Every finding on record at Asbury Gardens NSG & Rehab

Based on observation, interview, and record review, the facility failed to provide a comfortable environment. This applies to 2 of 3 (R15 and R29) residents reviewed for environment in a sample of 23.The findings include:1. R15's MDS (Minimum Data Sheet) dated 12/08/2025 said she was cognitively intact. On 1/13/2026 at 10 AM, R15 was in her room wearing a shawl (clothing wrap) covering her upper body. R15 said she was upset because she was cold. R15 said the room's heating unit had not been working since 1/10/2026. R15's room felt cool, and the unit was unplugged. R15 said she reported it to the staff on duty on 1/10/2026, and V11 (Maintenance Assistant) came to assess it on 1/12/2026. R15 said the unit could not be fixed and no one had returned to reassess it. R15 said she was concerned because the weather was expected to get colder. R15's progress note dated 1/13/2026 (during the survey) said R15 was moved to another room due to the current room's heater not functioning properly. 2. R29's (R15's roommate) MDS dated [DATE] said she was severely cognitively impaired.On 1/13/2026 at 10:35 AM, R29 was severely cognitively impaired and nonverbal. R29 was unable to be interviewed regarding the room's heating unit and temperature. R29's progress note dated 1/13/2026 (during the survey) said R29 was moved to another room due to the [NAME] not working properly and requiring repair. On 1/14/2026 at 11 AM, V10 (Receptionist) said the nursing staff on duty notified her on 1/12/2026 at 3 PM that R15's heating unit was not working. V10 said she notified V11 (Maintenance Assistant) directly and did not make a work order. V10 said the reception staff enters maintenance work orders in the computer system, and then the maintenance department logs in the completed work. On 1/13/2026 at 11:15 AM, V11 (Maintenance Assistant) said V10 (Receptionist) notified him via telephone of R15's heater unit not working on 1/12/2026. V11 said he assessed the unit, and it was not working. V11 said he was unable to repair it and left it unplugged. V11 confirmed that no work order was completed. On 1/13/2026 at 11 AM, V9 (Maintenance Director) said he was not aware of R15's heating unit not working, and there was no active maintenance order. V9 assessed the unit, and it made a loud, muffled sound. V9 confirmed the unit's motor was not working, and the outside vendor would need to be notified for repair. V9 said the room felt cool and the temperature was around 71 Fahrenheit degrees. V9 said confirmed the forecasted weather was a drop in the temperature, and the residents (R15 and R29) would need to be moved to another room. V9 said residents' rooms needed proper operating heating units to ensure they can adjust the temperature to their comfort level. V9 said staff was expected to notify him of open work orders to ensure they were completed accordingly. The National Weather Service website said the current (11 AM-12 PM) temperature on 1/13/2026 was around 44 Fahrenheit degrees, and with a forecasted drop in temperature between 16-19 Fahrenheit degrees. The facility's policy titled Safe and Homelike Environment dated 2025, said the facility would provide a safe, clean, comfortable, and homelike environment to all residents in accordance with residents' rights. Including, ensuring Comfortable and safe temperature levels, meaning that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk for hypothermia/hyperthermia, and is comfortable for the resident. Temperature levels will be maintained if and when a resident prefers his or her room temperature be kept below 71 degrees Fahrenheit or above 81 degrees Fahrenheit, the facility will assess the safety of this practice on the resident and the resident's roommate.

Based on observation, interview, and record review, the facility failed to ensure a dependent resident received timely incontinence cares.This applies to 1 of 5 residents (R67) reviewed for activities of daily living.The findings include:On 1/13/2026 at 10:10 AM, R67 was in bed wearing a gown. R67 was severely confused and fidgeting in her bed. There was a strong foul urine smell in R67's room. R67 had incontinence products on the bedside table. On 1/13/2026 at 11 AM, R67 was still in bed. There was still a strong foul urine smell. V14 (Registered Nurse/RN) said it was difficult to provide incontinence care to R67 because she had the tendency to resist due to her severe dementia. V14 assessed R67's incontinence brief and said it was soiled with urine, and there was a strong foul odor. R67 had two cloth pads underneath her, and the top pad was soiled with a dark yellow stain. V14 said the pad's urine stain was dry. V14 said he was unsure when R67 was last provided with incontinence care.On 1/13/2026 at 11:20 AM, V12 (Certified Nurse Assistant/CNA) and V13 (CNA) said they were going to provide incontinence care to R67. V12 said she last provided incontinence care to R67 around 8 AM. V12 assessed the soiled cloth pad underneath R67 and said she believed it was not present prior, and it was now dry.R67's care plan said she was cognitively impaired and required assistance with her ADLs (Activities of Daily Living), including toileting. The care plan's interventions included for staff to provide total incontinence and hygiene care.On 1/14/2026 at 2:45 PM, V2 (Director of Nursing/DON) said she expected nursing staff to check at a minimum every two hours and as needed for incontinence care. V2 said R67 should have been provided with timely incontinence care. And, if needed, she should have been premedicated with her as-needed antianxiety medication to ensure staff could provide her basic toileting care needs.The facility's policy titled Incontinence care dated 05/2025, said all residents who are incontinent will receive appropriate treatment and services based on the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to follow physician orders for fluid management. This applies to 3 of 4 (R15, R29, R34) residents reviewed for nursing care services in a sample of 23.The findings include:1. On 1/14/2026 at 2 PM, R15 was in bed. R15's bilateral lower extremities were swollen with non-pitting edema. R15 said she had CHF (congestive heart failure), which caused her lower extremities to swell with fluid. R15 said her cardiologist was managing her condition and adjusted her diuretic as needed. R15 continued to say the nursing staff was to obtain her weight daily but recently it had not been done and was unsure why.On 1/16/2026 at 9:40 AM, V15 (RN) said R15's CHF management required her to be on a fluid restriction and for the nursing staff to monitor her weight daily as ordered. V15 said R15's weight had to be monitored closely to ensure she did not go into fluid overload. V15 said if a weight gain was identified, R15's cardiologist had to be notified and may require an adjustment of her diuretic medication or fluid restriction.R15's Order Summary Report showed multiple active orders for her CHF management, including Daily weight- Notify Md/NP if weight gain of 2-3 lbs. overnight or if weight gain >5 lbs. in 1 week every day shift for CHF.R15's care plan said she required management of her CHF condition, including monitoring weights as ordered.R15's Weights and Vitals Summary report for January 2026 showed no daily weight recording on 1/10/2026, 1/12/2026, and 1/13/2026.On 1/16/2026 at 10:30 AM, V2 (DON) said nursing staff was expected to follow CHF orders, including daily weights and the application of edema compression stocking to ensure the proper fluid monitoring and management of residents with the condition.2. On 1/13/2026 at 10:35 AM, R29 was sitting in her wheelchair. R29's lower extremities had generalized edema. R29 was wearing regular ankle socks and shoes.On 1/14/2026 at 12 PM, R29 was sitting in her wheelchair again. R29 was wearing regular ankle socks with slippers.On 1/16/2026 at 9:40 AM, R29 was again wearing regular ankle socks with slippers.On 1/16/2026 at 10:15 AM, V16 (RN) said R29 had chronic edema in her lower extremities related to her CHF and required the use of compression stockings to manage the swelling. V16 said R29 was dependent on the nursing staff apply her compression stockings. V16 said nurses were expected to follow physician's orders for applying compression stockings as ordered.R29's Order Summary Report showed an active order for Compression stockings, put on in the morning, take off at night for edema.R29's care plan said she required management of her CHF condition, including for the nursing staff to monitor for edema in her legs and feet.3. On 1/13/2026 at 10:35 AM, R34 was in her wheelchair. R34's lower extremities had generalized edema.On 1/16/2026 at 9:45 AM, V15 (RN) said R34 had CHF and required her weight to be monitored daily. V15 said nurses were responsible for obtaining daily weights and entering them into the EMR (Electronic Medical Record). V15 continued to say it was important to monitor for weight changes as ordered and ensure the physician was notified accordingly. V15 said that if needed, the physician could then adjust the residents' weight management plan to prevent further CHF complications.R34's Order Summary Report showed an active order for Daily Weight, Notify MD/NP if weight gain of 2-3 pounds overnight or 5 pounds in 5-7 days every day shift.R34's care plan said she required management of her CHF condition, including obtaining and monitoring weights as ordered.R34's Weights and Vitals Summary report for January 2026 showed no daily weight recording on 1/01/2026, 1/03/2026, 1/04/2026, 1/05/2026,1/08/2026, 1/10/2026, 1/11/2026, and 1/15/2026.The facility's policy titled Weight Monitoring, dated 5/01/2025, said the facility would monitor residents' weight status based on their comprehensive assessments. The gathering assessment information included the resident's general appearance, weight, fluid intake, fluid loss or retention, and laboratory/diagnostic data. Then the facility would develop an individualized care plan to address specific needs based on professional standards to maintain acceptable parameters of nutritional status.

Based on observation, interview, and record review the facility failed to ensure a resident was allowed family visitors for 1 of 3 residents (R1) reviewed for resident rights regarding visitation in the sample of 6.The findings include:R1's admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease and unspecified dementia. R1's annual resident assessment and care screening of 10/7/25 documents R1 has moderate cognitive impairment.On 1/10/26 at 9:40 AM, R1 said he has a blended family, he has 3 daughters, and his wife has a son and a daughter. R1 said there has been a lot of internal conflict. R1 said he has no problems with his daughters coming to visit with him. R1 said his stepson (V7) is his Power of Attorney (POA). R1 said V7 does not get along with his daughters and has blocked them from the phones and blocked them from visiting. R1 said there should not be any restrictions to any of his children visiting. 1/9/26 at 1:40 PM, V6 (R1's daughter) said on 1/3/26 she drove 3.5 hours to visit R1. Upon her arrival the staff asked her name, and she told them she was R1's daughter. The staff informed V6 she was on a list of people not allowed to visit per the POA. V6 said the staff called the police to have V6 removed, and when the police arrived the police said V6 was trespassing and the POA did not want her there. V6 said she then called V5 (Ombudsman) because there was no reason for the visit to be denied. On 1/9/26 at 8:30 AM, V5 said V5 was called on 1/3/26 by V6 stating the facility had called the police on V6 for attempting to visit her father (R1). V5 said there has been a dispute with the POA and the POA was denying visitation. V5 said the facility is under the impression there is no contact. V5 said there should not be any impasse, and it is a basic resident right. The facility has a responsibility to the resident to allow a visit. V5 said there should never have been a barrier to this visit.On 1/10/26 at 8:41 am a sign posted at the nurse's station read: As per R1 and (R1s wife) POA request, please restrict visitation of the following: V6 and V11 (daughter and son in law), V9 and V16 (daughter and son in law), V10 and V17 (daughter and son in law), and V18 (family). If they refuse to leave the premises, you may contact the police. -[NAME] Management.On 1/10/26 at 9:33 AM, V1 (Administrator) said R1 was alert and oriented to maybe 2 or 3, he does have his off days. He has been in the facility about 8 months. He said he has an interesting family. His stepson is the POA, and (R1) has 3 daughters. The family dynamics have spilled over since he has been here, and there is a lot of bad blood. (V7) does not get along with the daughters. Even so, the POA cannot restrict visits. (R1) can have anyone visit. V1 said the sign posted at the nurse's station reflects what V7 had requested, but it does need to come down. V1 said the sign should probably say to alert V1 or V2 Director of Nursing when the daughters arrive in the facility. On 1/10/26 at 11:50 AM, V15 (Receptionist) said on 1/3/26, she was working at the desk when V6 came in to visit. V6 said she was there to visit her father and refused to give her name. V15 said she informed V6 she was not able to see her father and reported to V12 (Registered Nurse). V15 said V12 informed V6 she was not able to see R1, and the police were called. When the police arrived, they were given the note at the nurse's station and the police told V6 she could not be there. V15 said there had been an incident a couple of months ago when the police had to be called on the family, and that is when the note went up stating the daughter was not allowed.On 1/10/26 at 1:00 PM, V12 said V6 had come in the facility over the summer and created a disturbance. V12 said, After that incident the paper was put up at the nurse's station that says these people can't come and see (R1), so we have to ask names. The daughter came in and said they were visiting and when asked her name, she said she was not telling me. So (V12) asked for her ID, and (V6) refused to do that also. She was asked to leave she said no. V12 said the note at the desk says to call the police, so she called the non-emergency police number. V12 said the POA has said to restrict visitation for these people.On 1/10/26 at 12:17 PM, V4 (Director of Operations) said she was on call 1/3/26 when the incident occurred. She spoke with V12 and was told V6 was at the facility demanding to see R1. The staff are under the understanding they were not to visit R1. V4 said it comes down to R1 and if he wants to visit. And R1 said he did want to visit V6. V4 said she feels the staff are knowledgeable on what to do, and does not know where the sign came from, the POA cannot deny visitation. On 1/10/26 at 1:06 pm, V7 said he has been R1's POA for 3-4 years. V7 said V6 has created issues and feels she should be the POA. V7 said V6 can come and visit as long as V6 is civil. V7 said he was unaware there had been any note posted. The facility's 3/25/25 policy for Resident Rights documents the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 5. Self-determination. D. The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner, that does not impose on the rights of another resident.

Based on interview and record review, the facility failed to safely transfer a resident.This failure resulted in R1 sustaining a right leg laceration requiring stitches when V4 (CNA/Certified Nursing Assistant) transferred R1 without a gait belt.This applies to 1 of 3 residents (R1) reviewed for resident injury in the sample of 3.The findings include:R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, epilepsy, asthma, aphasia, and cellulitis of right lower limb. R1's MDS (Minimum Data Set) dated October 9, 2025, showed R1 was cognitively intact. The MDS continued to show R1 required substantial/maximal assistance from facility staff for toileting hygiene and toilet transfers. R1's ADL (Activity of Daily Living) care plan dated October 5, 2023, showed, [R1] has a deficit in ADL self-care related to disease processes of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, epilepsy, history of TIA (Transient Ischemic Attack), osteoarthritis, and weakness. The care plan continued to show multiple interventions dated January 23, 2024, including, Toilet transfer: Resident requires substantial/maximal assistance of one staff member with the use of a gait belt for all transfers. On December 10, 2025, at 11:13 AM, R1 said a couple weeks ago she got a cut on her leg when a CNA was transferring her from the toilet to her wheelchair. R1 said the CNA did not use a gait belt and R1's leg got stuck on the wheelchair. R1 said she had to go to the hospital to get stitches on her leg. On December 10, 2025, at 11:49 AM, V4 said on November 24, 2025, V4 was transferring R1 from the toilet to her wheelchair. V4 said he was trying to move R1's wheelchair closer but he did not notice R1's foot was stuck where the leg rest goes on the wheelchair. V4 said he was not using a gait belt to transfer R1 and was holding onto R1's brief to transfer R1 from the toilet to the wheelchair. V4's statement dated November 25, 2025, showed, Assigned to [unit] on this evening, [another CNA] asked me to take [R1] off the toilet. I went to her bathroom, and she did not have a brief on. I had applied a new brief, and I asked her to stand up so I could wipe her. Then I pulled up her brief and she said she did not want her pants pulled up because she wanted to lay down. When I pulled up her brief, I tried to make her turn so she could sit down in the wheelchair behind her. When I tried to pull the wheelchair closer both wheels were locked, and the right foot was caught under the little tire and when she tried to sit down her right leg swung out in front of her and made it hit the frame of the wheelchair. After she was seated, I was going to put her in bed and that is when I noticed her leg was bleeding and notified the nurse. She came into the room and grabbed ADON (Assistant Director of Nursing). We're mostly able to transfer her independently but her foot was stuck and that what caused her to bump her leg. On December 10, 2025, at 12:10 PM, V5 (Rehab Director) said R1 was discharged from therapy on August 2, 2025, and therapy's recommendation was for R1 to be an assist of one facility staff member for toilet transfers. V5 said facility staff should use a gait belt when transferring R1 for R1's safety. On December 10, 2025, at 1:00 PM, V6 (R1's Doctor) said R1's leg laceration was caused by the improper transfer. V6 said facility staff should be following proper procedure and use a gait belt when transferring a resident. On December 10, 2025, at 3:28 PM, V2 (DON/Director of Nursing) said facility staff should use a gait belt when transferring a resident. V2 said R1's care plan and medical record showed facility staff were to use a gait belt when transferring R1. V2 said V4 should have used a gait belt when transferring R1 from the toilet to the wheelchair. The facility's final report dated November 28, 2025, completed by V3 (ADON) showed, Complete Description of Occurrence: [R1] has BIMS (Brief Mental Score) of 13, has diagnosis of right sided hemiplegia, aphasia following cerebral infarction, osteoarthritis, and unspecified thrombocytosis. On Monday evening about [4:30 PM], resident was assisted by a CNA (Certified Nursing Assistant) from the toilet, and when attempting to sit back into the wheelchair her right foot was caught in the small tire of the right side of the wheelchair causing her right lower leg to swing forward once she was seated in the chair and bump into the frame of the wheelchair. The aide observed the injury and summoned the nurse to the bathroom. First aid was rendered, and pressure was applied to right lower leg laceration. Resident reported complaints of discomfort and [Physician] notified. Order received to transfer resident to emergency room for further evaluation and treatment. POA (Power of Attorney) made aware of incident and order to transfer to the emergency room, per POA request [local hospital] is first hospital of choice. EMS (Emergency Medical Services) notified of bypass request to [local hospital] and resident was transferred to [local hospital] ER (Emergency Room). Resident returned to the facility approximately [10:30 PM]. The resident was assessed and returned with 10 sutures to right lower leg with physician order to remove sutures in 10 days. Investigation being conducted. Final Investigation: On 11/25/2025 around [4:15 PM], [R1] was assisted to the bathroom. This aide reported entering the bathroom, asked if she was ready and she nodded. He placed a new brief around her legs, and as he stood on her right side, she used her left arm to pull herself up from the bathroom grab bar. While she stood, he cleaned her from behind, was in the process of pulling up her brief and pants, while pulling up her brief, she was turned to face the wall, to sit back in her wheelchair and while her chair was locked, the aide attempted to pull the wheelchair closer behind her legs. She sat back into the wheelchair and her right foot was against the front tire of the wheelchair causing her right leg (which is contracted) to swing forward and land back onto the frame of the wheelchair where the leg rest had been removed. When the aide had unlocked her chair to pull her out of the bathroom, there was blood on her right lower leg. The nurse was summoned to the room, and first aid was rendered. Pressure was applied and [Physician] notified, order was received to transfer resident to emergency room for further evaluation and treatment. POA made aware. Resident was transferred to [local hospital] per the request of the POA, because it is her hospital of choice. Resident returned to facility at approximately [10:30 PM], while at the emergency room resident was administered an Tdap (Tetanus, Diphtheria, and Pertussis) vaccine, x-ray of the right tibia and fibula which showed no acute abnormalities and right lower leg laceration was closed with 10 sutures. An order was received to monitor site for signs/symptoms of infection and remove sutures in 10 days. Per staff interviews, resident participates with transfers despite right sided hemiplegia. Currently, [R1] has no changes in her ADLs from the laceration and propels self on unit. Upon completion of the investigation, it was determined transfers would now be two person assist to help guide the residual affected side post stroke. In addition, Restorative Nursing will assess transfer/safety needs. Plan of care has been updated; treatment and monitoring orders are in place for right leg laceration aftercare. Facility to remove sutures in 10 days as ordered. R1's emergency room medical records dated November 24, 2025, showed R1 went to the emergency room for a leg laceration which occurred while being transferred. The records continued to show R1's right leg laceration was 3 centimeters and required eight stitches. The facility's undated policy titled Use of Gait Belt showed Policy: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Policy Explanation and Compliance Guidelines: 1. Each nursing department employee will be given a gait belt during orientation. 2. All employees will receive education on the proper use of gait belt during orientation and annually. 3. It will be the responsibility of each employee to ensure they have it available for use at all times when at work.

Based on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with eating, personal hygiene and grooming. This applies to 4 of 5 residents (R16, R42, R50 and R51) reviewed for ADL (activities of daily living) in the sample of 15. The findings include: 1. R50 had multiple diagnoses including malignant neoplasm of the stomach, severe protein-calorie malnutrition, cerebral infarction and Barret's esophagus with low grade dysplasia, based on the face sheet. R50's significant change in status MDS (minimum data set) dated September 3, 2024 showed the resident was cognitively intact. The same MDS showed R50 required assistance from the staff with eating and personal hygiene. R50's active order summary report showed on August 27, 2024, the resident was admitted to hospice care due to malignant carcinoid tumor of the stomach. On November 12, 2024 at 10:40 AM, R50 was sitting in his wheelchair inside the main dining room. R50 had accumulation of long facial hair and his fingernails were long, jagged with black substances under some of the nails. R50 stated he needs the staff's assistance with shaving, and fingernails trimming and cleaning. On November 12, 2024 at 12:42 PM, R50 was sitting in his wheelchair, inside the main dining room. R50 was served regular textured meal consisting of lasagna, green beans and a garlic bread. R50 was also served a cup of coffee, a scoop of ice cream and a nutritional supplement in an open carton. R50's meal and drinks were untouched. At 1:00 PM, V12 (Licensed Practical Nurse) moved R50's wheelchair to allow another resident to pass behind him (R50), then placed R50 back to face his dining table. During time, R50's lunch meal and drinks remained untouched, but V12 did not encourage or cued resident to eat and/or drink. At 1:13 PM, V13 (CNA/Certified Nursing Assistant) asked R50 if he was done eating but did not attempt to encourage or cue the resident to eat, since R50's lunch meal and drinks remained untouched. During the same time, V14 (CNA) came and asked R50 if he was done eating. R50 responded yes then V14 started wheeling the resident away from his dining table towards the dining room door. At this time V14 was stopped and V2 (DON/Director of Nursing) was called by the surveyor. V2 was led to R50's dining table and shown the untouched meal and drinks of the resident. V2 poured the nutritional supplement from the carton into a cup and gave it to R50 and the resident drank 100% of the nutritional supplement. V2 placed R50 in-front of his table and started to cue and assisted the resident with feeding. With the assistance of V2, R50 took at least three bites of lasagna, two bites of green beans, one bite of the garlic bread, a few sips of the coffee, a few small bites of ice cream (vanilla and the blue ice cream) and consumed 100% of the 2% milk in a cup which was additionally given to the resident by V2. On November 13, 2024 at 9:08 AM, R50 was sitting in his wheelchair by the front lobby. R50 had accumulation of long facial hair and his fingernails were long, jagged with black substances under some of the nails. V3 (ADON/ Assistant Director of Nursing) was present during the observation and acknowledged R50's facial hair needs shaving and the resident needs nail care from the staff. R50's active care plan initiated on August 27, 2024 showed the resident has an ADL self-care performance deficit. 2. R51 had multiple diagnoses including dementia without behavioral disturbance, Parkinson's disease and need for assistance with personal care, based on the face sheet. R51's admission MDS dated [DATE] showed the resident was moderately impaired with cognition and required maximum assistance from the staff with personal hygiene. On November 12, 2024 at 10:21 AM, R51 was in bed, alert and verbally responsive. R51 had accumulation of long facial hair and his fingernails were long and jagged. R51 stated R51 wanted to have his fingernails trimmed and his facial hair shaved. V4 (CNA) was present and heard the request of R51. On November 13, 2024 at 9:10 AM, R51 was in bed, alert and verbally responsive. R51 had accumulation of long facial hair and his fingernails were long and jagged. V3 (ADON) was present during this observation and acknowledged R51's fingernails needed trimming and his facial hair needed shaving. According to V3, R51 needs the staff assistance with fingernails care and shaving to ensure grooming and hygiene. R51's active care plan initiated on October 16, 2024 showed the resident has an ADL self-care performance deficit and needs the staff assistance with ADLs. The same care plan showed multiple interventions including provision of assistance with personal hygiene. On November 13, 2024 at 2:50 PM, V2 (DON) stated it is part of the facility's nursing care and services to assist all residents needing assistance with ADLs including shaving/removal of unwanted facial hair and nail care. According to V2, all residents needing assistance with ADLs should be assisted by the staff to ensure and maintain the residents good hygiene and grooming. During the same interview, V2 stated based on her observation of R50 during the lunch meal on November 12, 2024, the resident needed a lot of cuing and assistance from the staff to eat and drink. According to V2, the staff should have provided cuing and assistance to R50 since his lunch meal and drinks were untouched to encourage and ensure the resident eat and drink to maintain and ensure nutrition and hydration. 36567 3. R16's diagnoses on face sheet included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, contracture, left hand. R16's quarterly MDS dated [DATE] showed that R16 was severely impaired in cognition and dependent on staff for personal hygiene. On November 12, 2024 at 11:13 AM, R16 was seated in a reclining chair in dining room and was feeding self with her right hand. Some of R16's nails on right hand appeared very long (about 1/2 inch) and/or jagged and most nails had blackish substance underneath the nails. R16's left arm was tucked under blanket and not visible. R16 was unable to respond adequately to queries. On November 12, 2024 at 8:41 AM, R16 was seated in the dining room after breakfast. R16's nails on right hand remained long with blackish substance underneath the nails. R16's left arm remained tucked under the blanket. V5 CNA (Certified Nursing Assistant) who was in the dining room was asked to remove the blanket from the left arm and R16's thumb finger was noted to have a very long nail. The other four fingers were curled into the fist and the nails were not visible and R16 would not open her fingers. V5 was notified about R16's long fingernails and V5 stated that she will take care of it. R16's POS (Physician Order Sheet) initiated June 25, 2024 included: Trim nails and keep it short. R16's care plan-initiated May 17, 2023 included that R16 has a deficit in ADL self-care performance related to diagnosis of Dementia, Anemia, Anxiety Disorder, Major Depressive Disorder, Glaucoma, and left hand contracture. Intervention for the same included that R16 is dependent on staff for personal hygiene. 41855 4. R42's EMR (Electronic Medical Record) showed R42 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease, major depression, periprosthetic fracture around internal prosthetic hip joint, subsequent encounter, hypertensive heart and chronic kidney disease with heart failure, generalized anxiety, muscle wasting and atrophy not elsewhere classified, and obstructive sleep apnea. R42 was admitted to hospice on October 5, 2024. R42's change of condition MDS (Minimum Data Set) dated October 15, 2024, showed R42 was cognitively impaired. R42 required substantial/maximal assistance for showering and personal hygiene. R42's care plan showed R42 was admitted to hospice care for diagnosis of Alzheimer's and is expected to have an overall unavoidable decline in function, nutrition, skin integrity, mood, and communication. Interventions included staff to adjust provisions of ADLs (Activities of Daily Living) to compensate for resident's changing abilities. R42's care plan showed R42 has a deficit in ADL self-care performance related to history of falling, osteoarthritis, pain, muscle wasting, and atrophy. Interventions showed R42 was dependent on staff for transfer to shower with mechanical lift and required substantial/maximal assistance for showering and personal hygiene. R42's shower sheets for the last two weeks provided by the facility on November 13 at 2: 30 PM, showed on October 30, 2024 there was no mention of nail care being provided. On November 4, 2024, there was no mention of nail care being provided. On November 6, 2024, there was no mention of nail care being provided. On November 11, 2024, showed R42 has scratches to the back of his left hand, on his left upper thigh, and a scab on his scalp. There was no mention of nail care being provided. On November 11, 2024, at 9:59 AM, R42 had whiskers on his cheeks and chin. R42 said he would like to be shaved. His nails were long and there was brown substance noted under them. On November 13, 2024, at 9:47 AM, R42 was in the small activity room asleep in his high backed chair with his head forward. There were whiskers still noted on his cheeks and chin and his nails were still long with brown substance under them. R42's hair has not been combed as evidenced by hair sticking up on top and sides and in the back the hair was parted and matted to his head with some hair going to the right and some hair going to the left. On November 13, 2024, at 12:20 PM, V2 (DON/Director of Nursing) said residents are offered two showers per week, per their schedule. R42's shower day is scheduled for Tuesday; day shift, and Friday; evening shift. The CNAs (Certified Nurse Assistant) will fill out the shower sheet and then the nurses must sign off on the sheets. On shower days the staff are to wash hair, do oral care, a skin assessment and notify the nurse if there are any issues, cut fingernails, if toenails are long, let nurse know so resident can get on podiatry list, and comb hair. Any refusal should be documented on the shower sheet. On a non-shower day, the CNAs should still be washing face and hands, grooming (oral care, shaving, and nail care) and any refusals should be documented. Facility provided their policy titled, [Name of the facility] Activities of Daily Living (ADLs) with a revision date of February 2024. The policy showed Care and services will be provided for the following activities of daily living: 1. Bathing and dressing, grooming and oral care 4. Eating to include meals and snacks Policy Explanation and Compliance Guidelines 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Facility provided their policy titled, [Name of the facility] Nail Care with a renewal/revision date of November 2023 showed, Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nail for grooming and health 3. Routine nail care and inspection of nails will be provided during ADL (Activity of Daily Living) care and on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises.

Based on observation, interview and record review, the facility failed to puree the maple glazed ham to pureed consistency for residents on pureed diets. This applies to 8 of 8 residents (R2, R3, R9, R23, R26, R45, R47, R159) reviewed for mechanically altered diets in the sample of 15. The findings include: On November 13, 2024 at around 10:50 AM, the pureed meal preparation of maple glazed baked ham done by V9 (Cook) was observed in the facility kitchen. V9 stated that she is preparing for 8 residents who are on pureed diets. The maple glazed baked ham was pre-sliced and still had the rind intact. V9 placed the sliced ham into the blender and added about a cup of [NAME] to the blender and pureed the mixture for about two minutes. V9 stated that she is adding the glaze for the flavor. V9 was seen opening the blender and testing the product during the process and then continued to puree the mixture. V9 then opened the lid and after tasting it. V9 stated that it was ready for service. The pureed product had small pieces of rind still visible in the mixture. On taste testing the product, the rinds were still intact and unable to be chewed and got stuck in the throat when swallowed. On November 13, 2024 at 10:55 AM, V10 (Dining Director) was notified that the pureed maple glazed baked ham was not safe to serve due to the presence of pieces of rind in it. V10 stated the pureed product should be like pudding consistency that can be swallowed without chewing. Facility 'Diet Type Report' printed on November 12, 2024 showed that R2, R3, R9, R23, R26, R45, R47 and R159 were on pureed consistency diets. Week at a glance menu (Week 1) included maple glazed baked ham for the lunch meal on November 13, 2024. Recipe for Pureed Maple Glazed Baked Ham included 'Place potion of prepared ham in food processor with hot broth and blend to a smooth consistency. Facility policy for Therapeutic Diets (issued September 1, 2021) included as follows: Guidelines: Mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician' or delegated registered or licensed dietitian's order. Facility policy for Liberalized Diets (issued September 1, 2021) included as follows: Guidelines: 5. e. Pureed -Regular diet that is processed to a smooth, mashed potato or pudding consistency

Based on observation, interview, and record review, the facility failed to provide assistance with hearing aid placement for a resident who required assistance. This applies to 1 of 1 resident (R31) reviewed for assistance with hearing aids in the sample of 15. The findings include: R31's electronic medical record showed her to be a [AGE] year old female admitted to the facility on [DATE] with medical diagnoses that include Carpal Tunnel Syndrome of the right upper limb, Torticollis, Neuropathy, Poly-osteoarthritis, Pain in the right wrist, Weakness, and Need for assistance with personal care. R31's Activities of daily living (ADL) care plan dated December 9, 2023 showed the following [R31] has a deficit in ADL self-care performance related to Chronic Pain, Osteoarthritis, Bilateral artificial knee joints, difficulty in walking, need for assistance with personal care, weakness, poly-osteoarthritis, and Torticollis. [R31] requires the following assistance with ADLs: Upper body dressing: Partial/moderate Assistance. R31's Minimum Data Set (MDS) section GG showed R31 requires partial to moderate assistance with upper body dressing. R31's Hearing Aid Care Plan dated January 25, 2024 showed the following intervention: Assist the resident to put the hearing aid in place. On November 13, 2024 at 9:59 AM, during the resident council interview R31 was alert and oriented and stated she can't use her hearing aids unless someone puts them in. R31 stated she would ask, and no one would put her hearing aids in. R31 stated she got tired of asking, and she stopped asking because they would not do it. R31 stated the staff do not ask her if she wants help putting her hearing aids in. R31 did not have any hearing aids in her ears during the resident council interview and was having some difficulty hearing in the dining room where the resident council interview was being held. On November 13, 2024 at 12:08 PM, R31 was in her room and still did not have any hearing aids in her ear. R31 stated that the last time she had her hearing aids is when the ear doctor put them in, it was a while ago, and she wasn't sure of the date. R31 stated she is right handed and has carpal tunnel in the right arm and that is why she can't put the hearing aids in herself. R31 showed surveyor that she had her hearing aids. On November 13, 2024, at 12:11 PM V15 (Registered Nurse) stated she has taken care of R31 in the past and was taking care of her today, and she was not aware R31 was hard of hearing. Surveyor asked if she has seen resident with hearing aids in her ears. V15 said she has occasionally seen R31 with hearing aids in her ears. V15 stated the Certified Nursing Assistants (CNA) puts them in for the residents. V15 stated R31 has never asked V15 to put her hearing aids in. On November 13, 2024 at 12:13 PM, V16 (CNA) stated she is caring for R31 today and has been assigned to her a lot in the past. V16 stated she has never helped R31 put her hearing aids in. V16 stated it has been a while since she has seen R31 with her hearing aids in. On November 13, 2024, at 4:02 PM, R31 still had no hearing aids in her ears. R31 stated after surveyor left earlier in the day, the nurse came in and said she would put her hearing aids in, but she had to go pass a medication first. R31 stated she thinks it was around 2:00 PM. R31 stated V15 did not put her hearing aids in. R31 stated that the nurse also said she would let the morning shift know to put R31's hearing aids in for her. R31's Progress note written by V15 on November 13, 2024 at 5:37 PM showed the following: Nurse asked resident if she had her hearing aids in, resident stated no. Nurse asked why she did not have her hearing aids and resident replied because no one ever mentions it, or ask me if I want them put in. Explained to the resident that she needs to ask the staff and hit her call light any time help is needed with inserting hearing aids. On November 13, 2024 at 4:06 PM, V3 (Assistant Director of Nursing) residents who need assistance with putting on their hearing aids have orders to that effect and/or it is in their care plan. V3 stated she expects her staff to follow the care plan and assist residents who require assistance with putting on their hearing aids. V3 stated the nurse, or the CNA can assist the resident in putting their hearing aids in.

Based on observation, interview and record review the facility failed to assess and provide splint to a resident, to prevent further reduction in ROM (range of motion). This applies to 1 of 1 resident (R38) reviewed for range of motion in the sample of 15. The findings include: R38 was admitted to the facility on [DATE]. R38 had multiple diagnoses including spastic hemiplegia affecting left dominant side, mild dementia with other behavioral disturbance and contracture of left hand muscle, based on the face sheet. R38's significant change in status MDS (minimum data set) dated November 1, 2024 showed the resident was moderately impaired with cognition. The MDS showed R38 had functional limitation in ROM on one side of both upper and lower extremities. The same MDS showed R38 required maximum to total assistance from the staff with most of her ADLs. On November 12, 2024 at 10:11 AM, R38 was sitting in her wheelchair outside of her room. R38 had left arm and hand weakness. R38 was not able to move her left hand and/or open her left fingers. R38 had no splint or positioning device in place. According to R38 she does not use any splint or positioning device on her left hand. On November 13, 2024 at 8:58 AM, R38 was sitting in her wheelchair inside her room. R38 had left hand weakness and was not able to move her left hand and/or open her left fingers. R38 had no splint or positioning device in place. V3 (Assistant Director of Nursing) was present during the observation and stated R38 had left hand contracture. V3 was prompted to have the therapy department screen R38 to determine the need for a splint or positioning device on the resident's left hand. On November 13, 2024 at 11:56 AM, V11 (Occupational Therapist) stated she screened R38 morning per request of the facility. V11 stated based on the screening, R38 had left hand contracture which included all her left finger joints and the resident also had left elbow contracture. V11 stated the contracture were partially stretchable and because of this she had recommended for R38 to use a left hand roll at all times as tolerated and should be removed during ADL (activities of daily living) care to prevent further contracture/stiffness and or deformity and to prevent skin breakdown. According to V11, she also recommended for R38 to use a left elbow orthosis at least six hours during the day also to prevent further contracture/stiffness and or deformity and to prevent skin breakdown. R38's Occupational Therapy problem identification checklist created by V11 on November 13, 2024 showed the resident was, Developing loss in range of motion due to contracture. The checklist showed, Recommended left hand roll and left elbow orthosis.

Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents the total census was 64 residents. On [DATE] at 11:06 AM, V12 (Dietary Manager) 63 residents eat from the facility kitchen. On [DATE] starting at 10:13 AM, the facility kitchen was toured in the presence of V12 (Dietary Manager) and V13 (Dietary Manager-in-Training). The following was found: Walk-in refrigerator: 1. Two large bins of pre-cooked roast beef in silver bins, one tray stacked on top of the other, dated [DATE]. Both trays had tin foil on the top and was not sealed. The foil was broken with meat exposed in both containers. Drips of brown liquid were present on the tinfoil of the bottom tray. 2. Ten trays of fruits in small pre-portioned bowls. V13 said they were pears and strawberries and cream. None of the ten trays were labeled or dated. Dry Storage: 3. A 22-quart bin of brown sugar without a label or date. 4. A 27-pound box of maraschino cherries with five 4 pound 8 ounce containers inside. Three of the containers were sticky with red substance leaked on the outside and the bottom and top of the box. 5. A 6-pound 12 ounce can of pineapple tidbits with a large dent on the circulation rack for resident consumption. On [DATE] at 12:36 PM, V12 (Dietary Manager) said all foods need to be labeled and dated so residents do not get served expired foods. V12 said all foods need to be sealed to prevent contamination and/or cross-contamination. V12 said it is not okay to stack the silver food bins, one on top of the other, because of the risk of cross contamination from the contents of one pan spilling into the other. V12 said all dented food cans should be removed from circulation because of the risk of botulism. V12 said if food from a dented can is served to the residents, residents can get sick and/or the quality of the food can be affected. The facility's policy titled, Quick Resource Tool: Receiving issued [DATE] states, Standard: Safe food handling procedures for the time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. Guidelines: .4. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . The facility's policy titled, Quick Resource Tool: QRT Food Storage issued [DATE] states, Standard: . All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Guidelines: .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination .

Based on interview and record review, the facility failed to have a designated certified Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP). This affects all 64 residents in the facility. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/23/24 documents the total census was 64 residents. On 01/24/24 at 12:10 PM, V2 DON (Director of Nurses) said the facility no longer has an IP. V2 said she believed that the IP quit around the end of September 2023 and the facility has not hired anyone to fill the position since. V2 said she does some of the ICPC along with the facility's nurse consultant. V2 said she is not certified as an IP. On 01/25/24 at 09:42 AM, V19 (Nurse Consultant) said she did the screening, education, and offering of the flu and /covid-19 for the staff at the facility but she was not certified as an IP. The facility's Infection Preventionist policy (date 11/14/22) showed the facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. The facility will ensure the IP (Infection Preventionist) is qualified by education, training, experience or certification. The facility's Payroll Action form for V22 (Facility's former IP) showed her resignation date of 11/13/23.

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition. This applies to all residents residing in the facility, and all staff and visitors that come to the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/23/24 documents that the total census was 64 residents. On 1/23/24 at 10:59 AM, the hotbox electrical cord in the kitchen was observed frayed/damaged at both ends with wires exposed. The end of the cord that attached to the electrical plug was frayed, and the end of the cord that attached to the hot box was also frayed, exposing wires underneath at both ends. V12 (Dietary Manager) said she put in a work order about a month ago to V14 (Maintenance Director) to replace the hot box cord. On 1/24/24 at 10:36 AM, V14 (Maintenance Director) said the work order to replace the hotbox cord was never put in writing so he did not know when he was first told by V12 (Dietary Manager) that it needed to be replaced. V14 said he thought it was a few weeks ago when he was notified by V12 that the hotbox cord needed to be replaced. On 1/24/24 at 12:36 PM, V12 said she remembered telling V14 about the hot box cord issue around the beginning of December and the fraying had progressively gotten worse since then. V12 said the frayed cord is an electrical fire risk and potential harm of electrical shock if someone touched the exposed wires or tried to move the equipment without realizing it was damaged. The facility's policy titled, Electrical Safety Precautions Policy dated February 2023 states, Policy: To assure that all personnel are aware of electrical safety precautions to be followed when performing tasks associated with position responsibilities. Policy specifications: .7. Worn, cut, frayed, spliced, exposed, or burned power cords should be reported .18. All defective equipment, outlets, electrical cords, etc., should be tagged to prevent use by others .

Based on observation, interview and record review, the facility failed to ensure lint was removed from the facility's dryers, posing a fire hazard. This applies to all residents residing in the facility, all staff, and visitors that come to the facility. The findings include: On 01/24/24 at 10:26 AM, all four clothes dryers were observed with clothes in them and with lint on the screens, from about an eighth to a half inch thick. Each dryer had a front panel at the bottom of the dryer, and when removed, two piles of lint were noted inside each dryer. The sizes of the piles all ranged from six to eighteen inches across, four to six inches high, and three to six inches deep. V20 (Director of Housekeeping) said all the dryers were fire hazards because of the lint in them. V20 said the dryers are to be cleaned every two hours and he believed they had not been cleaned that day at all. The facility lint trap log showed that the lint traps had not been cleaned for the last two days, 1/23/24 and 1/24/24. The lint trap log starts at 6 AM and runs through 6 AM. As of 1/24/24 at 10:26 AM, the log showed last time the lint had been cleaned from the dryers was on 1/22/24 at 10 AM, two days earlier. The log also showed that no lint had been cleaned from the dryers on 1/12/24 & 1/15/24. The log showed that on the days that lint was cleaned from the dryers, it was only cleaned twice in the 24-hour day, on dates of 1/1/24 - 1/11/24, 1/13/24 - 1/14/24, 1/16/24 -1/22/24. On 01/24/24 at 01:43 PM, V14 (Maintenance Director) said lint should be clean after three loads and an accumulation of lint in a dryer is a fire hazard. V14 said the facility's policy is to clean after every three loads, then nightly and monthly with shop vac. The facility's dryer manual, Tumble Dryers 50-pound capacity 75 pound capacity (date April 2019) page 14 showed, to avoid fire and explosion, keep surrounding areas free of flammable and combustible products. Regularly clean the cylinder and exhaust tube should be cleaned periodically by competent maintenance personnel. Daily remove debris from lint screen filter and inside of filter compartment. The facility's Dryer Safety policy (no date) showed that the lint screen must be brushed and cleaned every 2 hours if not, the screen will become packed with lint. When this occurs, the warm air moving through the system is blocked, raising the temperature in the basket and causing a potentially dangerous situation (i.e., where one spark on lint can cause a fire).

Based on observation, interview and record review, the facility failed to maintain residents' dignity while transporting a resident to the shower room and while feeding residents. This applies to 5 of 5 residents (R33, R43, R54, R56 and R115) reviewed for resident rights in a sample of 25. The findings include: 1. On 1/23/24 at 9:16 AM, while signing in at the facility in the open reception area, V5 (CNA/Certified Nurse Aide) was heard yelling down the hallway saying, coming through, coming through. At the same time, V5 CNA and V6 CNA were observed pushing R115 in the shower chair from one hallway to the shower room in another hallway. R115's buttocks were exposed in the shower chair. The nursing station is opposite the shower room and there were about 10 residents in the hallway along with two staff at the nurse's station and the receptionist by the entrance. On 1/23/24 at 11:41 AM, V5 CNA said R115 had a large bowel movement in his room, and they had to give him a shower. V5 said they should not have transported R115 in the shower chair and they should have used a blanket to cover his back because his buttocks were exposed. V5 said they should have used a wheelchair instead of the shower chair. On 1/24/24 at 11:36 AM, V6 (CNA) said R115 had a bad bowel movement, and he needed to be cleaned up, so they used the shower chair to transport him to the shower to clean him up. V6 said they should have a sheet to cover his back so his buttocks would not be exposed. On 1/25/24 at 10:51 AM, V2 (DON/Director of Nursing) said it was not appropriate for staff to transfer R115 using the shower chair because his buttocks were exposed. 2. On 1/23/24 at 12:30 PM during dining observation, V7 CNA was observed feeding R43 and R54 at the same time in the dining room. V7 said both residents needed assistance with their meals. Observations were made from 12:30 PM to 12:50 PM. R43's MDS (Minimum Data Set) of 11/2/23 shows that R43's cognition is severely impaired and needs substantial/maximal assistance with eating. R54's MDS of 11/30/23 shows that R54's cognition is severely impaired. The facility's Promoting/Maintaining Resident Dignity policy (revised 2/2023) states that the facility is to protect and promote resident rights and treat each resident with respect and dignity. The facility's Promoting/Maintaining Resident Dignity during Mealtimes policy (revised 2/2023) states to feed only one resident at a time. 46003 3. On 1/23/24 at 12:15 PM, V17 (CNA) was observed feeding R33 and R56 at the same time. R33's Face Sheet showed diagnoses of Alzheimer's disease, chronic pain, dementia with behavioral disturbances, generalized anxiety disorder and a history of falling. R33's January 2024 physician orders for a general pureed textured diet with regular thin liquids and nutritional supplements three times per day. The care plan dated 1/4/24 stated R33 has a self-care performance deficit and requires substantial / maximal staff assistance with eating and is at risk for altered nutritional status. Interventions showed R33 should be observed for signs of pocketing, choking, coughing, drooling or holding food in her mouth. R56's Face Sheet showed diagnoses of senile degeneration of the brain, adult failure to thrive, and dysphagia (difficulty swallowing). R56's physician's orders include general pureed diet with nectar thick liquids. R56's care plan dated 12/9/23 states she has self-care performance deficit and is dependent on staff for eating. R56 is at risk for altered nutritional status and should be observed for pocketing, choking, coughing, drooling or holding food in her mouth. On 1/25/24 at 10:13 AM, V2 DON (Director of Nursing) stated CNAs should be feeding one person at a time so they can pay attention to each resident individually in a normal manner. V2 added that CNAs should notice how each resident is chewing, swallowing, and eating their food and should not be distracted from the resident they are assisting.

Based on observations, interviews, and record reviews, the facility failed to appropriately store and secure medications safely for 4 residents (R13, R19, R61, & R315) in a sample of 25. Findings include: 1. On 01/24/24 at 1:30 PM, R315's oxycodone 5mg medication punch card was observed with the #7 pill slot punched open and a pill inside. V15 (Nurse), who was said she did not know the facility's policy for when a control medication is punched open, but she would not discard the medication because it didn't hit the floor and if she were to discard the medication, she would have to get a second nurse and they may not be available. R315's EHR (Electronic Health Record) showed that she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including unilateral primary osteoarthritis of right knee. R315's physician's order dated 1/12/24 showed oxycodone HCl Oral Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for moderate-severe pain rated 4-6 2. On 01/24/24 at 1:30 PM, R19's Lorazepam 0.5mg medication punch card was observed with the #12 pill slot punched open, with tape over it and a pill inside. On 1/25/24 at 11:37 AM, R19's Lorazepam 0.5mg medication punch card was observed with the #3 pill slot punched opened with a pill inside. V2 DON (Director of Nurses) who was present at the time, said the medication needs to be disposed of. R19's EHR showed that she is an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including bilateral primary osteoarthritis of hip, and generalized anxiety disorder. R19 did not have an active order for the Lorazepam 0.5mg. R19's last order for Lorazepam 0.5mg was on 10/22/23 for lorazepam 0.5mg every 8 hrs. as needed for anxiety with and end date of 11/5/23. On 01/25/24 11:27 AM, V2 DON (Director of Nurses) said her expectations are that there is to be no taping closed of controlled medications. V2 said she told the nurses they need to get a second nurse to dispose of the medication. V2 said this is done to prevent drug diversion. On 1/24/23 at 1:42 PM, V11 (Nurse) said if a narcotic punch card is open, the pill should be discarded/wasted with another nurse. V11 said she would not tape it back up. V11 said she did not know the facility's policy. The facility's 3.3 Controlled Substances policy (date 12/2018) showed medications classified by the FDA as controlled substances have high abuse potential and may be subject to special handling storage and record keeping. All controlled substances will be dispensed in a tamper resistant container designed for easy counting of content. 44387 3. On 1/23/24 at 11:13 AM, R61 was resting in bed in her room. R61 had tube of Triamcinolone Acetonide 0.1% cream on her bedside table. On 1/24/24, at 11:34 AM, the Triamcinolone cream was still on R61's bedside table. On 1/25/24 at 10:05 AM, the Triamcinolone cream was still present on R61's bedside table. R61's POS (Physician Order Sheet) shows order for Triamcinolone Acetonide External Cream 0.1% apply to affected area topically every 12 hours as needed for rash with redness and itching. R61 did not have an order for medication to be stored in the resident room. 4. On 1/23/24 at 11:21 AM, R13 had a tube of Trolamine Salicylate 10% Arthritis pain relieving cream and a tube of Iodosorb Cadexomer Iodine gel tube on the cabinet in her room. At 11:32 AM, R13 said she uses the arthritis cream because she has arthritis but does not use the Iodosorb cream. On 1/24/24 at 11:35 AM, arthritis cream and the Iodosorb cream were on R13's cabinet. On 1/25/24 at 10:07 AM, both creams were still on R13's cabinet. Review of R13's current POS shows that there were no orders for Iodosorb or the Arthritis pain relieving cream and or to have medications stored in resident's room. On 1/25/24 at 10:49 AM, V2 (DON/Director of Nursing) said R13 and R61 do not have orders for medications to be stored in their rooms. The facility's Medication Storage policy (revised 2/2023) states to ensure all medications are stored in pharmacy and/or medication rooms, stored in locked compartments.

Based on interviews and record review, the facility failed to ensure a resident's code status was consistent throughout the medical record to accurately reflect a resident's end of life choice. This applies to 1 of 25 residents (R9) reviewed for advanced directives in a sample of 25. Findings include: R9's Face Sheet showed diagnoses of chronic atrial fibrillation, diabetes, hypertension, and history of venous thrombosis and embolism (blood clot). R9's MDS (Minimum Data Set) dated [DATE] shows R9 is cognitively intact. R9's advance directive care plan (initiated [DATE]) showed Pursuant to resident rights and the individual's desire to retain control and autonomy over their health care decisions, [R9] has executed/completed . POLST: Practitioner Order for Life-Sustaining Treatment. The Goal in the care plan (initiated [DATE]) showed [R9's] wishes for DNR status, as specified in their advance directive documents, will be honored and clearly delineated in the medical record, in compliance with state law. Interventions (initiated [DATE]) showed Inform caregivers of code status. R9 signed a POLST (Practitioner Order for Life-Sustaining Treatment) form on [DATE], selecting NO CPR- Do Not Attempt Resuscitation (DNR). R9's Active (Physician) Orders as of [DATE] showed a [DATE] order of Attempt Resuscitation/CPR . Farther down on the orders, it showed a [DATE] order that read DNR. Immediately below that order, another order showed a [DATE] order for Full treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, mechanical ventilation and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated. Further down is a [DATE] order that read POLST-Do Not Attempt Resuscitation/DNR. The banner at the top of R9's EMR (Electronic Medical Record) showed all the orders combined, showing Code Status: Attempt Resuscitation/CPR (selecting CPR means Full Treatment in Section B is selected). DNR. Full Treatment: Primary goal of sustaining life by medically indicated means. In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, mechanical ventilation and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated. POLST- Do Not Attempt Resuscitation/DNR. On [DATE] at 9:42 AM, V15 RN (Registered Nurse) caring for R9 stated a resident's code status can be located on the Medication Administration Record, doctors' orders, admission records or the banner at the top of the EMR. V15 stated R9's banner was confusing because the verbiage says two different things, stating R15 had two different orders and they needed to be clarified. On [DATE] at 10:03 AM, V10 CNA (Certified Nursing Assistant) the code status for residents is found in the EMR or by asking the nurse. On [DATE] at 10:08 AM, V17 CNA stated resident code status is in the EMR. V17 stated if she were confused by the code status, she would ask the nurse. On [DATE] at 10:13 AM, V2 D.O.N (Director of Nursing) stated staff look for resident's code status in the banner at the top of the EMR or the physician orders. V2 stated the previous order to attempt resuscitation should have been removed by the person updating the order. V2 verified R9's POLST says DNR, adding the two orders are confusing, and the resident's wishes should be honored. The facility policy Communication of Code Status dated ,d+[DATE] states It is the facility's policy to adhere to residents' rights to formulate advanced directives. In accordance with these rights, the facility will implement procedures to communicate a residents' code status to those individuals who need to know this information.

Based on observation, interview, and record review, the facility failed to implement a resident's pressure ulcer intervention in a timely manner. This applies to 1 of 7 residents (R53) reviewed for pressure ulcer in a sample of 25. The findings include: On 1/23/24 at 11:20 AM, R53 was in bed resting. No low air-loss mattress was present. On 1/24/24 at 11:45 AM, V3 (ADON/Assistant Director of Nursing) performed wound care treatments to R53's bilateral buttocks. V3 said that R53 had bilateral DTI (deep tissue injuries) to her buttocks. V3 stated wound rounds are done weekly with the nurse practitioner and R53's wounds were measured on Monday, 1/22/24. V3 stated R53's DTI had purplish discoloration, there was no drainage, and she had a skin tear to her left buttock. On 1/24/24 at 11:45 AM, no low-air loss mattress was present on R53's bed. On 1/25/24 at 12:42 PM, R53 was in her room eating her lunch. No low air-loss mattress was present. R53's EMR (Electronic Medical Records) showed diagnoses of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and type 2 diabetes mellitus with unspecified complication. R53's MDS (Minimum Data Set) of 11/6/23 shows R53 is at risk for developing pressure ulcers/injuries and she had MASD (Moisture Associated Skin Damage). R53's Weekly Skin Check of 12/21/23 shows that there was redness to R53's left gluteal fold. R53's Weekly Skin Check of 1/4/24 shows that there was redness to R53's coccyx area and excoriation to the left lower leg. R53's Weekly Skin Check of 1/18/24 shows that R53 had rashes, erythema to sacrum. R53's Weekly Wound Documentation (1/22/24) shows that R53 had DTI, the date acquired was 1/21/24, wound measurements to left buttocks showed length 2 cm, width 2 cm, depth 0 cm; wound measurement to right buttocks length 3cm, width 1cm, depth 0 cm; Peri- wound tissue with mild MASD. The special equipment/preventive measures for the DTI were Calazime Skin Protectant External paste, low air-loss mattress ordered 1/21/24 by hospice, arrived 1/24/24. On 1/25/24 at 2:06 PM, V21 (Hospice Clinical Director) said they were not notified until 1/23/24 (two days later) that R53 needed a low air-loss mattress, and they delivered the mattress on 1/24/24. On 1/25/24 at 1:35 PM, V3 (ADON) said R53's air loss mattress was ordered on 1/21/24 when the DTI was discovered, and air loss mattress came in yesterday (1/24/24). R53 was currently on the air loss mattress. On 1/25/24 at 1:44 PM, V2 (Director of Nursing) said R53 was just placed on the low air loss mattress about five minutes ago. Progress notes from wound care provider of 1/22/24 documents R53 has history of pressure wounds, and active problems of pressure-induced deep tissue damage of the right and left buttock. On 1/25/24 at 1:03 PM, V2 (DON/Director of Nursing), said they do weekly skin checks on R53 and that R53 has had the MASD on and off and has been treated with zinc oxide and A & D ointment since 9/27/23. V2 said that on 1/18/24, there was redness noted to R53's sacrum and on 1/21/24, DTI was discovered and R53 was seen by the nurse practitioner on 1/22/24. V2 said R53 was on hospice and on 1/25/24, there was an order for R53 to have an air loss mattress. V2 said the hospice provides the air loss mattress, and it usually gets to the facility within 24 hours once the order is placed. On 1/25/24 at 1:40 PM, V19 (Clinical Director/Consultant) said R53 was currently on the air loss mattress, hospice usually brings the mattress within 24 hours from when it is ordered. V19 said they could always order the low air loss mattress from another company, and it would arrive at the facility the same day or next day if the order came was placed at night. The facility's Pressure Injury Prevention and Management policy (revised 10/2022) states that the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.

Based on interview and record review, the facility failed follow up and document pharmacist recommendations made during the monthly medication review. This applies to 3 of 5 residents (R4, R12 and R26) reviewed for unnecessary medications in a sample of 25 residents. Findings include: 1. R4's medical history includes Chronic Pulmonary Obstructive Disease, Dementia, Peripheral Vascular Disease, Major Depressive disorder, and Hypertension. R4's progress notes from the pharmacist were reviewed for the prior twelve months. On 2/27/23, 3/20/23, 8/30/23 and 11/30/23 the pharmacist documented in the EMR (Electronic Medical Record). MMR (Monthly Mediation Review) completed: irregularity noted. See Consultant's report. No details regarding the irregularity were found in the R4's EMR. The facility did not provide any copies of the consultant reports or physician response to recommendations. 2. R12's medical history includes Chronic Respiratory failure, Dementia, Bipolar Disorder, Recurrent Depressive Disorder, Generalized Anxiety Disorder, Chronic Pain and History of falling. R12's progress notes from the pharmacist were reviewed for the prior twelve months. On 1/30/23, 2/6/23, and 5/22/23 the pharmacist documented progress note in the EMR stated MMR (Monthly Mediation Review) completed: irregularity noted. See Consultant's report. No details regarding the irregularity were found in the R12's EMR. The facility did not provide any copies of the consultant reports or physician response to recommendations. 3. R26's medical history includes Parkinson's Disease, Dementia, Major Depressive Disorder, Anxiety Disorder and History of Falling. R26's MMR (Monthly Medication Review) consultant report dated 10/13/23 post fall review recommendations - if antipsychotic therapy is necessary consider a non-dopamine antagonist. The facility did not provide the physician response to the recommendation made by the pharmacist. 1/25/24 at 4:25 PM, V2 DON (Director of Nursing) stated the pharmacist documents the MMR (Monthly Medication Review) was completed in each resident EMR (Electronic Medical Record). The pharmacist document is no irregularities were found or irregularities, see report. V2 stated the pharmacist recommendation reports come to her. V2 stated there is a form with all recommendations provided to the medical director and the medical director addresses concerns for him. V2 stated there are nursing recommendations and physician recommendations that they review themselves. If recommendations are related to psychotropic medications, they are sent to the psych services. V2 stated she sometimes get verbal orders from the physician or nurse practitioner. V2 stated the pharmacy recommendations are not scanned into the EMR. V2 stated she scans the recommendations back to the pharmacist, so he is aware of what has been addressed. The facility undated policy Medication Regime Review states the facility is responsible for ensuring that all clinical records are available for review. For facilities that utilize an eMAR (Electronic Medication Record) system, the consultant pharmacist's review will be in the eMAR system. The consultant pharmacist will document in the progress notes section if any recommendations are made, and the note will be electronically signed. The facility undated policy Distribution of Medication Regimen Review Report states the attending physician and /or medical director will document their review and response to the recommendations made by the consultant pharmacist directly on the medication regimen review report form or in the medical record. If the physician disagrees with the recommendations or no change is to be made, the physician must document the rational in the resident's medical record.

Based on observation, interview, and record review, the facility failed to provide thickened liquids as ordered by the Physician for a resident with aspiration precautions. This applies to 1 of 6 residents (R267) reviewed for diet texture in a sample of 25. The findings include: The EMR (Electronic Medical Record) showed R267 was admitted to the facility on [DATE], with multiple diagnoses which included cerebrovascular disease affecting the right dominant side and with right oropharyngeal dysphagia, pneumonia, chronic obstructive pulmonary disease, and asthma. R267's 1/22/2024 Minimum Data Set showed he was cognitively intact. R267's risk for altered nutritional status care plan dated 1/17/2024 showed multiple interventions including, Observed for document report PRN any s/sx of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in mouth, several attempts at swallowing, Refusing to eat, Appears concentered during meals .Provide, serve diet as ordered. R267's Order Summary Report showed a 1/18/2024 diet order for a general diet with pureed texture and nectar consistency liquids. On 1/23/2024 at 12:08 PM, R267 was in the dining room for lunch and started to cough while drinking a cup of coffee. V9 (Certified Nurse Assistant/CNA) said R267 had difficulty swallowing and he was supposed to receive thickened liquids and a pureed diet. V9 stirred and inspected R267's cup of coffee, which showed it was a thin consistency. V9 said she thought the thickener had not settled and moved the cup to the side. V9 then returned and removed the cup of coffee away from R267. V6 (CNA) provided R267 with a new cup of thickened coffee. V6 said she thickened R267's coffee to a honey-thick consistency. On 1/24/2024 at 3:56 PM, V8 (Speech Language Pathologist/SLP) said she was treating R267 for dysphagia and he had swallowing precautions. V8 said R267 had a history of lots of respiratory problems, including a previous tracheotomy. V8 said R267's diet was pureed with nectar thick liquids and if not received as ordered, he could aspirate. V8 said staff should have followed R267's diet on his meal ticket, which shows he should receive thickened liquids. On 1/25/2024 at 9:35 AM, V2 (Director of Nursing/DON) said she expects CNAs to read the resident's meal ticket and follow the ordered diet. V2 continued to say R267 should have been served the correct consistency of thickened liquids as ordered, and if not provided, he could aspirate, get pneumonia or sepsis, or die. The facility's policy, titled Swallowing Evaluation Protocol not dated, showed Policy Specifications: 1. The speech language pathologist will assess the resident for dysphagia and make recommendations to the physician for proper food consistency and fluid thickness. A physician's order is needed for food consistency changes .4. Appropriate information on safe swallow strategies for the resident is readily available to nursing and dining room staff. This information, provided to staff by the speech pathologist, will be included on the tray card or ticket or in an appropriate form available to staff.

Based on interview and record review, the facility failed to follow their policy to transfer a resident according to the resident's care plan. This applies to 1 of 3 residents reviewed for improper nursing care in the sample of 5. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, heart failure, dementia, anxiety, and falls. R1 was discharged from the facility on November 11, 2023. R1's MDS (Minimum Data Set) dated August 10, 2023, showed R1 had severe cognitive impairment. R1 required extensive assistance from two facility staff for transfers between surfaces. R1's ADL (Activity of Daily Living) care plan dated September 28, 2019, showed, [R1] requires extensive to total assist with ADL, non-ambulatory requiring total staff assist with transfers with [mechanical lift]. Has diagnosis of Parkinson's and dementia receiving hospice care. Potential for ROM (Range of Motion) decline due to immobility and use of [high back wheelchair]. Multiple interventions dated November 19, 2020, including, Transfer: [mechanical lift], extensive assistance, two plus persons physical assist. The care plan continued to show an intervention dated August 11, 2022, [Mechanical lift] for transfers. On November 20, 2023, at 1:03 PM, V3 (CNA/Certified Nursing Assistant) said V3 cared for R1 on November 4 and November 5, 2023. V3 said he transferred R1 multiple times during those shifts and each time he transferred R1 by himself and did not use the mechanical lift. V3 said V3 put his arms under R1's armpits and picked R1 up and pivoted R1 to the bed or the wheelchair. V3 said V3 knew R1 required a mechanical lift for transfer, but since R1 was so small V3 did a manual transfer by himself without the mechanical lift. On November 20, 2023, at 1:45 PM, V5 (CNA) said V5 cared for R1 on November 3, 2023. V5 said when V5 transferred R1 he used the mechanical lift by himself. V5 said V5 transferred R1 by himself because R1 was having a good day and V5 thought it would be safe to transfer R1 by himself. V5 said facility staff are always supposed to transfer residents with a mechanical lift with two staff members. On November 20, 2023, at 4:21 PM, V2 (DON/Director of Nursing) said V3 and V5 should have transferred R1 using the mechanical lift with two facility staff members present. Facility documentation showed an interview with V3 on November 10, 2023. The documentation showed V3 said, Got her up Saturday, she sat at the edge of bed. I put my arms crossed under the back of her. Lifter her up under her arms and turned her and placed her in the chair. He placed her in bed before he left for the day. Got her up and back to bed by himself. The documentation showed an interview with V5 on November 10, 2023. The documentation showed V5 cared for R1 on November 3, 2023, and V5 said, I use the [mechanical lift]. She wasn't fighting any that day. Did [mechanical lift] by myself. Put her to bed by myself. There was no redness or swelling.

Based on interview and record review, the facility failed to implement interventions to supervise a resident with identified risk for aspiration of food. This failure resulted in the choking death of R1. This applies to 1 of 5 residents (R1) reviewed for altered diets and supervision while eating, in the sample of 7. The findings include: According to the Progress Notes in the facility electronic medical record, R1 was admitted to the facility on (MONTH) 4, 2019 with [DIAGNOSES REDACTED]. Additionally, R1's most recent Brief Interview for Mental Status was done in (MONTH) of (YEAR) and showed a score of 3, significant cognitive and memory impairment. The facility incident investigation Reportable Form dated (MONTH) 9, 2019 shows R1 and R2 were seated at the lunch table at the beginning of lunch service, when R2 alerted staff that R1 was in distress. A staff member responded, starting [MEDICATION NAME] maneuver. R1 became unresponsive as the Nurse took over continuing [MEDICATION NAME] thrusts. The Nurse then attempted to obtain vital signs, finding no pulse or respirations. R1 did have a Do Not Resuscitate (DNR) order, so further Cardiopulmonary Resuscitation (CPR) was not done. On (MONTH) 13, 2019 at 9:52 am, V17 (Coroner's office) stated he worked on the autopsy of R1. V17 stated he found the throat packed with solid white meat. V17 went on to state R1 had a Zenker's diverticulum (a deformation of the esophagus which forms a pouch-like structure) that was also packed with solid food. Finally, V17 stated the autopsy report is not complete due to pending toxicology reports, but the preliminary Cause of Death is aspiration of food bolus. On (MONTH) 13, 2019 at 3:43pm, V13 (Speech therapist) stated she saw R1 in (MONTH) after staff at the supportive living facility reported R1 with coughing and choking during eating. V13 stated she did a bedside swallow exam and did observe coughing and choking in that exam so set up a video fluoroscopic swallow study. It was discovered at that exam that R1 had the Zenker's diverticulum. V13 further stated that R1 had difficulty swallowing that was partially relieved by alternating bites of food, chewing slowly, and then a sip of liquid. V13 stated she could do this with cueing. On (MONTH) 13, 2019 at 11:32 am, V10 (Medical Doctor - MD) stated he was familiar with R1 and was involved in the facility investigation of R1's death. V10 went on to explain R1 had lost weight due to not wanting to eat related to discomfort with the diverticulum in her throat and so taking only liquid diet. V10 stated also, R1's son did not want to allow corrective surgery for [REDACTED]. V10 stated as well, R1 was at high risk for choking. V10 stated the pureed diet was ordered for R1's comfort as she was then on hospice. On (MONTH) 12, 2019 at 2:30pm, V5 (Certified Nurse Assistant - CNA) stated she was familiar with R1 and that R1 had a pureed diet. She stated she was not informed of any special need to monitor R1 beyond any others. V5 stated on (MONTH) 9, 2019 she was serving lunch in the dining room and heard a resident (R2) call out, She's choking. V5 said she stopped what she was doing and heard R1 state, in a quiet voice, I need something to drink. V5 went on to state R1 reached for a cup on the table with non-thickened liquid and brought it up, then began turning blue very quickly and her lips became pale. V5 stated V6 (CNA) began doing [MEDICATION NAME] maneuver on V1. Additionally, V5 stated she saw a food plate next to R1 on the table containing regular (not pureed) food, a pork chop which had been cut up. On (MONTH) 12, 2019 at 2:05 pm, V4 (CNA) stated as she started serving food in the dining room, she heard, She is choking and when she turned saw V6 doing [MEDICATION NAME]. V4 stated she saw a plate with non-pureed pork chop on it. V4 went on to say she had seen R1 reach for other resident's food on at least 2 occasions before. V4 stated R1 had said she doesn't like her pureed food. V4 stated she has taken solid food from R1 on previous occasions. V4 stated she was not instructed to monitor beyond normal. On (MONTH) 12, 2019 at 2:40 pm, V6 stated she heard someone say, is she choking- it may have been V5. V6 further described that R1 had a cup with thin liquid in her hand and was turning color. I said, if she's choking, she shouldn't be drinking. V6 went on, she started doing [MEDICATION NAME] and we called for the Nurse (V11) who arrived very quickly and took over [MEDICATION NAME]. V6 stated as well she saw a regular diet plate next to R1 on the table. V6 stated also, she later went to the cook and said, Please tell me R1 wasn't given the wrong plate! V6 stated R2 (at the same table) might have put the food in front of R1 as she had shared her food at other times. V6 stated R1 could feed herself and staff did not assist her nor had staff been informed of any additional choking risk for R1. R2 was interviewed on (MONTH) 12, 2019 at 3:00 pm but remembered poorly what occurred at lunch on (MONTH) 9, 2019. On (MONTH) 13, 2019 at 12:02 pm, V11 stated she was just outside the dining room when a CNA called for her and started [MEDICATION NAME] as soon as she arrived and continued as they moved R1 from the dining room to the resident room. V11 stated a scant amount of food came out that was pork chop color. V11 stated as well, she saw only one plate on the table next to R1 with a regular diet on it. V11 stated she had been informed of R1 having a problem with choking and heard R1 had behavior of grabbing food from other resident's plates. On (MONTH) 12, 2019 at 10:48 am, V12 (Dietary server and supervisor) stated she was serving on (MONTH) 9 during lunch. V12 stated she remembered the meal ticket for R1 was still on the steam table shelf at the time of R1's choking incident and so she knew R1 had not yet received her pureed lunch. The physician's orders [REDACTED]. The Interim Care Plan (initial care plan started at admission to the facility) shows R1 is able feed herself. As well, the care plan shows R1 has a risk of aspiration and on (MONTH) 6, 2019, R1's tablemate shared solid food with R1. The intervention shown in the Interim Care plan was supervision and monitoring in the dining room and inform the tablemate's not to share. The Progress notes presented by the facility show that on (MONTH) 10, 2019, prior to admission to the facility, R1 was transferred to the hospital via emergency transport after a choking incident with change of color and loss of ability to speak.

Based on interview and record review the facility failed to supervise residents at high risk for falls, identify individulaized risks related to falls and implement interventions to reduce the risk and prevent avoidable injuries. This applies to 2 (R1 and R2) of 3 residents reviewed for accidents, supervision and injuries. This failure resulted in R1 sustaining two falls with significant injuries requiring hospitalization , sutures to the scalp and surgical repair of the left hip. The findings include: R1 was admitted to the facility on [DATE] with a left humeral fracture from a fall. R1 also has a medical history of [REDACTED]. R1's initial care plan dated 8/31/15 documents problems of ADL(activities of daily living) deficit related to the fractured arm. Fall risk was initiated on 9/4/15. The interventions were not individualized to R1's needs and the there were no identified risk factors. The interventions included, to put the call light in reach and observe the ability to use. R1 has dementia with a BIMS(brief interview for mental status) score of 3 of 15 showing her to be significantly cognitively impaired. The care plan also documents to review past information of falls and to determine root cause if possible. This is not evident in the interventions in the care plan. R1 was on antipsychotic medication, had dementia, and a UTI(urinary tract infection) and episodes of [DIAGNOSES REDACTED]. None of these were identified in R1's care plan for risk factors for falls. R1 sustained two falls in September 2015: 9/7/15 and 9/24/15. No injuries with these falls. On 9/7/15 chair and bed alarms were initiated as well as floor mats. No new interventions were added on 9/24/15. R1 sustained two falls with injury in October 2015. On 10/3/15 a CNA (Certified Nursing Assistant) took R1 to the bathroom, closed the door and told R1 to pull call light when done and left the room. CNA later returned and found R1 next to the bed on the floor bleeding from her head. R1 was transferred to the local hospital and received sutures to her head wound. On 11/25/15 at 1:15 PM, E2(DON, Director of Nursing) stated the CNA was new to the facility and should have been with her orientation partner at the time. E2 stated it was not appropriate action to leave R1 in the bathroom alone. On 10/13/15 R1 was documented to be in the dining room finishing breakfast while the staff nurse was passing medications and heard R1's chair alarm go off and R1 was on the floor. R1 sustained a fractured left femur and was sent to the local hospital for surgical repair and returned 10/17/15 to the facility. The only care plan update done at that time was staff inserviced to not leave resident alone in the bathroom. There were no new additional interventions added to R1's plan of care. On 11/3/15 Z1 (Physician) documented in the physician notes that R1 had multiple falls, hit her head and since that time has mentally declined. R1 was noted to be on an antipsychotic medication, Risperdal, started 9/21/15 at 0.75 mg at bedtime for dementia. On 10/9/15 the medication was decreased to 0.5 mg at 6:00 PM. R1's targeted behaviors for October 2015 were documented as depressed and restless. The facility also documents monitoring for side effects related to antipsychotics such as tremors and tardive dyskinesia (uncontrolled movements of lips and tongue) all month and is documented as none. The nursing notes dated 10/29/15 at 10:37 AM, documents R1 had drowsiness with slurred speech. At 10:38 AM, the nursing notes document R1 had intermittent tremors and protruding tongue. There is no documentation to show the physician was notified. There are multiple nursing notes from different nurses stating R1 was sleepy, lethargic or drowsy yet the risperdal was only held for 4 days in the month of October until R1's POA(Power of Attorney) requested it be discontinued due to increased confusion. On 10/9/15 the nursing notes triggered an automatic medication warning for Tramadol (pain medication), Risperdal (antipsychotic) and Donepezil (Alzheimer's-dementia medication) stating they may precipitate unexpected central nervous system toxicity including, tremors, gait instability and protruding tongue. R1's care plan under behavior problem and anxiety documents observe , document and report any adverse reactions such as unsteady gait, tardive dyskinesia(involuntary movements of lips or tongue), frequent falls, loss of appetite, weight loss or behavior symptoms not usual to the resident. These symptoms were documented but not reported. The undated facility fall policy documents the staff and physician will identify pertinent interventions to try and prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes cannot be identified, staff will try various interventions, based on the assessment and the nature of the fall until falling stops or reduces. This was not evident in the care plan for R1 or R2. 2. R2 has a medical history of [REDACTED]. R2 has a BIMS of 0/15 showing R2 is not cognitively intact. R2's MDS(Minimum Data Set) dated 9/17/15 shows R2 to need extensive assist from one person when ambulating and one person assist with transfers. R2 sustained two falls while in the facility one on 9/21/15 and one on 10/13/15. Both without significant injury. R2's care plan related to falls initiated on 4/13/15 and a target date of 12/27/15, documents multiple falls in April 2015 and one of the falls in October, 10/13/15. The interventions are not individualized to R2's needs as well as individualized risk factors for R2. All the intervention listed are dated 4/13/15 and one for 7/10/15 and 8/24/15. No new interventions were identified for the October 2015 falls and the plan of care was not updated. R2's care plan documents one of the interventions to be a bed and wheel chair alarm. The nursing notes dated 10/13/15 12:53 PM, documents R2 was heard yelling help from her room. Found on floor with her wheel chair on top of her. The chair pad alarm was on her chair and on but did not sound an alarm. 11/10/15 03:47 AM, R2 ambulated to nurses station crying and had a bowel movement all over her and the room, bed alarm did not sound. 11/18/15 at 7;21 PM, R2 noted to be self transferring to the bed x 1 and ambulating unassisted in the hall x 1 both times alarms were not activated. On 12/3/15 at 11:00 AM, E2 stated she was not aware of R2's alarms not working. E2 (DON) stated she does 24 hour checks on nursing notes but does not recall those multiple situations of alarms not working or not being activated. R2's care plan intervention under falls also documents to not leave R2 alone in her room in the wheelchair. dated 7/10/15. On 11/25/15 at 2:00 PM R2 was in her room in the wheelchair watching television. E3 (CNA) then came in and asked if she wanted to lay down. The call light was attached to the wheel chair although E3 stated she was mentally unable to use it. On 11/25/15 at 2:15 PM E3 stated they try to toilet R2 after meals and keep her busy with activities to prevent falls. E3 stated it was all of the CNA's and staff nurses responsibility to check and ensure the wheel chair and bed alarms are working. There is no specific protocol or policy to check the alarms.