risk Assessment form, dated 12/20/2024, the Fall Risk Assessment form indicated Resident 1 had a fall risk score of 28 (a total score above 10 represents a high risk for falls). During a review of Resident 1's Interdisciplinary (or Interdisciplinary Team [IDT] - is a collaborative, team-based approach where professionals from different specialties work together to create and implement a single, unified, and comprehensive care plan for a resident) Care Conference Review form, dated 12/20/2024, the IDT Care Conference Review form indicated that on 12/20/2024 Resident 1 had an episode of fall. The IDT Care Conference Review form indicated that while ambulating (walking) to the restroom, Resident 1 slipped and was assisted to the floor by a facility staff (name not indicated).During a review of Resident 1's Care Plan for functional abilities of everyday activities, initiated on 5/19/2025, the Care Plan indicated that Resident 1 required assistance with bed mobility (movement). The Care Plan interventions indicated that as needed, two or more facility staff will assist Resident 1 with bed mobility. During a review of Resident 1's Fall Risk Assessment form, dated 10/22/2025, the Fall Risk Assessment form indicated Resident 1 had a fall risk score of 20. The Fall Risk Assessment form indicated Resident 1 had one or two falls in the past 90 days. During a review of Resident 1's Incident Report (an objective, written account of an unexpected event such as falls or injuries affecting residents) for a witnessed fall, dated 11/1/2025, the Incident Report indicated on 11/1/2025, at 6:15 a.m., RN 4 received a report from Licensed Vocational Nurse (LVN) 1 that Resident 1 was observed on the floor next to her (Resident 1) bed during the morning care. The Incident Report indicated that while CNA 1 turned Resident 1 to her (Resident 1) side on the bed to place a bed protector (waterproof, and absorbent barrier placed over sheets to protect the mattress from incontinence, fluids, and damage), Resident 1 was unable to hold herself (Resident 1) and fell. The Incident Report indicated there was no floor mat (high-impact, shock-absorbing pads placed beside beds to minimize injury from falls, fractures, and head trauma) present on the floor. The Incident Report indicated RN 4 observed a laceration on the left side of the left eyebrow with bleeding, skin tear on the left side of the forehead, and skin tear on the left wrist. The Incident report indicated Resident 1 complained of pain level of three out of 10 on the numeric pain rating. The Incident Report indicated an ice pack was applied to Resident 1's forehead and Resident 1 received Tylenol 325 mg 2 tablets. During a review of Resident 1's Progress Note, dated 11/1/2025, timed at 2 p.m., the Progress Note indicated Resident 1 returned to the facility from GACH at 12 p.m. (on 11/1/2025). The Progress Note indicated Resident 1 had seven sutures and skin tear on the left forearm (skin tear measurement not indicated). During a review of Resident 1's Progress Note, dated 11/1/2025, timed at 2:28 p.m., the Progress Note indicated that on 11/1/2025, at 12 p.m., Resident 1 returned to facility from GACH. The Progress Note indicated Resident 1's laceration site measured six (6) centimeters (cm - unit of measurement) in length, 1.5 cm in width, and 0.1 cm in depth. During a review of Resident 1's Physician Orders, the Physician Orders indicated the following:- 11/1/2025: Transfer Resident 1 via 911 (phone number used to contact the emergency services) for further evaluation related to fall. - 11/1/2025: Amoxicillin (a medication used to treat infections caused by bacteria such as skin infection) Capsule 500 milligram (mg-unit of measurement). Give one capsule by mouth every eight hours prophylactically (to prevent infection) for sutures. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 11/2025, the MAR indicated Resident 1 received Tylenol 325 mg two tablets at 6:15 a.m. for a pain level of five (5 - moderate) out of 10 on the numeric pain rating scale (the Incident Report dated 11/1/2025 indicated pain level of 3, while MAR indicated pain level of 5).During a review of Resident 1's Interdisciplinary Care Conference Record, dated 11/3/2025, the IDT Care Conference Record indicated that Resident 1 had stated she (Resident 1) was feeling weak and was not able to hold herself (Resident 1) trying to turn and fell from the bed. The IDT Care Conference Record indicated that Resident 1 stated that she (Resident 1) was not comfortable for CNA 1 to care for her (Resident 1) again. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/27/2025, the MDS indicated Resident 1 had intact cognitive functioning (resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS indicated Resident 1 was dependent (helper does all of the effort) on facility staff for toileting hygiene, showers, and lower body dressing. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) from facility staff for moving from sitting on the side of the bed to lying flat on the bed, moving from lying on the back to sitting on the side of the bed, upper body dressing, and personal hygiene. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) from facility staff for rolling from lying on back to left and right side on the bed. The MDS indicated Resident 1 was frequently incontinent (having no or insufficient voluntary control) of bowel and bladder. During a review of CNA 1's Performance Correction Notice, dated 2/17/2026, the Performance Correction Notice indicated that CNA 1 was receiving a final written warning related to Resident 1's fall on 11/1/2025 and was suspended until further notice. The Performance Correction Notice indicated that CNA 1 must follow safety, health, and security rules and procedures when providing care to residents. The Performance Correction Notice indicated that CNA 1 should have gotten additional help or have requested assistance from a Charge Nurse (LVN) while providing care to Resident 1. During an interview on 2/12/2026 at 4:10 p.m. with Resident 1, Resident 1 stated that few months ago (could not recall exact date) while CNA 1 was changing bed linens and turned Resident 1 to left side, Resident 1 lost hold of the bed and fell on the floor. Resident 1 stated her face touched the floor and she sustained a cut on the left side of the forehead. During a concurrent observation and interview on 2/12/2026 at 4:30 p.m. with RN 2 in Room A (Resident 1's room), there was no floor mat (high-impact, shock-absorbing pads placed beside beds to minimize injury from falls, fractures, and head trauma) observed next to Resident 1's bed. RN 2 stated it was the responsibility of the RN and charge nurse to ensure that Resident 1's Care Plan interventions were followed. RN 2 stated failure to provide bilateral floor mats to Resident 1 had the potential to increase Resident 1's risk of injury such as fractures if Resident 1 fell again.During a concurrent interview and record review on 2/12/2025 at 4:46 p.m. with RN 2, Resident 1's Care Plan for witnessed fall initiated on 11/3/2026, was reviewed. The Care Plan interventions indicated Resident 1 would have bilateral floor mats. RN 2 stated it was the responsibility of the RN and charge nurse to ensure that Resident 1's Care Plan interventions were followed. RN 2 stated failure to provide bilateral floor mats to Resident 1 had the potential to increase Resident 1's risk of injury such as fractures if Resident 1 fell again.During an interview on 2/13/2026 at 12:16 p.m. with RN 4, RN 4 stated that on 11/1/2026, at approximately 6:15 a.m. (per progress note), she (RN 4) received a call from LVN 1 regarding a fall incident at Station A (Resident 1's nursing station). RN 4 stated she immediately entered Resident 1's room and found Resident 1 lying supine (lying flat on the back with face and torso facing upward) on the floor next to Resident 1's bed. RN 4 stated that there was blood visible on Resident 1's forehead near the left eyebrow (cannot recall the exact location) and approximately one milliliter (ml - unit of measurement) blood was visible on the floor next to Resident 1's head. RN 4 stated she assessed Resident 1 and cleaned Resident 1's forehead wound with normal saline and gauze (bleached cotton cloth of plain weave used for bandages and dressing). RN 4 stated that CNA 1 had told her (RN 4) that during cleaning Resident 1 was weak and was not able to hold herself (Resident 1) in bed. RN 4 stated that facility staff should consider safety of residents before starting care and ask for assistance if needed. During an interview on 2/13/2026 at 1:05 p.m. with LVN 4, LVN 4 indicated there was no documented evidence that Resident 1 was added to the Falling Star Program prior to 11/1/2025.During a concurrent interview and record review on 2/17/2026 at 11:14 a.m. with LVN 2, Resident 1's Fall Risk Assessment forms, dated 7/25/2025 to 10/22/2025 were reviewed. LVN 2 stated the facility failed to complete a fall risk assessment after Resident 1 had an episode of fall on 11/1/2025. LVN 2 stated a fall risk assessment should be completed upon residents' admission, quarterly and after a fall incident. LVN 2 stated since Resident 1's fall risk was not assessed after a fall episode there was a potential for Resident 1's fall prevention intervention to be incomplete or inaccurate. LVN 2 stated failure to compete a fall risk assessment after Resident 1's fall episode on 11/1/2025 had the potential to increase Resident 1's risk of recurrent falls.During an interview on 12/17/2026 at 12:04 p.m. with RN 1, RN 1 stated a fall risk assessment should have been completed after Resident 1's fall episode on 11/1/2025. RN 1 stated based on the post fall risk assessment facility staff will identify appropriate interventions to prevent falls. RN 1 stated failure to assess Resident 1 had the potential to increase Resident 1's risk for falls.During an interview on 2/17/2026 at 12:29 p.m. with RN 1, RN 1 stated it was the responsibility of the licensed facility staff to update Resident 1's Care Plan after post fall IDT meeting on 12/20/2024. RN 1 stated Care Plan was a guide for the facility staff to provide care to residents. RN 1 stated failure to update Resident 1's Care Plan with fall prevention interventions had the potential to increase Resident 1's risk for fall.During a concurrent interview and record review on 2/17/2026 at 3:02 p.m. with LVN 3, Resident 1's Care Plan was reviewed. LVN 3 stated the information discussed during the IDT meeting after Resident 1's fall episode on 12/20/2024 should have been addressed in Resident 1's Care Plan. LVN 3 stated there was no documented evidence that Resident 1's Care Plan was updated after the fall incident on 12/20/2024. LVN 3 stated the failure to revise Resident 1's Care Plan post fall had the potential for Resident 1 not to receive appropriate fall prevention interventions possibly leading to a recurrent incident of fall.During an interview on 2/18/2026 at 11:22 a.m. with CNA 1, CNA 1 stated that she was the CNA assigned to Resident 1 on 11/1/2025 for 11 p.m. to 7 a.m. shift (work schedule). CNA 1 stated on 11/1/2025, at approximately 6 a.m., she (CNA 1) entered Resident 1's room to provide morning care prior to end of the shift. CNA 1 stated that when she (CNA 1) entered Resident 1's room Resident 1 was sleeping. CNA 1 stated she explained to Resident 1 that she (CNA 1) will change Resident 1's bed linens and incontinent briefs. CNA 1 stated she (CNA 1) could not recall asking Resident 1 if she (Resident 1) was able to move and hold herself (Resident 1) on the side of the bed prior to initiating care on 11/1/2025 at 6 a.m. CNA 1 stated that after cleaning Resident 1 while Resident 1 was supine, she (CNA 1) turned Resident 1 to her (Resident 1) left side to place the bed protector. CNA 1 stated she was holding Resident 1 with right hand from Resident 1's right arm while trying to place the bed protector with left hand. CNA 1 stated that approximately 10 to 15 minutes after initiation of care, while lying on her (Resident 1) left side at the edge of the bed, Resident 1 slipped from her (CNA 1) hand and fell on floor. CNA 1 stated she (CNA 1) immediately approached Resident 1 who was lying next to the bed, on the floor. CNA 1 stated she (CNA 1) immediately screamed for assistance and LVN 1 entered Resident 1's room. CNA 1 stated that Resident 1 had visible blood on the left side of her face near the forehead, approximately equal to the size of her (CNA 1) palm. CNA 1 stated that prior to the fall incident on 11/1/2025, CNA 1 had noticed that Resident 1 was less active and was having more difficulty moving in bed. CNA 1 stated that she should have asked for assistance from facility staff before providing care to Resident 1. CNA 1 stated Resident 1's fall on 11/1/2025 could have been prevented if another facility member was assisting her (CNA 1) during Resident 1's morning care on 11/1/2025. During an interview on 2/18/2026 at 11:54 a.m. with the Director of Nursing (DON), the DON stated that Resident 1's fall on 11/1/2025 could have been prevented if CNA 1 had asked for additional assistance from facility staff during Resident 1's as it was indicated in Resident 1's Care Plan. The DON stated that CNA 1 had received a performance correction notice and training related to poor care provided to Resident 1. During an interview on 2/18/2026 at 1:36 p.m. with LVN 1, LVN 1 stated that on 11/1/2025, at approximately 6 a.m. (cannot recall exact time), while in Station A (nursing station where Resident 1's room was located), she (LVN 1) heard CNA 1 call for assistance in Resident 1's room. LVN 1 stated that upon entering Resident 1's room, she (LVN 1) observed Resident 1 on the floor next to the bed, lying on her (Resident 1) back. LVN 1 stated Resident 1's bed was high at approximately half of her (LVN 1) height of 5 feet (ft - unit of measurement) and 4 inches (in-unit of measurement). LVN 1 stated there was visible blood on Resident 1's forehead. LVN 1 stated there was blood on the floor next to Resident 1's head approximately equal to a large drink and required 3 face towels to clean. LVN 1 stated that Resident 1 told her (LVN 1) that she (Resident 1) was not young and could not sustain herself (Resident 1) on the bed. During a concurrent interview and review on 2/18/2026 at 12:29 p.m., the facility-provided policy and procedure (P&P) titled, Falling Star Program, reviewed on 7/28/2025, was reviewed with RN 1. The P&P indicated, The Facility will ensure that staff is aware of resident who is at high risk for falls. I. The Facility's Interdisciplinary Team (IDT) will determine the need to place resident in 'Falling Star' Program. II. The 'Falling Star' program will be used as a post-fall intervention to prevent falls and injuries. RN 1 stated that Resident 1 should have been added to the facility's Falling Star Program after Resident 1 was identified as having high risk for fall and experiencing a fall episode in the facility. RN 1 stated the staff failed to follow facility's Falling Star Program P&P. RN 1 stated the failure to add Resident 1 to the Falling Star Program had the potential to increase Resident 1's risk of falls.During a review of the facility-provided P&P titled, Fall Management Program, last reviewed on 7/28/2025, the P&P indicated, it is the policy of this facility to provide the highest quality care in the safest environment for the residents residing in the facility. The Facility has developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. I. Assessment: A. The Licensed Nurse will assess each resident for their risk of falling upon admission, quarterly, with significant change in condition, and as needed. C. Based on the information gathered from the history and assessment of the resident, the Nursing staff, and Interdisciplinary Team (IDT), with input from the Attending Physician, will identify the implement interventions to reduce the risk of falls. II. Care Planning: A. The Nursing Staff will develop a plan of care specific to the residents' needs with interventions to reduce the risk of falls. B. The Interdisciplinary Team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. Interventions will be implemented or changed based on the resident's condition and response. During a review of the facility-provided policy and procedure titled, Response to Falls, last reviewed on 1/26/2026, the P&P indicated, To ensure the Facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention. V. The Interdisciplinary Team (IDT) will review the investigation reports on a regular bases, as they may occur and make systemic changes to reasonably limit future occurrences, consider change in POC interventions, system changes, etc. Documentation: A. Licensed Nurse . vii. Revise resident's Care Plan as necessary.During a review of the facility-provided policy and procedure titled, Care Planning, last reviewed on 1/26/2026, the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals.B. As indicated by changes in the resident's condition; (care plans must be updated for any change in condition, regardless of physician's orders promptly).

Based on interview and record review, the facility failed to ensure the medical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure accurate documentation of Fall Risk Assessment (a tool to identify residents at high risk of falling by evaluating factors such as medical conditions, vision, balance, mobility, medications) form. This deficient practice had the potential for inaccurate medical interventions for Resident 1. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 6/27/2019 and readmitted on [DATE] with diagnoses including chronic diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), right shoulder rotator cuff tear or rupture (damage to the muscles/tendons, causing pain, weakness, and limited motion), wedge compression fracture of T11-T12 vertebra sequela (lasting effects of a collapsed, wedge-shaped thoracic vertebra), and muscle weakness. During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 7/1/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/21/2026, the MDS indicated Resident 1 had intact cognitive functioning (resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS indicated Resident 1 was dependent (helper does all of the effort) on facility staff for toileting hygiene, showers, and lower body dressing. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) from facility staff for rolling from lying on back to left and right side on the bed, moving from sitting on the side of the bed to lying flat on the bed, moving from lying on the back to sitting on the side of the bed, upper body dressing, and personal hygiene. During a concurrent interview and record review on 2/18/2026 at 12:29 p.m. with Registered Nurse (RN) 1, Resident 1's Fall Risk assessment dated [DATE], 10/1/2025, and 10/22/2025 were reviewed. The Fall Risk Assessments dated 7/29/2025, 10/1/2025, and 10/22/2025 indicated that section F (Assessment of resident's systolic blood pressure variation when changing positions between lying and standing) was not assessed. RN 1 stated Resident 1's Fall Risk Assessment for the months of July (2025) and October (2025) were incomplete. RN 1 stated the assessment did not describe Resident 1's condition correctly which could potentially lead to lower score level. RN 1 stated failure to complete the fall assessment correctly had the potential to affect Resident 1's care leading to higher risk for falls. During a review of the facility-provided policy and procedure titled, Documentation Nursing, last reviewed on 1/26/2026, the P&P indicated, Nursing documentation will be concise, clear, pertinent, and accurate. Alert Charting: A. Alert charting is documentation done to track a medical event for a period of 72 hours or B. Alert charting is completed by professional staff rather than non-professional staff. D. Alert charting describes what is going on. (a) Describe the resident's condition, include what you see, hear, smell, feel, etc . (c) Describe what you have done in response to what is going on with the resident.

Based on interview and record review, the facility failed to protect the right of one of three sampled residents (Resident 1) to be free from physical restraint (is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body). On 1/14/2026 at 3 a.m., Licensed Vocational Nurse (LVN) 1 found the hands of Resident 1, who had severe cognitive impairment (is a profound, often irreversible loss of mental capacity involving a major inability to think, remember, learn, communicate, or make decisions, requiring daily assistance with basic tasks like eating, dressing, or safety) and was dependent on staff (helper does all of the effort) for care, were firmly tied together at the wrist with a scarf with no way of getting out, no wiggle room, and with no ability to move or release her hands while Resident 1 was in bed in her (Resident 1) room. The facility failed to: 1. Ensure that a licensed nurse completed an assessment prior to the application of a physical restraint restricting Resident 1's freedom of movement in accordance with the facility's policy and procedure (P&P) titled, Restraints, last reviewed on 7/28/2025, indicating, . a physical restraint shall be used only after the interdisciplinary team (IDT - a collaborative group of healthcare professionals who work together to create, implement, and evaluate a personalized, comprehensive care plan for residents) has performed an assessment, attempted to determine and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device. 2. Ensure Certified Nursing Assistant (CNA) 1, who was assigned to Resident 1, was suspected of tying Resident 1's hands, and was caught sleeping during that time, was immediately removed from duty on 1/14/2026 at 3 a.m. CNA 1 remained on schedule and continued providing care to Resident 1 until clocking out at 7:16 a.m. on 1/14/2026. This failure allowed potential continued or further abuse. The facility failed to follow its P&P titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, indicating, Facility staff members accused of committing abuse, neglect or mistreatment against a resident are suspended until the investigation is complete and the findings have been reviewed by the Administrator. 3. Follow the facility's P&P titled, Restraints, dated 11/1/2017, indicating, Residents shall be provided an environment that is restraint-free. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. The facility will ensure that restraints will not be imposed for purposes of discipline or convenience. 4. Follow the facility's P&P titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, indicating, Each resident has the right to be free from abuse, neglect, mistreatment. The Facility has zero-tolerance for abuse. Staff must not permit anyone to engage in . physical abuse, neglect, mistreatment. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff. As a result, on 1/14/2026, CNA 1 allegedly subjected Resident 1 to a physical restraint while under the care of the facility. On 1/14/2026 at 2 a.m., LVN 1 heard Resident 1 chanting which became louder, increased in frequency, and getting worse. On 1/14/2026 at around 2:50 a.m., LVN 1 entered Resident 1's room and found Resident 1's blanket on the floor and Resident 1 who was lying in her bed making wiggly (quick, irregular shaking or twisting motion from side to side or up and down) body movements to show LVN 1 her hands were bound with a scarf. Also, based on the reasonable person concept (refers to a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial [relating to the interrelation of social factors and individual thought and behavior] outcome the deficiency may have had on a reasonable person in the resident's position), due to Resident 1's severe impaired cognitive skills and medical condition, an individual subjected to abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation. On 2/3/2026 at 12 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (Adm), the Director of Nursing (DON), and the Risk Management Nurse (RMN) due to the facility's failure to protect Resident 1's right to be free from physical restraint beginning on 1/14/2026 at 3 a.m., when LVN 1 found the hands of Resident 1 firmly tied together at the wrist with a scarf with no way of getting out, no wiggle room, and with no ability to move or release her hands while under the care of the facility. On 2/4/2026 at 4:26 p.m., the RMN provided an acceptable IJ removal plan (a detailed plan to address the IJ findings) for the facility's failure to protect Resident 1's right to be free from physical restraint on 1/14/2026 at 3 a.m. On 2/4/2026 at 4:50 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to protect Resident 1's right to be free from physical restraint was no longer present. The SSA removed the IJ situation, while onsite, on 2/4/2026 at 4:50 p.m., in the presence of the DON and the RMN. The immediate jeopardy was removed on 2/4/2026, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not IJ (noncompliance causing minimal discomfort or potential to compromise resident functioning). The acceptable IJ Removal Plan included the following summarized actions: 1. On 1/14/2026 at about 7:20 a.m., LVN 1 reported to the facility's Human Resources (HR) and the DON the alleged abuse incident. Upon reporting to the DON, LVN 1 stated that Resident 1 was found with her (Resident 1) hands bound by a scarf, and she (LVN 1) immediately removed the scarf and notified the Ombudsman (OMB- an advocate for residents of nursing homes, board and care centers, and assisted living facilities). 2. On 1/14/2026 at 7:45 a.m. the facility suspended CNA 1 pending HR's investigation. 3. On 1/15/2026 at 7:45 a.m. LVN 1 was provided with written warning due to her failure to report the incident to the RN Supervisor on duty, who would have suspended CNA 1 immediately. 4. On 1/16/2026, the facility terminated CNA 1. 5. On 1/28/2026 at 1:58 p.m., the Director of Staff Development (DSD) reported CNA 1 to the CNA Licensing Board. 6. On 2/3/2026, Registered Nurse (RN) Supervisors 1, 2, and 3 conducted rounds on all units to visually observe all residents in-house for any signs of physical restraints, inappropriate use of devices that could function as restraints, or any signs of abuse or neglect. No other residents were identified. 7. On 2/3/2026 at 9 :30 p.m., RN Supervisors 4, 5, 6, and 7 conducted another facility-wide sweep of all residents to screen for restraints. No other residents were identified. 8. On 2/3/2026 at 2 p.m., the facility's HR and Adm suspended LVN 1 due to failure to follow facility's policy (did not indicate which policy). 9. On 2/3/2026, the Assistant DSD initiated an in-serviced facility staff regarding restraints and the Assistant DSD and DSD will continue to provide in-services until completion by 2/6/2026. During orientation, facility will in-service newly hired staff on abuse and physical restraints. The in-service will include: a. Review of facility's Abuse Prevention and Prohibition Program policy, with emphasis on Residents being free from physical restraints, regulatory requirements and facility policy regarding physical restraints, including the definition of physical restraint, prohibition of restraints for discipline or convenience, and requirement for physician orders and assessments. b. Resident rights including the right to be free from restraints and abuse. c. Immediate reporting requirements. d. Facility's zero-tolerance policy for abuse and requirement to report suspected abuse immediately. e. Documentation requirements. 10. On 2/4/2026 at 12 p.m., the DON created a root cause analysis (a structured, team-based, and non-punitive process used to investigate and to uncover underlying system, process, or human factor [NAME] rather than assigning individual blame). 11. On 2/4/2026, the Adm and DON instructed staff that there will be immediate removal of staff from duty when abuse/neglect is suspected. 12. Effective 2/4/2026, shift to shift report (handover process where the nurse ending his/her shift transfers responsibility, accountability, and essential resident information to the incoming staff member) will include report of any suspected abuse and immediate suspension of staff involved. 13. Department Managers, Managers of the Day, and RN Supervisor on duty will conduct daily rounds inclusive of every shift, weekends and holidays to validate no restraints observed weekly for four weeks, then monthly for two months, to ensure residents feel safe and are free from restraints.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/16/2025 with diagnosis including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and abnormalities of gait (manner of walking) and mobility (ability to move). During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand residents' health which combines medical history and a physical examination), dated 9/5/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Fall Risk Assessment (a process used by healthcare providers to determine a resident's likelihood of falling), dated 12/8/2025, the Fall Risk Assessment indicated Resident 1's fall risk score was 21 meaning Resident 1 was a high risk for fall. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 1 rarely understood and was rarely understood. The MDS indicated Resident 1 was dependent on staff for showering, required substantial assistance (helper does more than half the effort) with upper body dressing, and required partial assistance (helper does less than half the effort) with eating, oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of CNA 1's Timecard, dated 1/13/2026, the Timecard indicated CNA 1 clocked into work on 1/13/2026 10:46 p.m. and clocked out on 1/14/2026 at 7:16 a.m. During a review of Resident 1's Progress Note, dated 1/15/2026 timed at 8:45 a.m., the Progress Note indicated that during the night shift on 1/14/2026 (time not indicated), Resident 1 was restless, yelling on and off and LVN 1 asked CNA 1 to check on Resident 1. The Progress Note indicated that CNA 1 came out from Resident 1's room and stated that Resident 1 was okay and always behaves like this but after approximately 10 minutes later, Resident 1 was again yelling in her language. The Progress Note indicated LVN 1 entered Resident 1's room, saw Resident 1's blanket on the floor, picked up the blanket, and was about to place the blanket on Resident 1, who was lying in her bed, when LVN 1 saw Resident 1's wrist tied in front of her (Resident 1) by what looked like to be a long scarf. The Progress Note indicated LVN 1 untied the scarf and quickly assessed Resident 1 with no visible injury noted. During a concurrent interview and record review on 1/28/2026 at 9 a.m. with the Adm, CNA 1's Timecard on 1/13/2026 was reviewed. The Adm stated CNA 1 clocked in on 1/13/2026 at 10:46 p.m. and clocked out on 1/14/2026 at 7:16 a.m. During an interview on 1/28/2026 at 11:25 a.m. with CNA 1, CNA 1 stated she worked on 1/13/2026 during the 11 p.m. to 7 a.m. shift (work schedule) and was the CNA for Resident 1. CNA 1 stated she continued to work with Resident 1 until the end of her (CNA 1) shift. CNA 1 stated she was not taken off Resident 1's care. During an interview on 1/28/2026 at 1:02 p.m. with the RMN, the RMN stated she saw the picture of Resident 1's hands tied up in the front (of Resident 1) on top of each other like a cross, but she cannot say if the scarf was tight or not. The RMN stated that when a resident is tied up it can prevent the resident from getting up and, also, the resident would not be able to use the call light. The RMN stated Resident 1 was a fall risk and this can result in Resident 1 attempting to get up and hurt herself because her hands were tied and would not be able to catch herself if falling. The RMN stated this can be a potential for Resident 1 not to be able to drink water, as well. The RMN stated CNA 1 completed her shift and continued to work with Resident 1 on 1/14/2026. The RMN stated LVN 1 should have removed CNA 1 immediately from the assignment and should have left the premises of the facility. During an interview on 1/28/2026 at 2:49 p.m. with LVN 1, LVN 1 stated she worked on 1/13/2026 during the 11 p.m. to 7 a.m. shift. LVN 1 stated on 1/13/2026 at around 1:30 a.m. to 2 a.m. she heard Resident 1 making sounds like Resident 1 was chanting in a different language. LVN 1 stated she (LVN 1) does not speak that language and was unable to understand what Resident 1 was saying. LVN 1 stated she asked CNA 1, who was Resident 1's assigned CNA and speaks the same language as Resident 1, what Resident 1 was saying and CNA 1 responded that Resident 1 always did that. LVN 1 stated that a few minutes later (did not indicate exact time) Resident 1's chanting got louder and increased in frequency. LVN 1 stated she asked CNA 1 to check on Resident 1, so CNA 1 went into Resident 1's room, talked with Resident 1, and left Resident 1's room. LVN 1 stated Resident 1's chanting got worse and getting louder and around 2:50 a.m. (on 1/14/2026) LVN 1 went into Resident 1's room and saw Resident 1's blanket on the floor and thought Resident 1, who was lying in her bed, might be cold. LVN 1 stated she bent down to get the blanket, shook the blanket, and noted Resident 1's hands were bound. LVN 1 stated Resident 1's hands were firmly bound at the wrist with a scarf, in front of Resident 1 with no way of getting out and no wiggle room. LVN 1 stated Resident 1's hands were hog tied tied at the wrist with a figure eight at least three times. LVN 1 stated that prior to removing the scarf she took a picture of Resident 1's tied hands to show to her supervisors and untied Resident 1 around 3 a.m. LVN 1 stated that when she initially came into Resident 1's room Resident 1 looked relieved and became wiggly as she was moving around wanting LVN 1 to see she (Resident 1) was bound. LVN 1 stated that after that she looked for CNA 1 and she saw CNA 1 at the desk in the Nursing Station sleeping and snoring (woke up at unknown time to continue her shift). LVN 1 stated CNA 1 completed her (CNA 1) shift taking care of Resident 1. During an interview on 1/28/2026 at 3:32 p.m. with the RMN, the RMN stated this is abuse, because Resident 1 was unable to move due to being tied down. The RMN stated there was no way to determine how long Resident 1 was tied down. The RMN stated having CNA 1 still work after allegation of abuse placed Resident 1 at further risk and other residents at risk of abuse. During an interview on 2/2/2026 at 3:19 p.m. with the DON, the DON stated LVN 1 showed a picture of Resident 1 whose hands were bound by her wrists, side by side, with a greenish scarf. The DON stated she could not tell how tight it was, but it looked solid that there was no way Resident 1 could have pulled her arms apart. The DON stated the scarf would inhibit Resident 1 from grabbing the handrails and thinks that was why it was done to prevent Resident 1 from pulling herself up and getting out of the bed. The DON stated Resident 1 would not be able to use the call light and the way her wrists were bound she would not be able to drink water or even scratch her face. The DON stated that because Resident 1's hands were tied Resident 1 was at a higher risk for falling due to not being able to balance. The DON stated she thought CNA 1 bound Resident 1's hands to prevent Resident 1 from getting up out of bed. The DON stated there was no assessment specifically for the use of the scarf as a restraint. The DON stated the scarf was used as a restraint. The DON stated the scarf was used as convenience for CNA 1 because CNA 1 knew Resident 1 would not be able to get out of bed. The DON stated this was physical abuse and use of physical restraint because Resident 1 could have the potential for an injury from a fall due to her lack of mobility as her wrists were tied. The DON stated because she (Resident 1) was bound, Resident 1 was restricted, and this would impact Resident 1's sleep. The DON stated that psychosocially this would affect Resident 1's mental status because Resident 1 would be confused why she was unable to move. The DON stated Resident 1's increased chanting was indicative of Resident 1 being agitated because she was bound. The DON stated the scarf was used as a restraint on Resident 1. The DON stated it was not a proper way of using scarf as a restraint. The DON stated there is no policy where the facility can use a scarf as a restraint. The DON stated when a restraint is used, the facility must conduct a total assessment to ensure the resident is able to remove the restraint, must be documented and signed off, and there must be a consent for the use of the restraint. The DON stated there was no assessment and/or consent for the use of a scarf as a restraint for Resident 1. During an interview on 2/2/2026 at 4:44 p.m. with the Adm, the Adm stated he is the facility's abuse coordinator. The Adm stated Resident 1 being tied with a scarf is a form of restraint and it falls under abuse. The Adm stated this would be physical abuse. The Adm stated he believed CNA 1 was the one that tied Resident 1, and it was for the convenience of CNA 1 because Resident 1 was restless during that time. The Adm stated CNA 1 should have been removed immediately from the work schedule once LVN 1 found Resident 1 was bound because there was a potential for CNA 1 to do it to other residents, and can get in the way of the investigation, as well. During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, the P&P indicated, Each resident has the right to be free from abuse, neglect, mistreatment. The facility has zero-tolerance for abuse , neglect, mistreatment. Staff must not permit anyone to engage in . physical abuse, neglect, mistreatment. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff. A. The facility protects residents during investigation of abuse, neglect or mistreatment. B. Facility staff members accused of committing abuse, neglect or mistreatment against a resident are suspended until the investigation is complete and the findings have been reviewed by the Administrator. During a review of the facility's P&P titled, Restraints, last reviewed on 7/28/2025, the P&P indicated, Residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measure shall be used. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. The facility will ensure that restraints will not be imposed for purposes of discipline or convenience. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to: A. Treat the medical symptom (something a person feels or experiences that may indicate they have a disease or condition); B. Protect the resident's safety; and C. Help the resident attain the highest level of his/her physical or psychological well-being. Except in emergency situation, a physical restraint shall be used only after the interdisciplinary team (IDT) has performed an assessment, attempted to determine and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device. Assessment - An assessment will be completed by a Licensed Nurse prior to the application of any device that restricts movement or access to one's body.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of six sampled residents (Resident 1) when on 7/25/2025 at approximately 2:30 p.m., Resident 2 threw a four-ounce (oz - a unit of measurement) thickened flavored water cup at Resident 1, inside Room A (Resident 1 and Resident 2's shared room), hitting Resident 1 on the left lower lip. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. On 7/25/2025, Resident 1 sustained a three (3) centimeter (cm - unit of measurement) scratch (a type of wound characterized by damage on the surface of the skin) to Resident 1's left lower lip with bleeding that needed first aid (initial assistance and care given to a resident who has been injured). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 8/19/2024 with diagnoses including cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis [loss of ability to move] of the arm, leg, and trunk on the same side of the body), and dysphagia (difficulty swallowing). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 8/20/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/6/2025, the MDS indicated Resident 1 had moderately impaired cognitive functioning (a decline in a resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS further indicated Resident 1 required maximal assistance (helper does more than half of the effort) from staff with oral hygiene, upper body dressing, and was dependent (helper does all of the effort) on staff for toileting hygiene, showers, and personal hygiene. During a review of Resident 1's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form, dated 7/25/2025, timed at 3:51 p.m., the COC form indicated that on 7/25/2025 (time not indicated), CNA 1 entered Room A after hearing shouting between two residents (Resident 1 and Resident 2). The COC form indicated that Resident 1 was observed with blood on the lower lip, resulting from a three cm scratch on Resident 1's left side of the lip. The COC form further indicated that Resident 2 admitted to throwing a four-ounce thickened flavored water cup at Resident 1. The COC form indicated that the scratch on Resident 1's lower lip was cleansed and left open to air (uncovered). The COC form indicated Resident 1 was placed on monitoring for discoloration (change in the skin's natural color) of the affected area, monitoring for the condition of the scratch on the left lower lip, and for signs of emotional distress (a state of significant psychological discomfort or suffering, impacting a person's ability to function normally) related to receiving aggression (behaviors intended to cause harm) from Resident 2. During a review of Resident 1's CP (untitled), initiated on 7/28/2025, the CP indicated that Resident 1 sustained a skin tear (a type of wound where the outer layers of skin separate from each other due to friction, shear or blunt force) on the left side of the mouth due to roommate (Resident 2) throwing a cup of thickened liquid at Resident 1 on 7/25/2025. (Resident 1's COC indicated the injury as scratch.) The CP interventions included cleansing the affected area (Resident 1's left lower lip) with normal saline (a mixture of water and salt). During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/10/2025 with diagnoses including CVA, hemiplegia, and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's H&P dated 2/12/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognitive functioning (the state where a resident's mental processes, including memory, attention, language, reasoning, and executive functions, are working at a normal or expected level for their age and background). The MDS further indicated Resident 2 required moderate assistance (helper does less than half of the effort) from staff with oral hygiene and upper body dressing. The MDS further indicated Resident 2 required maximal assistance from staff with toileting hygiene, showers, and lower body dressing. During a review of Resident 2's COC form, dated 7/25/2025, timed at 2:48 p.m., the COC form indicated that on 7/25/2025 (time not indicated), CNA 1 entered Room A after shouting was heard between two residents (Resident 1 and Resident 2). The COC form indicated Resident 1 was observed with blood on the lip, resulting from a three cm scratch on the left side of Resident 1's lower lip. The COC form further indicated that Resident 2 admitted to throwing a four-ounce thickened flavored water cup at Resident 1. During a review of Resident 2's CP (untitled), initiated on 7/28/2025, the CP indicated that on 7/25/2025, Resident 2 was involved in an incident in which he (Resident 2) threw an object at his roommate (Resident 1). During a review the facility's five-day conclusion report titled, Abuse Investigation Reporting Form, dated 7/28/2025, the report indicated Resident 2 threw a four-ounce thickened flavored cup at Resident 1 on 7/25 2025 at 2:30 p.m. The report indicated Resident 1 had blood on his lip from a three-centimeter scratch on the left side of the lower lip. The report indicated Resident 1's left lower lip scratch was cleaned and left open to air. During an interview on 8/1/2025 at 10:18 a.m., with Resident 2, Resident 2 stated that during an argument with his roommate (Resident 1), in Room A , Resident 1 used profanity (offensive language) towards him (Resident 2) after which Resident 2 threw a cup at Resident 1, hitting Resident 1 in the face (left lower lip). Resident 2 was unable to recall the exact date and time of the incident. During an interview on 8/1/2025 at 1:18 p.m., with LVN 1, LVN 1 stated the incident (Resident 2 threw a cup at Resident 1) happened at approximately 2:30 p.m., (unable to recall the exact date of the incident). LVN 1 stated LVN 2 requested assistance from her (LVN 1) to provide translation in Room A. LVN 1 stated that during the interview with Resident 1, Resident 1 stated that he (Resident 1) had asked Resident 2 to lower the television volume, at which point Resident 2 threw a cup at Resident 1. LVN 1 further stated that during a separate interview (on 7/25/2025) with Resident 2, Resident 2 admitted to throwing an object (cup) from his (Resident 2's) meal tray at Resident 1 to scare him (Resident 1). LVN 1 further stated Resident 1 was observed to have a scratch on the lower lip. LVN 1 stated that the incident between Resident 1 and Resident 2 was physical abuse. LVN 1 further stated that Resident 2 could potentially hit Resident 1 in the head, which could result in a hematoma (a localized collection of blood outside of blood vessels, often resulting in a swollen, painful lump or bruise [an injury where blood vessels under the skin break, causing blood to leak into surrounding tissues]), or other serious injuries. During an interview on 8/1/2025 at 1:28 p.m., with LVN 2, LVN 2 stated that on 7/25/2025 (unable to recall the exact time of the incident), he (LVN 2) observed CNA 1 exiting Room A and requesting assistance. LVN 2 stated upon entering Room A, LVN 2 observed Resident 1 with bleeding from a scratch on the mouth. LVN 2 stated that during an interview (on 7/25/2025), with LVN 1 providing translation services, Resident 2 admitted to throwing a cup at Resident 1. LVN 2 further stated that the incident between Resident 1 and Resident 2 was a resident-to-resident physical abuse (refers to situations where one resident intentionally inflicts physical harm on another resident). During an interview on 8/4/2025 at 12:05 p.m., with the Director of Nursing (DON), the DON stated that the incident between Resident 1 and Resident 2 was a resident-to-resident physical abuse resulting in Resident 1 sustaining a scratch on his (Resident 1) mouth (left lower lip). The DON further stated that the incident had the potential to negatively affect Resident 1's psychosocial (refers to the interplay between psychological factors [thoughts, feelings, behaviors] and social factors [relationships, environment, culture]) well-being. During an interview on 8/4/2025 at 12:40 p.m., with the Administrator, the Administrator stated that the incident between Resident 1 and Resident 2 was a physical abuse that resulted in Resident 1 sustaining a scratch on his mouth (left lower lip). During a review of the current facility-provided policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, the P&P indicated, To ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to . protect residents, and to ensure a standardized methodology for the prevention . of abuse . in accordance with federal and state requirements. Each resident has the right to be free from abuse. The facility has zero-tolerance for abuse . Staff must not permit anyone to engage in . physical abuse. The Facility is committed to protecting residents from abuse by anyone, including but not limited to . other residents

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 224) when on 6/28/2025 at 2:45 p.m., Certified Nursing Assistant 11 (CNA 11) witnessed Resident 45 approached Resident 224 and hit Resident 224 on the head and right lower extremity (RLE - right side of the lower part of the human body) with a single point cane (a mobility aid with a single tip that provides basic support and balance assistance for individuals with minor mobility issues). This deficient practice resulted in Resident 224 being subjected to physical abuse by Resident 45 while under the care of the facility. On 6/28/2025, Resident 224 sustained bruising (discoloration of the skin caused by blood pooling beneath the surface) and swelling on the RLE, redness on top of the head, and pain level of two (mild pain) out of 10 on the numeric pain rating scale (a pain assessment tool that uses a scale ranging from zero [0 - no pain] to 10 [worst pain imaginable], to quantify pain intensity). Resident 224 complained of mild headache on 6/28/2025 at 3:15 p.m. and Tylenol (a brand of medication used to treat mild to moderate aches and pains) 325 milligrams (mg - unit of measurement) two (2) tablets were administered to Resident 224. Findings: a. During a review of Resident 224's admission Record, undated, the admission Record indicated the facility originally admitted Resident 224 on 3/23/2022 and readmitted in the facility on 5/12/2024 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 224's Order Summary Report dated 5/12/2024, the Order Summary Report indicated a physician's order for Tylenol oral tablet 325 mg, give two tablets by mouth every four hours as needed for mild pain or general discomfort not to exceed three (3) grams (gm - a unit of measurement) per 24 hours. During a review of Resident 224's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 5/1/2025, the H&P indicated Resident 224 did not have the capacity to understand and make decisions. During a review of Resident 224's Minimum Data Set (MDS - a resident assessment tool), dated 4/30/2025, the MDS indicated Resident 224 had severely impaired cognition (significant decline in a resident's mental abilities that profoundly impacts their daily life and independence), and usually had the ability to make self understood and understand others. The MDS indicated Resident 224 required partial or moderate assistance (helper does less than half of the effort) with eating and was totally dependent (helper does all of the effort) on staff with all other activities of daily living (ADLs - routine tasks or activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 224's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form, dated 6/28/2025, timed at 5 p.m., the COC form indicated on 6/28/2025 at 2:45 p.m., Resident 224 was in the hallway (across Room A) sitting in the wheelchair and was yelling. The COC indicated that CNA 11 observed Resident 45 exiting Room A, approaching Resident 224 and hitting Resident 224 on the head and RLE with a cane. During a review of Resident 224's Incident Note, dated 6/28/2025, timed at 5:15 p.m., the Incident Note indicated that on 6/28/2025 at 2:45 p.m., Resident 224 was in the hallway (across Room A) sitting in the wheelchair and was yelling. The Incident Note indicated that CNA 11 observed Resident 45 exiting Room A, approaching Resident 224 and hitting Resident 224 on the head and RLE with a cane and that upon further assessment, bruising and swelling were noted on Resident 224's RLE and redness on top of Resident 224's head. The Incident Note indicated Resident 224 complained of mild headache at 3:15 p.m. (on 6/28/2025) and Tylenol 325 mg two tablets were administered to Resident 224 as ordered. During a review of Resident 224's Progress Notes dated 6/29/2025 at 12:10 a.m., 6/29/2025 at 1:08 p.m., 6/30/2025 at 7:04 a.m., 6/30/2025 at 2:49 p.m., and 6/30/2025 at 9:05 p.m., the Progress Notes indicated Resident 224 had bruising present on Resident 224's RLE. During a review of Resident 224's Care Plan (CP) titled, Resident has been involved in an incident on 6/28/2025 (struck by another resident), initiated on 6/30/2025, the CP indicated to provide appropriate pain relief measures, including pharmacological (the use of medications to treat prevent a medical condition) and non-pharmacological (any health intervention that doesn't involve medications) interventions as one of the interventions to maintain resident's safety and comfort. During a review of Resident 224's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 6/2025, the MAR indicated Resident 224 received Tylenol 325 mg two tablets at 3:15 p.m. for a pain level of two out of 10 on the numeric pain rating scale. b. During a review of Resident 45's admission Record, undated, the admission Record indicated the facility originally admitted Resident 45 on 6/27/2023 and readmitted in the facility on 5/8/2025 with diagnoses including Alzheimer's disease, dementia, anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 45's H&P, dated 5/14/2025, the H&P indicated Resident 45 had the capacity to understand and make decisions. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45 had moderately impaired cognition (slight decline in thinking and memory), and usually had the ability to make self understood and understand others. The MDS indicated Resident 45 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating and bed mobility and partial or moderate assistance to substantial/maximal assistance from staff with all other ADLs. During a review of Resident 45's COC form, dated 6/28/2025, timed at 4:56 p.m., the COC form indicated that on 6/28/2025 at 2:45 p.m., CNA 11 observed Resident 45 becoming agitated and annoyed at Resident 224 who was yelling from across the hall near his (Resident 45) room (Room A). The COC indicated that CNA 11 observed Resident 45 exiting Room A, approaching Resident 224 and hitting Resident 224 on the head and RLE with a cane. During a review of Resident 45's CP (untitled), initiated on 6/28/2025, the CP indicated Resident 45 was observed manifesting impulsive behavior (acting on a whim or urge without thinking through the potential consequences), physical aggression (refers to behavior that is intended to cause physical harm to another person) towards another resident (Resident 224), and being aggressive during afternoon breaks. During an interview on 7/17/2025 at 2:58 p.m. with CNA 11, CNA 11 stated that on 6/28/2025 at 2:45 p.m., as he (CNA 11) was walking past Room C, in the hallway, he (CNA 11) observed Resident 224 sitting in the wheelchair outside Room B, yelling. CNA 11 stated that he (CNA 11) saw Resident 45 exit Room A, which is directly across from Room B, approach Resident 224, and hit Resident 224 on the head and RLE with a single point cane. CNA 11 further stated that Resident 45 was speaking in a foreign language (did not state specific language) with an angry tone and appeared agitated prior to hitting Resident 224. CNA 11 stated Resident 224 and Resident 45 were separated immediately by the staff (CNA 11 and Licensed Vocational Nurse [LVN] 16). CNA 11 stated the incident between Resident 45 and 224 is physical abuse as he (CNA 11) witnessed Resident 45 physically hit Resident 224 and he (CNA 11) observed redness on Resident 224's right lower leg after being hit by Resident 45. During an interview on 7/18/2025 at 9:15 a.m. with Registered Nurse (RN) 4, RN 4 stated she was notified by the Charge Nurse (CN) that on 6/28/2025 at 2:45 p.m., CNA 11 observed Resident 45 became agitated and annoyed due to Resident 224 yelling from across the hall from his (Resident 45) room (Room A). RN 4 stated Resident 45 exited Room A approached Resident 224 and hit Resident 224. RN 4 stated that during an interview (on 6/28/2025) with Resident 45, Resident 45 stated that he (Resident 45) wanted Resident 224 to stop yelling. RN 4 further stated that the incident between Resident 224 and Resident 45 was a resident-to-resident physical abuse. RN 4 stated all residents in the facility should be free from any type of abuse. During an interview on 7/18/2025 at 12:28 p.m. with Social Services Designee (SS Designee), the SS Designee stated the SS Department follows up with the residents involved after an allegation of abuse for psychosocial support and to ensure the residents their safety while in the facility. The SS Designee stated during her (SS Designee) visit with Resident 45 on 6/30/2025, Resident 45 stated that Resident 224 was making too much noise, so he (Resident 45) hit Resident 224. The SS Designee stated the incident between Resident 224 and Resident 45 was a physical abuse and the facility should ensure that all residents are free from any type of abuse. During a concurrent interview and record review on 7/18/2025 at 10:05 a.m., with the Risk Management Nurse (RMN), Resident 224's COC, Incident Note, Progress Notes, and MAR were reviewed. The RMN stated the facility was able to substantiate that physical abuse happened between Residents 224 and 45 and that Resident 224 suffered bruising on the RLE and redness on the head. The RMN stated that all residents in the facility have the right to be free from any form of abuse, in order to ensure their safety and well-being at all times. During an interview on 7/18/2025 at 2:30 p.m. with the Director of Nursing (DON), the DON stated that all residents should be free from abuse. The DON stated that the provoking behavior was Resident 224 yelling and making noise in the hallway. The DON stated Resident 45 became agitated by Resident 224's yelling and, in response, hit Resident 224 on the head and RLE, resulting in bruising and swelling on Resident 224's RLE. The DON stated the incident is considered physical abuse and may have a negative psychosocial impact (refers to the negative effects that an incident has on a person's mental health, psychological well-being and social interactions) on Resident 224. The DON further stated that the facility failed to prevent the physical abuse between Residents 224 and Resident 45, as CNA 11 was unable to intervene in a timely manner to prevent the incident. During a review of the current facility-provided policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, last reviewed by the facility on 4/28/2025, the P&P indicated, To ensure the facility established, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to . protect residents, and to ensure a standardized methodology for the prevention . of abuse . in accordance with federal and state requirements. Each resident has the right to be free from abuse. The Facility has zero-tolerance for abuse. The staff must not permit anyone to engage in . physical abuse. The facility is committed to protecting residents from abuse by anyone, including but not limited to . other residents.

Based on interview and record review, the facility failed to ensure one of four sample residents (Resident 1), who had moderate impaired cognition (a stage where individuals experience noticeable and significant difficulties in functions like memory, language, and problem-solving, affecting their ability to manage daily activities independently), was free from sexual abuse (any sexual activity that occurs without consent [permission]), by Resident 2 (Resident 1's roommate) on 6/20/2025 by failing to: 1. Protect Resident 1 from Resident 2 when Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 witnessed Resident 2, topless with breasts uncovered, was at the head of Resident 1's bed leaning on top of Resident 1 who was lying on her (Resident 1) bed. Resident 2 was rubbing her (Resident 2) exposed breasts against Resident 1's chest while Resident 2 was sucking Resident 1's chin causing it (Resident 1's chin) to be red. 2. To identify the potential risks of Resident 2's sexually inappropriate behavior (masturbatory behavior) to other residents (in general). 3. Prevent sexual abuse by ensuring facility licensed staff monitored and documented Resident 2's sexually inappropriate behavior (masturbatory behavior) and develop interventions and implement interventions to prevent abuse to other residents (in general). 4. Identify and evaluate if Resident 1 had the capacity to consent (when someone understands what they are being asked to do, and they give their permission clearly and freely without being pressured) to perform sexual activity with Resident 2 or other residents to prevent sexual abuse. 5. Assess Resident 1 for possible injuries after the sexual abuse incident on 6/20/2025 at around 4:50 a.m. in accordance with the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, with review date of 4/28/2025, indicating, A Licensed Nurse assesses the resident (alleged victim) for possible injuries. 6. Follow its P&P titled, Abuse Prevention and Prohibition Program, with review date of 4/28/2025, indicating, Each resident has the right to be free from abuse. The Facility has zero-tolerance for abuse. Staff must not permit anyone to engage in . sexual . abuse. These deficient practices resulted in Resident 1 being subjected to sexual abuse by Resident 2 while under the care of the facility. CNA 1 stated Resident 1 looked in panic and in shock during the incident. CNA 3 went to Resident 1 to offer to change Resident 1 (who refused to be changed by CNA 1) after the sexual abuse incident stated Resident 1 started to become agitated, shaking, and looks nervous. On 6/20/2025 at 10:24 a.m., the facility sent Resident 2 to General Acute Care Hospital (GACH) 1 for psychological evaluation (a comprehensive assessment conducted by a mental health professional to understand an individual's psychological state, including their thoughts, feelings, behaviors, and personality). Based on the reasonable person concept (refers to a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial outcome of the deficiency may have had on a reasonable person in the president's position), due to Resident 1's moderately impaired cognitive skills, an individual subjected to abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). On 6/25/2025 at 5:14 p.m. while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.12 Freedom from Abuse, Neglect (failed to care for properly), and Exploitation (illegal or improper use of a person's resources) in the presence of the Administrator (ADM), Director of Nursing (DON), and the Risk Manager Nurse (RMN) due to the facility's failure to protect Resident 1's right to be free from sexual abuse on 6/20/2025 at around 4:50 a.m. On 6/27/2025 at 4:32 p.m., the ADM provided the SSA with an acceptable IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 6/27/2025 at 5:12 p.m., while onsite at the facility and after verifying and confirming the facility's implementations of the IJ Removal plan through observations, interviews, and record reviews, the SSA removed the IJ situation in the presence of the ADM, DON, Assistant DON (ADON), RMN, and DSD (Director of Staff Development). The acceptable IJ Removal Plan included the following summarized actions: 1. On 6/20/2025 at 4:50 a.m., CNA 1 found Resident 2 on top of Resident 1 and CNA 1 separated Resident 1 and Resident 2 (both are still in the same room). LVN 2 monitored Resident 1 to prevent reoccurrence. 2. On 6/20/2025 at about 5 a.m., CNA 2 and CNA 3 alternated being in Resident 1 and Resident 2's room to assure the safety of Resident 1 and prevent recurrence until the end of their (CNA 2 and CNA 3) shift at 6:45 a.m. at which point CNA 4 was at Resident 1's bedside providing one-on-one supervision (a staff member is assigned to solely observe and attend to the needs of a specific resident) until Resident 2 was transferred by ambulance at 10:24 a.m. to GACH 1 for psychological evaluation. As of 6/27/2025, Resident 2 remains to be hospitalized and in no direct threat to any current residents. 3. On 6/20/2025 at 12:22 p.m., Resident 1 was transferred to a different room. 4. On 6/25/2025 at about 6 p.m., the DON, ADON, Social Services Director (SSD), and RMN completed an audit of all the residents and identified two residents (Resident 3 and Resident 4) with inappropriate behaviors. Room changes were offered to the roommates, but they (roommates) declined. 5. On 6/25/2025 at 6:30 p.m., the DSD initiated in-service trainings (ongoing education and training provided to staff to enhance their knowledge, skills, and competency in providing care) on staff focusing on abuse. 6. On 6/25/2025 at 7 p.m., Licensed Vocational Nurse (LVN) 3 updated Resident 1 and Resident 2's care plans with interventions including routine checks by CNAs. 7. On 6/25/2025 starting at 7 p.m., RN 3, RN 4, and RN 5, along with the assistance of the SSD, screened all residents to identify any other potential for abuse using the Resident's Psychological Well Being Questionnaire (formulated by the facility) which included questions of feeling safe or ever being sexually abused at the facility. During completion of the screening, there were no other residents identified to be affected. 8. On 6/25/2025 starting at 8 p.m., LVN 3 reviewed the care plans of two residents (Resident 3 and Resident 4) with a history of sexually inappropriate behaviors, as well as their roommates. Focus for Resident 3 included grabbing staff inappropriately with interventions to intervene as necessary to protect the rights and safety of others in a calm manner, divert attention, explain and reinforce appropriate behavior. Resident 4's focus is to prevent displaying inappropriate sexual behaviors towards other residents with interventions of monitoring every two hours during routine rounds (scheduled times when staff visits the residents to check on their well-being, assess their needs, and ensure their comfort and safety) for inappropriate sexual behavior, provide calm and non-shaming redirection if the resident initiates inappropriate behavior. CNAs are monitoring Resident 4 during the required rounds every two hours by RNs every shift. 9. The facility has implemented a new system for monitoring residents with sexually inappropriate behaviors. On 6/25/2025, the behavior monitoring tool was initiated on Electronic Health Record (EHR - a cloud based electronic health record platform) 1 and implemented on 6/26/2025. The CNAs are to monitor every two hours any residents with sexually inappropriate behavior. Licensed nurses are to document all sexual behaviors of residents. Interdisciplinary team (IDT - a group of healthcare professionals from various disciplines who collaborate to provide comprehensive and coordinated care to residents) will meet weekly to discuss sexually inappropriate behavior issues of residents. 10. On 6/26/2025 at 10:30 a.m. Resident 1 was seen by Psychologist 1 (a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) with no changes in mood or depressive manner. Resident 2 remains hospitalized . Once Resident 2 is determined safe to return to the facility, a new care plan will be created focusing on her hypersexuality (an excessive and uncontrolled sexual behavior that causes significant distress or impairment in a person's life) with interventions including monitoring one-on-one indefinitely. Monitoring will be set for Resident 2's whereabouts, pattern in her activity and sexual behavior by a hash mark system (tally marks) on EHR. 11. On 6/26/2025 at 10:30 a.m., Psychiatrist 1 (a medical practitioner specializing in the diagnosis and treatment of mental illness) visited Resident 3 and Resident 4 who were identified with history of sexually inappropriate behaviors. Psychiatrist 1's evaluation of Residents 3 and 4 did not identify any potential harm to others. 12. On 6/26/2025 at 2:50 p.m., the DSD sent a message to all staff with instructions that any staff on vacation or leave cannot return to work on the floor until completion of in-service trainings on Abuse. As of 6/27/2025, 82 percent (% - one part in every hundred) of staff have been in-serviced. 13. For any new residents admitted to the facility, the DON/ADON will screen residents by checking their history and physical, medication regimen (a structured plan designed by a healthcare provider to manage a resident's medical condition or illness through the use of medication), conduct interview with the resident's responsible party if resident has any history of sexually inappropriate behavior. Room assignments will also be evaluated to ensure appropriate placement of residents. Monitoring will be set in place for residents, such as CNAs doing the required rounds every two hours to ensure resident safety. 14. Effective 6/26/2025, Performance Improvement Quality Improvement (PIQI - systematic, data driven approaches to enhance resident care and organizational efficiency) nurses conduct weekly audits of Resident 3 and Resident 4 who were identified with sexually inappropriate behaviors to ensure care planned prevention interventions are appropriate and implemented. 15. Effective 6/27/2025, RN supervisors conduct rounds every shift to ensure residents are not engaged in inappropriate behaviors related to sexual abuse. This will be documented on the facility's supervisor round form. 16. Effective 6/27/2025, the SSD or designee will interview random residents to ensure they feel safe and free from any abuse, including sexual abuse. This is to be done weekly for four weeks, then monthly for two months, using the social services weekly review. 17. The Quality Assurance Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) committee will meet on 6/30/2025 to discuss initiating a form for consenting to sexual activity basing on the regulatory guidelines. The QAPI Team plans to discuss determining factors, developing policy and procedures and how to determine a monitoring system. 18. The DON reports audit findings to the QAPI committee monthly for three months, then quarterly thereafter. The QAPI committee will evaluate the effectiveness of the plan and make changes as needed until substantial compliance is achieved and maintained. Findings: During a review of Resident 1’s admission Record, the admission Record indicated the facility admitted Resident 1 on 4/18/2023 with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (clogged heart arteries without chest pain) and hypertension (high blood pressure). During a review of Resident 1’s Initial History and Physical, dated 4/11/2025, the Initial History and Physical indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 6/1/2025, the MDS indicated Resident 1 was moderately impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1’s Progress Notes, dated 6/20/2025 at 10:22 a.m., the note indicated that at 4:50 a.m. CNA 1 reported to LVN 1 that Resident 2 was found on top of Resident 1 with Resident 2’s breasts exposed and rubbed against Resident 1 and Resident 2 was sucking Resident 1’s chin. The note indicated LVN 1 noted a red-mark color on Resident 1’s chin as a result from Resident 2’s sucking Resident 1’s chin. The note indicated RN 1 notified the Physician. During a review of Resident 2’s admission Record, the admission Record indicated the facility originally admitted Resident 2 on 1/22/2021 and readmitted on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris and hypertension. During a review of Resident 2’s Initial History and Physical, dated 1/30/2025, the Initial History and Physical indicated Resident 2 had fluctuating capacity to understand and make decisions due to dementia (decline in mental abilities, like memory and thinking, that is severe enough to interfere with daily life). During a review of Resident 2’s MDS, dated [DATE], the MDS indicated Resident 2 was moderately impaired with thought process and required substantial to partial assistance from staff to complete ADLs. During a review of Resident 2’s Care Plan Report, dated 9/17/2024, the Care Plan Report indicated Resident 2 exhibited masturbatory behavior. During a review of Resident 2’s Progress Notes, dated 6/20/2025 at 4:50 a.m., the note indicated that at 4:50 a.m. CNA 1 reported to LVN 1 that Resident 2 was found on top of Resident 1 with Resident 2 breasts exposed and rubbed against Resident 1 and Resident 2 was sucking Resident 1’s chin. The note indicated LVN 1 noted a red-mark color on Resident 1’s chin as a result from Resident 2’s sucking Resident 1’s chin. The note indicated RN 1 notified the Physician. The note indicated on 6/20/2025 at 10:24 a.m., the Physician gave an order to transfer Resident 2 to GACH 1 for further evaluation. During an interview on 6/23/2025 at 11:13 a.m., with LVN 1, LVN 1 stated that while LVN 1 was in nurse’s station on 6/20/2025 at “around 4:50 a.m.,” CNA 1 was standing at the door of Residents 1 and 2’s room (near the nurse’s station) and reported to LVN 1 that Resident 2 was on top of Resident 1. CNA 1 stated Resident 2’s blouse was down to her (Resident 2’s) waist, and Resident 2 rubbed her (Resident 2) uncovered breasts against Resident 1’s chest. LVN 1 stated CNA 1 reported Resident 2 was sucking Resident 1’s chin. LVN 1 stated she (LVN 1) immediately went to Resident 1 and 2’s room and observed that Resident 2 was still on top of Resident 1 and LVN 1 asked Resident 2 to get away from Resident 1 and to return to Resident 2’s bed. LVN 1 stated Resident 2 started to get a little agitated and Resident 2 started to give a hand gesture to LVN 1 to go away. LVN 1 stated Resident 1’s chin was red from Resident 2’s sucking. LVN 1 stated she notified RN 1 right away. LVN 1 stated that when she (LVN 1) got hired since 2/2025, LVN 1 already knew and observed Resident 2’s behavior of patting and touching her (Resident 2) own private area and touching her (Resident 2) own breasts. LVN 1 stated staff in the unit were aware of Resident 2’s behavior. LVN 1 stated this was considered as sexual abuse due to inappropriate behavior of Resident 2 towards Resident 1 by rubbing her (Resident 2) breasts to Resident 1’s chest and sucking Resident 1’s whole chin which left a redness on Resident 1’s chin. During an interview on 6/23/2025 at 11:38 a.m. with CNA 1, CNA 1 stated that she (CNA 1) found Resident 2 on top of Resident 1 with Resident 2’s blouse down to her (Resident 2) waist, rubbing her (Resident 2) breasts against Resident 1, sucking Resident 1’s chin. CNA 1 stated she (CNA 1) reported the incident to LVN 1 right away. CNA 1 stated this was considered as sexual abuse because Resident 1 did not give any consent to Resident 2 because Resident 1 was confused. During an interview on 6/23/2025 at 12:29 p.m. with CNA 4, CNA 4 stated Resident 2 usually touches herself and CNA 4 usually provides privacy to Resident 2. During an interview on 6/24/2025 at 6:29 a.m. with CNA 1 in Resident 1 and 2’s room, CNA 1 stated she (CNA 1) was in another resident’s (name not indicated) room (a room across Residents 1 and 2’s room) and heard a bed-squishing noise prompting her (CNA 1) to check and go to the door of Residents 1 and 2’s room. CNA 1 was observed demonstrating how Resident 2 was standing on the right side on the top part of Resident 1’s bed. CNA 1 stated Resident 2 was rubbing her (Resident 2) exposed breasts to Resident 1’s chest and sucking Resident 1’s chin. CNA 1 stated during that time CNA 1 observed Resident 1 looked panic and shocked. During an interview on 6/24/2025 at 6:39 a.m. with CNA 3, CNA 3 stated she was assigned to care for Resident 1 after the sexual abuse incident on 6/20/2025 at around 4:50 a.m. CNA 3 stated she (CNA 3) offered to change Resident 1 and observed Resident 1 was agitated holding her (Resident 1) hands close to her (Resident 1) chest, very nervous, shaking, and refusing to be changed. CNA 3 stated Resident 1 later on agreed to be changed after explanation that she (Resident 1) needed to be changed. During a concurrent interview and record review on 6/25/2025 at 11:13 a.m. with RN 2, Resident 2’s care plan titled, “Exhibiting Masturbatory Behavior,” dated 9/17/2024, all other current care plans since admission, Medication Administration Record (MAR), and Progress Notes from 5/8/2024 to 6/20/2025 were reviewed. RN 2 stated there was no intervention to monitor Resident 2’s masturbatory behavior based on Resident 2’s care plan and no behavioral monitoring found in Resident 2’s MAR and progress notes. RN 2 stated Resident 2’s care plan was not assessed and revised to indicate how Resident 2’s masturbatory behavior will potentially affect other residents. RN 2 stated had the facility created a care plan on how Resident 2’s masturbatory behavior will potentially affect other residents; this incident could have been prevented. RN 2 stated that there was no assessment or documentation about Resident 2’s masturbatory behavior during a review of Resident 2’s progress notes from 5/8/2024 to 6/20/2025. RN 2 stated that as a result Resident 2’s behavior was not monitored, and Resident 2 sexually abused her roommate (Resident 1). During a concurrent interview and record review on 6/25/2025 at 1:05 p.m. with Resident Care Planner (RCP) 1, Resident 2’s care plan titled, “Exhibiting Masturbatory Behavior,” dated 9/17/2024, was reviewed. RCP 1 stated she (RCP) was the author of the care plan, and a nurse (could not remember who the nurse was) reported that Resident 2 had an episode of masturbation behavior (cannot remember the date). RCP 1 stated monitoring Resident 2’s behavior was not included in Resident 2’s care plan interventions. RCP 1 stated Resident 2’s behavior should be monitored to know if the interventions are effective. RCP 1 stated there was no intervention included to identify the risk of Resident 2’s behavior to other residents. RCP 1 stated it was important to include how Resident 2’s behavior will affect other residents and possibly this sexual abuse incident could have been prevented if there was a proper intervention for Resident 2. During a concurrent interview and record review on 6/24/2025 at 9:56 a.m. with Risk Manager Nurse (RMN), Resident 1’s Progress Notes dated between 6/20/2025 to 6/24/2025 and vital signs (measurements of the body’s most basic functions) dated 6/20/2025, were reviewed. Resident 2’s Progress Notes dated between 6/20/2025 and vital signs dated 6/20/2025, were also reviewed. RMN stated there was no documented evidence that assessment was done, and vital signs were taken after the sexual abuse incident on 6/20/2025 at “around 4:50 a.m.” for Resident 1 and Resident 2. RMN stated Resident 1’s condition must be monitored after the sexual abuse incident for 72 hours every shift, but it was not done. During a telephone interview on 6/25/2025 at 10:11 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 was a conservative person so this sexual abuse incident on 6/20/2025 at around 4:50 a.m. will destroy, traumatize, and mentally damage Resident 1. FM 1 stated Resident 1 will lose a lot of sleep, will not know what to do, feel victimize, and will feel her life will be ruined just like other sexual victims. FM 1 stated the family members (FM 1, FM 2, and FM 3) were shocked and traumatized. FM 1, FM 2, and FM 3 cried, felt angry and felt guilty by choosing this facility. FM 1 stated FM 1, FM 2 and FM 3 lost sleep, felt anxious, and uneasy when they found out about Resident 1’s sexual abuse incident on 6/20/2025 at around 4:50 a.m. During a concurrent interview and record review on 6/25/2025 at 11:13 a.m. with Registered Nurse (RN) 2, Resident 1’s Progress Notes, dated between 6/20/2025 to 6/24/2025 and vital signs dated 6/20/2025 were reviewed. Resident 2’s Progress Notes dated between 6/20/2025 and vital signs dated 6/20/2025, were also reviewed. RN 2 stated there was no head-to-toe assessments (a systematic and comprehensive physical examination that evaluates all major body systems, from the head to the feet, to determine a resident’s overall health status) and no vital signs were taken for Resident 1 and Resident 2 after the sexual abuse incident last 6/20/2025 at 4:50 a.m. RN 2 stated that staff must do a head-to-toe assessment, check vital signs and monitor Resident 1 and Resident 2 (was discharged to GACH 1 on 6/20/2025 at 10:24 a.m.) every shift for 72 hours every shift to know how this incident could affect them (Resident 1 and Resident 2). RN 2 stated it was important to monitor Resident 1 closely. During an interview on 6/25/2025 at 2:26 p.m. with CNA 6, CNA 6 stated she (CNA 6) was the regular CNA assigned in the morning for Resident 2 and had been taking care of her (Resident 2) since she (Resident 2) was admitted . CNA 6 stated she (CNA 6) observed Resident 2 will call her (CNA 6) inside Resident 2’s room and will start patting her (Resident 2) private area and this happened three times last week on different days before the incident that happened on 6/20/2025 at around 4:50 a.m. CNA 6 stated she (CNA 6) reported those observations to LVN 4 for LVN 4 to talk to Resident 2 to stop doing those inappropriate sexual behavior (patting the vagina). During an interview on 6/25/2025 at 2:34 p.m. with LVN 4, LVN 4 stated she was the regular charge nurse for Resident 1 and Resident 2. LVN 4 stated CNA 6 reported about two to three times (dates not indicated) that Resident 2 was patting her abdomen but did not document anything or did not report to anyone because LVN 4 did not think it was a sexual behavior because Resident 2 was patting her abdomen. LVN 4 later on stated CNA 6 reported to her (LVN 6) that Resident 2 was patting her (Resident 2) private area (vagina) but cannot imagine Resident 2 doing that. LVN 4 stated she (LVN 4) did not document and did not report Resident 2’s inappropriate sexual behaviors (patting the vagina) to the RN and Physician. During a concurrent interview and record review on 6/26/2025 at 4:01 p.m. with the DON and RMN, Resident 1’s admission record, history and physical, MDS (dated 6/1/2025), care plans (dated 4/11/2024 to 6/9/2025) and progress notes (dated 6/2/2025 to 6/23/2025) were reviewed. The DON stated Resident 1’s cognition was moderately impaired and was diagnosed with dementia. The DON stated Resident 1’s History and Physical, dated 4/11/2025, indicated Resident 1 did not have the capacity to make decisions. The DON stated she (DON) observed Resident 1 could nod her head for yes or no and could only answer a certain question (did not indicate what question). The DON and RMN stated Resident 1 was unable to give consent for any sexual activity. During an interview on 6/26/2025 at 4:35 p.m. with the DON, the DON stated the facility failed to provide safety for Resident 1 and knowing that Resident 2’s behavior was exhibited since 9/2024. The DON stated there were no monitoring and no documentation of Resident 2’s sexually inappropriate behaviors (masturbatory behaviors). The DON stated there was lack of documentation and reporting. The DON stated this resulted to Resident 2 sexually assaulted Resident 1. During a review of the current facility-provided policy and procedure titled, “Abuse Prevention and Prohibition Program,” with review date of 4/28/2025, the policy and procedure indicated, “The Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to … protect residents…. Each resident has the right to be free from abuse…. The Facility has zero-tolerance for abuse…. Staff must not permit anyone to engage in … sexual … abuse…. The Facility is committed to protecting residents from abuse by anyone, including but not limited to … other residents…. Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict…. The Administrator then acts to ensure the following steps are taken: … ii. A Licensed Nurse assesses the resident (alleged victim) for possible injuries.”

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of eight sampled residents (Resident 1) when on 3/12/2025, at around 5:45 p.m. Resident 2 scratched Resident 1's right upper nose during a physical altercation (refers to a confrontation or fight involving physical contact or force) in the dining room. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a skin scratch with bleeding on Resident 1's right upper side of nose and complained of moderate pain (a level of discomfort that is significant but not severe) with a score of four out of 10 using the pain scale (a score from zero [0] to ten where ten is the worst possible pain) on her (Resident 1) right upper nose. Based on the Reasonable Person Concept (what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer because of the noncompliance), due to Resident 1's impaired cognition (mental action or process of acquiring knowledge and understanding), an individual subjected to physical abuse may have physical pain, psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 2/10/2021 and readmitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (is a group of lung diseases characterized by long-term breathing difficulty and airflow obstruction), dementia (a broad term describing a decline in memory, thinking, and reasoning skills, impacting daily life, and often caused by damage to brain cells that affects their ability to communicate), and Alzheimer's disease (a type of dementia marked by a decline in mental abilities severe enough to interfere with daily activities). During a review of Resident 1's Order Summary Report, dated 2/18/2025, the report indicated to give two tablets of acetaminophen (a medication used to relieve pain) 325 mg (milligram - a unit of measurement) by mouth every four hours as needed for mild pain or general discomfort. During a review of Resident 1's History & Physical (H&P - refers to a comprehensive assessment of a resident's medical history and a physical examination, used to gather information for diagnosis and treatment planning), dated 2/20/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (a resident assessment tool), dated 2/25/2025, the MDS indicated Resident 1 had moderately impaired (generally signifies a level of impairment that is between mild and severe, indicating noticeable difficulties or limitations in a specific area, but not to the extent that it renders someone completely unable to function) cognitive skills (the mental processes and abilities that enable individuals to acquire, process, and apply knowledge, encompassing functions like memory, attention, language, and problem-solving) for daily decision making. The MDS indicated Resident 1 used a manual wheelchair (a chair on wheels designed for mobility, propelled by the user's hands or by someone else, without the use of a motor) while in the facility. The MDS indicated Resident 1 needs substantial/maximal assistance (helper does more than half the effort) during shower, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 was dependent (helper does all the effort) on toileting and needed partial/moderate assistance (helper does less than half the effort) during oral (mouth) hygiene and upper body dressing. During a review of Resident 1's Progress Notes dated 3/12/2025, the Progress Notes indicated that on 3/12/2025, at around 5:45 p.m., in the facility's dining station, a loud altercation (a noisy argument or disagreement) and yelling was heard from two residents (Resident 1 and Resident 2). Resident 1 was noted with a skin scratch in her (Resident 1) right upper nose. The progress notes indicated Resident 1's pain level was assessed at four out of ten and pain medication (acetaminophen) was given as ordered. During a review of Resident 1's Order Summary Report dated 3/12/2025, the report indicated to cleanse Resident 1's right side upper nose scratch with normal saline solution (salt water, used for cleaning wounds), pat dry, apply antibiotic (a medication used to treat bacterial infections) ointment, cover with dry dressing, and secure with tape twice a day for ten days. During a review of Resident 1's Medication Administration Record (MAR- a report detailing the drugs administered to a resident by a healthcare professional), dated 3/12/2025, two tablets of acetaminophen was given by mouth. During a review of Resident 1's care plan titled, Skin scratch: upper right side of nose, dated 3/12/2025, the care plan indicated interventions including to monitor Resident 1's affected area of the nose every shift for one month and to apply antibiotic ointment to the affected area of nose twice a day for two weeks as ordered. During a review of Resident 1's care plan titled, Resident has been substantially (to a great or significant) involved in a peer-to-peer (resident to resident) altercation on 3/12/2025, dated 3/13/2025, the care plan indicated goals for Resident 1 not to experience a repeat of the altercation. During a review of Resident 1 Interdisciplinary Care Conference Review (is a meeting where healthcare professionals from different disciplines gather to discuss a resident's care plan, share information, and coordinate interventions to improve resident outcomes), dated 3/13/2025, the Care Conference Review indicated Resident 1 was able to verbalize what happened during the incident (altercation with Resident 2). The care conference review indicated Resident 1 stated that while in the dining room the other resident (Resident 2), who was on a wheelchair, was hitting and bumping into her (Resident 1) wheelchair. The Care Conference Review indicated Resident 1 stated Resident 2 scratched her (Resident 1) face. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 3/21/2023 and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a problem with the body's metabolism or chemical processes, leading to issues with thinking, memory, and potentially even consciousness), dementia, and Alzheimer's disease. During a review of Resident 2's H&P, dated 2/26/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 was dependent during oral hygiene, toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 2 needed maximal assistance during upper body dressing and moderate assistance during eating. During a review of Resident 2's Interdisciplinary Care Conference Review, dated 3/13/2025, the Care Conference Review indicated that the facility staff (name not indicated) updated Family Member 1 about the incident (altercation) with Resident 2 and another resident (Resident 1) that was witnessed by two activity staff (this is wrong information as the incident was witnessed by Certified Nursing Assistants [CNA] 1 and 2 who were present in the dining room). During an interview on 3/25/2025 at 3:04 p.m., with Resident 1 together with the Activity Director, in Resident 1's room, the Activity Director acted as the interpreter translating Resident 1's statements in a foreign language to English who stated that Resident 2's wheelchair kept hitting her (Resident 1) wheelchair so Resident 1 told Resident 2 to not bother her (Resident 1) or Resident 1 will hit Resident 2. Resident 1 stated Resident 2 hit her (Resident 1) in her (Resident 1) nose. During an interview on 3/25/2025 at 3:43 p.m., with CNA 2 (CNA 1 was not available for interview), CNA 2 stated she (CNA 2) heard two residents (Resident 1 and Resident 2) yelling in the dining room and when she checked, she (CNA 2) witnessed Resident 2 scratched Resident 1's face and observed bleeding in Resident 1's right upper nose. CNA 2 stated Resident 2 had a strong grip in Resident 1 face because Resident 2 broke a nail from scratching Resident 1's face. CNA 2 stated the incident between Resident 1 and Resident 2 was considered a physical abuse because Resident 1 got a skin scratch with bleeding from Resident 2. During an interview on 3/26/2025 at 12:31 p.m., with the Director of Nursing (DON), the DON stated that Resident 2 got a little agitated (angry) and scratched Resident 1's skin. The DON stated this incident was considered as a physical abuse. During a review of the current facility-provided policy and procedure titled, Abuse Prevention and Prohibition Program, last reviewed date of 1/27/2025, the policy and procedure indicated, Each resident has the right to be free from . abuse The facility has zero-tolerance for abuse Staff must not permit anyone to engage in . physical abuse The facility is committed to protecting residents from abuse by anyone, including but not limited to . other residents

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 3), who was assessed as high risk for falls, had intermittent (not happening regularly or continuously) confusion, and required two-person staff assistance was free from falls and injury in accordance with Resident 3's care plan (a document that outlines the specific healthcare and support needs of a resident, along with strategies and interventions to address those needs), by failing to: 1. Provide Resident 3 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of residents who require support for mobility) when on 1/24/2025 at 9:30 a.m. Certified Nursing Assistant 1 (CNA 1) transferred Resident 3, by himself, from the wheelchair to the shower bench. 2. Ensure CNA 1 did not move Resident 3 after the witnessed fall, from the shower room floor to the wheelchair before a registered nurse (RN) had assessed Resident 3 for injuries. As a result, on 1/24/2025 at 9:30 a.m., Resident 3 fell from the wheelchair and hit his (Resident 3) right knee on the shower bench. Resident 3 sustained a mild displaced avulsion fracture (a small piece of bone attached to a tendon [a strong, flexible cord of strong fibrous tissue attaching a muscle to the bone] or ligament [a band of tough tissue that connects two bones or holds together a joint] gets pulled away from the main part of the bone) that involved the tibial tuberosity (the top of the tibia [shinbone] where the patellar [kneecap] tendon connects). Resident 3 was given pain medication and was transferred to General Acute Care Hospital 1 (GACH 1) on 1/25/2025 for further evaluation and treatment. Findings: During a record review of Resident 3's Admission Record, the Admission Record indicated the facility admitted Resident 3 on 2/9/2020 with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and age-related osteoporosis (a disease that causes bones to become weak and brittle, making them more likely to break) without current pathological fracture (a broken bone in an area weakened by another disease, not by an injury). During a record review of Resident 3's Physician Order, dated 6/14/2024, the Physician Order indicated Resident 3 may use a mechanical device (mechanical lift) for transfers. During a record review of Resident 3's Fall Risk Assessment, dated 11/19/2024, the Fall Risk Assessment indicated Resident 3 had a total score of 16. A total score of above ten represented high risk for falls. During a record review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/20/2024, the MDS indicated Resident 3's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were moderately impaired. The MDS indicated Resident 3 had a functional limitation in range of motion (ROM - extent of movement of a joint) on both sides of the upper extremity (shoulder, elbow, wrist, and hand) and the lower extremity (hip, knee, ankle, and foot). The MDS indicated Resident 3 was dependent (resident does none of the effort to complete the activity or the assistance of two or more helpers [staff] were required for the resident to complete the activity) on facility staff with mobility (movement) such as sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed), chair or bed-to-chair transfer (the ability to transfer to and from bed or chair to a chair or wheelchair), toilet transfers, and shower transfers. During a record review of Resident 3's Physician Order, dated 12/6/2024, the Physician Order indicated Tylenol (a brand name for acetaminophen [medication used to relieve mild to moderate pain]) 325 milligrams (mg - unit of measurement) two tablets every four hours as needed for mild pain or general discomfort. During a record review of Resident 3's Activities of Daily Living (ADLs - refers to everyday tasks that individuals need to care for our bodies and maintain overall well-being) Hygiene Task section, dated 1/24/2025, the ADL Hygiene Task indicated Resident 3 was provided a shower on 1/24/2025. During a record review of Resident 3's ADL Transfer Task section, dated 1/24/2025, the ADL Transfer Task indicated Resident 3 was dependent on facility staff with shower transfers. The ADL Transfer Task indicated there was no mechanical device used in Resident 3's transfers on 1/24/2025. During a record review of Resident 3's Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/24/2025, the RN/LVN Progress Notes indicated that on 1/24/2025 at 9:30 a.m., CNA 1 was inside the shower room with Resident 3 when Resident 3 became agitated (unable to relax and be still) and pushed CNA 1 (with no assistance from any other facility staff) during the transfer of Resident 3 from the wheelchair to the shower bench. The RN/LVN Progress Notes further indicated Resident 3's knee (side not specified in the progress notes) hit the shower bench and swelling was observed. The RN/LVN Progress Notes indicated Resident 3 received Tylenol for facial grimacing (a distorted, pained facial expression). The RN/LVN Progress Notes indicated on 1/24/2025 at 6:30 p.m., Resident 3 had skin discoloration (a change in the skin's natural skin tone), swelling, and a nine out of ten pain (a numeric scale used to describe the pain with zero as no pain and 10 as the worst pain) on Resident 3's right lower leg. The RN/LVN Progress Notes indicated Resident 3's physician was notified and ordered for stat (immediately and without delay) X-ray (a medical imaging procedure that captures images of the structures inside the body). During a record review of Resident 3's Physician Order, dated 1/24/2025, the Physician Order indicated stat X-ray of the right tibia and fibula (the two bones in the lower leg), two views due to right leg pain. During a record review of Resident 3's X-ray results of the right tibia and fibula, dated 1/24/2025, the X-ray results indicated Resident 3 had acute (recent onset) oblique coronal fracture (an angled break in a bone that occurs on a plane that cuts across the bone like a slice) through the base of the tibial tuberosity with approximately 7.8 millimeter (mm - unit of measurement) diastases (an abnormal separation of parts normally joined together). The X-ray indicated Resident 3 had joint subluxation (a partial dislocation of a joint). During a record review of Resident 3's X-ray results, dated 1/24/2025, the X-ray result indicated Resident 3 had acute to subacute (rather recent onset or rapid change) mild displaced avulsion fracture involving the tibial tuberosity. During a record review of Resident 3's Physician Order, dated 1/24/2025, the Physician Order indicated to transfer Resident 3 to GACH 1 for further evaluation. During a record review of Resident 3's Interdisciplinary Team (IDT, a team of healthcare professionals from different professional disciplines who work together to address and manage the needs of the resident) Care Conference Review, dated 1/24/2025, the IDT Care Conference Review indicated on 1/24/2025, during shower transfer, Resident 3 became agitated, pushed CNA 1, and her (Resident 3) right knee hit the shower bench that resulted to Resident 3's right knee swelling. The IDT Care Conference Review indicated an ice pack was placed on Resident 3's right knee for 15 minutes every six hours and Resident 3 was given Tylenol for facial grimacing. The IDT Care Conference Review indicated on 1/24/2025 at 6:30 p.m., Resident 3 had skin discoloration and swelling on the right lower leg. Resident 3 had an X-ray of the right tibia and fibula done. Resident 3 had nine out of ten on the pain scale when Resident 3's right leg was moved. Resident 3's physician was notified and ordered to send Resident 3 to GACH 1 for further evaluation and treatment. During an interview on 2/7/2025 at 10:19 a.m., with CNA 1, CNA 1 stated on 1/24/2025 at around 9:30 a.m., Resident 3 had an aggressive behavior. CNA 1 stated Resident 3 required two-person staff assistance with transfers. CNA 1 stated on 1/24/2025 between 9 a.m. to 10 a.m., he (CNA 1) transferred Resident 3 from the resident's bed to the resident's wheelchair without the use of a mechanical device for transfers. CNA 1 stated he (CNA 1) brought Resident 3 to the shower room utilizing a wheelchair. CNA 1 stated he stood in front of Resident 3, locked the wheelchair wheels and placed his arms under Resident 3's arms to transfer Resident 3 from the wheelchair to the shower bench. CNA 1 stated Resident 3 became agitated and pushed CNA 1. CNA 1 stated he (CNA 1) lost grip on Resident 3. Resident 3's right knee hit the shower bench before Resident 3's right knee landed on the floor. CNA 1 stated he sat Resident 3 on the shower room floor. CNA 1 stated he assisted Resident 3 back to the wheelchair without the use of a mechanical device for transfer and before a licensed nurse had assessed Resident 3. CNA 1 stated he brought Resident 3 (resident was on a wheelchair) to the nurse station and informed Licensed Vocational Nurse 4 (LVN 4) and Registered Nurse 1 (RN 1) about Resident 3's fall inside the shower room. CNA 1 stated if there were two staff that assisted Resident 3 on transfers, the fall would have been prevented. CNA 1 stated Resident 3 had the potential for more injury because Resident 3 was moved before RN 1 assessed Resident 3. During a concurrent interview and record review on 2/7/2025 at 11:22 a.m., with LVN 4, Resident 3's care plan on Functional Abilities of Everyday Activities dated 12/22/2023 was reviewed. The care plan on Functional Abilities of Everyday Activities dated 12/22/2023 indicated a goal for the resident to be transferred safely as evidenced by no fall through the target date of 3/4/2025. The care plan intervention indicated to transfer Resident 3 in and out of bed or wheelchair daily as needed using a mechanical lift and provide two-person physical assist. The care plan intervention indicated Resident 3 required two-person physical assist as needed when bathing or showering. LVN 4 stated Resident 3's care plan was not followed and resulted in Resident 3's fall with injury on 1/24/2025. LVN 4 stated on 1/24/2025, after the fall incident, Resident 3 was observed with facial grimace. LVN 4 stated she (LVN 4) gave Resident 3 Tylenol 325 mg two tablets for pain. During a concurrent interview and record review on 2/7/2025 at 12:25 p.m., with the Director of Nursing (DON), Resident 3's care plan on Functional Abilities of Everyday Activities dated 12/22/2023 was reviewed. The DON stated Resident 3 had a fall on 1/24/2025 and sustained a right leg fracture (break or crack in the bone). The DON stated Resident 3 should have been assisted by two facility staff during transfers and mobility as indicated in Resident 3's care plan. The DON stated CNA 1 should have not moved Resident 3 before RN 1 and the Physical Therapist (a health professional trained to evaluate and treat residents who have conditions or injuries that limit their ability to move and do physical activities) assessed Resident 3 for injuries. The DON stated moving Resident 3 before RN 1's assessment had the potential to cause more injury. The DON stated Resident 3's care plan was not followed and resulted to Resident 3's fracture. The DON stated the facility failed to follow the fall prevention interventions, Resident 3's care plan interventions, and Resident 3's physician order dated 6/14/2024 to use a mechanical device (mechanical lift) for transfers. During a concurrent interview and record review on 2/7/2025 at 1:56 p.m., with LVN 4, Resident 3's RN/LVN Progress Notes, IDT Care Conference Review, and care plans from 1/1/2025 to 1/23/2025 were reviewed. LVN 4 stated there were no documented evidence found regarding Resident 3's agitation (a condition in which a person is unable to relax and be still) and aggressive (actions or conduct that are intended to cause harm, intimidate others) behavior in Resident 3's RN/LVN Progress Notes, IDT Care Conference Review, and care plans. During a follow up interview on 2/7/2025 at 2:19 p.m., with the DON, the DON stated Resident 3's agitated and aggressive behavior should be documented for every occurrence and a plan of care should have been created to address Resident 3's aggression and agitation. The DON stated Resident 3's behaviors that were not communicated to Resident 3's care givers had the potential to affect the care provided for Resident 3. During a record review of the current facility-provided policy and procedure (PnP) titled, Fall Management Program, last reviewed on 1/27/2025, the PnP indicated the facility will provide the highest quality in the safest environment for the residents residing in the facility. The PnP indicated upon completion of the resident care assessment upon admission, quarterly, with significant change in condition, and as needed, MDS nurse will assess how many persons assist was needed for the resident. The PnP indicated based on the information gathered from the history and assessment of the resident, the nursing staff . will identify and implement interventions to reduce the risk of falls. During a record review of the current facility-provided PnP titled, Care Planning, last reviewed on 1/27/2025, the PnP indicated the purpose to ensure a comprehensive person-centered care plan was developed for each resident based on their individual assessed needs. The PnP indicated each resident's comprehensive care plan will describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being. During a record review of the current facility-provided PnP titled, Transfer of Residents, last reviewed on 1/27/2025, the PnP indicated the purpose to provide the form of transfer best suited to the resident's needs and to maintain resident safety during the procedure. The PnP indicated a licensed nurse, or the Director of Rehabilitation services assess and determine lifting and transfer requirements, and the procedure used for each resident. The procedure is recorded in the resident's care plan. The PnP indicated residents must be lifted or transferred according to the determined procedure. During a record review of the current facility-provided PnP titled, Response to Falls, last reviewed on 1/27/2025, the PnP indicated upon witnessing a fall or finding a resident in a position indicating a fall, stay with the resident and send another staff member to notify a licensed nurse if the first responder was not a licensed personnel. The PnP indicated do not move the resident initially until after an assessment has been completed. The PnP indicated to call for assistance.

Based on interview and record review, the facility failed to prevent a fall and injury for one of three sampled residents (Resident 1), who was identified as a high fall risk, with unsteady standing and walking balance, with decreased muscular coordination requiring use of assistive device (a tool or piece of equipment that helps a person with disability perform tasks and activities such as a walker [a device that helps a person maintain balance and stability while walking]) and needed supervision to prevent falls and injuries. The facility failed to: a. Provide an assistive device for safe ambulation (the ability to walk from one place to another safely or move around independently). b. Implement the facility's policy and procedure (P&P) titled Falling Star Program by failing to ensure Resident 1's name was printed on a brightly colored paper (yellow) by the door outside of Resident 1's room to ensure that staff is aware Resident 1 is at high risk for falls. As a result, on 10/29/2024 at 7:08 a.m., Resident 1 fell while walking towards the bathroom unassisted and without a walker. Resident 1 sustained a laceration (a deep cut or tear in the skin) at the back of the head and required transfer to General Acute Care Hospital 1 (GACH 1) on 10/29/2024 at 7:36 a.m. where Resident 1 was diagnosed with closed displaced intertrochanteric fracture of left femur (the upper part of the thigh bone was broken, and the broken pieces were not aligned, without any open wounds on the skin around the break). Resident 1 underwent left femur (thigh bone) intramedullary nailing (IM nailing - a surgical procedure that involves inserting a metal rod into the center of a broken bone to stabilize and aid in healing) at GACH 1. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility admitted the resident on 1/31/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), and generalized muscle weakness. During a review of Resident 1's History and Physical, dated 2/24/2024, the History and Physical indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2024, the MDS indicated Resident 1's cognitive (the ability of the brain to think and reason) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 required a walker and wheelchair for mobility (the ability to move freely). The MDS indicated Resident 1 required moderate assistance with toileting and personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or steadying as resident completes activity) while walking at least 10 feet (ft. - unit of measure), while walking 50 ft. with two turns and when walking 150 ft. During a review of Resident 1's Fall Risk Assessment, dated 10/2/2024, the Fall Risk Assessment indicated Resident 1 had a total score of 22 (a total score above 10 represents a high risk for falls). The Fall Risk Assessment indicated Resident 1 had intermittent confusion (a medical condition that involves a sudden or worsening change in mental state), balance problem while standing and while walking, decreased muscular coordination, unsteady gait (a manner of walking) when walking through the doorway, unstable when making turns and requires use of assistive device. During a review of Resident 1's Weekly Summary, dated 10/11/2024, the Weekly Summary under the functional status section indicated the resident (Resident 1) required assistance when walking. The Weekly Summary under the Special Treatment/ Procedures/ Programs section indicated Resident 1 required contact guard assist (CGA - a light touch or contact is made to help steady the body and help with balance), use of a front wheel walker (a device designed for people who are unstable to walk, has two wheels in front of the walker) and use of a walking belt (a device used to help safely transfer a person from a bed to a wheelchair, and assist with walking, sitting and standing) when walking 175 ft. to 200 ft. daily. The Weekly Summary further indicated to monitor Resident 1's balance for steadiness (refers to stability and balance while walking) during transitions (change from one position, step or movement to another) and walking and to provide assistance to Resident 1. During a review of Resident 1's Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) Progress Notes, dated 10/29/2024, timed at 7:40 a.m., the RN/LVN Progress Notes indicated on 10/29/2024 at 7:08 a.m., Restorative Nursing Assistant 1 (RNA 1) informed LVN 1 that Resident 1 was found on the floor, next to Resident 1's bed, inside the resident's room. LVN 1 documented she (LVN 1) observed Resident 1 lying supine (lying on the back with the face and body facing up) on the floor with a small amount (exact amount not specified) of blood at the back of Resident 1's head. The RN/LVN Progress Notes indicated LVN 1 applied pressure on the small laceration at the back of Resident 1's head. LVN 1 documented Resident 1 was not able to move the left lower extremity (hip, thigh, knee, leg, ankle, and foot) and complained of left hip pain. The RN/LVN Progress Notes indicated Resident 1 stated the fall happened while walking on the way to the bathroom. The RN/LVN Progress Notes indicated at 7:36 a.m. (on 10/29/2024), Resident 1 was transferred to GACH 1. During a review of Resident 1's Physician Order Sheet, dated 10/29/2024, the Physician Order Sheet indicated Attending Physician 1 (MD 1) ordered to transfer Resident 1 to GACH 1 via 911 (a phone number to contact the emergency services) after a fall for further evaluation. During a review of Resident 1's Post Fall Summary and Intervention form, dated 10/29/2024, the Post Fall Summary and Intervention form indicated Resident 1 had a fall on 10/29/2024 at 7:08 a.m. inside Resident 1's room. The Post Fall Summary form indicated the cause of Resident 1's fall were unsteady gait (when a person is having trouble with their balance of the way they walk), poor judgment, non-compliant (inability or unwillingness to follow a prescribed treatment plan), and dementia. During a review of Resident 1's Paramedics' (trained personnel that provides emergency medical care to people who are injured or ill) Patient Care Report, dated 10/29/2024, the Patient Care Report indicated the paramedics, who were on scene (at the facility) at 7:26 a.m. (on 10/29/2024), found Resident 1 lying supine on the ground and complained of left hip pain. The Patient Care Report under the narrative section indicated Resident 1 had a small abrasion (scrape on the skin) on the top of the head and had a possible left leg shortening with outward rotation and tender (painful) to touch. During an interview on 11/12/2024 at 10:40 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA 1) observed Resident 1 use a walker at times. CNA 1 stated Resident 1 was observed unstable when walking to the bathroom independently without a walker. CNA 1 stated residents that were identified as a high fall risk had their names on the residents' room doors highlighted (colored) in yellow. CNA 1 stated Resident 1 was not identified as a fall risk because the resident's name on the room door was not highlighted in yellow. During an interview on 11/12/2024 at 10:52 a.m. with CNA 2, CNA 2 stated Resident 1 required assistance with walking to the bathroom and was unstable when walking without a walker. CNA 2 stated Resident 1 did not have a yellow highlighted name outside Resident 1's room. CNA 2 stated that on 10/29/2024 she (CNA 2) observed Resident 1 lying on the floor by the resident bed's foot part with the Resident 1's head towards the door and the towards the bathroom. CNA 2 stated Resident 1 wanted to go to the bathroom. CNA 2 stated Resident 1 did not have a walker in the room. During an interview on 11/12/2024 at 1:44 p.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN 2) did not see an assistive device or walker inside Resident 1's room. During a concurrent interview and record review on 11/12/2024 at 2:50 p.m., with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy (PT) Discharge Summary, dated 3/16/2024 was reviewed. The PT Discharge Summary dated 3/16/2024 indicated Resident 1 had a treatment diagnosis of unspecified abnormalities of gait and mobility (a diagnosis used when a resident has abnormal gait or mobility that does not fit into other categories). The DOR stated Resident 1's treatment diagnosis indicated the resident's gait was compromised and warranted therapy at the time of Resident 1's evaluation. During a concurrent interview and record review on 11/12/2024 at 2:56 p.m. with the Director of Nursing (DON), the DON stated Resident 1's balance was not stable and stated Resident 1 was a fall risk. The DON stated Resident 1's strength and mobility was declining, and the resident was not safe to ambulate (walk) without assistance. Resident 1's Care Plan on ambulation, initiated on 10/3/2024 was reviewed. The DON stated Resident 1 required CGA on ambulation due to unsteady gait and balance. The Care Plan Intervention indicated to assist Resident 1 to ambulate 175 ft. to 200 ft. daily with CGA and with the use of a front wheel walker. During a review of Resident 1's Care Plan on falls, initiated on 2/13/2023, indicated the resident was at risk for falls. The Care Plan Intervention indicated to remind Resident 1 to follow fall precaution and to ambulate with walker and with staff assistance. The DON stated Resident 1's name should have been highlighted in yellow (by the door outside Resident 1's room) to indicate Resident 1 was a high fall risk. The DON stated that on 10/29/2024, Resident 1 sustained a laceration on the head and a left femur fracture from a fall. The DON stated the walker should have been available for Resident 1's use. The DON stated the facility failed to provide Resident 1 with a walker as indicated on Resident 1's fall care plan. The DON stated the facility failed to ensure Resident 1's name (by the door outside Resident 1's room) was in yellow identifying Resident 1 as a high risk for fall. During a review of Resident 1's GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the pelvis (the bony structure between the lower stomach and upper thighs that connects the spine to the legs), dated 10/29/2024, the CT indicated Resident 1 had angulated (tilts at an angle) and impacted (the broken ends of the bone were jammed together by the force of the injury) intertrochanteric fracture of the proximal (closer to the center of the body or to the point of attachment to the body) left femur. During a review of Resident 1's undated GACH 1 clinical record (provided by the facility), the clinical record indicated on 10/29/2024 Resident 1 was admitted to GACH 1 after a fall resulting to the resident's left hip pain. The clinical records indicated Resident 1 had a fall and sustained a closed displaced intertrochanteric fracture of the left femur and traumatic (a sudden and severe physical injury that requires immediate medical attention) left intertrochanteric fracture. The clinical records indicated Resident 1 underwent a left femur IM nailing. During a review of the current facility-provided P&P titled, Fall Management Program, last reviewed in 1/29/2024, indicated the facility to provide the highest quality care in the safest environment for the residents in the facility. The P&P indicated the facility strived to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. The Universal Fall Prevention Measures for all Residents section indicated to reassess resident's mobility status daily and encourage use of assistive devices such as walker or wheeled walker, as appropriate. During a review of the current facility-provided P&P titled, Falling Star Program, last reviewed in 1/29/2024, indicated the facility will ensure that staff was aware of residents who were at high risk for falls. The P&P indicated the resident's name will be printed on brightly colored paper by the door outside of resident's room.

Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Residents 119, 139, 141, and 34) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) received treatment and services to prevent further decline in ROM, by failing to: 1. Accurately complete Joint Mobility Assessments (JMA, brief assessment of a resident's range of motion in both arms and both legs) for Residents 119, 139, 141, and 34 in accordance with the facility's policy titled, Joint Mobility Assessment, revised on 5/1/2018 and reviewed on 1/29/2024. 2. Assess both of Resident 119's elbow splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for proper fit during the JMAs, dated 12/7/2022, 3/3/2023, 8/23/2023, 11/24/2023, and 8/4/2024, after Resident 119's discharge from Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) on 8/19/2022 and 10/6/2022. 3. Assess Resident 119's right knee splint during JMAs, dated 12/7/2022, 3/3/2023, 8/23/2023, 11/24/2023, and 8/4/2024 for proper fit, after Resident 119's discharge from Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) on 10/28/2022. 4. Identify and report Resident 119's significant decline in ROM to both arms and legs on the JMA, dated 8/4/2024. 5. Provide passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both of Resident 119's hands on 8/7/2024. The physician's order is to PROM to both arms every day. 6. Apply Resident 119's right elbow splint properly by applying the splint right-side up (not upside down) on 8/7/2024. 7. Identify and report Resident 119's right knee splint was not aligned with the right knee for at least two weeks, including on 8/7/2024 and 8/8/2024. 8. Identify and replace Resident 139's loose left hand compressive glove (worn after a burn or skin injury to provide consistent and even pressure to the healed skin to decrease the severity of scarring). These failures resulted in Resident 119's undetected worsening contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to both elbows and knees and the development of contractures to both hips and hands. These failures resulted in inaccurate monitoring of ROM in both arms and legs for Resident 119, 34, 139, and 141. These failures had the potential for Resident 139 to experience a decline in ROM to the left hand. Cross reference F726. Findings: a. During a review of Resident 119's Admission Record, the facility admitted Resident 119 on 5/11/2017 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life), dementia (decline in mental ability severe enough to interfere with daily life), age-related osteoporosis (medical condition in which the bones become brittle and fragile from loss of tissue), and dysphagia (difficulty swallowing). During a review of Resident 119's census (record of hospitalization s, room changes, and payor source changes), the census indicated Resident 119 resided at the facility since 5/11/2017 without any hospitalization s. During a review of Resident 119's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 5/13/2024, the MDS indicated Resident 119 had unclear speech, rarely expressed ideas and wants, rarely understood verbal content, and was severely impaired (never/rarely made decisions) for daily decision making. The MDS indicated Resident 119 had ROM impairments in both arms and legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) with eating, toileting, showering/bathing, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers. During a review of Resident 119's physician orders, dated 11/9/2020, the physician orders indicated for Resident 119 to receive PROM exercises to both arms and legs, every day. During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 6/8/2022, the OT Evaluation indicated Resident 119 was referred to OT due to a decline in ROM, decreased balance, and increased need for assistance from others. The OT Evaluation indicated Resident 119's ROM to the right elbow, both wrists, and both hands were within functional limits (WFL, sufficient movement without significant limitation). The OT Evaluation indicated Resident 119's impaired ROM included right shoulder flexion (lifting the arm upward) 0 to 80 degrees (0 to 80 degrees, normal 0 to 180 degrees), right shoulder abduction (lifting the arm up and away from the body) 0 to 75 degrees (normal 0 to 180 degrees), left shoulder flexion 0 to 40 degrees, left shoulder abduction 0 to 40 degrees, and left elbow extension (straightened) was limited to 80 degrees (normal 0 degrees, positioned in 80 degrees of elbow flexion [bend]). During a review of Resident 119's OT Treatment Encounter Notes, dated 8/19/2022, the OT Treatment Encounter Notes indicated Resident 119's ROM included right shoulder flexion 0 to 90 degrees (shoulder height), right shoulder abduction 0 to 80 degrees, right elbow extension to 20 degrees (elbow positioned in 20 degrees of flexion), left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees (elbow positioned in 30 degrees of elbow flexion). During a review of Resident 119's OT Discharge Summary, dated 8/19/2022, the OT Discharge Summary indicated Resident 119 safely wore splints to both elbows for two hours without signs of redness, swelling, discomfort, or pain. The OT Discharge Summary recommendations included a Restorative Nursing Program ([RNP] nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and mobility) to provide Resident 119 with PROM and to apply both elbow splints for two hours daily as tolerated. During a review of Resident 119's Restorative Nursing Program (RNP) Referral/Care Plan, dated 8/19/2022, the RNP Referral/Care Plan indicated Occupational Therapist 2 (OT 2) reviewed Resident 119's program with Restorative Nursing Assistant 5 (RNA 5) to apply both elbow splints for two hours. During a review of Resident 119's physician orders, dated 8/19/2022, the physician orders indicated for RNA to apply both elbow splints for two hours daily as tolerated. During a review of Resident 119's Registered Nurse (RN)/Licensed Vocational Nurse (LVN) Progress Notes, dated 10/4/2022, the RN/LVN Progress Notes indicated Resident 119 was on RNA program for PROM exercises to both arms and both legs and application of both elbow splints for two hours as tolerated. The RN/LVN Progress Notes indicated Resident 119 was noted with abnormal posture (position in which someone holds their body) while sitting up in the wheelchair and/or lying in bed and was at-risk for developing contractures. The RN/LVN Progress Notes indicated Resident 119 will continue to be monitored. During a review of Resident 119's RN/LVN Progress Notes, dated 10/5/2022, the RN/LVN Progress Notes indicated Resident 119 continued to have abnormal posture while sitting up in the wheelchair and lying in bed and was at-risk for developing contractures. The RN/LVN Progress Notes indicated a discussion with family included providing Resident 119 with PT and OT Evaluations to ensure correct body alignment, positioning, and prevention of contractures. During a review of Resident 119's Joint Mobility Screening (JMA completed by PT and OT), dated 10/6/2022, the Joint Mobility Screening indicated Resident 119's ROM included severe ROM limitation (more than 50 percent [%] loss of motion) in the left shoulder, moderate ROM limitation (25 to 50% loss of motion ) in the right shoulder, minimum ROM limitation (less than 25% loss of motion) in both elbows and knees, and full ROM in both hands, hips, and ankles. The Joint Mobility Screening indicated recommendations for Resident 119 to receive PT and OT Evaluations and to continue with the RNA program. During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 10/6/2022, the OT Evaluation indicated Resident 119 was seen for an Evaluation Only (no intervention recommended). The OT Evaluation Only indicated Resident 119's ROM was WFL in both wrists and hands but had impairment in both shoulders and elbows, including right shoulder flexion 0 to 90 degrees (shoulder height), right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, and left elbow extension to 30 degrees. The OT Evaluation Only indicated Resident 119 was already provided with both elbow splints and did not have any significant change in condition requiring OT intervention. During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 10/6/2022, the PT Evaluation indicated Resident 119 was referred to PT due to a new onset of decreased ROM, decreased postural alignment when sitting up in the wheelchair, and at-risk for contracture development. The PT Evaluation indicated Resident 119's ROM in both hips and ankles were WFL but had impaired ROM to both knees. The PT Evaluation indicated Resident 119's right knee extension was limited to 30 degrees (normal 0 degrees, knee positioned in 30 degrees of knee flexion) and left knee extension was limited to 15 degrees (knee positioned in 15 degrees of knee flexion). During a review of Resident 119's PT Discharge Summary, dated 10/28/2022, the PT Discharge Summary indicated Resident 119 tolerated sitting up in a standard wheelchair with a cushioned seat for four hours, had right knee extension to 20 degrees, and tolerated a right knee extension splint for two hours. The PT Discharge recommendations included a RNP to provide Resident 119 with PROM and to apply the right knee extension splint. During a review of Resident 119's RNP Referral/Care Plan, dated 10/28/2022, the RNP Referral/Care Plan indicated the Physical Therapist 3 (PT 3) reviewed Resident 119's program with RNA 5 to provide PROM to both legs and to apply the right knee splint for two hours. During a review of Resident 119's physician orders, dated 10/28/2022, the physician orders indicated for the RNA to apply the right knee splint for two hours with skin checks every 30 minutes daily as tolerated. During a review of Resident 119's JMAs, dated 12/7/2022 and 3/3/2023, the JMA indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMAs indicated Resident 119 received RNA for PROM to both arms and legs as tolerated. The JMAs did not indicate the RNA applied both elbow splints and the right knee splint. During a review of Resident 119's JMAs, dated 8/23/2023 and 11/24/2023, the JMAs indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMAs indicated Resident 119 received RNA for PROM to both arms and legs. The JMAs did not indicate the RNA applied both elbow splints and the right knee splint. During an interview on 8/6/2024 at 9:34 a.m. with the Director of Rehabilitation (DOR) in the therapy gym, the DOR stated RNA was a maintenance program to maintain a resident's ROM and mobility. The DOR stated the DOR, RNA Team Lead (RNA 1), and the RNA assigned to each station had weekly meetings to discuss new admissions and any changes with residents. The DOR stated limitations in ROM (in general) can lead to limitations in function and the development of contractures, which could cause pain. The DOR stated ROM exercises and application of splints can assist in maintaining ROM and preventing contractures. The DOR stated PT and OT did not complete the JMA quarterly or annually. During an observation on 8/6/2024 at 3:45 p.m. in the bedroom, Resident 119 was being transferred from the bed to a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) using a mechanical lift (used to transfer residents between surfaces). Resident 119 was fully dressed, did not have any splints applied to either arm or leg, but did have cushioned heel protectors (minimizes risk of injury to the heels) applied to both feet. Resident 119's both knees were bent while sitting up in the Geri chair. During a concurrent observation and interview on 8/7/2024 at 9:10 a.m. in the dining room with Restorative Nursing Assistant 2 (RNA 2), Resident 119 was sitting upright in the Geri chair without any splints applied to either arm or leg but had cushioned heels protectors applied to both feet. RNA 2 stated Resident 119 was seen by RNA 2 for ROM exercises to both arms and both legs and the splints were applied this morning. RNA 2 stated Resident 119's Certified Nursing Assistant (CNA) may have removed the splints. During an observation on 8/7/2024 at 12:40 p.m. in the bedroom, RNA 2 stated Resident 119's primary (routinely assigned) RNA was RNA 5. RNA 2 stood on the right side of Resident 119's bed and performed ROM exercises on Resident 119's right shoulder. RNA 2 could not lift the right arm to shoulder height. RNA 2 bent and extended the right elbow to perform ROM exercises but could not fully extend the right elbow, which remained in a bent position. RNA 2 performed wrist flexion (bent down) and wrist extension (bent up) exercises but did not perform any exercises to Resident 119's right hand. RNA 2 massaged Resident 119's right arm into extension prior to applying the right elbow splint upside down. RNA 2 bent and extended Resident 119's right hip and knee at the same time, causing Resident 119 to moan with a facial grimace (expression of pain or strong dislike). RNA 2 could not extend the right knee, which continued to have a bend of approximately 90 degrees. RNA 2 performed exercises to the right ankle into rotation, dorsiflexion (ankle bent with toes pointing toward the body), and plantarflexion (ankle bent with toes pointing away from the body), and then applied the cushioned heel protector. RNA 2 applied Resident 119's right knee splint, which was fixed in a nearly straight position, and fastened a strap over the right kneecap. Resident 119's knee splint was not applied directly on the right knee but toward the right ankle. RNA 2 stood on the left side of Resident 119's bed and performed ROM exercises on the left shoulder. RNA 2 lifted the left arm higher than the right shoulder joint but could not lift the left arm to shoulder height. RNA 2 bent and extended the left elbow to perform ROM exercises but could not fully extend the left elbow, which remained in a bent position. RNA 2 performed wrist flexion and extension exercises but did not perform any exercise to Resident 119's left hand. RNA 2 applied the left elbow splint. RNA 2 bent and extended Resident 119's left hip and knee at the same time. RNA 2 could not fully extend Resident 119's left hip and knee. RNA 2 then performed ankle exercises to Resident 119's left ankle into rotation, dorsiflexion, and plantarflexion and then applied the left cushioned heel protector. During an interview on 8/7/2024 at 1:04 p.m. with RNA 2, RNA 2 stated the splints will be checked every 30 minutes and will remove the splints after 2 hours. RNA 2 stated ROM was not performed to Resident 119's hands because both hands were good and stated Resident 119 could straighten the fingers. During a concurrent observation and interview on 8/7/2024 at 1:09 p.m. with the DOR and Physical Therapy Assistant 1 (PTA 1) in the bedroom, Resident 119 was observed lying in bed while wearing both elbow splints and the right knee splint. PTA 1 stated Resident 119's right knee splint was applied lower than the knee. PTA 1 checked the right knee splint and stated Resident 119's knee splint was set to 30 degrees of extension but Resident 119's right knee was bent to approximately 90 degrees. PTA 1 stated the right knee splint did not fit Resident 119 because the bend in the splint did not match the bend in Resident 119's knee. PTA 1 stated an inappropriately fitted splint could put pressure on the skin and bones of Resident 119's right knee, which could result in pressure sores (localized damage to the skin and underlying soft tissues over a bony prominence) and dislocation (injury caused when the normal position of a joint is disturbed) of the right knee. During a concurrent observation and interview on 8/7/2024 at 1:19 p.m. with the DOR and PTA 1 in the bedroom, the DOR removed Resident 119's right knee splint. The skin on Resident 119's right knee, which was directly under the strap of the knee splint, was observed with redness. PTA 1 stated Resident 119 had redness to the pressure sensitive area of the right kneecap. The DOR observed Resident 119's elbow splints, stated the right elbow splint was applied upside down, and adjusted both of Resident 119's elbow splints. During a concurrent interview and record review on 8/7/2024 at 1:45 p.m. with the DOR, Resident 119's census, OT Evaluation, dated 6/8/2022, OT Discharge Summary, dated 8/19/2022, OT Evaluation Only, dated 10/6/2022, PT Evaluation, dated 10/6/2022, and PT Discharge Summary, dated 10/28/2022, were reviewed. The DOR reviewed Resident 119's census and stated Resident 119 was admitted to the facility on [DATE] and did not leave the facility for any reason. The DOR stated Resident 119 received an OT Evaluation on 6/8/2022 due to a change of condition ([COC] major decline or improvement in a resident's status that will not resolve itself without intervention), including declining ROM, reduced balance, and increased need for assistance from others, but did not receive a PT Evaluation (unknown reason). The DOR stated Resident 119's ROM in both wrists and hands were WFL but had ROM limitations in both shoulders and elbows. The DOR stated Resident 119's ROM upon discharge from OT on 8/19/2022 was right shoulder flexion 0 to 90 degrees, right shoulder abduction 0 to 80 degrees, right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees. The DOR stated OT 2 discharged Resident 119 on 8/19/2022 with recommendations for RNA to provide PROM to both arms and apply both elbow splints for two hours. The DOR stated Resident 119 received an OT Evaluation Only on 10/6/2022 but treatment was not provided since Resident 119's ROM did not change from OT discharge on 8/19/2022. The DOR stated the OT Evaluation Only, dated 10/6/2022, indicated to continue RNA for PROM to both arms and application of both elbow splints. The DOR reviewed the PT Evaluation, dated 10/6/2022, and stated Resident 119's ROM in both hips and ankles were WFL but had ROM limitation in both knees, including right knee extension to 30 and left knee extension to 15 degrees. The DOR stated Resident 119 was discharged from PT on 10/28/2022 with right knee extension to 20 degrees. The DOR stated PT 3 (no longer works at the facility) discharged Resident 119 on 10/28/2022 with recommendations for RNA to provide PROM to both legs and apply the right knee extension splint. The DOR stated OT has not performed any treatment to Resident 119 since 10/6/2022 and PT has not performed any treatment to Resident 119 since 10/28/2022 (approximately 22 months ago). During a concurrent observation and interview on 8/8/2024 at 8:30 a.m. in the bedroom with RNA 5, Resident 119 was lying in bed awake with the head-of-bed (HOB) fully elevated and the elbow splint applied to the right arm. RNA 5 stated Resident 119 was usually nonverbal and that RNA 5 was Resident 119's primary RNA. The skin on Resident 119's right kneecap was observed with pink areas. RNA 5 stated Resident 119's splints were applied this morning at approximately 7:00 a.m. but the right knee and left elbow splints were removed after 15 minutes due to skin redness on both sites. During a concurrent observation and interview on 8/8/2024 at 9:05 a.m. with Physical Therapist 1 (PT 1) in the bedroom, Resident 119's ROM in both knees and the right knee extension splint were observed. Resident 119 was lying in bed with the HOB fully elevated and both knees were in bent positions. PT 1 extended both knees and stated Resident 119 had contractures to both knees. PT 1 stated the right knee extended to 90 degrees (right knee positioned in 90 degrees of flexion) and the left knee extended to 55 degrees (left knee positioned in 55 degrees of flexion). PT 1 observed Resident 119's right knee extension splint, which was set to 30 degrees, and stated the right knee splint was not an appropriate fit because Resident 119's right knee was bent more than 30 degrees. PT 1 stated the right knee extension splint could cause injury to Resident 119's right leg if applied to the right knee. During a concurrent observation and interview on 8/8/2024 at 9:16 a.m. with PT 1 and RNA 5 in the bedroom, RNA 5 applied Resident 119's knee extension splint. RNA 5 stated Resident 119's right knee extension splint did not fit because Resident 119's right knee ROM had worsened. PT 1 stated he was not notified of Resident 119's worsening ROM in the right knee and the inability to apply the right knee splint appropriately. During a review of Resident 119's physician orders, dated 8/8/2024 timed at 9:30 a.m., the physician orders indicated to discontinue the right knee splint and both elbow splints. The physician orders also indicated for OT and PT to evaluate and treat. During an interview on 8/8/2024 at 10:40 a.m. with the Director of Nursing (DON), Registered Nurse Supervisor 1 (RN 1), Performance Improvement Quality Improvement Licensed Vocational Nurse 1 (PIQI 1), and PIQI 2, RN 1 stated the facility process is that the RN, PIQI, and RNA assigned to each nursing station complete the JMA for each resident upon admission, quarterly, change of condition, and annually. The DON stated the previous DOR provided a training on how to complete the JMA to the DON, RN Supervisors, PIQI LVNs, and RNAs approximately five years ago. The DON stated there has not been any recent training on how to complete the JMAs. PIQI 2 stated the JMA assessed a resident's active or passive joint limitations depending on if the resident can move. During a concurrent interview and record review on 8/8/2024 at 11:55 a.m. with RN 1, PIQI 1, PIQI 2, Resident 119's quarterly JMAs from 3/3/2023, 6/1/2023, 8/23/2023, 11/24/2023, 2/16/2024, 5/11/2024, and 8/4/2024. RN 1 stated the splints should be assessed for proper fit during the JMAs. RN 1 stated Resident 119's JMAs from 3/3/2023 to 8/4/2024 indicated Resident 119 had severe ROM limitations in both shoulders, moderate ROM limitations in both elbows, hips, knees, and ankles, and minimum ROM limitations in both wrists. RN 1 stated Resident 119's JMAs from 3/3/2023 to 8/4/2024 indicated Resident 119's ROM limitations remained the same and did not change. During an interview on 8/8/2024 at 3:21 p.m. with the DON, the DON stated the Supervising RN, PIQI LVN, and RNA assigned to the nursing station were supposed to perform each resident's JMA. The DON stated the Supervising RN assessed the resident, the PIQI LVN was present to gather information about each resident, and the RNA provided the ROM movement as part of the assessment. The DON stated the RNs, including the DON, did not have competency assessments (systematic process that evaluated an individual's skill and knowledge) to perform JMAs. The DON stated there was no way to ensure the JMAs for all residents were accurate since the RNs did not have a competency to perform the JMAs. During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 8/8/2024 completed by OT 2, the OT Evaluation indicated Resident 119 had ROM impairments in both shoulders, both elbows, and both hands. The OT Evaluation indicated Resident 119's ROM limitations included right shoulder flexion 0 to 50 degrees, right shoulder abduction 0 to 61 degrees, right elbow extension to 26 degrees, right hand with less than 25% loss of motion, left shoulder flexion 0 to 66 degrees, left shoulder abduction 0 to 61 degrees, left elbow extension to 43 degrees, and left hand with 25 to 50% loss of motion. During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 8/8/2024 completed by Physical Therapist 2 (PT 2), the PT Evaluation indicated Resident 119 had ROM impairments in both hips, both knees, and the left ankle. The PT Evaluation indicated Resident 119's ROM limitations included right hip flexion (bending the leg at the hip joint toward the body) 30 to 96 degrees (normal 0 to 120 degrees), right hip abduction (moving the leg away from the body) 0 to 13 degrees (normal 0 to 45 degrees), right knee extension to 73 degrees, left hip flexion 26 to 70 degrees, left hip abduction 0 to 11 degrees, left knee extension to 17 degrees, and left ankle dorsiflexion 0 to 4 degrees (normal 0 to 20 degrees). During an interview and record review on 8/9/2024 at 8:37 a.m. with RNA 5, PIQI 1 and PIQI 2, Resident 119's JMAs, dated 2/16/2024, 5/11/2024, and 8/4/2024, were reviewed. PIQI 1 and PIQI 2 stated the Supervising RN, PIQI LVN, and the RNA assigned to the nursing station were supposed to be present during each resident's JMA (in general). PIQI 1 and PIQI 2 stated the RNA moved the resident and applied the splints (if applicable), the RN assessed the resident's ROM and splints, and the PIQI recorded the resident's joint mobility limitations based on the RN's assessment. PIQI 1 stated PIQI 3 and RN 5 participated in Resident 119's JMA on 8/4/2024. RNA 5 stated she watched but did not move Resident 119 or apply any splints during Resident 119's JMAs on 2/16/2024, 5/11/2024, and 8/4/2024. During a telephone interview on 8/9/2024 at 8:56 a.m. with PIQI 3, PIQI 3 stated RN 5 and PIQI 3 performed Resident 119's JMA on 8/4/2024 without RNA 5. PIQI 3 stated Resident 119's splints were not applied during the JMA on 8/4/2024 but should have been applied to assess whether the splints fit. During an interview on 8/9/2024 at 10:36 AM with the DOR, the DOR stated contractures developed over time. The DOR stated performing ROM exercises, positioning and applying splints assisted in preventing contractures, which could cause pain, limited function, increased skin issues, and increased the potential for injury. During a concurrent interview and record review on 8/9/2024 at 11:16 a.m. with the DOR and PT 2, Resident 119's PT Discharge Summary, dated 10/28/2022, and PT Evaluation, dated 8/8/2024, were reviewed. PT 2 stated Resident 119 did not have any ROM limitations in both hips upon PT Discharge on 10/28/2022. PT 2 stated Resident 119 developed flexion contractures on both hips since both hips could not be extended to neutral (0 degrees) and were significantly limited in hip abduction. PT 2 stated Resident 119's right knee extended to 20 degrees upon PT Discharge on 10/28/2022 but currently had 73 degrees of right knee extension which was a significant decline in ROM. PT 2 stated Resident 119's development of and worsening contractures could limit the ability to reposition Resident 119 and increased Resident 119's risk for skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure). The DOR and PT 2 stated Resident 119's decline in ROM on both legs were not reported to the therapy department. During a concurrent interview and record review on 8/9/2024 at 11:37 a.m. with OT 2, Resident 119's OT Evaluation Only, dated 10/6/2022, and OT Evaluation, dated 8/8/2024, were reviewed. OT 2 stated Resident 119 had 0 to 90 degrees of right shoulder flexion and 0 to 80 degrees of left shoulder flexion during the OT Evaluation on 10/6/2022. OT 2 stated Resident 119 currently had 0 to 50 degrees of right shoulder flexion and 0 to 61 degrees of left shoulder flexion which was a significant decline in ROM. OT 2 stated Resident 119's ROM in both hands were WFL during the OT Evaluation on 10/6/2022. OT 2 stated both of Resident 119's hands currently cannot extend completely. OT 2 stated Resident 11 developed flexion contractures on both hands and had worsening contractures on both shoulders and elbows. OT 2 stated contractures could cause discomfort and pain. OT 2 stated Resident 119's decline in ROM on both arms were not reported to the therapy department. During an interview on 8/9/2024 at 2:06 p.m. with RNA 5, RNA 5 stated she did not report but was supposed to report to the LVN charge nurse or the RN supervisor that Resident 119's right knee splint did not fit. RNA 5 stated Resident 119 resisted ROM because Resident 119 was in pain and had facial expressions of pain whenever RNA 5 touched Resident 119. During a concurrent interview and record review on 8/9/2024 at 3:49 p.m. with the DON, 13 RNA employee files were reviewed. The DON stated RNAs were important to maintain, improve, and prevent any decline in a resident's mobility, ROM, and overall physical condition. The DON stated 7 of 13 RNA staff did not have any competency evaluations for the provision of RNA services. The DON Stated 6 of 13 RNA staff were evaluated by the Director of Staff Development (DSD) who were not competent in the provision of RNA services. The DON stated 13 of 13 RNAs did not have the competency to accurately perform their duties, including providing ROM, applying splints, and detecting declines in ROM and mobility. During a concurrent interview and record review on 8/9/2024 at 4:30 p.m. with the DON, Resident 119's quarterly JMAs from 3/3/2023 to 8/4/2024 were reviewed. The DON stated the JMA (in general) was completed to determine if there were any changes in a resident's joint mobility and ROM. The DON stated Resident 119's JMAs were the same because the RN Supervisors were not competent to assess joint mobility and therefore did not notice any changes in Resident 119's ROM. The DON stated contractures (in general) develop due to immobility and could be prevented with ROM exercises and application of splints. The DON stated contractures limited movement, could cause discomfort and pain, and increased a resident's risk of skin impairments. The DON stated contracture prevention was important for a resident's quality of life to prevent any restrictions in movement. During a concurrent interview and record review on 8/9/2024 at 6:19 PM with the DON, Resident 119's JMA, dated 12/7/2022, 3/3/2023, 8/23/2023, and 11/24/2023, were reviewed. The DON stated the JMAs did not indicate Resident 119 had both elbow and the right knee splints. The DON stated the splints were not assessed during the JMAs for fit if the splints were not documented. During a review of the facility's policy and procedure (P&P) titled, Joint Mobility Assessment, revised 5/1/2018 and reviewed on 1/29/2024, the P&P indicated all residents shall receive a joint mobility assessment upon admission, quarterly, and during a significant change in the resident's condition to identify any limitation in joint mobility and risk of contractures. The P&P indicated the DON or designee will monitor the completion and accuracy of joint mobility assessments. During a review of the facility's P&P titled, Range of Motion Exercise Guidelines, revised 3/1/2015 and reviewed on 1/29/2024, the P&P indicated ROM should be delivered by trained staff to maintain or increase ROM of a joint and to prevent or reduce contractures. b.1. During a review of Resident 139's Admission Record, the facility admitted Resident 139 on 4/28/2021 with d [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the facility's Registered Nurses (RNs) and Restorative Nursing Assistants ([RNA], certified nursing aide program that helps residents to maintain their function and joint mobility) were competent in providing assessments and services affecting four of four sampled residents (Residents 119, 139, 141, and 34) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move), by failing to: 1. Ensure the facility's system, which identified six RNs (Director of Nursing [DON], RN 1, RN 2, RN 3, RN 4, RN 5) who performed assessments of joint mobility at each major joint, had competency evaluations (systematic process that evaluated an individual's skill and knowledge) to perform the Joint Mobility Assessments (JMA, brief assessment of a resident's range of motion in both arms and both legs) in accordance with the facility's policy and procedure titled, Staff Competency Evaluations, upon admission, quarterly, annually, and for a change in condition for all 296 residents. 2. Ensure RNs were competent in the assessment of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) during the JMAs to ensure proper fit to prevent complications such as skin breakdown and contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). 3. Ensure RNAs 3, 4, 5, 7, 9, 11, and 13 had competency evaluations for RNA duties and responsibilities, including ROM exercises, application of splints, and ambulation (the act of walking) in accordance with the facility's job description titled, Restorative Nursing Assistant, and policy and procedure titled, Range of Motion Exercise Guidelines. 4. Ensure RNAs 1, 2, 6, 8, 10, and 12 had competency evaluations completed by a qualified staff member with knowledge and experience to evaluate staff competency in accordance with the facility's policy and procedure titled, Staff Competency Evaluations. These failures resulted in Resident 119's decline in ROM due to the facility-identified qualified personnels' (RNs) inability to identify ROM decline during JMAs, the RNAs' inability to correctly apply splints, and the RNAs' inability to identify and report a decline in ROM and mobility during the provision of care, including Resident 119's development of contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) to both hands and hips and worsening contractures to both shoulders, elbows, and knees while residing at the facility. These failures also had the potential for Residents 139, 141, and 34, to experience a decline in ROM. Cross reference F688. Findings: During an interview on 8/6/2024 at 9:34 a.m. with the Director of Rehabilitation (DOR) in the therapy gym, the DOR stated the RNA program was a maintenance program to maintain a resident's ROM and mobility. The DOR stated limitations in ROM could lead to limitations in function and the development of contractures, which could cause pain. The DOR stated ROM exercises and application of splints can assist in maintaining ROM and preventing contractures. The DOR stated Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) did not complete the residents' JMA quarterly or annually. During an interview on 8/8/2024 at 9:41 a.m. with Registered Nurse Supervisor 2 (RN 2), RN 2 stated the RN Supervisor and the RNA assigned to the nursing station completed the JMAs for each resident upon admission and quarterly. RN 2 stated the facility did not provide any training on how to perform the JMA. During an interview on 8/8/2024 at 10:40 a.m. with the Director of Nursing (DON), RN 1, Registered Nurse Supervisor 1 (RN 1) Performance Improvement Quality Improvement Licensed Vocational Nurse 1 (PIQI 1), and PIQI 2, RN 1 stated the RN, PIQI, and RNA assigned to each nursing station performed the JMA for each resident upon admission, quarterly, change of condition, and annually. The DON stated the previous DOR provided a training on how to perform the JMA to the DON, RN Supervisors, PIQI LVNs, and RNAs approximately five years ago. The DON stated there has not been any recent training on how to complete the JMAs. PIQI 2 stated the JMA assessed a resident's active or passive joint limitations depending on if the resident can move. During an interview on 8/8/2024 at 1:15 p.m. with PIQI 1, PIQI 1 stated the JMA needed to be accurate because a change in a resident's ROM could be missed if the JMA was not accurate. During an interview on 8/8/2024 at 1:47 p.m. with DOR and PT 1, the DOR stated the nursing staff were not provided with any recent in-service training for the completion of JMAs. During an interview on 8/8/2024 at 3:21 p.m. with the DON, the DON stated the Supervising RN, PIQI, and RNA assigned to the nursing station were supposed to perform each resident's JMA. The DON stated the Supervising RN assessed the resident, the PIQI was present to gather information about each resident, and the RNA provided the ROM for the assessment. The DON stated competency evaluations ensured the nurse was knowledgeable in providing care. The DON stated the RNs, including the DON, did not have competency evaluations to perform the JMA. The DON stated she did not know the reason the facility did not have competency evaluations for RNs to perform the JMA. The DON stated the RNs should have a competency evaluation especially since ROM and joint mobility was not a nursing specialty. The DON stated there was no way to ensure the JMAs for all residents were accurate since the RNs did not have the competence to perform the JMA. During an interview on 8/8/2024 at 3:43 p.m. with the DON, the DON stated the DON was provided education on performing the JMAs but stated RN 1, RN 2, RN 3, RN 4, and RN 5 performed the residents' JMAs. During an interview on 8/9/2024 at 8:37 a.m. with PIQI 1 and PIQI 2, PIQI 1 and PIQI 2 stated the Supervising RN, PIQI, and the RNA assigned to the nursing station were supposed to be present during each resident's JMA. PIQI 1 and PIQI 2 stated the RNA moved the resident and applied the splints (if applicable), the RN assessed the resident's ROM and splints, and the PIQI recorded the resident's joint mobility limitations based on the RN's assessment. During a review of the employee files for the DON, RN 1, RN 2, RN 3, RN 4, and RN 5, the employee files, the employee files included a performance appraisal (process that evaluates and records how well an employee performed their job) for the DON, dated 12/2023, and for RN 4, dated 4/14/2023. The employee files for the DON and RN 4 did not include a competency skills checklist. A review of the employee files included a competency skills checklist for RN 1, dated 5/2024, for RN 2, dated 1/22/2024, for RN 3 dated 7/2023, and for RN 5, dated 3/2024. The competency skills checklist did not include a competency for assessment of splints and performing the JMA. During a concurrent interview and record review on 8/9/2024 at 3:24 p.m. with the DON, the DON, RN 1, RN 2, RN 3, RN 4, and RN 5's employee files on skill competency evaluations were reviewed. The DON stated skill competency evaluations were completed annually to ensure the RNs were knowledgeable in the necessary and appropriate care provided to the residents. The DON stated she evaluated the RNs for their annual skills competency but stated the facility never performed a skills competency for the DON. The DON stated RN 1, RN 2, RN 3, and RN 5, had skill competency evaluations for the provision of ROM exercises but did not have any competencies to assess ROM to perform the JMA. The DON stated RN 4 was a PIQI RN and did not have an annual competency evaluation since RN 4 did not provide any direct resident care. The DON stated the skills competency evaluations for the DON, RN 1, RN 2, RN 3, RN 4, and RN 5 did not include splint assessment and JMA assessment. The DON stated the JMAs for all residents would be inaccurate since the RNs did not have any competency skills to assess splints and perform the JMA. During a review of the employee files for the RNAs, the employee files included a Restorative Nursing Skills Evaluation which included but was not limited to the provision of ROM, application of splints, transfers, and walking for RNA 1, dated 5/2024, for RNA 2, dated 6/1/2024, for RNA 6, dated 6/10/2024, for RNA 8, dated 7/26/2024, for RNA 10, dated 7/26/2024, and for RNA 12, dated 7/16/2024. A review of the employee files did not include a Restorative Nursing Skills Evaluation for RNA 3, RNA 4, RNA 5, RNA 7, RNA 9, RNA 11, RNA 13. During a concurrent interview and record review on 8/9/2024 at 3:49 p.m. with the DON, 13 RNA employee files on competency skills evaluations were reviewed, including RNA 1, RNA 2, RNA 3, RNA 4, RNA 5, RNA 6, RNA 7, RNA 8, RNA 9, RNA 10, RNA 11, RNA 12, and RNA 13. The DON stated RNAs were important to maintain, improve, and prevent any decline in a resident's ROM, mobility, and overall physical condition. The DON stated seven of 13 RNAs, including RNA 3, RNA 4, RNA 5, RNA 7, RNA 9, RNA 11, and RNA 13, did not have any competency skills evaluations to determine appropriate provision of RNA services, including providing ROM, splint application, and mobility. The DON stated six of 13 RNAs, including RNA 1, RNA 2, RNA 6, RNA 8, RNA 10, and RNA 12, had Restorative Nursing Skills Evaluations completed by the Director of Staff Development (DSD) who was not competent in the provision of RNA services. The DON did not know why the skills competency evaluations for the RNAs were not provided by a facility staff member with knowledge of ROM, splint application, and mobility. The DON stated 13 of 13 RNAs did not have appropriate competency skills evaluations to determine whether the RNAs accurately performed their duties. The DON stated the residents could develop ROM limitations and contractures if the RNAs were not competent in the application of splints and provision of ROM and mobility. The DON stated the resident could develop undetected changes and declines in ROM since the RNAs were not competent in the provision of services and the RNs were not competent in performing the JMAs. During an interview on 8/9/2024 at 4:30 p.m. with the DON, the DON stated contractures develop due to immobility and could be prevented with ROM exercises and application of splints. The DON stated contractures result in limited movement, and could cause discomfort, and pain, and increased a resident's risk of skin impairments. The DON stated contracture prevention was important for a resident's quality of life to prevent any restrictions in movement. During a review of the facility's policy and procedures (P&P) titled, Staff Competency Evaluations, revised on 7/12/2018 and reviewed on 1/29/2024, the P&P indicated annual competency evaluations for all nursing and clinical staff ensured the facility maintained the highest standards of care and resident safety. The P&P indicated annual competency evaluations will be conducted by qualified personnel who have the appropriate knowledge and experience to assess staff competency. During a review of the facility's job description titled, Restorative Nursing Assistant, revised 10/2011, the job description indicated RNAs performed restorative nursing procedures that maximized the resident's abilities and minimized the negative effects of disability. The RNA job description also indicated duties and responsibilities included providing restorative nursing care as directed and ordered, including ROM, ambulation, and transfers. During a review of the facility's P&P titled, Restorative Nursing Program Guidelines, revised on 3/1/2015 and reviewed on 1/29/2024, the P&P indicated RNAs provide interventions to achieve or maintain optimal physical functioning, including providing ROM exercises, applying splints, transfer training, and walking. During a review of the facility's P&P titled, Range of Motion Exercise Guidelines, revised on 3/1/2015 and revised reviewed on 1/29/2024, the P&P indicated the purpose of the policy included maintaining or increasing ROM of a joint and to prevent or reduce contractures. The P&P indicated ROM should be delivered by staff trained in the procedures. 1. During a review of Resident 119's Admission Record, the Admission Record indicated the facility admitted Resident 119 on 5/11/2017 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life), dementia (decline in mental ability severe enough to interfere with daily life), age-related osteoporosis (medical condition in which the bones become brittle and fragile from loss of tissue), and dysphagia (difficulty swallowing). During a review of Resident 119's census (record of hospitalization s, room changes, and payor source changes), the census indicated Resident 119 resided at the facility since 5/11/2017 without any hospitalization s. During a review of Resident 119's Minimum Data Set ([MDS], a comprehensive assessment and care planning tool), dated 5/13/2024, the MDS indicated Resident 119 had unclear speech, rarely expressed ideas and wants, rarely understood verbal content, and was severely impaired (never/rarely made decisions) for daily decision making. The MDS indicated Resident 119 had ROM impairments in both arms and legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating, toileting, showering/bathing, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers. During a review of Resident 119's physician orders, dated 11/9/2020, the physician orders indicated for Resident 119 to receive passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both arms and legs, every day. During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 6/8/2022, the OT Evaluation indicated Resident 119 was referred to OT due to a decline in ROM, decreased balance, and increased need for assistance from others. The OT Evaluation indicated Resident 119's ROM to the right elbow, both wrists, and both hands were within functional limits (WFL, sufficient movement without significant limitation). The OT Evaluation indicated Resident 119's impaired ROM included right shoulder flexion (lifting the arm upward) 0 to 80 degrees (0 to 80 degrees, normal 0 to180 degrees), right shoulder abduction (lifting the arm up and away from the body) 0 to 75 degrees (normal 0 to 180 degrees), left shoulder flexion 0 to 40 degrees, left shoulder abduction 0 to 40 degrees, and left elbow extension (straightened) was limited to 80 degrees (normal 0 degrees, positioned in 80 degrees of elbow flexion [bend]). During a review of Resident 119's OT Treatment Encounter Notes, dated 8/19/2022, the OT Treatment Encounter Notes indicated Resident 119's ROM included right shoulder flexion 0 to 90 degrees (shoulder height), right shoulder abduction 0 to 80 degrees, right elbow extension to 20 degrees (elbow positioned in 20 degrees of flexion), left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees (elbow positioned in 30 degrees of elbow flexion). During a review of Resident 119's OT Discharge Summary, dated 8/19/2022, the OT Discharge Summary indicated Resident 119 safely wore splints to both elbows for two hours without signs of redness, swelling, discomfort, or pain. The OT Discharge Summary recommendations included a Restorative Nursing Program ([RNP], nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and mobility) to provide Resident 119 with PROM and to apply both elbow splints for two hours daily as tolerated. During a review of Resident 119's RNP Referral/Care Plan, dated 8/19/2022, the RNP Referral/Care Plan indicated Occupational Therapist 2 (OT 2) reviewed Resident 119's program with Restorative Nursing Assistant 5 (RNA 5) to apply both elbow splints for two hours. During a review of Resident 119's Joint Mobility Screening (JMA completed by OT and PT), dated 10/6/2022, the Joint Mobility Screening indicated Resident 119's ROM included severe ROM limitation (more than 50 percent [%] loss of motion) in the left shoulder, moderate ROM limitation (25 to 50% loss of motion ) in the right shoulder, minimum ROM limitation (less than 25% loss of motion) in both elbows and knees, and full ROM in both hands, hips, and ankles. The Joint Mobility Screening indicated recommendations for Resident 119 to receive PT and OT Evaluations and to continue with the RNA program. During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 10/6/2022, the OT Evaluation indicated Resident 119 was seen for an Evaluation Only (no intervention recommended). The OT Evaluation Only indicated Resident 119's ROM was WFL in both wrists and hands but had impairment in both shoulders and elbows, including right shoulder flexion 0 to 90 degrees (shoulder height), right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, and left elbow extension to 30 degrees. The OT Evaluation Only indicated Resident 119 was already provided with both elbow splints and did not have any significant change in condition requiring OT intervention. During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 10/6/2022, the PT Evaluation indicated Resident 119 was referred to PT due to a new onset of decreased ROM, decreased postural alignment when sitting up in the wheelchair, and was at-risk for contracture development. The PT Evaluation indicated Resident 119's ROM in both hips and ankles were WFL but had impaired ROM to both knees. The PT Evaluation indicated Resident 119's right knee extension was limited to 30 degrees (normal 0 degrees, knee positioned in 30 degrees of knee flexion) and left knee extension was limited to 15 degrees (knee positioned in 15 degrees of knee flexion). During a review of Resident 119's PT Discharge Summary, dated 10/28/2022, the PT Discharge Summary indicated Resident 119 tolerated sitting up in a standard wheelchair with a cushioned seat for four hours, had right knee extension to 20 degrees, and tolerated a right knee extension splint for two hours. The PT Discharge recommendations included a RNP to provide Resident 119 with PROM and to apply the right knee extension splint. During a review of Resident 119's RNP Referral/Care Plan, dated 10/28/2022, the RNP Referral/Care Plan indicated the Physical Therapist 3 (PT 3) reviewed Resident 119's program with RNA 5 to provide PROM to both legs and to apply the right knee splint for two hours. During a review of Resident 119's JMA, dated 12/7/2022 and 3/3/2023, the JMA indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMA indicated Resident 119 received RNA for PROM to both arms and legs as tolerated. The JMA did not indicate the RNA applied both elbow splints and the right knee splint. During a review of Resident 119's JMA, dated 6/1/2023, the JMA indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMA indicated Resident 119 received RNA for PROM to both arms and legs and application of both elbow splints and the right knee splint. During a review of Resident 119's JMA, dated 8/23/2023 and 11/24/2023, the JMAs indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMA indicated Resident 119 received RNA for PROM to both arms and legs. The JMA did not indicate the RNA applied both elbow splints and the right knee splint. During a review of Resident 119's JMA, dated 2/16/2024, 5/11/2024, and 8/4/2024, the JMAs indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMAs indicated Resident 119 received RNA for PROM to both arms and legs and application of both elbow splints and the right knee splint. During an observation on 8/7/2024 at 12:40 p.m. with Restorative Nursing Assistant 2 (RNA 2) RNA 2 in the bedroom, RNA 2 stated Resident 119's primary (routinely assigned) RNA was RNA 5 who was off today that day (8/7/2024) but will return the next day tomorrow. RNA 2 stood on the right side of Resident 119's bed and performed ROM exercises on Resident 119's right shoulder. RNA 2 could not lift the right arm to shoulder height. RNA 2 bent and extended the right elbow to perform ROM exercises but could not fully extend the right elbow, which remained in a bent position. RNA 2 performed wrist flexion (bent down) and wrist extension (bent up) exercises but did not perform any exercises to Resident 119's right hand. RNA 2 massaged Resident 119's right arm into extension prior to applying the right elbow splint upside down. RNA 2 bent and extended Resident 119's right hip and knee at the same time, causing Resident 119 to moan with a facial grimace (expression of pain or strong dislike). RNA 2 could not extend the right knee, which continued to have a bend of approximately 90 degrees. RNA 2 performed exercises to the right ankle into rotation, dorsiflexion (ankle bent with toes pointing toward the body), and plantarflexion (ankle bent with toes pointing away from the body). RNA 2 applied Resident 119's right knee splint, which was fixed in a nearly straight position, and fastened a strap over the right kneecap. RNA 2 stood on the left side of Resident 119's bed and performed ROM exercises on the left shoulder. RNA 2 lifted the left arm higher than the right shoulder joint but could not lift the left arm to shoulder height. RNA 2 bent and extended the left elbow to perform ROM exercises but could not fully extend the left elbow, which remained in a bent position. RNA 2 performed wrist flexion and extension exercises but did not perform any exercise to Resident 119's left hand. RNA 2 applied the left elbow splint. RNA 2 bent and extended Resident 119's left hip and knee at the same time. RNA 2 could not fully extend Resident 119's left hip and knee. RNA 2 then performed ankle exercises to Resident 119's left ankle into rotation, dorsiflexion, and plantarflexion. During an interview on 8/7/2024 at 1:04 p.m. with RNA 2, RNA 2 stated the splints will be checked every 30 minutes and will be removed remove the splints after 2 hours. RNA 2 stated ROM was not performed to Resident 119's hands because both hands were good and stated Resident 119 could straighten the fingers. During a concurrent observation and interview on 8/7/2024 at 1:09 p.m. with the DOR and Physical Therapy Assistant 1 (PTA 1) in Resident 119's the bedroom, Resident 119 was observed lying in bed while wearing both elbow splints and the right knee splint. PTA 1 stated Resident 119's right knee splint was applied lower than the knee. PTA 1 checked the right knee splint and stated Resident 119's knee splint was set to 30 degrees of extension but Resident 119's right knee was bent to approximately 90 degrees. PTA 1 stated the right knee splint did not fit Resident 119 because the bend in the splint did not match the bend in Resident 119's knee. PTA 1 stated an inappropriately fitted splint could put pressure on the skin and bones of Resident 119's right knee, which could result in pressure sores (localized damage to the skin and underlying soft tissues over a bony prominence) and dislocation (injury caused when the normal position of a joint is disturbed) of the right knee. During a concurrent observation and interview on 8/7/2024 at 1:19 p.m. with the DOR and PTA 1 in the bedroom, the DOR removed Resident 119's right knee splint. The skin on Resident 119's right knee, which was directly under the strap of the knee splint, was observed with redness. PTA 1 stated Resident 119 had redness to the pressure sensitive area of the right kneecap. The DOR observed Resident 119's elbow splints, stated the right elbow splint was applied upside down, and adjusted both of Resident 119's elbow splints. During a concurrent interview and record review on 8/7/2024 at 1:45 p.m. with the DOR, Resident 119's census, OT Discharge Summary, dated 8/19/2022, OT Evaluation Only, dated 10/6/2022, PT Evaluation, dated 10/6/2022, and PT Discharge Summary, dated 10/28/2022, were reviewed. The DOR reviewed Resident 119's census and stated Resident 119 was admitted to the facility on [DATE] and did not leave the facility for any reason. The DOR stated Resident 119's ROM upon discharge from OT on 8/19/2022 was right shoulder flexion 0-90 degrees, right shoulder abduction 0-80 degrees, right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees. The DOR stated OT 2 discharged Resident 119 on 8/19/2022 with recommendations for RNA to provide PROM to both arms and apply both elbow splints for two hours. The DOR stated Resident 119 received an OT Evaluation Only on 10/6/2022 but treatment was not Provided since Resident 119's ROM did not change from OT discharge on 8/19/2022. The DOR stated the OT Evaluation Only, dated 10/6/2022, indicated to continue RNA for PROM to both arms and application of both elbow splints. The DOR reviewed the PT Evaluation, dated 10/6/2022, and stated Resident 119's ROM in both hips and ankles were WFL but had ROM limitation in both knees, including right knee extension to 30 and left knee extension to 15 degrees. The DOR stated Resident 119 was discharged from PT on 10/28/2022 with right knee extension to 20 degrees. The DOR stated PT 3 (no longer works at the facility) discharged Resident 119 on 10/28/2022 with recommendations for RNA to provide PROM to both legs and apply the right knee extension splint. The DOR stated OT has not performed any treatment to Resident 119 since 10/6/2022 and PT has not performed any treatment to Resident 119 since 10/28/2022 (approximately 22 months ago). During a concurrent observation and interview on 8/8/2024 at 8:30 a.m. in Resident 119's the bedroom with RNA 5, Resident 119 was lying in bed awake with the head-of-bed (HOB) fully elevated and the elbow splint applied to the right arm. RNA 5 stated Resident 119 was usually nonverbal and that RNA 5 was Resident 119's primary RNA. The skin on Resident 119's right kneecap was observed with pink areas. RNA 5 stated Resident 119's splints were applied this morning at approximately 7:00 a.m. but the right knee and left elbow splints were removed after 15 minutes due to skin redness. During a concurrent observation and interview on 8/8/2024 at 9:05 a.m. with PT 1 Physical Therapist 1 (PT 1) in Resident 119's the bedroom, Resident 119's ROM in both knees and the right knee extension splint were observed. Resident 119 was lying in bed with the HOB fully elevated and both knees were in bent positions. PT 1 extended both knees and stated Resident 119 had contractures to both knees. PT 1 stated the right knee extended to 90 degrees (right knee positioned in 90 degrees of flexion) and the left knee extended to 55 degrees (left knee positioned in 55 degrees of flexion). PT 1 observed Resident 119's right knee extension splint, which was set to 30 degrees, and stated the right knee splint was not an appropriate fit because Resident 119's right knee was bent more than 30 degrees. PT 1 stated the right knee extension splint could cause injury to Resident 119's right leg if applied to the right knee. During a concurrent observation and interview on 8/8/2024 at 9:16 a.m. with PT 1 and RNA 5 in Resident 119's the bedroom, RNA 5 applied Resident 119's knee extension splint. RNA 5 stated Resident 119's right knee extension splint did not fit because Resident 119's right knee ROM had worsened. PT 1 stated he was not notified of Resident 119's worsening ROM in the right knee and the inability to apply the right knee splint appropriately. During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 8/8/2024, completed by OT 2, the OT Evaluation indicated Resident 119 had ROM impairments in both shoulders, both elbows, and both hands. The OT Evaluation indicated Resident 119's ROM limitations included right shoulder flexion 0 to 50 degrees, right shoulder abduction 0 to 61 degrees, right elbow extension to 26 degrees, right hand with less than 25% loss of motion, left shoulder flexion 0 to 66 degrees, left shoulder abduction 0 to 61 degrees, left elbow extension to 43 degrees, and left hand with 25 to 50% loss of motion. During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 8/8/2024, completed by PT 2, Physical Therapist 2 (PT 2), the PT Evaluation indicated Resident 119 had ROM impairments in both hips, both knees, and the left ankle. The PT Evaluation indicated Resident 119's ROM limitations included right hip flexion (bending the leg at the hip joint toward the body) 30 to 96 degrees (normal 0 to 120 degrees), right hip abduction (moving the leg away from the body) 0 to 13 degrees (normal 0 to 45 degrees), right knee extension to 73 degrees, left hip flexion 26 to 70 degrees, left hip abduction 0 to 11 degrees, left knee extension to 17 degrees, and left ankle dorsiflexion 0 to 4 degrees (normal 0 to 20 degrees). During an interview on 8/9/2024 at 10:36 AM with the DOR, the DOR stated contractures developed over time. The DOR stated performing ROM exercises, positioning and applying splints assisted in preventing contractures, which could cause pain, limited function, increased skin issues, and increased the potential for injury. During a concurrent interview and record review on 8/9/2024 at 11:16 a.m. with the DOR and PT 2, Resident 119's PT Discharge Summary, dated 10/28/2022, and PT Evaluation, dated 8/8/2024, were reviewed. PT 2 stated Resident 119 did not have any ROM limitations in both hips per the PT Discharge Summary. PT 2 stated Resident 119 developed flexion contractures on both hips since both hips could not be extended to neutral (0 degrees) and were significantly limited in hip abduction. PT 2 stated Resident 119's right knee extended to 20 degrees per PT Discharge Summary but currently had 73 degrees of right knee extension per PT Evaluation which was a significant decline in ROM. PT 2 stated Resident 119's development of and worsening contractures could limit the ability to reposition Resident 119 and increased Resident 119's risk for skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure). The DOR and PT 2 stated Resident 119's decline in ROM on both legs from the PT Evaluation were not reported to the therapy department. During a concurrent interview and record review on 8/9/2024 at 11:37 a.m. with OT 2, Resident 119's OT Evaluation Only, dated 10/6/2022, and OT Evaluation, dated 8/8/2024, were reviewed. OT 2 stated Resident 119 had 0-90 degrees of right shoulder flexion and 0-80 degrees of left shoulder flexion during the OT Evaluation on 10/6/2022. OT 2 stated Resident 119 currently had 0-50 degrees of right shoulder flexion and 0-61 degrees of left shoulder flexion per OT Evaluation on 8/8/2024, which was a significant decline in ROM. OT 2 stated Resident 119's ROM in both hands were WFL during the OT Evaluation on 10/6/2022. OT 2 stated both [TRUNCATED]

Based on interview and record review, the facility failed to ensure a resident was free from neglect (the failure to provide healthcare services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of seven residents (Resident 1), who had impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), at high risk for falls, and was diagnosed with parkinsonism (brain conditions that cause slowed movements, stiffness and tremors), by failing to: 1. Provide Resident 1 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of individuals who require support for mobility) in weighing Resident 1 on 6/1/2024 at around 11 a.m. 2. Ensure Certified Nursing Assistant 1 (CNA 1) did not leave Resident 1 unattended. On 6/1/2024 at around 11 a.m., CNA 1, by herself, brought a mechanical lift inside Resident 1's room to weigh Resident 1. After CNA 1 placed the sling lift (a fabric device used on lift machines to carry patients in a hammock-type position) underneath Resident 1, CNA 1 left Resident 1 unattended to get another staff to assist in weighing Resident 1 using the mechanical lift. 3. Ensure CNA 1 followed Resident 1's care plan (a summary of a person's health condition and current treatment interventions associated with care needs) on Parkinson's disease (a brain disorder causing uncontrolled movements including shaking or difficulty with balance and coordination), initiated on 7/12/2021, regarding Resident 1's risk for injuries from tremors (condition that includes shaking or trembling movements in one or more parts of the body) and involuntary (not done intentionally) muscle movements, indicating the goal of Resident 1's safety with interventions including observing environment for safety measures and to keep it free from hazards (any source of potential damage, harm or adverse health effects). When CNA 1 brought the mechanical lift at Resident 1's bedside on 6/1/2024 at around 11 a.m., it (mechanical lift) posed as a hazard to Resident 1 when CNA 1 left Resident 1 unattended. 4. Ensure Resident 1 had a physician's order for the use of the mechanical lift to weigh Resident 1 in accordance with the current facility-provided policy and procedure titled, Total Mechanical Lift, revised on 8/1/2014, indicating, The resident will have a physician's order for the use of a mechanical lift. As a result, on 6/1/2024 at around 11 a.m., Resident 1 sustained a fall resulting in Resident 1's face landing on the base of the mechanical lift device. Resident 1 sustained a skin tear with bleeding on her forehead and bleeding from the left eye and nose. The facility transferred Resident 1 to a General Acute Care Hospital (GACH) for further evaluation where Resident 1 was identified with multiple facial fractures (bone breakage) and facial laceration (skin tear), and ultimately passing away on the afternoon of 6/1/2024 (time not determined) in the GACH due to the extent of injuries related to the fall. On 6/13/2024 at 2:35 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON), and the Risk Management Registered Nurse (RM 1) due to the facility's failure to ensure Resident 1 was free from neglect under 42 CFR S 483.12 Freedom from Abuse, Neglect, and Exploitation. On 6/14/2024 at 4:03 p.m., the ADM submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified and confirmed the facility's implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM, DON, and RM 1 on 6/14/2024 at 4:50 p.m. The acceptable IJ Removal Plan included the following summarized actions: 1) On 6/1/2024 the resident (Resident 1) affected by the deficient practice was immediately transferred to the GACH for treatment. Resident 1 passed away at the GACH. 2) On 6/1/2024, CNA 1 who was involved in the incident was immediately suspended pending investigation. On 6/7/2024, the employee was terminated upon the completion of the investigation. 3) On 6/1/2024, the facility's Registered Nurse (RN) Supervisors immediately initiated facility rounds to ensure no other residents were affected by the deficient practices. 4) On 6/3/2024, the interdisciplinary team (IDT - comprises of professionals from various disciplines who work in collaboration to address a patient with multiple needs) conducted a root cause analysis (the process of discovering the root causes of problems to identify appropriate solutions) of the incident and identified the potentially affected populations: those with Parkinson's disease and parkinsonism as well as those requiring the use of a mechanical lift. No other residents were found to be affected. 5. On 6/3/2024 Information Systems Nurse conducted a diagnosis search to identify all residents with diagnosis of Parkinson's Disease or parkinsonism. 17 residents were identified in-house. The list was provided to Care Planner Nurses, who then conducted a chart audit of residents' care plans to ensure that the care plans were comprehensive, individualized, measurable, realistic, and goal oriented. No additional residents were identified as being affected by the deficient practice. 6. On 6/03/2024, the Director of Staff Development (DSD) initiated in-services (training) for all nursing staff pertaining to: safety, use of mechanical lift device (during weighing and transfers), resident environment by keeping free it of hazards (not leaving any equipment in residents' rooms unattended), ensuring presence of two or more (2+) staff when utilizing lifting machines, and following residents' care plans regarding safety. 7. On 6/03/2024, RN Supervisors and Risk Management Nurse conducted rounds (to go around and see the residents) throughout the shift (the time assigned for work) to ensure that all residents who required the use of lift machines were transferred appropriately and safely according to facility's policy and procedures. 8. On 6/5/2024 at 1:42 p.m., the ADM informed all nursing staff (CNAs, Restorative Nursing Assistants [RNAs], and Licensed Nurses) via Carefeed (a communication platform that interfaces with facility's electronic medical software as well as payroll software) that two persons must be present when utilizing a mechanical lift. 9. On 6/13/2024, RN Supervisors on the shift initiated additional in-services for all CNAs and licensed vocational nurses (LVNs) pertaining to safety, use of mechanical lift (during weighing and transfers), and keeping the environment free of hazards (by not leaving any equipment in the residents' rooms unattended), ensuring presence of 2+ staff when utilizing lifting machines, following residents' care plans regarding safety, and ensuring that all residents who utilize mechanical lifts have physician orders for its use (licensed nurses only). 10. On 6/13/2024, the Regional Mentor (a licensed Occupational Therapist) provided additional training to all nursing staff on all shifts to ensure additional reinforcement of procedures, safety protocols, with one-on-one (person-to-person contact) return demonstrations to verify acknowledgment and demonstrate learning. On 6/14/2024, the Regional Mentor initiated training for all nursing and rehab staff utilizing a mechanical lift and a mannequin for hands-on demonstrations and return demonstrations to be completed by every employee in attendance. 11. On 6/13/2024, the Minimum Data Set (MDS) Nurses reviewed all 30 residents' charts (medical records) who required the use of mechanical lifts to ensure presence of physician orders for use of mechanical lifts. No additional residents were identified to be affected by the deficient practice. 12. Effective 6/14/2024, an in-service was provided by an outside entity to all current nursing and rehabilitation staff (staff who assist individuals with a disability and/or illness that is continuing for a long time to attain and maintain maximum function) with mandatory (required) return demonstrations (a teaching strategy that involves the learner demonstrating their understanding or mastery of a skill or concept by performing it themselves) for all those present on the use of mechanical lift and safe transfers. Any nursing staff not on duty will receive training upon returning to work. 13. On 6/14/2024, the CNA, RNA, Licensed Nursing, and rehabilitation team skills checklists were updated to include return demonstrations of transfer skills utilizing mechanical lifts. 14. Updated skills checklists were included in the newly hired packets for all nursing staff and rehabilitation department to ensure proper training and return demonstrations of transfer techniques and use of lift machines is correct prior to staff working with residents. Any staff not on duty will receive training upon return to work. 15. All newly admitted and readmitted residents will be assessed by RN Supervisors upon admission/readmission for dependence on use of mechanical lift for transfers. 16. On 6/13/2024, the DON posted a memo notifying all staff that effective immediately, weighing (monthly and/or weekly) will be done on Mondays during morning shift only, in the presence of Risk Management Nurse, DSD, or RN Supervisors. 17. Effective 6/13/2024 MDS nurses will communicate with the DON, RN Supervisors and PIQI (Performance Improvement, Quality Improvement) Nurses regarding residents who suddenly require the use of a mechanical lift. The DON, RN Supervisors, and/or PIQI Nurses will then obtain an order from the physician for resident transfers with the use of mechanical lift. Resident teaching will be provided to resident and/or responsible party with updated care plan. 18. Effective 6/14/2024, the Administrator, DON, Director of Rehab, Information Systems Nurses, and MDS nurses will discuss the residents who are newly admitted /readmitted and those with any changes of condition who may require mechanical lifting machine for transfers as a part of the daily Stand-Up meeting (short meeting to discuss progress and identify blockers) that takes places Mondays through Fridays. Any changes over the weekend will be discussed on the following business day. 19. The DON and/or designee (during the weekends) will review the Shift Monitoring and Reporting Tool daily to gather data on RN Supervisors' visual audits of staff transfer practices on all shifts to monitor adherence and maintain/sustain compliance. Any identified concerns will be reported to the ADM for resolution as warranted. 20. The PIQI Nurses and/or RN Supervisors (on the weekends) will review the Shift Monitoring and Reporting Tool for compliance and report the findings to the ADM and DON. The ADM and DON will then present findings to the PIQI Committee monthly for the first 3 months and quarterly for at least 8 quarters, until substantial compliance of 100 percent (% - one part in every hundred) is achieved. Cross Reference with F689. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 7/9/2021 with diagnoses including parkinsonism, Alzheimer's disease (a brain disorder affecting memory and thinking skills that worsens over time), dementia (loss of thinking or remembering affecting daily life), and age-related osteoporosis (loss of bone mass with increasing risk for bone breakage). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/14/2024, indicated that Resident 1's cognitive skills (ability to think and process information) for daily decision-making tasks were severely impaired. The MDS indicated Resident 1 was dependent (helper does ALL the effort and resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) for eating, oral hygiene (cleaning teeth), toileting hygiene, shower or bathing, upper and lower body dressing, putting on or removing footwear, and personal hygiene needs (combing hair and washing or drying face or hands). A review of Resident 1's record titled, Progress Notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1's assigned CNA (CNA 1) was about to weigh Resident 1 with a lift machine (mechanical lift, a lift device with a weighing scale designed to lift and transfer patients from a bed to a wheelchair or vice versa). CNA 1 then left Resident 1 unattended to ask for assistance from another staff member (unidentified). CNA 1 was then quoted as stating, I was almost at the door when I heard a loud sound. I turned my back, opened the curtain and I saw my resident (Resident 1) on the floor on the legs of the lifting machine. The record indicated CNA 1 noted blood around Resident 1's head. A review of Resident 1's record titled, Physician's Order Sheet, dated 6/1/2024 at 12 p.m., indicated the order to Transfer the resident to hospital via 911 (a phone number to contact the emergency services) for further treatment and evaluation status post (after) fall. A Review of Resident 1's GACH Emergency Department (ED) records, dated 6/1/2024 at 7:09 p.m., indicated Resident 1 was noted with a V-shaped laceration (a deep cut or tear on the skin) across the forehead extending to glabella (area of skin between the eyebrows and above the nose) and nasal bridge (the bony part of the nose), a laceration to the right infraorbital (below the right eye) region, and bilateral periorbital ecchymosis (discoloration to the left and right surrounding eye area due to trauma). Per ED records, a Computed Tomography scan (CT scan - medical imaging used to obtain detailed internal images of the body) was done on 6/1/2024 at 12:47 p.m. revealing Resident 1 to have a Type lll Odontoid Fracture (bone breakage located in the neck area of the spine) and multiple maxillofacial (affecting the mouth, face, and jaw) bone fractures resulting in Resident 1 passing away in the ED in the afternoon (time not determined). On 6/6/2024 at 1:45 p.m., during an interview, CNA 4 stated she had been assigned with Resident 1 in the past, and that Resident 1 was not alert and was fully dependent on staff for care. CNA 4 stated that Resident 1 needed a lift machine for transferring from the bed to the wheelchair, or from the wheelchair back to the bed. CNA 4 stated, For use of a lift machine, it is always with two staff because it's dangerous if done by self. CNA 4 stated, If it is just one person, it's dangerous because the sling (mechanical lift sling, a flexible strap or belt used in the form of a loop to support or raise a weight) moves, or the resident can move. CNA 4 stated, having only one staff cannot hold the lift machine and keep the resident steady on the sling all at the same time. On 6/6/2024 at 2:47 p.m., during an interview, LVN 1 stated that on 6/1/2024 at approximately between 11 a.m. to 11:20 a.m., LVN 1 was called to Resident 1's room with Resident 1 found on the floor with blood coming out from Resident 1's forehead. LVN 1 stated CNA 1's explanation was CNA 1 placed the mechanical lift sling underneath Resident 1, then CNA 1 left to call for assistance, and that was when Resident 1 rolled off the bed hitting Resident 1's head against the metal legs of the mechanical lift machine. On 6/6/2024 at 3:22 p.m., during an interview, Registered Nurse 1 (RN 1) stated (on 6/1/2024 at around 11 a.m.) RN 1 rushing to Resident 1's room and saw Resident 1 on the floor with the nursing staff (unidentified) attempting to stop the bleeding from Resident 1's head. RN 1 asked what CNA 1 should have done differently for Resident 1's safety, RN 1 stated, I would not have left the resident (Resident 1) alone. On 6/7/2024 at 11:26 a.m. during a phone interview, CNA 1 stated on 6/1/2024, at around 11 a.m., CNA 1 went to Resident 1's room to weigh Resident 1. CNA 1 stated she used the mechanical lift machine. CNA 1 stated the rules for using a lift machine is with two staff members. CNA 1 described the procedure as, I put the sling under the resident (while in bed), the sling is what carries the resident. I turned around towards the door, then I heard a loud noise and saw the resident face down on the leg of the lift machine. CNA 1 stated, From the start of this, I would have walked in with the second person already from the beginning so they can assist with the care needed for the resident (Resident 1). CNA 1 was asked if there was a floor mat beside the bed, CNA 1 stated, There was no floor mat where the patient (Resident 1) had landed. On 6/7/2024 at 3:05 p.m., during a concurrent interview and a review of Resident 1's care plans for fall and functional abilities, RN 4 stated Resident 1's fall risk score was 16. RN 4 stated a score of 10 and above represented high risk for falls. Resident 1's Fall Risk Care Plan initiated on 3/3/2024 indicated the care plan interventions included placing a floor mat next to resident's bed to prevent the resident from injuries. RN 4 stated a floor mat allowed the resident (in general) to fall on the cushion. RN 4 stated, Having a fall is not desirable, but it is better to land on a soft surface than a hard surface. Resident 1's care plan titled, Functional Abilities of Everyday Activities, initiated on 3/3/2024, indicated the intervention was to have two or more persons physical assist for all activities as needed. RN 4 stated the care plan indicated when transferred Resident 1 in and out of bed or wheelchair daily, staff needed to provide two or more persons physical assist when using mechanical lift. On 6/13/2024 at 11:56 a.m., during a phone interview, CNA 1 stated two staff (in general) are needed to use the lift machine. CNA 1 stated one staff needed to stand next to the lift machine and the other staff needed to attend to the resident. CNA 1 stated, I should not have left the resident (Resident 1) alone and should not have left the machine with the resident. On 6/14/2024 at 12:04 p.m., during a concurrent interview and record review of Resident 1's physician orders for 6/2024, and Resident 1's Progress Notes, dated 6/1/2024, RN 4 stated that Resident 1 did not have a Physician's Order for use of a mechanical lift device RN 4 stated, I would not have left the resident (Resident 1) alone RN 4 stated I would not leave the lift machine unattended because we always make sure the residents' environment needs to be free from hazards. RN 4 stated this lifting machine for this case was a hazard because it is made of metal. RN 4 stated, because CNA 1 left Resident 1 alone, and because the mechanical lift was left unattended at Resident 1's bedside, Resident 1 ended up having a fall with a sustained injury. A concurrent record review of Resident 1's Progress notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1 had a skin tear on the forehead, and was bleeding from the left eye and nose. On 6/14/2024 at 1:05 p.m., during an interview, LVN 5 stated CNA 1 left Resident 1 alone with the lift machine (mechanical lift) in the room, and CNA 1 was supposed to keep Resident 1 safe. LVN 3 stated, The machine should not be there, and it should have been the floormat as per care plan. LVN 3 stated CNA 1 could lower the bed, replace the floormat, and remove the machine. LVN 3 stated, Because this was not done, the resident fell off the bed. LVN 3 stated Resident 1 sustained a skin tear on the forehead, and bleeding from the left eye and nose. A review of the current facility-provided policy and procedure titled, Total Mechanical Lift, revised on 8/1/2014, indicated, The resident will have a physician's order for the use of a mechanical lift. A review of the current facility-provided policy and procedure titled, Resident Rooms and Environment, with last revised date of 11/1/2017, indicated, Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk. A review of the current facility-provided policy and procedure titled, Care Planning, with last revised date of 10/24/2022, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The policy indicated, The resident has the right to receive the services and/or items included in the plan of care. A review of the current facility-provided policy and procedure titled, Safety of Residents, with last revised date of 5/1/2023, indicated the purpose, To provide a safe environment for residents and Facility staff. A review of the current facility-provided policy and procedure titled, Fall Management Program, with last revised date of 2/29/2024, indicated, It is the policy of this facility to provide the highest quality of care in the safest environment for the residents residing in the facility. A review of the current facility-provided policy and procedure titled, Abuse Prevention and Prohibition Program, with last revised dated 8/1/2023, indicated, 1. Each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property (illegal use of another person's property of funds). The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of property. 2. The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff The policy also defines neglect as Leaving someone unattended who needs supervision.

Based on interview and record review, the facility failed to ensure one of seven residents (Resident 1), who was with impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was high risk for falls, and was diagnosed with parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), was free from accidents, by failing to: 1. Provide Resident 1 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of individuals who require support for mobility) in weighing Resident 1 on 6/1/2024 at around 11 a.m. 2. Ensure Certified Nursing Assistant 1 (CNA 1) did not leave Resident 1 unattended. On 6/1/2024 at around 11 a.m., CNA 1, by herself, brought a mechanical lift inside Resident 1's room to weigh Resident 1. After CNA 1 placed the sling lift (a fabric device used on lift machines to carry patients in a hammock-type position) underneath Resident 1, CNA 1 left Resident 1 unattended to get another staff to assist in weighing Resident 1 using the mechanical lift. 3. Ensure CNA 1 followed Resident 1's care plan (a summary of a person's health condition and current treatment interventions associated with care needs) on Parkinson's disease (a brain disorder causing uncontrolled movements including shaking or difficulty with balance and coordination), initiated on 7/12/2021, regarding Resident 1's risk for injuries from tremors (condition that includes shaking or trembling movements in one or more parts of the body) and involuntary (not done intentionally) muscle movements, indicating the goal of Resident 1's safety with interventions including observing environment for safety measures and to keep it free from hazards (any source of potential damage, harm or adverse health effects). When CNA 1 brought the mechanical lift at Resident 1's bedside on 6/1/2024 at around 11 a.m., it (mechanical lift) posed as a hazard to Resident 1 when CNA 1 left Resident 1 unattended. 4. Ensure Resident 1 had a physician's order for the use of the mechanical lift to weigh Resident 1 in accordance with the current facility-provided policy and procedure titled, Total Mechanical Lift, revised on 8/1/2014, indicating, The resident will have a physician's order for the use of a mechanical lift. As a result, on 6/1/2024 at around 11 a.m., Resident 1 sustained a fall resulting in Resident 1's face landing on the base of the mechanical lift device. Resident 1 sustained a skin tear with bleeding on her forehead and bleeding from the left eye and nose. The facility transferred Resident 1 to a General Acute Care Hospital (GACH) for further evaluation where Resident 1 was identified with multiple facial fractures (bone breakage) and facial laceration (skin tear), and ultimately passing away on the afternoon of 6/1/2024 (time not determined) in the GACH due to the extent of injuries related to the fall. On 6/13/2024 at 2:35 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON), and the Risk Management Registered Nurse (RM 1) due to the facility's failure to ensure Resident 1 was free from accidents under 42 CFR S S483.25 (d) (1) (2) Accidents. On 6/14/2024 at 4:03 p.m., the ADM submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified and confirmed the facility's implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the in the presence of the ADM, DON, and RM 1 on 6/14/2024 at 4:50 p.m. The acceptable IJ Removal Plan included the following summarized actions: 1) On 6/1/2024 the resident (Resident 1) affected by the deficient practice was immediately transferred to the GACH for treatment. Resident 1 passed away at the GACH. 2) On 6/1/2024, CNA 1 who was involved in the incident was immediately suspended pending investigation. On 6/7/2024, the employee was terminated upon the completion of the investigation. 3) On 6/1/2024, the facility's Registered Nurse (RN) Supervisors immediately initiated facility rounds to ensure no other residents were affected by the deficient practice. 4) On 6/3/2024, the interdisciplinary team (IDT - comprises of professionals from various disciplines who work in collaboration to address a patient with multiple needs) conducted a root cause analysis (the process of discovering the root causes of problems to identify appropriate solutions) of the incident and identified the potentially affected populations: those with Parkinson's disease and parkinsonism as well as those requiring the use of a mechanical lift. No other residents were found to be affected. 5. On 6/3/2024 Information Systems Nurse conducted a diagnosis search to identify all residents with diagnosis of Parkinson's Disease or parkinsonism. 17 residents were identified in-house. The list was provided to Care Planner Nurses, who then conducted a chart audit of residents' care plans to ensure that the care plans are comprehensive, individualized, measurable, realistic, and goal oriented. No additional residents were identified as being affected by the deficient practice. 6. On 6/03/2024, the Director of Staff Development (DSD) initiated in-services (training) for all nursing staff pertaining to: safety, use of mechanical lift device (during weighing and transfers), resident environment by keeping free it of hazards (not leaving any equipment in residents' rooms unattended), ensuring presence of two or more (2+) staff when utilizing lifting machines, and following residents' care plans regarding safety. 7. On 6/03/2024, RN Supervisors and Risk Management Nurse conducted rounds (to go around and see the residents) throughout the shift (the time assigned for work) to ensure that all residents who required the use of lift machines were transferred appropriately and safely according to facility's policy and procedures. 8. On 6/5/2024 at 1:42 p.m., the ADM informed all nursing staff (CNAs, Restorative Nursing Assistants [RNAs], and Licensed Nurses) via Carefeed (a communication platform that interfaces with facility's electronic medical software as well as payroll software) that two persons must be present when utilizing a mechanical lift. 9. On 6/13/2024, RN Supervisors on the shift initiated additional in-services for all CNAs and licensed vocational nurses (LVNs) pertaining to safety, use of mechanical lift (during weighing and transfers), and keeping the environment free of hazards (by not leaving any equipment in the residents' rooms unattended), ensuring presence of 2+ staff when utilizing lifting machines, following residents' care plans regarding safety, and ensuring that all residents who utilize mechanical lifts have physician orders for its use (licensed nurses only). 10. On 6/13/2024, the Regional Mentor (a licensed Occupational Therapist) provided additional training to all nursing staff on all shifts to ensure additional reinforcement of procedures, safety protocols, with one-on-one (person-to-person contact) return demonstrations to verify acknowledgment and demonstrate learning. On 6/14/2024, the Regional Mentor initiated training for all nursing and rehab staff utilizing a mechanical lift and a mannequin for hands-on demonstrations and return demonstrations to be completed by every employee in attendance. 11. On 6/13/2024, the Minimum Data Set (MDS) Nurses reviewed all 30 residents' charts (medical records) who required the use of mechanical lifts to ensure presence of physician orders for use of mechanical lifts. No additional residents were identified to be affected by the deficient practice. 12. Effective 6/14/2024, an in-service was provided by an outside entity to all current nursing and rehabilitation staff (staff who assist individuals with a disability and/or illness that is continuing for a long time to attain and maintain maximum function) with mandatory (required) return demonstrations (a teaching strategy that involves the learner demonstrating their understanding or mastery of a skill or concept by performing it themselves) for all those present on the use of mechanical lift and safe transfers. Any nursing staff not on duty will receive training upon returning to work. 13. On 6/14/2024, the CNA, RNA, Licensed Nursing, and rehabilitation team skills checklists were updated to include return demonstrations of transfer skills utilizing mechanical lifts. 14. Updated skills checklists were included in the newly hired packets for all nursing staff and rehabilitation department to ensure proper training and return demonstrations of transfer techniques and use of lift machines is correct prior to staff working with residents. Any staff not on duty will receive training upon return to work. 15. All newly admitted and readmitted residents will be assessed by RN Supervisors upon admission/readmission for dependence on use of mechanical lift for transfers. 16. On 6/13/2024, the DON posted a memo notifying all staff that effective immediately, weighing (monthly and/or weekly) will be done on Mondays during morning shift only, in the presence of Risk Management Nurse, DSD, or RN Supervisors. 17. Effective 6/13/2024 MDS nurses will communicate with the DON, RN Supervisors and PIQI (Performance Improvement, Quality Improvement) Nurses regarding residents who suddenly require the use of a mechanical lift. The DON, RN Supervisors, and/or PIQI Nurses will then obtain an order from the physician for resident transfers with the use of mechanical lift. Resident teaching will be provided to resident and/or responsible party with updated care plan. 18. Effective 6/14/2024, the Administrator, DON, Director of Rehab, Information Systems Nurses, and MDS nurses will discuss the residents who are newly admitted /readmitted and those with any changes of condition who may require mechanical lifting machine for transfers as a part of the daily Stand-Up meeting (short meeting to discuss progress and identify blockers) that takes places Mondays through Fridays. Any changes over the weekend will be discussed on the following business day. 19. The DON and/or designee (during the weekends) will review the Shift Monitoring and Reporting Tool daily to gather data on RN Supervisors' visual audits of staff transfer practices on all shifts to monitor adherence and maintain/sustain compliance. Any identified concerns will be reported to the ADM for resolution as warranted. 20. The PIQI Nurses and/or RN Supervisors (on the weekends) will review the Shift Monitoring and Reporting Tool for compliance and report the findings to the ADM and DON. The ADM and DON will then present findings to the PIQI Committee monthly for the first 3 months and quarterly for at least 8 quarters, until substantial compliance of 100 percent (% - one part in every hundred) is achieved. Cross Reference with F600. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 7/9/2021 with diagnoses including parkinsonism, Alzheimer's disease (a brain disorder affecting memory and thinking skills that worsens over time), dementia (loss of thinking or remembering affecting daily life), and age-related osteoporosis (loss of bone mass with increasing risk for bone breakage). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/14/2024, indicated that Resident 1's cognitive skills (ability to think and process information) for daily decision-making tasks were severely impaired. The MDS indicated Resident 1 was dependent (helper does ALL the effort and resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) for eating, oral hygiene (cleaning teeth), toileting hygiene, shower or bathing, upper and lower body dressing, putting on or removing footwear, and personal hygiene needs (combing hair and washing or drying face or hands). A review of Resident 1's record titled, Progress Notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1's assigned CNA (CNA 1) was about to weigh Resident 1 with a lift machine (mechanical lift, a lift device with a weighing scale designed to lift and transfer patients from a bed to a wheelchair or vice versa). CNA 1 then left Resident 1 unattended to ask for assistance from another staff member (unidentified). CNA 1 was then quoted as stating, I was almost at the door when I heard a loud sound. I turned my back, opened the curtain and I saw my resident (Resident 1) on the floor on the legs of the lifting machine. The record indicated CNA 1 noted blood around Resident 1's head. A review of Resident 1's record titled, Physician's Order Sheet, dated 6/1/2024 at 12 p.m., indicated the order to Transfer the resident to hospital via 911 (a phone number to contact the emergency services) for further treatment and evaluation status post (after) fall. A Review of Resident 1's GACH Emergency Department (ED) records, dated 6/1/2024 at 7:09 p.m., indicated Resident 1 was noted with a V-shaped laceration (a deep cut or tear on the skin) across the forehead extending to glabella (area of skin between the eyebrows and above the nose) and nasal bridge (the bony part of the nose), a laceration to the right infraorbital (below the right eye) region, and bilateral periorbital ecchymosis (discoloration to the left and right surrounding eye area due to trauma). Per ED records, a Computed Tomography scan (CT scan - medical imaging used to obtain detailed internal images of the body) was done on 6/1/2024 at 12:47 p.m. revealing Resident 1 to have a Type lll Odontoid Fracture (bone breakage located in the neck area of the spine) and multiple maxillofacial (affecting the mouth, face, and jaw) bone fractures resulting in Resident 1 passing away in the ED in the afternoon (time not determined). On 6/6/2024 at 1:45 p.m., during an interview, CNA 4 stated she had been assigned with Resident 1 in the past, and that Resident 1 was not alert and was fully dependent on staff for care. CNA 4 stated that Resident 1 needed a lift machine for transferring from the bed to the wheelchair, or from the wheelchair back to the bed. CNA 4 stated, For use of a lift machine, it is always with two staff because it's dangerous if done by self. CNA 4 stated, If it is just one person, it's dangerous because the sling (mechanical lift sling, a flexible strap or belt used in the form of a loop to support or raise a weight) moves, or the resident can move. CNA 4 stated, having only one staff cannot hold the lift machine and keep the resident steady on the sling all at the same time. On 6/6/2024 at 2:47 p.m., during an interview, LVN 1 stated that on 6/1/2024 at approximately between 11 a.m. to 11:20 a.m., LVN 1 was called to Resident 1's room with Resident 1 found on the floor with blood coming out from Resident 1's forehead. LVN 1 stated CNA 1's explanation was CNA 1 placed the mechanical lift sling underneath Resident 1, then CNA 1 left to call for assistance, and that was when Resident 1 rolled off the bed hitting Resident 1's head against the metal legs of the mechanical lift machine. On 6/6/2024 at 3:22 p.m., during an interview, Registered Nurse 1 (RN 1) stated (on 6/1/2024 at around 11 a.m.) RN 1 rushing to Resident 1's room and saw Resident 1 on the floor with the nursing staff (unidentified) attempting to stop the bleeding from Resident 1's head. RN 1 asked what CNA 1 should have done differently for Resident 1's safety, RN 1 stated, I would not have left the resident (Resident 1) alone. On 6/7/2024 at 11:26 a.m. during a phone interview, CNA 1 stated on 6/1/2024, at around 11 a.m., CNA 1 went to Resident 1's room to weigh Resident 1. CNA 1 stated she used the mechanical lift machine. CNA 1 stated the rules for using a lift machine is with two staff members. CNA 1 described the procedure as, I put the sling under the resident (while in bed), the sling is what carries the resident. I turned around towards the door, then I heard a loud noise and saw the resident face down on the leg of the lift machine. CNA 1 stated, From the start of this, I would have walked in with the second person already from the beginning so they can assist with the care needed for the resident (Resident 1). CNA 1 was asked if there was a floor mat beside the bed, CNA 1 stated, There was no floor mat where the patient (Resident 1) had landed. On 6/7/2024 at 3:05 p.m., during a concurrent interview and a review of Resident 1's care plans for fall and functional abilities, RN 4 stated Resident 1's fall risk score was 16. RN 4 stated a score of 10 and above represented high risk for falls. Resident 1's Fall Risk Care Plan initiated on 3/3/2024 indicated the care plan interventions included placing a floor mat next to resident's bed to prevent the resident from injuries. RN 4 stated a floor mat allowed the resident (in general) to fall on the cushion. RN 4 stated, Having a fall is not desirable, but it is better to land on a soft surface than a hard surface. Resident 1's care plan titled, Functional Abilities of Everyday Activities, initiated on 3/3/2024, indicated the intervention was to have two or more persons physical assist for all activities as needed. RN 4 stated the care plan indicated when transferred Resident 1 in and out of bed or wheelchair daily, staff needed to provide two or more persons physical assist when using mechanical lift. On 6/13/2024 at 11:56 a.m., during a phone interview, CNA 1 stated two staff (in general) are needed to use the lift machine. CNA 1 stated one staff needed to stand next to the lift machine and the other staff needed to attend to the resident. CNA 1 stated, I should not have left the resident (Resident 1) alone and should not have left the machine with the resident. On 6/14/2024 at 12:04 p.m., during a concurrent interview and record review of Resident 1's physician orders for 6/2024, and Resident 1's Progress Notes, dated 6/1/2024, RN 4 stated that Resident 1 did not have a Physician's Order for use of a mechanical lift device RN 4 stated, I would not have left the resident (Resident 1) alone RN 4 stated I would not leave the lift machine unattended because we always make sure the residents' environment needs to be free from hazards. RN 4 stated this lifting machine for this case was a hazard because it is made of metal. RN 4 stated, because CNA 1 left Resident 1 alone, and because the mechanical lift was left unattended at Resident 1's bedside, Resident 1 ended up having a fall with a sustained injury. A concurrent record review of Resident 1's Progress notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1 had a skin tear on the forehead, and was bleeding from the left eye and nose. On 6/14/2024 at 1:05 p.m., during an interview, LVN 5 stated CNA 1 left Resident 1 alone with the lift machine (mechanical lift) in the room, and CNA 1 was supposed to keep Resident 1 safe. LVN 3 stated, The machine should not be there, and it should have been the floormat as per care plan. LVN 3 stated CNA 1 could lower the bed, replace the floormat, and remove the machine. LVN 3 stated, Because this was not done, the resident fell off the bed. LVN 3 stated Resident 1 sustained a skin tear on the forehead, and bleeding from the left eye and nose. A review of the current facility-provided policy and procedure titled, Total Mechanical Lift, revised on 8/1/2014, indicated, The resident will have a physician's order for the use of a mechanical lift. A review of the current facility-provided policy and procedure titled, Resident Rooms and Environment, with last revised date of 11/1/2017, indicated, Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk. A review of the current facility-provided policy and procedure titled, Care Planning, with last revised date of 10/24/2022, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The policy indicated, The resident has the right to receive the services and/or items included in the plan of care. A review of the current facility-provided policy and procedure titled, Safety of Residents, with last revised date of 5/1/2023, indicated the purpose, To provide a safe environment for residents and Facility staff. A review of the current facility-provided policy and procedure titled, Fall Management Program, with last revised date of 2/29/2024, indicated, It is the policy of this facility to provide the highest quality of care in the safest environment for the residents residing in the facility.

46445 Based on observation, interview, and record review, the facility failed to provide safe eating practices for four of ten sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) who were on aspiration precaution (precautions followed to prevent aspiration [food or liquid goes into the airway instead of the stomach]) by: 1. Failing to ensure Family Member 1 (FM 1) was provided education and training before being allowed to assist with Resident 1 ' s meals. 2. Failing to monitor and supervise Resident 1 while FM 1 was assisting Resident 1 with dinner on [DATE]. 3. Failing to provide Resident 1 with a Restorative Nursing Assistant (RNA) to assist Resident 1 in eating during dinner on [DATE]. 4. Failing to ensure Resident 1 ' s care plan on Therapeutic Diet (a meal plan that controls the intake of certain foods or nutrients) Secondary to Hypertension and Dysphagia (swallowing difficulties): At Risk for Choking/Aspiration . was specific to Resident 1 ' s needs. On [DATE] at 5:30 p.m., facility staff allowed FM 1 to assist Resident 1 in eating dinner at the north dining room patio without the presence of a facility staff to monitor Resident 1. On [DATE] at 5:45 p.m., FM 1 observed Resident 1 was unresponsive. Licensed Vocational Nurse 1 (LVN 1) found Resident 1 pulseless and was not breathing. A facility staff member (name not given) called the paramedics (health professionals certified to perform advanced life support procedures) through 911 (a phone number to contact the emergency services). As a result, the paramedics brought Resident 1 to General Acute Care Hospital 1 (GACH 1) on [DATE] at 5:45 p.m. On [DATE] at 2:36 p.m., Resident 1 passed away at GACH 1 with death diagnoses including aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs instead of being swallowed), cardiac arrest (occurs when the heart stops beating suddenly), anoxic brain injury (caused by a complete lack of oxygen to the brain which results in the death of brain cells after approximately four minutes of oxygen deprivation), and acute respiratory failure with hypoxemia (occurs when a person did not have enough oxygen in the blood). 5. Failing to ensure the family members of Residents 2, 3, and 4, who were on aspiration precautions, were provided education and training before being allowed to assist with Residents 2, 3, and 4 ' s meals. This deficient practice had the potential for Residents 2, 3, and 4 to have aspiration incidents. On [DATE] at 1:27 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure under 42 CFR S 483.25 Quality of care. On [DATE] at 6:04 p.m., the ADM and DON submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified and confirmed the facility ' s implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON on [DATE], at 7:04 p.m. The acceptable IJ Removal Plan included the following summarized actions: 1. On [DATE], the DON and ADM identified all residents with a care plan for aspiration precautions and choking, and diagnosis of dysphagia through a diagnosis search in the Electronic Health Record (EHR - Point Click Care [PCC]). All residents currently residing at the facility (census 249) had a potential to be affected by the same deficient practice. 2. On [DATE], licensed nurses reviewed all the residents ' dietary cards on the dinner trays for accuracy and completeness. 3. On [DATE], Registered Nurse (RN) supervisors on the evening shift completed full body assessments on all residents to ensure that no residents were affected by the deficient practice. No further individuals were identified. 4. On [DATE], the DON, the ADM, and RN Supervisors provided 1:1 education on safe feeding techniques and supervision to all families present in the dining rooms, patios, and resident rooms during meals. 5. On [DATE], all families present at dinnertime were provided with Feeding Guidelines and instructed by RN Supervisors to move to the dining rooms during feeding for close observation and supervision. 6. On [DATE], the ADM composed a letter and the facility ' s business office mailed the letter to the residents ' responsible parties addressing the importance of following policies and procedures for safe eating techniques during visitation and checking in with Charge Nurse (CN) on duty before providing and/or assisting residents with any food. The letter addressed the importance of all family members who were involved in assisting the residents on eating, received proper training on safe eating and swallowing techniques and completeness of tray. The letter addressed the importance of following the residents ' prescribed diets, not giving the residents food that were outside of their diet plan, the importance of not force-feeding residents, and providing residents with right to decline food. A Visitor Education on Feeding Precautions was attached to the letter that the facility sent out to families listing the facility protocols that included only food within the resident ' s diet (nutrition and texture) were permitted, the licensed nurse must approve all food given to a resident, residents must be positioned at a 90-degree angle while eating, and residents must be allotted sufficient time to chew and swallow food. The facility protocol indicated visitors must wash their hands prior to handling food, visitors shall not assist other residents except for whom they were visiting, visitors must remain under staff supervision while assisting the resident in eating, recommended locations are dining rooms, visitors shall not force feed, and visitors must be sitting down at eye level with the resident while assisting the resident in eating. 7. On [DATE], the ADM modified the Visitor Education on Feeding Precautions form to include resident ' s name, visitor ' s name, relationship, date, and visitor ' s signature. The form included a section for questions and licensed nurses ' signature as evidence of provided training. 8. On [DATE] and [DATE], the Adm and the DON provided the receptionists and RN supervisors blank copies of the Visitor Education on Feeding Precautions acknowledgment form. Receptionists and RN supervisors were provided education on the new system of providing the form to all visitors. On [DATE], the ADM and the DON provided instructions to licensed nurses and receptionists to provide the forms to all visitors as evidence of education on the new policy, upon visiting a resident in the facility. 9. On [DATE], the ADM provided the facility ' s business office a copy of the family letter and Visitor Education on Feeding Precautions form to be included in the new admission packet for all future residents. 10. On [DATE] at 11:14 a.m., the ADM texted all residents ' contacts listed in PCC about the new policies and procedures pertaining to assisting residents in eating. 11. The ADM and the DON created a binder for the Visitor Education on Feeding Precautions acknowledgment forms with alphabetical listing of all residents in the facility. The binder was located at the reception desk. 12. On [DATE], The ADM updated the policy and procedures on Visitor Rules (RR-14 Form A, section Visitor Protocols) to reflect the new forms and procedures. 13. On [DATE], the DON and the facility ' s care planning team developed a new Care Plan for all residents pertaining to family education related to residents ' safe eating precautions. 14. The DSD posted the Visitor Education on Feeding Precautions in the facility lobby, dining rooms, and on patio doors. 15. RN Supervisors on duty monitored visitors for compliance with new feeding protocols during facility rounds, particularly during mealtimes, and document on the Shift Monitoring & Reporting Tool every shift. Any noncompliance will be documented in the pink licensed notes in the resident ' s chart. Responsible parties will be notified if the noncompliance with feeding is observed from a visitor. 16. On [DATE], the Food & Nutritional Supervisor updated all residents ' tray cards for breakfast, lunch, and dinner to list the items that must be present on the resident ' s meal tray and ensure completeness of the meal tray. 17. On [DATE] and [DATE], the ADM, the DON, and the DSD in-serviced all receptionists, licensed nurses, and certified nursing assistants (CNAs) in the morning and evening shifts, on the new visitor protocols and guidelines. RN supervisor on duty or the DSD will train the facility staff that were absent from training upon returning to work. 73% of nursing staff (146 of approximately 200) were in-serviced from [DATE] to [DATE]. 18. On [DATE], the DON and the DSD in-serviced all licensed nurses, CNAs, and RNAs on the new system of updated tray cards/tickets, on aspiration precautions, visitor education, and visitor supervision while assisting residents with eating. 19. On [DATE], the ADM, the DON, and the DSD updated the RNA schedule to have RNA feeding program during dinner time. 20. Performance Improvement Quality Improvement (PIQI) nurses will monitor Family Education Care Plan quarterly to ensure presence, completion, accuracy, and implementation. 21. PIQI nurses will report quarterly to the PIQI Committee the results of PIQI findings pertaining to residents ' care plan. Findings: a. A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included dysphagia oropharyngeal (the middle part of the throat, behind the mouth) phase, Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks), and Parkinsonism (a motor syndrome that manifests as rigidity, tremors, and bradykinesia [slowness of movement and progressive hesitation or halts as movements are continued]). A review of Resident 1 ' s Care Plan on dysphagia, initiated on [DATE], indicated the resident was at risk for choking and aspiration. The Care Plan indicated that on [DATE] Resident 1 required assistance in eating. On [DATE], the Care Plan indicated Resident 1 was on RNA dining program. Resident 1 ' s Care Plan Goal indicated the resident will tolerate food texture/fluid consistency as evidenced by no choking/aspiration. The Care Plan interventions indicated to set up tray and assist Resident 1 during meal and snack times daily as needed and RNA to provide therapeutic dining program for breakfast and lunch. Resident 1 ' s Care Plan interventions also included to observe for tolerance of food texture/fluid consistency, notify the medical doctor of any difficulties, and to follow safe swallow precautions. There were no interventions on teaching Resident 1 ' s family members on aspiration precautions and giving eating assistance to Resident 1. A review of Resident 1 ' s Speech Therapy (ST-a health professional who diagnoses and treats communication and swallowing problems) Plan of Care on dysphagia, dated [DATE], indicated the resident ' s problems were impaired swallowing, impaired chewing skills, reduced ability to follow safe swallow precautions, and on modified texture/consistency diet. The care plan goal indicated safe and efficient swallow on least restrictive diet, to maintain nutritional or oral (mouth) gratification needs without risk of aspiration. The care plan approaches indicated training in safe swallow strategies and caregiver training. The care plan did not indicate the specific caregiver that was given the training. A review of Resident 1 ' s Physician ' s Order Sheet, dated [DATE], indicated to downgrade to fortified, no added salt (NAS), puree textures (a food that had been blended, mixed, or processed into a smooth and uniform texture), and mildly thickened liquids. The physician order indicated to follow safe swallow precautions. A review of Resident 1 ' s Initial History and Physical, dated [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE], indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on eating. The Swallowing and Nutritional Status section of the MDS indicated Resident 1 required a mechanically altered diet (required change in texture of food or liquids such as pureed food and thickened liquids) and therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) while a resident in the facility. A review of Resident 1 ' s Certified Nursing Assistant (CNA) documentation on the resident ' s nutrition, dated ,d+[DATE], indicated Resident 1 was dependent (resident does none of the effort to complete the activity) on staff on eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). A review of Resident 1 ' s Weekly Summary, dated [DATE], indicated the resident ' s hearing and vision was impaired. It indicated that Resident 1 had unclear speech, did not have the ability to understand others, and make self understood. The Functional Status section indicated Resident 1 was totally dependent on staff on eating. A review of Resident 1 ' s meal ticket, dated [DATE], indicated the resident had fortified NAS, puree, nectar thickener, and mildly thick (MT2) consistency for dinner. The meal ticket indicated Resident 1 ' s preference was magic cup (dietary supplement) and may have soft bread and cheese. The meal ticket did not indicate Resident 1 ' s allergies and dislikes. A review of Resident 1 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated [DATE], indicated that at 5:45 p.m. Life Enrichment Coordinator 1 (LEC 1 - activity coordinator) informed LVN 1 that Resident 1 was not feeling good. The RN/LVN notes indicated that LVN 1 observed Resident 1 to be unresponsive, with eyes and mouth open, and no visible food in the resident ' s mouth. The notes indicated that Resident 1 appeared to be choking on food provided by Resident 1 ' s daughter. It indicated that Heimlich maneuver (the manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea) was initiated by LVN 1 and was unsuccessful. The RN/LVN notes indicated that 911 was called. LVN 1 performed Cardio-Pulmonary Resuscitation (CPR), gave oxygen at three liters per minute (unit of measurement) through nasal cannula (a device that delivers extra oxygen through a tube and into the nose), and suctioned Resident 1. It indicated that at 5:50 p.m., the paramedics arrived and took over Resident 1 ' s resuscitation. Resident 1 was transferred to GACH 1 at 6:20 p.m., unresponsive and had a heart rate of 111 beats per minute (normal resting heart rate for adults ranges from 60 to 100 beats per minute). The RN/LVN Notes did not indicate that FM 1 was instructed on aspiration precautions when assisting Resident 1 with meals. A review of Resident 1 ' s Physician ' s Order Sheet, dated [DATE], indicated to transfer Resident 1 to GACH 1. A review of Resident 1 ' s Los Angeles Fire Department (LAFD) paramedics report, dated [DATE], indicated that the paramedics were notified at 5:50 p.m. on [DATE]. The paramedics report indicated that Resident 1 was unresponsive, apnea (no airflow or stopped breathing), pale, and sluggish pupils (the black opening in the middle of the colored part of the eye). The Arrest Details section indicated that LAFD personnel initiated the CPR. Resident 1 ' s heart rate started after two doses of epinephrine (the primary medication administered during CPR to reverse cardiac arrest) 0.01 milligrams (mg - unit of measurement). Resident 1 was transferred to GACH 1. A review of Resident 1 ' s GACH 1 Emergency Department (ED) Provider Note, dated [DATE], indicated the resident arrived at the ED unresponsive, pale, pupils dilated and fixed, course breath sounds received bagged (a medical devise placed over the nose and mouth of a patient in respiratory distress) breaths, and presence of emesis (vomitus) around the lips, face, and in the oropharynx (the area from the soft palate to the base of the tongue). The ED Notes indicated Resident 1 ' s diagnoses of respiratory failure and cardiac arrest. A review of Resident 1 ' s GACH 1 History and Physical, dated [DATE], indicated the resident ' s active problems included aspiration pneumonia, acute hypoxemic respiratory failure secondary to aspiration pneumonia, cardiac arrest with likely anoxic brain injury (caused by a complete lack of oxygen not the brain that results in the death of brain cells after approximately four minutes of oxygen deprivation), and seizures (sudden uncontrolled bursts of electrical activity in the brain) secondary to likely anoxic brain injury. A review of Resident 1 ' s GACH 1 Death Summary, dated [DATE], indicated that [DATE] at 2:38 p.m. was Resident 1 ' s date and time of death. The Death Summary indicated diagnoses that included cardiac arrest, anoxic brain injury, aspiration pneumonia, acute respiratory failure with hypoxemia (a low level of oxygen in the blood). On [DATE] at 3:13 p.m., during a concurrent interview and record review, RN 1 stated Resident 1 ' s family members usually visited Resident 1 around dinner time and assisted the resident in eating. RN 1 stated that on [DATE] at 5 p.m., Resident 1 was in the north dining room seated on a high back wheelchair. RN 1 stated that a facility staff (name not given) transferred Resident 1 and FM 1 to the north dining room patio. RN 1 stated that Resident 1 was on puree diet because Resident 1 had Parkinson ' s disease (a movement disorder affecting movement including tremors, slowness of movements and trouble walking) and had weakening of the throat muscles and dysphagia. RN 1 stated that family members assisting residents with eating were verbally reminded on admission and before assisting the resident, about the aspiration precautions. RN 1 was not able to provide documented evidence that Resident 1 ' s family members were provided with training on aspiration precautions. RN 1 stated that LVN 1 screamed for help, and she followed LVN 1 to the north dining room patio. RN 1 stated that she saw LVN 1 was performing Heimlich maneuver on Resident 1. RN 1 stated that she checked for Resident 1 ' s pulse and breathing but the resident was pulseless, not breathing, pale, and with eyes open. RN 1 stated that there were no facility staff outside at the north dining room patio with Resident 1 and FM 1. RN 1 stated that Resident 1 and FM 1 were seated on the first table near the north dining room patio door. RN 1 stated that it took around one minute and 30 seconds to go to the north dining room patio from the north nurse station, perform Heimlich maneuver and assessment on Resident 1, wheel Resident 1 back to the room, and transfer Resident 1 from the wheelchair to the resident ' s bed. On [DATE] at 4:23 p.m., during an interview, using Language Interpreter 1 ([NAME] 1), Life Enrichment Coordinator 1 (LEC 1) stated Resident 1 was in the north dining room seated on a high back wheelchair. LEC 1 stated that at around 5:15 p.m., FM 1 visited Resident 1 in the north dining room. LEC 1 stated that FM 1 wanted to assist Resident 1 in eating and had asked LEC 2 if Resident 1 could go to the north dining room patio. LEC 1 stated that a CNA (name not given) took Resident 1 ' s food tray outside to the patio with Resident 1 and FM 1. LEC 1 stated that there were no facility staff in the north dining room patio with Resident 1 and FM 1. LEC 1 stated that she could not see Resident 1 from the north dining room because Resident 1 was on a high back wheelchair with the resident ' s back turned towards the dining room. LEC 1 stated that Resident 1 was on RNA program (a facility-implemented program that focuses on achieving and maintaining the residents ' optimal physical, mental, and psychosocial functioning) and the CNAs assist the resident with eating. LEC 1 stated that this was not the first time Resident 1 ' s family members assisted Resident 1 to eat. LEC 1 stated that around 5:40 p.m., FM 1 came in the dining room and stated that Resident 1 was not breathing well. LEC 1 stated she went to the north dining room patio and saw Resident 1 was weak, the resident ' s eyes were open, and the resident was not breathing well. LEC 1 stated that she went inside to ask LVN 1 for help. LEC 1 stated that she went back inside to assist other residents and did not know what happened to Resident 1. On [DATE] at 5:35 p.m., during a concurrent observation and interview, LEC 1 demonstrated Resident 1 and FM 1 ' s position at the north dining room patio. LEC 1 stated that Resident 1 and FM 1 were at the far end of the north dining room patio. LEC 1 demonstrated Resident 1 and FM 1 ' s position and stated that the resident was sitting on a high back wheelchair with the resident ' s back turned towards the dining room. LEC 1 demonstrated that FM 1 was seated at Resident 1 ' s right side facing the resident. On [DATE] at 9:59 a.m., during a telephone interview, LVN 1 stated that at around 5 p.m., FM 1 went to the north dining room. LVN 1 stated that at 5:45 p.m., LEC 1 informed him that Resident 1 was not feeling good. LVN 1 stated he did not know where Resident 1 was so LEC 1 pointed to the north dining room patio. LVN 1 stated that Resident 1 ' s mouth and eyes were open, the resident had no reflexes on the arms, and the resident did not have a pulse. LVN 1 stated that Resident 1 was sitting on a high back wheelchair with the resident ' s back turned towards the north dining room. LVN 1 stated that he did a mouth sweep and there was no food inside Resident 1 ' s mouth. LVN 1 stated that he did a Heimlich maneuver three times on Resident 1 and there was no food that came out of the resident ' s mouth. LVN 1 stated that it took less than one minute from the time LEC 1 reported Resident 1 ' s condition to the time CPR was started inside the resident ' s room. LVN 1 stated that CNAs were assisting residents in eating dinner. LVN 1 stated that LVNs and CNAs supervise family members assisting residents in eating. LVN 1 stated that a facility staff member should be supervising family members assisting residents in eating at the patio. LVN 1 stated that residents should be facing the dining room for more supervision. On [DATE] at 12:10 p.m., during a concurrent interview and record review, Resident 1 ' s Speech Language Pathologist (SLP) Discharge Summary, dated [DATE], was reviewed with the SLP, indicated Resident 1 had a treatment diagnosis of dysphagia, oropharyngeal phase. The SLP stated that Resident 1 was on puree diet and was able to tolerate soft bread and cheese for oral gratification. SLP stated that Resident 1 had difficulty tolerating mechanical soft regular diet and had difficulty on swallowing. The SLP stated that Resident 1 was discharged from speech therapy to Restorative Nursing Assistant (RNA) program. The Functional Outcomes section of the SLP Discharge Summary indicated that Resident 1 ' s swallowing ability was moderate. The Training section indicated Resident 1, and caregivers were instructed on safe swallow techniques with 100 % carryover demonstrated by caregivers. The SLP defined caregivers as everybody that took care of Resident 1 including the family if they were involved. The SLP stated that Resident 1 ' s SLP Discharge Summary did not indicate the specific caregivers that demonstrated 100 % understanding. The SLP stated that Resident 1 was 100 % total dependence on a person to assist the resident on eating. On [DATE] at 1:18 p.m., during an interview, using [NAME] 2, LEC 2 stated FM 1 requested to stay at the north dining room patio to assist Resident 1 in eating. LEC 2 stated that she opened the door for FM 1. LEC 2 stated she was not sure who brought Resident 1 ' s tray to the north dining room patio. LEC 2 stated that there were no facility staff members in the patio while FM 1 was assisting Resident 1 with eating. LEC 2 stated that since she started working at the facility six months ago, she did not observe family members getting trained on how to assist residents with aspiration precautions in eating. On [DATE] at 9:29 a.m., during a concurrent interview and record review, Resident 1 ' s Care Plan on therapeutic RNA dining program, dated [DATE], was reviewed with RNA Team Leader (RNA TL). Resident 1 ' s Care Plan indicated the RNA dining program was for breakfast and lunch to promote dietary intake and decrease distraction at mealtime. The RNA TL stated that she created the RNA care plans for the residents on the RNA program and updated the RNA care plans every three months based on the MDS assessment or on the residents ' change of condition. Resident 1 ' s Care Plan goal on the therapeutic dining program had a target date of [DATE]. The RNA TL stated that Resident 1 was on the continuous RNA dining program. The RNA TL stated that Resident 1 ' s care plan was not updated after the target date. The RNA TL stated that she should ensure Resident 1 ' s RNA dining program care plan was updated. The TL stated that care plans that were not updated had the potential for resident ' s care to not be good. The RNA TL stated that the RNA dining program was for breakfast and lunch only. The RNA TL stated that the RNAs assist the residents in eating and the family waits until the resident had finished eating. The RNA TL stated that RNAs were scheduled from 6:30 a.m. to 3 p.m. to assist residents during breakfast and lunch. RNA TL stated that CNAs assist the residents on eating dinner. The RNA TL stated that she did not know if the resident ' s family were allowed to assist residents on the RNA dining program. On [DATE] at 11:28 a.m., during a concurrent observation and interview, maintenance staff (MS) measured the distance from the right far end patio table located at the north dining room patio to Resident 1 ' s bedside where the facility staff performed CPR on the resident. MS stated that the total distance was 188 feet (ft - unit of measurement). On [DATE] at 2:15 p.m., during a concurrent interview and record review, the DON stated that Resident 1 ' s family members were given teachings on aspiration precautions during interdisciplinary team (IDT-a group of health care professionals with various area of expertise who work together toward the goals of the resident) meetings. Resident 1 ' s Interdisciplinary Care Conference Review form was reviewed with the DON, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], indicated that Resident 1 ' s family members participated through telephone call on one of eight interdisciplinary care conferences. The document did not indicate that Resident 1 ' s family members were provided instructions on aspiration precautions on all eight interdisciplinary care conferences. Resident 1 ' s RN/LVN Notes were also reviewed with the DON, and she was not able to provide documented evidence that Resident 1 ' s family members received specific instructions on assisting the resident while eating. On [DATE] at 1:25 p.m., during a telephone interview, FM 1 stated that around 5:30 p.m. on [DATE], FM 1 saw Resident 1 sitting in a wheelchair inside the north dining room. FM 1 stated that LEC 1 handed Resident 1 ' s dinner tray to FM 1 and told FM 1 to assist Resident 1 on eating the dinner at the north dining room patio. FM 1 stated that Resident 1 had a puree food on the dinner tray. FM 1 went in the dining room twice to get water. FM 1 gave Resident 1 two plastic spoons of mashed potatoes, but the resident spat out the second spoon of mashed potatoes. FM 1 placed Resident 1 ' s dinner tray on the side. FM 1 stated that upon turning back towards Resident 1, FM 1 saw the resident ' s eyes was looking up and the resident was not responding. FM 1 stated there were no facility staff in the north dining room patio while FM 1 was assisting Resident 1 with the dinner. FM 1 stated that the facility staff did not teach FM 1 about Resident 1 ' s aspiration precautions. On [DATE] at 8:25 a.m., during a concurrent observation and interview, observed a large orange water container on a cart with transparent plastic cups on the side. The water container was located on the far-left corner of the north dining room coming from the patio door. LEC 3 stated that the facility staff provided water with thickener to residents on aspiration precautions based on the posted list of residents who are on thickener. On [DATE] at 10:40 a.m., during a concurrent interview and record review, the Director for Staff Development (DSD) stated that she used the same checklist competency for RNAs and CNAs. The DSD stated that both RNAs and CNAs were trained to assist residents on eating. On [DATE] at 11:19 a.m., during a follow up interview, the DSD stated residents that required eating assistance, losing weight, and residents requiring extra time to eat were assigned to the RNA dining program for breakfast and lunch. The DSD stated that the RNAs were required to have a special training and a certificate. On [DATE] at 3:50 p.m., during a follow up telephone interview, FM 1 stated Resident 1 ' s tray did not have water in it. FM 1 went inside the north dining room and took a cup of water from the orange water container. FM 1 stated that facility staff were present in the north dining room when FM 1 went inside and got Resident 1 a cup of water. FM 1 stated that facility staff saw her getting water from the orange water container. The facility staff did not ask FM 1 who the water was for and did not offer help. FM 1 stated that Resident 1 ' s tray included a pre-packed orange juice which FM 1 gave the resident. Resident 1 finished drinking the orange juice without using a straw. FM 1 stated that facility staff did not provide FM 1 training on assisting Resident 1 on eating. On [DATE] at 10:31 a.m., during a concurrent interview and record review, the policies titled Education of Residents and Aspiration Precautions were reviewed with the ADM. The ADM stated family education does not need to be specific. ADM was asked to read the facility-provided policy and procedure titled, Education of Residents, dated [DATE]. The ADM stated that the policy indicated documentation is performed by the responsible discipline and will include a description of the education provided to the resident/family/responsible party. The policy titled, Aspiration Precautions, dated [DATE], was reviewed with the ADM. The ADM stated that the policy indicated that residents identified for aspiration, exhibiting signs of impaired swallowing, or displaying symptoms of potential aspiration will have aspiration precautions implemented. Aspiration precautions included assistance with feeding and supervision as indicated in the resident ' s plan of care. Resident 1 ' s care plan on therapeutic diet was reviewed with the ADM. The ADM stated the care plan intervention included to set up tray and assist resident daily. The ADM was asked to elaborate on the word daily. The ADM stated that daily meant all meals and snack times. The ADM was asked to elaborate the word assist. The ADM stated that assist meant putting the tray in front of the resident, opening the food, setting the food u[TRUNCATED]

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of four sampled residents (Resident 1). The facility failed to develop and implement individualized care plan interventions addressing: 1. Resident 1 ' s abnormal posture identified by the Physical Therapist (PT). 2. Resident 1 ' s non-compliance with instructions, restlessness, constantly leaning forward as described by Licensed Vocational 2 (LVN 2). 3. Resident 1 ' s repetitive movement of rocking back and forth as indicated by Registered Nurse 2 (RN 2). 4. Resident 1 ' s impulsiveness as stated by Certified Nursing Assistant 2 (CNA 2). 5. Discontinuation of Resident 1 ' s Risperdal (antipsychotic medication [to treat psychosis which is a mental illness characterized by a disconnection from reality]) given for the resident ' s constant attempts to get out of bed and wheelchair. There were no non-pharmacological (non-medication) behavioral interventions as recommended by the psychiatrist and monitoring Resident 1 ' s behavior after Risperdal was discontinued. As a result, on [DATE] at 3:30 p.m., Resident 1 fell forward from the wheelchair hitting the floor face first resulting in right facial fractures (broken bones) and brain bleed. Resident 1 died on [DATE] at 4:22 a.m. at General Acute Care Hospital 1 (GACH 1). Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident, on [DATE] with diagnoses including atherosclerotic heart disease (a condition that develops when sticky substance called plaque builds up inside the arteries) and Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills). A review of Resident 1 ' s Care Plan developed on [DATE] for the resident ' s fall risk, had an added problem on [DATE] of Resident 1 ' s abnormal posture but did not describe what the abnormal posture was that increased her fall risk. The care plan was not revised explain what the abnormal posture and to develop interventions related to Resident 1 ' s abnormal posture. A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to administer to Resident 1 the medication Risperdal 0.25 milligrams (mg) by mouth every evening for constant attempts to get out of bed and wheelchair. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 1 was unable to walk and was dependent on staff with locomotion on unit (how resident moves between location in her room and adjacent corridor on same floor), locomotion off unit (how resident moves to and returns from off-unit locations. Resident 1 used a wheelchair as mobility device. The MDS Mood section indicated Resident 1 was moving or speaking so slowly that other people have noticed or the opposite, being so fidgety or restless that she has been moving around a lot more than usual. This symptom was present in the past ,d+[DATE] days nearly every day. Resident 1 was receiving daily antipsychotic medication daily. A review of Resident 1 ' s Fall Risk Assessment, dated [DATE], indicated the resident had a total score of 15. A total score above 10 represented high risk for falls. A review of Resident 1 ' s Care Plan, dated [DATE] and revised on [DATE], indicated the resident was at risk for falls because of the abnormal posture but did not explain what the abnormal posture consisted of. The goal was minimizing potential for falls/injury. The care plan did not indicate specific and individualized intervention for Resident 1 ' s abnormal posture. A review of Resident 1 ' s Psychiatric Progress Notes, dated [DATE], indicated Resident 1 ' s behaviors were stable, had less episodes of trying to get out of bed and wheelchair. Will discontinue the Risperdal and provide non-pharmacological interventions. A review of Resident 1 ' s licensed nursing notes, medication and treatment administration records, and care plans, from [DATE] to [DATE], indicated no documentation Resident 1 was monitored for presence of the behaviors of restlessness and attempts to get out of bed and wheelchair and what non-pharmacological behavioral interventions nursing staff had to implement or had implemented. A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] timed at 3:30 p.m., signed by LVN 3, indicated CNA 2 wheeled Resident 1 to the dining room, when the resident suddenly moved forward, falling onto the floor hitting her face first. A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] timed at 7:45 a.m., by LVN 2, indicated the resident was non-responsive to verbal and tactile stimuli (to voice and touch) and did not open her eyes. LVN 2 documented she would notify the (RN) supervisor. LVN 2 documented Resident 1 did not sustain injuries and the attending physician (MD 1) was notified. A review of Resident 1 ' s RN/LVN Progress Notes, dated [DATE] at 8 a.m., by RN 2, indicated the resident was not responding to sternal rub (application of painful stimuli with the knuckles of a closed fist to the center chest of a patient who was not alert and does not respond to verbal stimuli), paramedics were called, and Resident 1 was transferred to GACH 1 on [DATE] at 9:15 a.m. A review of Resident 1 ' s paramedics Patient Care Report, dated [DATE], at the scene at 8:59 a.m., indicated Resident 1 was unresponsive and had a large hematoma (it happens when an injury causes blood to collect and pool under the skin) to the right eye. A review of Resident 1 ' s GACH 1 Emergency Department (ED) Trauma Emergency Department Record, dated [DATE] at 9:26 a.m., indicated Resident 1 had right periorbital ecchymosis (discoloration of the skin around the eyes due to the rupture of the blood vessels below the surface of the skin) and hematoma. A review of Resident 1 ' s GACH 1 ED Physician Note, dated [DATE] at 9:48 a.m., indicated the resident had raccoon eyes (dark purple or blue bruises under the eyes), contusion (a bruise), and right periorbital erythema (inflammation of the eyelids). A review of Resident 1 ' s GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the head report, dated [DATE] at 9:51 a.m., indicated the resident sustained extensive intracranial hemorrhage (bleeding between the brain tissue and skull) with leftward midline shift (occurs when something pushes the natural centerline of the brain to the left) and right facial fractures (broken bones in the face). A review of Resident 1 ' s GACH 1 Geriatric (a medical specialty focused on providing care for the unique health needs of older adults) Service Physician Note, dated [DATE], timed at 2:28 p.m., indicated CT of the head showed right facial fractures and extensive intracranial hemorrhage with severe mass effect (local pressure). Resident 1 was DNR (Do not Resuscitate or not try to revive) and DNI (do not intubate), neurosurgery (surgery of the nervous system) not indicated and was allowed to rest comfortably. A review of Resident 1 ' s GACH 1 Death Summary indicated Resident 1 died on [DATE], at 4:22 a.m. with the diagnosis of traumatic cerebral compression (an injury in which something increases the amount of pressure pushing on the brain, which can damage brain tissue) / compression of brain. During an interview on [DATE] at 3:21 p.m., LVN 2 stated that Resident 1 was confused, non-compliant with instructions, high risk for falls, restless, constantly leaning forward, and not able to follow directions. During an interview on [DATE] at 4:40 p.m., RN 2 stated Resident 1 had been observed to have a repetitive movement of rocking back and forth. RN 2 stated that Resident 1 ' s behavior had been ongoing for months. RN 2 could not explain why the behaviors were not monitored. During an interview on [DATE] at 5:16 p.m., CNA 2 stated Resident 1 was confused and impulsive. On [DATE] at 8:50 a.m., during an interview with the Director of Rehabilitation (DOR) and a concurrent review of Resident 1 ' s PT Evaluation and Plan of Treatment conducted on [DATE], the DOR was not able to provide documentation on the specific abnormal posture identified. The DOR stated the definition of abnormal posture was the inability of the person to hold a posture in normal alignment. Resident 1 ' s PT Discharge Summary, dated [DATE], indicated Resident 1 ' s short-term and long-term goal was to increase dynamic sitting balance (spontaneously righting self when needed to facilitate upright posture and reduce the risk for falls) from poor to fair. Resident 1 ' s baseline and discharge dynamic sitting balance was poor plus (+). The DOR stated poor + indicated Resident 1 was very high risk for fall if the resident shifted weight. There were no recommendations to use supporting devices while sitting to improve posture and safety. During an interview on [DATE] at 10:52 a.m., the Director of Nursing (DON) stated an individualized care plan should have been created to address Resident 1 ' s identified special needs. The DON stated there was no care plan created for the rocking behavior and restlessness. The DON stated PT should have made recommendations such as a custom-made wheelchair to address Resident 1 ' s abnormal posture and restlessness. The DON further stated Resident 1 ' s care plan did not include safety interventions related to abnormal posture and restlessness. A review of the facility ' s policy and procedure titled, Care Planning, dated [DATE], indicated the purpose of the policy was to ensure a comprehensive person-centered care plan was developed for each resident based on their individual assessed needs. Each resident ' s comprehensive care plan would describe services that were to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. A review of the facility ' s policy and procedures titled, Fall Management Program, dated [DATE], indicated the purpose of the policy was to prevent resident falls and minimize complications associated with falls through development of a fall management program. Nursing staff will develop a plan of care specific to the resident ' s needs with interventions to reduce the risk of falls. It also indicated that one of the universal fall prevention measures for all residents was to reassess mobility status and encourage use of assistive devices as appropriate.

Based on interview and record review, the facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries for one of four sampled residents (Residents 1). The facility failed to ensure: 1. Resident 1 was provided postural support while sitting in the wheelchair due to abnormal posture. 2. Resident 1 was monitored for behaviors of restlessness and constant episodes of trying to get out of bed and wheelchair after the antipsychotic medication Risperdal (to treat psychosis, a mental illness characterized by a disconnection from reality) was discontinued on [DATE]. 3. Resident 1 was provided with non-pharmacological (non-medication) interventions after Risperdal was discontinued on [DATE] if having episodes of trying to get out of bed and wheelchair, restlessness, rocking back and forth, and impulsive behaviors. As a result, on [DATE] at 3:30 p.m., Resident 1 fell out of the wheelchair hitting the floor face first. Resident 1 remained in the facility and on [DATE] at 8 a.m. she was unresponsive (not reacting or responding to an action: pain, touch, or verbal commands). Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with facial bone fractures (broken bones) and extensive intracranial hemorrhage (bleeding between the brain tissue and skull) with leftward midline shift (occurs when something pushes the natural centerline of the brain to the left). Resident 1subsequently died on [DATE] at 4:22 a.m. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] with diagnoses including atherosclerotic heart disease (a condition that develops when sticky substance called plaque builds up inside the arteries) and Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills). A review of Resident 1 ' s Care Plan developed on [DATE] for the resident ' s fall risk, had an added problem on [DATE] of Resident 1 ' s abnormal posture (did not explain what the abnormal posture consisted of) that increased her fall risk. The care plan did not include specific interventions for the abnormal posture. A review of Resident 1 ' s Care Plan for Fall Risk, dated [DATE], revised on [DATE], indicated the resident was at risk for falls because of the abnormal posture but did not describe what the abnormal posture was. The goal was minimizing potential for falls/injury. The care plan did not include specific and individualized intervention for Resident 1 ' s abnormal posture. A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to administer to Resident 1 the medication Risperdal 0.25 milligrams (mg) by mouth every evening for constant attempts to get out of bed and wheelchair. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 1 was unable to walk and was dependent on staff with locomotion on unit (how resident moves between location in her room and adjacent corridor on same floor), locomotion off unit (how resident moves to and returns from off-unit locations). Resident 1 used a wheelchair as mobility device. The MDS Mood section indicated Resident 1 was moving or speaking so slowly that other people have noticed or the opposite, being so fidgety or restless that she has been moving around a lot more than usual. This symptom was present in the past ,d+[DATE] days nearly every day. Resident 1 was receiving antipsychotic medication daily. A review of Resident 1 ' s Fall Risk Assessment, dated [DATE], indicated the resident had a total score of 15. A total score above 10 represented high risk for falls. A review of Resident 1 ' s Psychiatric (relating to mental illness or its treatment) Progress Notes, dated [DATE], indicated Resident 1 ' s behaviors were stable, had less episodes of trying to get out of bed and wheelchair. Will discontinue the Risperdal and provide non-pharmacological interventions. A review of Resident 1 ' s licensed nurses progress notes, medication and treatment administration records, and care plans, from [DATE] to [DATE], indicated there was no documentation Resident 1 was monitored for presence of the behaviors of restlessness and attempts to get out of bed and wheelchair and what non-pharmacological behavioral interventions nursing staff had to implement or had implemented. A review of Resident 1 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated [DATE] timed at 3:30 p.m., signed by LVN 3, indicated Certified Nursing Assistant 2 (CNA 2) was wheeling Resident 1 inside the dining room, the resident suddenly moved forward, falling onto the floor hitting her face first. LVN 2 documented Resident 1 did not sustain injuries and the attending physician (MD 1) was notified. A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] timed at 7:45 a.m., by LVN 2, indicated the resident was non-responsive to verbal and tactile stimuli (to voice and touch) and did not open her eyes. LVN 2 documented she would notify the (RN) supervisor. There was no documentation about the condition of Resident 1 ' s face (if swelling, pain, redness, or bruising). A review of Resident 1 ' s RN/LVN Progress Notes, dated [DATE] at 8 a.m., by RN 2, indicated the resident was not responding to sternal rub (application of painful stimuli with the knuckles of a closed fist to the center chest of a patient who was not alert and does not respond to verbal stimuli), paramedics were called, and Resident 1 was transferred to GACH 1 on [DATE] at 9:15 a.m. A review of Resident 1 ' s paramedics Patient Care Report, dated [DATE] at the scene at 8:59 a.m., indicated Resident 1 was unresponsive and had a large hematoma (it happens when an injury causes blood to collect and pool under the skin) to the right eye. A review of Resident 1 ' s GACH 1 Emergency Department (ED) Trauma Emergency Department Record, dated [DATE] at 9:26 a.m., indicated Resident 1 had right periorbital ecchymosis (discoloration of the skin around the eyes due to the rupture of the blood vessels below the surface of the skin) and hematoma. A review of Resident 1 ' s GACH 1 ED Physician Note, dated [DATE] at 9:48 a.m., indicated the resident had raccoon eyes (dark purple or blue bruises under the eyes), contusion (a bruise), and right periorbital erythema (inflammation of the eyelids). A review of Resident 1 ' s GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the head report, dated [DATE] at 9:51 a.m., indicated the resident sustained extensive intracranial hemorrhage (bleeding between the brain tissue and skull) with leftward midline shift (occurs when something pushes the natural centerline of the brain to the left) and right facial fractures. A review of Resident 1 ' s GACH 1 Geriatric (a medical specialty focused on providing care for the unique health needs of older adults) Service Physician Note, dated [DATE], timed at 2:28 p.m., indicated CT of the head showed right facial fractures and extensive intracranial hemorrhage with severe mass effect (local pressure). Resident 1 was DNR (Do not Resuscitate or not try to revive) and DNI (do not intubate) and neurosurgery (surgery of the nervous system) was not indicated, and Resident 1 was allowed to rest comfortably. A review of Resident 1 ' s GACH 1 Death Summary indicated Resident 1 died on [DATE], at 4:22 a.m. with the diagnosis of traumatic cerebral compression (an injury in which something increases the amount of pressure pushing on the brain, which can damage brain tissue) / compression of brain. A review of the facility ' s Investigation report indicated Resident 1 ' s fall incident ([DATE]) occurred in a crowded (with residents) dining room. The investigation did not address the crowded space may have triggered the resident to try to get out of the wheelchair and the lack of monitoring the behavior of trying to get out of bed and wheelchair. During an interview on [DATE] at 3:21 p.m., LVN 2 stated that Resident 1 was confused, non-compliant with instructions, high risk for falls, restless, constantly leaning forward, and not able to follow directions. During an interview on [DATE] at 4:40 p.m. with RN 2 stated Resident 1 had been observed to have a repetitive movement of rocking back and forth. RN 2 stated that Resident 1 ' s behavior had been ongoing for months. RN 2 could not explain why the behaviors were not monitored. During an interview on [DATE] at 5:16 p.m., CNA 2 stated Resident 1 was confused and impulsive. On [DATE] at 8:50 a.m., during an interview with the Director of Rehabilitation (DOR) and a concurrent review of Resident 1 ' s Physical Therapy (PT) Evaluation and Plan of Treatment conducted on [DATE], the DOR was not able to provide documentation on the specific abnormal posture identified. The DOR defined abnormal posture as the inability to hold a posture in normal alignment. Resident 1 ' s PT Discharge Summary dated [DATE], indicated Resident 1 ' s short-term and long-term goal was to increase dynamic sitting balance (spontaneously righting self when needed to facilitate upright posture and reduce the risk for falls) from poor to fair. Resident 1 ' s baseline and discharge dynamic sitting balance was poor plus (+). The DOR stated poor + indicated Resident 1 was very high risk for fall if the resident shifted weight. The DOR stated that care givers were educated on positioning techniques but there were no recommendations to use supporting device while sitting to improve posture and safety. During an interview on [DATE] at 10:52 a.m., the Director of Nursing (DON) stated an individualized care plan should have been created to address Resident 1 ' s identified special needs. The DON stated there was no care plan created for the rocking behavior and restlessness. The DON stated PT should have made recommendations to address Resident 1 ' s abnormal posture and restlessness to prevent falls and injuries. The DON further stated Resident 1 ' s care plan did not include safety interventions related to abnormal posture and restlessness to prevent accidents. The DON stated that after the Risperdal was discontinued there were no monitoring and no non-pharmacological behavioral interventions were done for Resident 1 from [DATE] to [DATE]. A review of the facility ' s policy and procedures titled, Fall Management Program, dated [DATE], indicated the purpose of the policy was to prevent resident falls and minimize complications associated with falls through development of a fall management program. Nursing staff will develop a plan of care specific to the resident ' s needs with interventions to reduce the risk of falls. It also indicated that one of the universal fall prevention measures for all residents was to reassess mobility status and encourage use of assistive devices as appropriate.

Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and or a position change alarm (an alarm to alert staff the resident needs assistance) when the resident stands without assistance, to prevent accidents for three of 35 sampled residents (Resident 223, Resident 201, and Resident 161) by: 1. Failing to ensure Resident 223, who was assessed at risk for falls and had multiple falls was provided with an alternative method to alert staff when the resident's was standing without assistance, when the magnetic alert device was discontinued, to minimize the chance for further falls. 2. Failing to fully address the need for close supervision as indicated in the care plan to meet the needs of Resident 223's in order to prevent falls. 3. Failure to assess Resident 223's need for continued use of a magnetic alert device (The pull cord alarms clips on the back of the resident's clothing and if the resident moves too far, the pull cord will release the magnet or tab and the alarm will sound) before discontinuation, to determine if the resident required the alarm for safety. 4. Failure to have a system in place to alert staff when Resident 223 stands up and attempts to walk by herself, in order to provide timely and necessary assistance to minimize falls. 5. Failing to provide adequate and continuous supervision and monitoring to prevent falls of Resident 201, who was assessed at risk for falls and was legally blind to prevent the occurrence of fall. 6. Implement Resident 201's care plan that indicated when walking, assure ambulation with walker and staff assistance at all times. 7. Follow the facility's policy and procedure that indicated to prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program, to identify and implement interventions to reduce the risk for falls, and that each resident receives adequate supervision and assistance to prevent accidents for Resident 201. 8. Failing to use two people to transfer Resident 161 from bed to wheelchair, using a Hoyer lift (sling lift, an mechanical assistive device that allows residents to be transferred between a bed and a chair, by the use of electrical or hydraulic power) as indicated in the care plan. 9. For Resident 201, the facility failed to identify specific intervention to address assistance need while ambulation to prevent actual fall. These deficient practices resulted in Resident 223 falling on February 16, 2017, September 4, 2017, and December 12, 2017, and the fourth fall on February 4, 2018, resulted in a left [CONDITION(S)] that required surgery and hospitalization for five days. As a result of the facility's failure Resident 201, sustained a fall and fracture of the left femur that required a surgical repair at the general acute care hospital (GACH) and hospitalization for eight days. These deficient practices placed Resident 161 at risk for receiving injury and possible fracture due to insufficient persons physically assisting the resident or machine error. Findings: a. On April 4, 2018 at 2:53 p.m., Resident 223 was observed lying in bed with call light within reach. Resident 223 was heard speaking in her native language. There was a floor mat on the right side of the bed. A review of the admission record indicated Resident 223 was initially admitted to the facility on [DATE], with diagnoses including but not limited to, dementia (a decline in mental ability severe enough to interfere with daily life), [CONDITION(S)] (disorder of the nervous system that affects movement marked by tremor (shaking) of resting muscles, stiffness, slowness of movement, impaired balance) and had history of fall. A review of Resident 223's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated December 15, 2017, indicated the resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were moderately impaired. The MDS indicated Resident 223 required extensive assistance from staff for moving in bed, transferring from bed to wheelchair, standing position and toilet use. A review of Resident 223's Fall Score (Fall Risk Assessment) dated December 15, 2017, indicated the resident was at risk for fall and required maximum assistance during ambulation and activities of daily living. A review of the Psychiatry Progress Notes dated June 17, 2017, August 12, 2017, May 23, 2017 and December 19, 2017, indicated Resident 223 had a disorganized thought process, impaired insight and judgment, impaired impulse control, impaired short and long term memory, impaired immediate recall and was disoriented. A review of Resident 223's At Risk for Fall care plan initiated on February 14, 2015 and reviewed every three months, last updated on March 9, 2018, indicated the resident had actual falls on February 16, 2017, September 4, 2017, December 12, 2017, and February 4, 2018. The care plan indicated the resident was at risk for falls secondary to unsteady balance during transitions, and walking. The care plan indicated the resident was only able to stabilize balance with staff assistance when moving from seated to standing position, walking with assistive device, and moving on and off toilet. The intervention included to assure the call light is available and answered promptly, to make sure magnetic alert device is working properly and attached to the resident at all times, for staff to chart at the station close to the resident's room to supervise resident closely while she is taking a nap from 1 p.m. to 3 p.m. and to instruct staff do not leave resident unattended alone in her room. A new intervention was added after an actual fall on February 4, 2018, for the certified nursing assistant (CNA) to take the resident to the Dining Room after breakfast to keep her under close supervision. The care plan did not specify how to ensure the resident had close supervision. A review of a the facility's Incident/Accident Report dated February 4, 2018, indicated on February 4, 2018 at 10:00 a.m., Resident 223 was observed on the floor in sitting position next to her roommate's bed. The report indicated Resident 223 stated she was trying to sit on the wheelchair and she fell . The report indicated Resident 223 was alert with episodes of confusion, complained of left leg pain and had a laceration (cut) on the left eyebrow. A review of the Physician's order dated February 4, 2018, indicated to transfer Resident 223 to a General Acute Care Hospital (GACH) for pain on the left lower extremity (leg) after an unwitnessed fall. A review of Resident 223's x-ray of the left hip obtained from GACH dated February 4, 2018, indicated acute (new) left intertrochanteric femoral fracture (left [CONDITION(S)]). A review of Resident 223's GACH Progress notes dated February 5, 2018, indicated the resident had an open reduction internal fixation (a type of surgery used to fix broken bones.) of the left hip. A review of Resident 223's Nurses Notes dated February 9, 2018, indicated the resident was readmitted back from GACH to the facility. A review of Resident 223's At Risk for Fall care plan updated on March 4, 2018, after the resident had another actual fall on March 4, 2018, indicated an intervention for staff to do frequent check every thirty minutes about the resident whereabouts and keep the resident under close supervision. On April 5, 2018 at 10:49 a.m. during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she cared for Resident 223 five days a week. LVN 1 stated Resident 223 was not ambulatory, but would try to get out of bed by herself. LVN 1 stated on February 4, 2018, after the resident fell , she and the registered nurse supervisor (RN 2) assessed the resident . LVN 1 stated Resident 223 left leg was shorter than the right leg . LVN 1 stated Resident 223 used to have a position change alarm to alert staff (of the resident's attempts of trying to get up by herself), but the facility no longer uses position change alarms. On April 5, 2018 at 11:21 a.m. during an interview, the Certified Nursing Assistant (CNA 1) stated on February 4, 2018, she heard Resident 223 screaming and she found the resident on the floor next to the roommate's bed. CNA 1 stated Resident 223 had a position alarm on her bed in the past, but the facility did not use alarms anymore. CNA 1 stated the position change alarm for Resident 223 worked well because it alerted her when the resident was trying to get up unassisted and she could assist the resident timely and prevent the resident from falling . On April 5, 2018 at 12:53 p.m. during an interview RN 2, stated on February 4, 2018, LVN 1 and CNA 1 informed her Resident 223 fell . RN 2 stated she observed Resident 223 on the floor and the resident complained of left leg pain. RN 2 stated, I noticed the shortness of the left leg and I suspected a possible fracture. RN 2 was unable to provide documentation that Resident 223 was assessed for a continued need for the use of the position change alarm before the alarm was discontinued. On April 6, 2018 at 2:52 p.m. during an interview CNA 2 stated even though Resident 223 did not know how to use the call light, she would always place the call light next to the resident while she was in bed. On April 6, 2018 at 2:53 p.m. during an observation, Resident 223 pressed the call light button only after the Licensed Vocational Nurse 1 (LVN 1) handed the call light to the resident and instructed her to push the button. On April 9, 2018 at 8:39 a.m. during an interview (via translation by the Administrator in training [ADMT]), Resident 223 was unable to explain what she does when she needs to call the nurse or the CNA. A review of the facility's Fall Management Program policy and procedure revised March 4, 2015, stipulated the nursing staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls. The Interdisciplinary Team (IDT, a group of medical professional) will routinely review the plan of care at a minimum of quarterly with significant change of condition and post-fall. Interventions will be implemented or change based on the resident condition and response and nursing staff will document response to interventions being utilized in the resident's medical record. A review of the facility policy and procedure revised on March 1, 2015, titled Response to Falls indicated the purpose of the policy and procedure is to ensure the facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention. The policy and procedure further indicated the Interdisciplinary Team (IDT, a group of medical professional) would review the investigative report on a regular basis as they may occur and make systemic changes to reasonably limit future occurrences, consider change in POC (plan of care) interventions, system changes, etc. b. According to the admission record, Resident 201 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included displaced hip bone, had history of fall, dementia, left eye age-related nuclear cataract, and [CONDITION(S)] (severe vision loss). The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognitive skills for daily decision-making was moderately impaired, had a mood symptom of feeling down, depressed, or hopeless, needed limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance)with one person physical assist for bed mobility, transfer, walking in the room and corridor, and extensive assistance (resident involved in activity, staff provide weight-bearing support) with one person physical assist for locomotion on and off the unit. A review of Resident 201's Nursing Fall Score dated October 31, 2017, indicated a total score of 10. A score of nine to 16 indicated the resident had a moderate risk (some risk of falling). A review of the care plan initiated on September 2, 2016, was updated on November 23, 2016, and last updated on May 21, 2017, indicated needs assistance in locomotion off unit and bathing, and needed assistance in bed mobility. The interventions included when walking, assure ambulation with walker and staff assistance at all times and for locomotion, assist resident on unit and/or assist take around facility daily as needed. A review of the Weekly Summary dated December 25, 2017, indicated under functional status, assist in ambulation. The Incident/Accident Report dated December 31, 2017, indicated Resident 201 had a fall that resulted to fracture on December 30, 2017 at 7 p.m. at the resident's room. The resident was observed on the floor next to walker in her room. Resident 201 stated the walker stuck to the threshold of doorway and fell to the floor. According to her, she lost her balance and fell over the walker. ROM (range of motion) to upper extremities, minimal pain of left hip and thigh, able to ambulate to bed. A review of the Radiology Report (from the facility) for one view of the left hip without the pelvis dated December 30, 2017, indicated new [CONDITION(S)]. A review of the undated Incident Investigation, indicated there was an unwitnessed fall. The roommate of Resident 201 was not in the room. The charge nurse stated the resident was screaming help me, help me. The resident was observed on the floor and the supervisor was called. There were no witnesses available. A review of the Post Fall Assessment/Intervention dated December 31, 2017, indicated Resident 201 had an unsteady gait, poor judgment, and dementia. Interventions indicated were medication review and instruct and reinforce with resident not to walk unassisted to prevent further incidents. However, giving instructions to the resident will not prevent further incidents of falls since the resident had poor judgment. On April 9, 2018, at 9:56 a.m., during an interview and record review with the Director of Nursing (DON), she stated Resident 201 was observed on the floor next to her walker in her room on December 30, 2017, at 7 p.m. She stated this was an unwitnessed fall. Resident 201 was alert and oriented. She was walking when the walker stuck at threshold of the doorway and she fell on the floor and lost her balance and fell over the walker. When the DON was asked on why the resident was not provided assistance when ambulating with one person physical assist, she stated the resident did not use the call light for help. However, reminding the resident to use call light for help will not prevent resident from a fall. The resident was diagnosed with dementia and was legally blind. The care plan indicated when walking, assure ambulation with walker and staff assistance at all times was not implemented at all times. The DON was not able to provide documented evidence that the staff had been vigilant in doing visual checks to the resident, ensure that the resident wore a non-skid socks or footwear, and had a special eyeglass. On April 9, 2018, at 10:05 a.m., during an interview and record review with Physical Therapist 1 (PT 1), she stated she worked with Resident 201 when resident was receiving physical therapy. She stated after physical therapy, the resident was placed on RNA (restorative nursing assistant) program prior to fall on December 30, 2017. The resident's last physical therapy was on November 26, 2016. At the time of discharge from PT service, the resident needed supervise assist with FWW and was in good standing balance. The facility's policy and procedure titled Fall Management Program dated March 1, 2015, indicated the purpose of the policy was to prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program. It is the policy of the facility to provide the highest quality care in the safest environment for the residents residing in the facility. The facility has developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. Based on the information gathered from the history and assessment of the resident, the nursing staff and interdisciplinary team (IDT), with input for the attending physician, will identify and implement interventions to reduce the risk for falls. The facility's policy and procedure titled Fall Risk assessment dated [DATE], indicated the facility will ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. c. During an observation and concurrent interview during the Initial Tour of the facility on April 3, 2018 at 9:55 a.m. Resident 161 was observed being moved by Certified Nursing Assistant 3 (CNA 3) from the bed to the wheelchair. A Hoyer lift (mechanical lift) was used to move the resident. There was no other staff assisting CNA 3. CNA 3 stated she should have asked another staff for help to move Resident 161, because it is not safe with only one person using the Hoyer lift. CNA 3 stated she usually asks another staff to assist her when she operates the Hoyer lift. A review of the admission record indicated Resident 161 was admitted to the facility on [DATE], with diagnoses including generalized muscle weakness, [CONDITION(S)] (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or Vitamin D), and history of falling. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated February 26, 2018, indicated Resident 161 was severely impaired in cognition (process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for transfer from bed to wheelchair. Resident 161 required two-person assistance in transfer from bed to wheelchair. A review of Resident 161's Care Plan for Bed Mobility, initiated April 24, 2016, indicated a goal: Will demonstrate the ability to transfer safely as evidenced by no fall. One of the interventions was to have two or more persons to transfer the resident in and out of bed and wheelchair daily as needed. Use mechanical lift as needed. During an interview with the Director of Staff Development (DSD), when asked what is taught to staff when using a Hoyer lift, she stated the facility's policy indicates there should be 1 to 3 staff but does not specifically indicate there has to be at least 2 people. The DSD stated it is better to have two staff operating the Hoyer lift, but she leaves it to the discretion of the CNA to ask for help if they need help. The DSD stated, if the MDS indicates there was an assessment made that the resident needs two people in transfer from bed to wheelchair, then there needs to be two staff in transfer, not one staff. During an interview with CNA 4 on April 4, 2018 at 2:18 p.m., she stated she always asks other staff for assistance when using the Hoyer lift for safety reasons. CNA 4 stated in her CNA school she was taught there needs to be two staff. CNA 4 stated she received a verbal in-service by the licensed nursing staff, the previous week on two person assistance with the Hoyer lift. During an interview with Licensed Vocational Nurse 7 (LVN 7) on April 5, 2018 at 8:20 a.m., she stated she was taught by the DSD to always use two staff when using the Hoyer lift. LVN 7 stated she reminds the CNAs to ask for assistance from another staff when using the Hoyer lift. During an interview with the Director of Nurses (DON) on April 5, 2018 at 10:15 a.m., she stated two staff should be used in using the Hoyer lift.