Every finding on record at Baldwin Gardens Nursing Center

Based on observation, interview and record review, the facility failed to ensure food was prepared and served to meet individualized needs for one of three sampled residents (Resident 3) when: 1. Dietary cook (DC) failed to honor Residents 3's food dislikes and served Resident 3 turkey for lunch. 2. Licensed nurses did not verify Resident 3's food was correct prior to serving food to Resident 3. These deficient practices did not meet Residents 3's individual needs. It had the potential to impact Resident 3's nutritional intake. It made Resident 3 feel unsatisfied with the meal and caused Resident 3 not to want to eat the meal. During an observation on 6/23/2026 at 12:38 p.m., in Resident 3's room, Resident 3 was sitting at bedside staring at food tray. Food was untouched. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and left artificial knee joint (a prosthetic knee joint (or artificial knee) replaces a missing or damaged natural joint). During a review of Resident 3's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 6/2/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/5/2026, the MDS indicated Resident 3's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident 3 required set up assistance for eating. The MDS indicated Resident 3 required moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, shower/bathing, dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 3's Nutritional Screen, dated 6/2/2026, the Nutritional Screen indicated under food preferences, no chicken, turkey, eggs, and fish. During a review of Resident 3's dietary slip, dated 6/23/2026, the dietary slip indicated Resident 3's food dislikes were fish, chicken, eggs, and turkey. During a review of facility's menu, dated 6/23/2026, the menu indicated lunch meal was roast turkey, bread dressing, and broccoli with garlic. During a concurrent observation and interview on 6/23/2026 at 12:40 p.m. with Resident 3 in Resident 3's room, Resident 3 pushed away food tray. Resident 3 stated Resident 3 was not eating lunch today because Resident 3 did not like fish. Resident 3 stated this had happened before where Resident 3 received fish and Resident 3 did not like fish. Resident 3 stated Resident 3 would not eat the meal. Resident 3 took a bite out of the food and stated it was not fish it was chicken but Resident 3 was not going to eat it because Resident 3 did not like chicken. Resident 3 stated the chicken did not taste good. Resident 3 stated Resident 3 had told dietary staff Resident 3 did not like chicken, fish, and turkey and did not know why they continued to serve food Resident 3 did not like. Resident 3 stated he would prefer to eat something else or not eat at all. Resident 3 stated when this happened before, staff removed the meal tray and did not offer a food substitution. During an interview on 6/23/2026 at 12:46 p.m. with Director of Staff Development (DSD), DSD stated DSD provided Resident 3 with meal tray. DSD stated DSD did not check Resident 3's food dislikes before providing Resident 3 meal. DSD stated DSD was supposed to check food for the correct diet, texture and food dislikes. DSD stated Resident 3 did not receive fish, it was chicken and that was ok. During a concurrent observation and interview on 6/23/2026 at 12:48 p.m., in Resident 3's room, Resident 3 told DSD Resident 3 did not like chicken and would prefer a substitution meal. Resident 3 stated Resident 3 tasted the food and it did not taste good. DSD stated DSD checked the menu and it was not chicken and that it was turkey. DSD stated Resident 3 could eat the food because it was not fish or chicken. Resident 3 stated turkey was also one of Resident 3's disliked food choice. During an interview on 6/24/2026 at 2:12 p.m. with Dietary Supervisor (DS), DS stated on 6/23/2026 residents received turkey, bread stuffing and some vegetables for lunch. DS stated nursing staff notified DS Resident 3 received turkey for lunch and that was one of Resident 3's food dislikes. DS stated the dietary cook (DC) was responsible to check residents' dietary slip and to serve food according to residents' dietary slip. DS stated DC must check residents' diet, food texture, and honor food dislikes. DS stated DC was responsible to serve food to all residents according to their dietary slip and DC did not do it for Resident 3 because Resident 3 received turkey for lunch. DS stated all meals should be checked for accuracy and for residents' safety. DS stated when residents received food they do not like there was a risk for residents not to eat and could potentially cause weight loss. DS stated nursing staff was also responsible to check residents' food before delivering food trays to residents. During an interview on 6/24/2026 at 2:56 p.m. with DSD, DSD stated before passing food tray to a resident, staff must check if food diet, food consistency, and food allergy was correct. DSD stated licensed nurses and certified Nursing Assistants (CNA) were responsible to check residents' food tray before delivering to residents. DSD stated it was important to check food before delivering it to a resident because nursing staff must ensure food was safe to eat and to make sure the food was something a resident liked and would want to eat. DSD stated on 6/23/2026 resident received chicken and Resident 3 did not like chicken. DSD stated DSD should have checked the food served to Resident 3 and changed the meal before it was delivered to Resident 3 but DSD did not do that. During an interview on 6/24/2026 at 3:40 p.m. with the Director of Nursing (DON), the DON stated dietary staff were responsible to serve the correct meal to all residents. The DON stated licensed nursing staff and CNAs were responsible to check the food prior to delivering it to the residents. The DON stated licensed nurses and CNAs must check if residents receive the correct diet, the correct food consistency, and the correct diet likes and dislikes. The DON stated licensed nurses must check diet list and residents dietary slip and compare it to the food that was served to the resident. DON stated if there was an issue with the food it must be sent back to the kitchen to get it fixed. The DON stated it was important to serve residents the correct food so they can eat it. The DON stated if residents did not receive the correct food, residents would not eat it and would not receive the proper nutrition. During a review of facility's Policy and Procedure (P&P) titled, Nutrition Care, dated 2018, the P&P indicated all residents must be ordered a substitute food item when an item they dislike is on the menu. The P&P indicated substitutes must be foods of similar nutrition value.

Based on observation and interview, the facility did not provide a working call light to one of four sampled residents (Resident 3). This deficient practice had the potential to cause a delay or the inability in obtaining necessary care and services for Resident 3. During an observation on 6/23/2026 at 12:42 p.m., in Resident 3's room, Resident 3 pushed call light and call light outside of room did not light up and there was no audible sound. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and left artificial knee joint (replaces a missing or damaged natural joint). During a review of Resident 3's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 6/2/2026, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/5/2026, the MDS indicated Resident 3's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident required set up assistance for eating. The MDS indicated Resident 3 required moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, shower/bathing, dressing, putting on/taking off footwear, and personal hygiene During an interview on 6/23/2026 at 12:40 p.m. with Resident 3, Resident 3 stated Resident 3 needed assistance with the meal that was served. Resident 3 stated Resident 3 pushed call light to get assistance but no one showed up to help. Resident 3 stated this was not the first time Resident 3's call light was not answered. Resident 3 stated using a call light was the only way to ask for assistance if Resident 3 needed something and staff should check if they worked. Resident 3 stated it was important for Resident 3 to be able to receive the assistance Resident 3 required especially during an emergency. During an interview on 6/23/2026 at 12:53 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated CNAs were responsible to check residents call lights to see if they were working. CNA 1 stated CNAs must push call lights and make sure the call lights outside of residents' room lit up and that it made a noise. CNA 1 stated CNA 1 did not check if Resident 3's call light was working today because CNA 1 forgot but everyone that entered Resident 3's room was responsible to check call lights too. CNA 1 stated it was important for residents to have a working call light so they could use it in case of an emergency. During a concurrent observation and interview on 6/23/2026 at 12:57 p.m. with CNA 1 in Resident 3's room, CNA 1 pushed on call light and the call light outside of Resident 3's room did not light up and there was no audible sound. CNA 1 stated Resident 3's call light was not working and needed to be reported. CNA 1 stated not having a working call light put Resident 3 at risk of not receiving the attention and care that Resident 3 required. During an interview on 6/24/2026 at 2:56 p.m. with Director of Staff Development (DSD), DSD stated a call light was used by residents to request assistance. DSD stated when a call light was pushed it caused a light outside of resident room and at nurse's station to turn on and it caused an audible sound to go off. DSD stated it was important for all residents to have a working call light to use during an emergency because that would be the fastest way for a resident to get help. DSD stated maintenance was responsible to check residents call lights to make sure they were in working condition. DSD stated maintenance checked call lights once a week. DSD stated nursing staff was responsible to check if call lights were nearby and assessable to residents. During an interview on 6/24/2026 at 3:28 p.m. with Director of Nursing (DON), the DON stated a call light was a system used by residents to ask for assistance. The DON stated maintenance and nursing staff were responsible to check if call lights were working. The DON stated the DON expected staff to make sure call lights were connected correctly and in working condition by pushing the call light and making sure it turned on. The DON stated DON expected CNAs to check call lights on every shift and maintenance to check weekly. The DON stated it was important to make sure all call lights worked to keep residents safe. The DON stated it was important for residents to have a working call light to prevent falls or to assist residents if they are not feeling good. During a review of facility's Policy and Procedure (P&P) titled, Call Light, undated, the P&P indicated the purpose was to ensure timely response to the resident's request and needs. The P&P indicated staff would make sure call light was plugged in and functioning at all times.

Based on interview and record review, the facility failed to develop and implement an individualized care plan (a document that outlines a person's health needs and the care they require) for one out of three sampled residents (Resident 1) when: 1. Facility did not ensure a care plan was developed for Resident 1's diagnosis of rhabdomyolysis ([rhabdo] a life-threatening medical condition involving the rapid breakdown of damaged skeletal muscle). This deficient practice negatively affected Resident 1's care and created an immediate risk to Resident 1's health, safety, and quality of life. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included rhabdomyolysis and encephalopathy (brain disease that alters brain function or structure causing a declining ability to reason and concentrate, memory loss, personality change, seizures, and twitching). During a review of Resident 1's History and Physical Examination (H&P, physician clinical evaluation and examination of the resident), dated 4/24/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 1's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was intact. The MDS indicated Resident required set up assistance for eating. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, shower/bathing, upper body dressing, and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for lower body dressing and putting on/taking off footwear. During a review of Resident 1's electronic medical record, unable to locate Resident 1's care plan for Resident 1's diagnosis of rhabdomyolysis. During an interview on 6/23/2026 at 1:10 p.m. with Resident 1, Resident 1 stated Resident 1 was upset with the care that Resident 1 had received at the facility. Resident 1 stated Resident 1 suffered from muscle spasms due to Resident 1's diagnosis of rhabdomyolysis. Resident 1 stated the muscle spasm caused pain on Resident 1's bilateral lower extremities. Resident 1 stated nursing staff did not know how to care for a resident with Resident 1's diagnosis and felt that instead of getting better Resident 1 was getting worse. Resident 1 stated nursing staff should receive training on how to care for residents with a diagnosis of rhabdomyolysis. During an interview on 6/24/2026 at 1:18 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was in constant pain due to muscles spams on bilateral lower extremities. LVN 1 stated Resident 1 had a diagnosis that caused Resident 1 to have muscle spasms. LVN 1 stated LVN 1 was not familiar with Resident 1's diagnosis. LVN 1 stated LVN 1 had to research Resident 1's disease to know what it was. LVN 1 stated a care plan offered a plan of care for resident diagnoses and licensed nurses must practice the interventions in the care plan. During a concurrent interview and record review on 6/24/2026 at 1:26 p.m. with LVN 1, Resident 1's care plans were reviewed. The care plans indicated no care plan for the diagnosis of rhabdomyolysis was developed. LVN 1 stated LVN 1 was not aware that a care plan was not developed for rhabdomyolysis because LVN 1 did not check the care plans. LVN 1 stated Resident 1 required a care plan for the diagnosis of rhabdomyolysis because it would guide nurses to provide the best care for Resident 1 and specifically because the diagnosis was not a common diagnosis. LVN 1 stated without a care plan Resident 1 would not receive the proper care and treatment for the diagnosis of rhabdomyolysis. During an interview on 6/24/2026 at 1:40 pm with Minimum Data Set (MDS) Nurse (clinical leader who manages comprehensive patient assessments), MDS Nurse stated a care plan was a problem-solving interventions and goal setting to address residents' problems or conditions. MDS Nurse stated residents' diagnoses must be part of resident's care plans. MDS Nurse stated MDS Nurse did develop a care plan for Resident 1's diagnosis of rhabdomyolysis. During a concurrent interview and record review on 6/24/2026 at 1:50 p.m. with MDS Nurse, Resident 1's care plan was reviewed. The care plans indicated no care plan was developed for the diagnosis of rhabdomyolysis. MDS Nurse stated it was important to develop a care plan to monitor Resident 1's condition and to set new interventions as needed. MDS Nurse stated no care plan had the risk of Resident 1 not being properly monitored for the effect of interventions in place. During an interview on 6/24/2026 at 3:35 p.m. with Director of Nursing (DON), the DON stated a care plan was a plan of care for residents' problems, set of goals, and interventions for residents' problem or concerns. The DON stated residents' diagnoses were implemented in the care plan. The DON stated a care plan was specific to a diagnosis and not a list of diagnoses because interventions would be different according to residents' problem. The DON stated the risk of not having a care plan was a resident would not receive the proper intervention or receive the proper assessment that they require for their condition. During a review of facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 11/2025, the P&P indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychological and functional needs would be developed and implemented for each resident. The P&P indicated the comprehensive, person-centered care plan would:Include measurable objectives and timeframes.Incorporate identified problems areas.Incorporate risk factors associated with identified problems.Aid in preventing or reducing decline in the resident's functional status and/or functional levels.

Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) for one of one facility kitchen, as evidenced by:1.Ground turkey meat bag dated 5/15/25 was placed on top of an ice bag inside the kitchen freezer. 2.Ten (10) fruit cups inside the kitchen refrigerator were expired, dated 1/26/26.3. Fourteen (14) red pudding cups inside the kitchen refrigerator were expired, dated 1/26/26.4. [NAME] rice and [NAME] rice inside plastic containers had a best by date of 1/6/26 in the dry storage room. 5. Test strips to measure the concentration of the sanitizer solution inside the Red bucket had an expiration date of 11/1/24. These deficient practices had the potential for food borne illnesses.Findings: During initial kitchen observation and interview with the Director of Nutrition (DN) on 1/27/26 at 8:12 AM, a bag of ground turkey meat dated 5/15/25 was placed on top of an ice bag inside the kitchen freezer. The DN stated the ice machine inside the kitchen broke the night before so ice bags were purchased for residents' use until the ice machine was fixed. The DN stated the bag of ground turkey meat should not have been placed on top of the bag of ice because if the ice bag is not completely sealed, the ground turkey meat could contaminate the ice. The DN stated if contaminated ice is served to the residents it could potentially make them sick. During an observation and interview with the Kitchen [NAME] (C1) on 1/27/26 at 8:18 AM, C1 stated the ground turkey meat should not have been placed directly on top of an ice bag if the meat was raw, but since the meat was frozen then it was ok. During a concurrent observation and interview with C1 on 1/27/26 at 8:20 AM, C1 stated the ground turkey meat was dated 5/15/25 but since it was frozen, the meat could still be used. During the same observation and interview, C1 pointed out a separate date of 11/25/25 that was placed on the bottom of the ground turkey meat bag. C1 stated, I think that's when they opened it. This one has two dates; one is when it was received and the other one is when it was opened. But the date doesn't specify which date is which. C1 stated the ground turkey meat should not be inside the freezer and should have been discarded because it could possible be expired at this time. During a follow up interview with the DN on 1/27/26 at 8:23 AM, the DN stated if the ground turkey meat had no label indicating the use by date or best by date, the food item should be discarded to ensure it was safe to eat and not expired. The DN stated residents could get sick if given expired food, which had a potential to cause harm. During the same kitchen observation and interview with the DN and C1 on 1/27/26 at 8:27 AM, ten (10) fruit cups and fourteen (14) red pudding cups were inside the kitchen refrigerator with a label dated 1/26/26 indicating for today's (1/27/26) lunch. C1 stated the items were dated 1/26/26 because that was when they were made. The DN stated that according to the date on the labels, the food items were expired and should have been thrown away. The DN stated expired items should be discarded to ensure they were not given to the residents by accident causing the residents to get sick. During a concurrent observation and interview with the DN of the kitchen dry storage room on 1/27/26 at 8:33 AM, a plastic container of brown rice and a plastic container of [NAME] rice with a best by date of 1/6/26 was found. The DN stated both types of rice should be discarded since the rice could be expired. During an observation and interview with the facility's kitchen's Dishwasher (DW) on 1/27/26 at 8:37 AM, the DW used test strips to measure the concentration of the sanitizing solution inside the Red-Bucket with an expiration date of 11/1/24. The DW stated the DW was not aware the test strips were expired. The DW stated it was important to check the concentration of the sanitizing solution inside the red bucket to determine if it was effective to kill bacteria and germs. The DW stated if the solution was not accurately concentrated, bacteria could spread in the kitchen causing contamination and could spread to the residents' food resulting in illness if consumed. The DW stated the sanitizing solution was used on the kitchen countertops where the clean utensils and serving spoons were kept. During an interview with the Dietary Supervisor (DS) on 1/27/26 at 8:45 AM, the DS stated using a sanitizing solution to clean and disinfect the kitchen area and surfaces help prevent cross-contamination and ensure food preparation surfaces, cutting boards, and equipment do not transfer bacteria from raw to cooked foods. The DS stated if expired strips had been used to measure the concentration of the sanitizing solution in the red bucket, more than likely the reading was not accurate. The DS stated using an effective sanitizing solution was critical to eliminate bacteria and to prevent foodborne illnesses. The DS stated most residents at the facility had weak immune system and foodborne illnesses could result in severe illness or hospitalization of residents. During an observation and interview with C2 inside the kitchen on 1/28/26 at 12:15 PM, C2 used a wet towel from the red bucket that contained sanitizing solution to clean the food prep countertop and other kitchen areas. C2 stated the solution used to clean and disinfect the counter tops in the food prep area needed to be checked using non-expired test strips. C2 stated if the solution did not have enough/effective concentration to kill and disinfect germs and bacteria, it could potentially cause cross contamination to other areas of the kitchen. C2 stated if contaminated food was served to the residents, it would make the residents sick. During an interview with the Infection Prevention Nurse (IPN) on 1/28/26 at 1:32 PM, the IPN stated test strips should not be expired. The IPN stated if the testing strips were expired, the result would be inaccurate. The IPN stated using an expired test strip was not allowed because the areas that were cleaned with the sanitizing solution would not be disinfected properly. During an interview with the IPN on 1/28/26 at 1:34 PM, the IPN stated kitchen staff needed to ensure nothing in the kitchen was expired. The IPN stated the kitchen should not have any expired food primarily because residents were highly vulnerable and had low immune system. The IPN stated if residents consume expired food, it would be dangerous because expired food could cause foodborne illnesses. During a review of the facility's P&P titled, Food Receiving and Storage, reviewed 11/2024, the P&P indicated, Food shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date). Refrigerated foods should be labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During a review of the facility's P&P titled, Kitchen-Sanitation and Infection Control, reviewed 3/20/25, the P&P indicated, The food service area is maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils were cleaned and sanitized using heat or chemical sanitizing solutions. Service area wiping cloth should be cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration.

Based on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for four of eight sampled residents (Residents 1, 27, 43, and 61) by failing to: a. Cover the [NAME] Valve's (a device that controlled fluid flow in medical tubing) port, which had dry brown crust inside on Resident 1's gastrostomy tube (G-tube [GT], a surgical opening fitted with a device to allow feedings/medications to be administered directly to the stomach) and ensure Resident 1's abdominal binder (a wrap that kept the belly secure to stop G-tube pulling) did not have brown stains. b. Ensure the incentive spirometer (IS, a tool that helps lungs breathe better) mouthpiece was not placed on the flat top surface of the nightstand for Resident 27. c. Date the nasal cannula (NC, a small plastic tube that fits into the person's nostrils for providing supplemental oxygen) storage bag for Resident 43. d. Keep the Foley catheter (FC, a soft, plastic or rubber tube inserted into the bladder to drain urine) drainage bag off the floor for Resident 61. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Residents 1, 27, 43, and 61. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses including dysphasia (difficulty swallowing) and aphasia (difficulty speaking or writing) following cerebral infraction (a blood vessel blockage in the brain) and encounter for attention to gastrostomy. During a review of Resident 1's History and Physical (H&P) dated 12/14/2025, the H&P indicated Resident 1 could not make needs known and did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 12/10/2025, the MDS indicated Resident 1 had severely impaired cognition (ability to understand). The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none) on staff for oral hygiene, toilet hygiene, personal hygiene, shower and bathing, upper and lower body dressing and putting on/taking off footwear. During a review of Resident 1's untitled Care Plan (CP) initiated on 11/21/25, the CP indicated the resident will remain free of side effects of complications related to tube feeding. The CP intervention indicated abdominal binder to be worn at all times to prevent the resident from pulling out the GT. During an observation of Resident 1 on 1/28/26 at 8:37 AM in Resident 1's room, Resident 1's GT line was hanging on the side of the bed, the medication port had dry brown crust inside and was not covered with a cap. During a concurrent observation of Resident 1 on 1/28/26 at 8:38 AM, Resident 1's abdominal binder was observed with brown stains. During an observation and interview inside Resident 1s room with the Wound Care Nurse (WCN) on 1/28/2026 at 8:41 AM, the WCN stated Resident 1's GT port was crusty, dry and it should have a cap to cover it. The WCN stated if bacteria were present in the GT port area, it could cause an infection to Resident 1. The WCN stated the GT port was dirty and bacteria could grow. The WCN stated the facility staff do not want the residents to get sick and staff were supposed to prevent any type of infection by making sure everything was clean in the facility. During a concurrent observation and interview on 1/28/2026 at 9:09 AM with the WCN at Resident 1's bedside, the WCN stated Resident 1's abdominal binder was dirty with brown stains. The WCN stated the abdominal binder should be kept clean primarily to prevent infection at the stoma site (the opening where the tube enters the skin). The WCN stated a soiled or dirty binder acts as a breeding ground for bacteria causing irritation of the GT site or infection to Resident 1. The WCN stated keeping the abdominal binder clean was essential to prevent infections, skin breakdown and to protect Resident 1 from leakage of the GT formula or stomach contents. During an interview with the facility's Infection Prevention Nurse (IPN) on 1/28/2026 at 1:32 PM, the IPN stated the GT port should be covered with a cap to close the opening when not in use. The IPN stated the charge nurse who last gave Resident 1's medications should close the GT port with a cap. The IPN stated keeping the GT ports clean and covered was critical to prevent serious complications of infection. During a concurrent interview with the IPN on 1/28/26 at 1:35 PM, the IPN stated Resident 1's abdominal binder should be kept clean at all times and it was not acceptable to see old dry stains on the resident's abdominal binder. The IPN stated having a dirty abdominal binder could affect the dignity of the resident and also affect the skin condition of the GT site. During a review of the facility's Policies and Procedures (P&P) titled Enteral Feeding Supplies ([NAME] Valve), Sanitization of Reusable, revised 3/2015, the P&P indicated, The purpose of this procedure was to guide the proper sanitizing of reusable enteral feeding supplies (Lopez valve) and to cover/cap the Lopez valve port after use. During a review of the facility's P&P titled Gastrostomy/Jejunostomy Site Care revised 10/2025, the P&P indicated, The purpose of this procedure was to promote cleanliness and to protect the gastrostomy or jejunostomy sites from irritation, breakdown and infection. During a review of the facility's P&P titled Quality of Life revised 2/2020, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feelings of self-worth and self-esteem. b. During a review of Resident 27's AR, the AR indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (sudden decline in brain function caused by chemical imbalance in the body) and dementia (a progressive state of decline in mental abilities). During a review of Resident 27's History and Physical (H&P) dated 1/4/2026, the H&P indicated Resident 27 could make needs known but could not make medical decisions. During a review of Resident 27's MDS dated [DATE], the MDS indicated Resident 27 had severely impaired cognition (ability to understand). The MDS indicated Resident 27 required setup assistance with eating. The MDS indicated Resident 27 required moderate assistance (helper did less than half the effort) with oral hygiene, toilet hygiene, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 27 required maximal assistance (helper did more than half the effort) with showering/bathing. During a concurrent observation and interview on 1/27/2026 at 9:24 AM with Resident 27, the IS mouthpiece was placed on the flat top surface of the resident's nightstand. Resident 27 stated Resident 27 used the IS for breathing exercises daily. During an observation on 1/27/2026 at 12:38 PM, at Resident 27's bedside, the IS mouthpiece was placed on the flat top surface of the resident's nightstand. During a concurrent observation and interview on 1/28/2026 at 1:44 PM with the Infection Preventionist Nurse (IPN) at Resident 27's bedside, the IS mouthpiece was on the flat top surface of the resident's nightstand. The IPN stated Resident 27's IS mouthpiece should be placed in a bag to prevent infection. The IPN stated the licensed nurse was responsible for keeping the IS mouthpiece away from dirty surface. During an interview on 1/30/2026 at 8:46 AM with the Director of Nursing (DON), the DON stated Resident 27's IS mouthpiece should not be touching the top surface of the table or nightstand due to the risk of respiratory infection. The DON stated the IS mouthpiece should be stored in a plastic bag. The DON stated the licensed nurse should change and date the plastic bag every seven days and as needed. During a review of the facility's P&P titled Incentive Spirometer, revised 10/2024, the P&P indicated The incentive spirometer shall be stored in a designated plastic bag when not in use. c. During a review of Resident 43's AR, the AR indicated Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure with hypoxia (lungs could not get enough oxygen into the blood) and muscle weakness. During a review of Resident 43's H&P dated 9/20/2025, the H&P indicated Resident 43 had the capacity to understand and make decisions. During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 had moderately impaired cognition. The MDS indicated Resident 43 required maximal assistance with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 43 was dependent (helper did all the effort) on staff with toileting hygiene, showering/bathing, and bed-to-chair transferring. During a review of Resident 43's Order Summary Report (OSR) with active orders as of 1/28/2026, the OSR indicated Resident 43 had an order for continuous oxygen via nasal cannula (NC) for shortness of breath (SOB), starting on 1/6/2026. During an observation on 1/27/2026 at 10:11 AM at Resident 43's bedside, the NC storage bag was not dated. During an observation on 1/27/2026 at 12:43 PM at Resident 43's bedside, the NC storage bag was not dated. During a concurrent observation and interview on 1/28/2026 at 1:44 PM with the IPN at Resident 43's bedside, the NC storage bag was not dated. The IPN stated the designated certified nurse assistant (CNA) should date and change the NC storage bag every seven days or as needed to ensure the NC storage bag was not dirty for infection control. The IPN stated residents could get respiratory infection from contaminated items. During an interview with on 1/30/2026 at 8:46 AM with the DON, the DON stated the designated CNA should have dated the NC storage bag for infection control. During a review of the facility's P&P titled Oxygen Administration, revised 1/28/2026, the P&P indicated the NC storage plastic bag will be dated. d. During a review of Resident 61's AR, the AR indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract) and benign prostatic hyperplasia (BPH, the prostate gland was enlarged but not cancerous, which made it hard to urinate). During a review of Resident 61's H&P dated 1/27/2025, the H&P indicated Resident 61 had the capacity to understand and make decisions. During a review of Resident 61's OSR with active orders as of 1/28/2026, the OSR indicated Resident 61 had an order of FC for obstructive uropathy (urine flow was blocked), starting on 1/26/2026. During a review of Resident 61's Care Plan (CP) for FC initiated on 1/26/2026, the CP goal indicated Resident 61 would not show signs or symptoms of urinary infection. During an observation on 1/27/2026 at 9:40 AM at Resident 61's bedside, the FC drainage bag was touching the floor. During a concurrent interview and picture review on 1/28/2026 at 1:44 PM with the IPN, the picture dated 1/27/2026 at 9:44 AM was reviewed. The IPN stated the picture indicated the FC drainage bag was touching the floor. The IPN stated the FC drainage bag should not be touching the floor for infection control. The IPN stated there should be a basin holding the FC drainage bag. The IPN stated the floor was dirty and bacteria could get into the resident's urinary system causing infection. The IPN stated nursing staff (in general) was responsible for ensuring the FC drainage bag was not touching the floor. During an interview on 1/30/2026 at 8:46 AM with the DON, the DON stated all staff should ensure the FC drainage bag was not touching the floor throughout the shift for infection control. During a review of the facility's P&P titled Catheter Care, Urinary, revised 9/2024, the P&P indicated to keep the catheter drainage bag off the floor.

Based on observation, interview, and record review for one of three sampled residents (Resident 3), the facility failed to:a. Ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) was set accurately for Resident 3.b. Obtain a physician order for the use of LALM for Resident 3. These failures had the potential to impede healing and worsen Resident 3's wounds and cause further skin injuries. Findings:a. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's History and Physical (H&P) dated 6/28/2025, the H&P indicated Resident 3 did not have the capacity to make decisions. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 12/22/2025, the MDS indicated Resident 3 had severely impaired cognition (ability to understand). The MDS indicated Resident 3 was dependent (helper did all the effort) on staff with oral hygiene, toileting hygiene, showering/ bathing, personal hygiene, and transferring. The MDS further indicated Resident 3 had eight pressure ulcers and was using a pressure reducing device for bed. During a review of Resident 3's Monthly Weight Report (MWR) dated 1/1/2026, the MWR indicated Resident 3 weighed 134 pounds (lbs.- unit of measurement to measure body mass). During a review of Resident 3's untiled Care Plan (CP) for skin impairment dated 1/26/2026, the CP indicated Resident 3 had LALM for skin management and the CP goal indicated Resident 3 would be free from skin injury. During a review of Resident 3's Order Summary Report (OSR) with active orders as of 1/29/2026, the OSR indicated a physician's order for licensed staff to monitor the LALM function and setting every shift starting on 1/28/2026. During an observation on 1/27/2026 at 9:53 AM in Resident 3's room, Resident 3 was lying on a LALM. The LALM weight setting was set at 200 lbs. During an observation on 1/27/2026 at 12:40 PM in Resident 3's room, Resident 3 was lying on a LALM. The LALM weight setting was set at 200 lbs. During a concurrent review and interview on 1/29/2026 at 10:19 AM with the facility's Wound Care Nurse 1 (WCN1), the pictures taken dated 1/27/2026 at 9:54 AM and 12:40 PM were reviewed. The pictures indicated Resident 3's LALM setting was set at 200 lbs. WCN 1 stated the LALM setting in the pictures was not the appropriate LALM setting according to Resident 3's weight of 134 lbs. WCN 1 stated the LALM would help with wound healing and should be set up according to resident's weight or preference. WCN 1 stated the LALM was firm when the setting was high, and would lose its purpose. WCN 1 stated WCN 1 would check with the responsible party (RP)'s preference for non-alert residents (in general). WCN 1 stated if the RP preferred the LALM to be firmer with the higher setting, WCN 1 would educate the risk and benefit and document on the nursing progress note as needed. WCN 1 stated there was no documentation indicating RP 2 preferred to have Resident 3's LALM setting at 200 lbs. WCN 1 stated the licensed nurse should monitor the resident's weight and the setting of LALM to ensure the resident's wound and skin integrity was not worsening. WCN 1 stated WCN1 checked the LALM setting during treatment. During an interview with the Director of Nursing (DON) on 1/30/2026 at 8:46 AM, the DON stated the LALM should be set according to the resident's weights when there was no documentation indicating the resident or the RP's preferences. During a review of the facility's Policy and Procedure (P&P), titled Specialty Mattress - Pressure Relieving Devices, revised on 1/2024, the P&P indicated staff were to follow the LALM manufacturer's user instructions for setup. During a review of Proactive medical products: Operator's Manual Item for Protekt Aire 4000DX/5000Dx, (undated), the LALM manual indicated the system was designed for prevention, treatment and management of pressure ulcers. The manual indicated to press the up or down buttons to select the correct patient weight. The manual indicated users could adjust air mattress to a desired firmness according to patient's weight or the suggestion for a health care professional. b. During a concurrent record review and interview on 1/29/2026 at 10:19 AM with WCN 1, Resident 3's OSR with active orders as of 1/29/2026, were reviewed. The OSR indicated a physician's order for licensed staff to monitor the LALM function and setting every shift starting on 1/28/2026. WCN 1 stated there should be a physician order for the use of LALM before 1/28/2026 for Resident 3. WCN 1 stated the admission nurse or WCN 1 should have obtained a LALM order before placing Resident 3 on the LALM. During an interview with the DON on 1/30/2026 at 8:46 AM, the DON stated the licensed nurse should have obtained the physician's order prior to starting the LAL, because it was the standard of nursing practice. The DON stated the licensed nurse should check the physician's order to ensure the order was current and active. During a concurrent record review and interview with the DON on 1/30/2026 at 12 PM, the facility's P&P titled Pressure Ulcers/Skin Breakdown -Clinical Protocol, revised on 11/2025, was reviewed. The DON stated the P&P indicated staff were to obtain the physician order for the use of LALM.

Based on interview and record review, the facility failed to obtain a signed Informed Consent (IC-ethical and legal process where a resident voluntarily confirms willingness for a procedure after being informed of relevant risks, benefits, and alternatives) from the resident's responsible party (RP) prior to the administration of Mirtazapine (medication used to treat depression [mood disorder causing persistent sadness]) 7.5 milligram (mg- unit of measurement), for one of one sampled resident (Resident 59). This deficient practice violated Resident 59 and the RP's right and had the potential for Resident 59 to receive medication against Resident 59 or Resident 59's RP's will. Findings: During a review of Resident 59's admission Record (AR), the AR indicated Resident 59 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung diseases that block airflow) and depression. During a review of Resident 59's History & Physical (H&P) dated 12/19/2025, the H&P indicated Resident 59 did not have the capacity to make medical decisions. During a record review of Resident 59's Order Summary (OS) dated with active orders as of 12/27/2025, the OS indicated for licensed staff to administer Mirtazapine 7.5mg, one time a day (QD), by mouth (PO), for depression manifested by (m/b) poor PO intake. During a review of Resident 59's Minimum Data Set (MDS, a resident assessment tool) dated 12/29/2025, the MDS indicated Resident 59 had severely impaired cognition (ability to understand and process thoughts) and was dependent on Activities of Daily Living (ADLs). During a review of Resident 59's Care Plan (CP) for antidepressant medication initiated on 12/29/2025, the CP indicated to educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of and to specify anti-depressant drugs being given. During a record review on 1/29/2026 at 12:27 p.m. of Resident 59's IC dated 12/19/2025, the IC for Mirtazapine 7.5 mg was not signed by Resident 59 nor Resident 59's RP. During a concurrent interview and record review on 1/30/2026 at 10:20 a.m. of Resident 59's IC, with Registered Nure 1 (RN 1), RN 1 stated the IC dated 12/19/2025 was signed with the Nurse's signature who received the order. RN 1 stated the Physician (MD) notifies the family and the family or resident or RP was required to sign the IC. RN 1 stated Resident 59's IC was not complete. During an interview on 1/30/2026 at 10:32 a.m. with the Director of Nursing (DON), the DON stated Resident 59's IC was not signed and the IC was not complete. The DON stated it was important to obtain a signed and complete IC so that the facility's licensed staff could administer medications. During a review of the facility's Policy and Procedure (P&P) titled, Informed Consent for Psychotherapeutic Medications, revised November 2025, the P&P indicated the Physician/Licensed Practitioner is responsible for obtaining informed consent for the use of psychotherapeutic drugs. The Physician or Licensed Practitioner shall examine the resident and obtain informed consent from the resident or the resident's representative.

Based on interview and record review, the facility failed to provide the notice of discharge to the Ombudsman (an advocate for residents of nursing homes) in a timely manner for one of one sampled resident (Resident 57). This deficient practice increased the risks of unsafe discharge and violation of Resident 57's rights.Findings: During a review of Resident 57's admission Record (AR), the AR indicated Resident 57 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (brain problem caused by body chemistry) and lack of coordination. During a review of Resident 57's Minimum Data Set (MDS, a resident assessment tool) dated 12/24/2025, the MDS indicated Resident 57 had severely impaired cognition (ability to understand). The MDS indicated Resident 57 was dependent (helper did all the effort) on staff with eating, oral hygiene, personal hygiene, toileting hygiene, showering/ bathing, and transferring. During a review of Resident 57's Physician Order (PO) dated 1/4/2026, the PO indicated to transfer Resident 57 to General Acute Care Hospital 2 (GACH 2) on 1/4/2026 for evaluation. During a review of Resident 57's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there was a change of condition among the residents) dated 1/4/2026, the SBAR indicated Resident 57 was transferred to GACH 2 for further evaluation on 1/4/2026 due to congestion and distress. During a review of Resident 57's Notice of Proposed Transfer/Discharge (NPTD) dated 1/4/2026, the NPTD indicated the copy of Resident 57's NPTD was provided to the Ombudsman on 1/13/2026. The NPTD indicated Resident 57's Responsible Party 1(RP 1) was notified on 1/4/2026. During a review of Resident 57's History and Physical (H&P) dated 1/19/2026, the H&P indicated Resident 57 did not have the capacity to understand and make decisions. During an interview on 1/29/2026 at 11:44 AM with Licensed Vocational Nurse 1(LVN 1), LVN 1 stated the social service department would fax the NPTD to the Ombudsman after transferring a resident. LVN 1 stated the purpose was to inform the Ombudsman that the facility transferred out the resident and where the resident was discharged . LVN 1 stated it was important to provide the NPTD to the Ombudsman in a timely manner because the Ombudsman needed to know the transfer reason. LVN 1 stated the Ombudsman protect the residents. LVN 1 stated the Ombudsman should be notified within a day of transfer because the resident sometimes return to the facility within the same day of transfer. LVN 1 stated, for Resident 57, it was late to notify the Ombudsman on 1/13/2026 when Resident 57 was transferred to GACH 2 on 1/4/2026. LVN 1 stated it affected the continuity of Resident 57's care. LVN 1 stated the licensed nurse, who transferred Resident 57 on 1/4/2026 should have faxed the NPTD to the Ombudsman on the day of transfer or the following day if the social service was not available during the weekend. During a concurrent interview and record review on 1/29/2026 at 12:29 PM with Social Service Director (SSD), Resident 57's NPTD dated 1/4/2026 was reviewed. Resident 57's NPTD indicated the copy was provided to the Ombudsman on 1/13/2026. The SSD stated the copy of Resident 57's NPTD was provided late to the Ombudsman on 1/13/2026. The SSD stated the SSD should have faxed the NPTD to the Ombudsman the following business day of the transfer. The SSD stated it was important to fax the NPTD to notify the Ombudsman of the resident's whereabout immediately. The SSD stated the Ombudsman was an advocate for the residents. During an interview on 1/30/2026 at 8:46 AM with the Director of Nursing (DON), the DON stated the SSD should fax the NPTD to the Ombudsman within 24 hours of transferring a resident because it was the regulation to notify the Ombudsman timely. The DON stated it violated the regulation when the NPTD was not faxed to the Ombudsman timely. The DON stated it was not acceptable to fax the NPTD to the Ombudsman on 1/13/2026 when Resident 57 was transferred to GACH 2 on 1/4/2026. During a review of the facility's Policy & Procedure (P&P) titled Transfer or discharge, facility-initiated, dated 2001, the P&P indicated the NPTD should be provided to the Ombudsman when practicable.

Based on observation, interview, and record review, the facility failed to complete a Significant Change - Minimum Data Set (MDS - a comprehensive assessment and care screening tool) assessment for one of one sampled resident (Resident 51). The resident was readmitted from the hospital with an indwelling catheter (a flexible tube that's put into your bladder to drain urine into an external bag).This failure had the potential to affect the accuracy of the resident's assessment, care planning, and monitoring of the resident's needs.Findings:During a review of Resident 51's admission Record, the admission record indicated Resident 66 was admitted to the facility on [DATE]. Resident 66's diagnoses included but are not limited to polyneuropathy, urinary tract infection (UTI- an infection in the bladder/urinary tract), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), depression (a serious mood disorder that causes persistent sadness and loss of interest in daily activities, affecting how a person thinks, feels, and behaves, and can lead to physical problems), obstructive and reflux uropathy (a blockage in your body that makes it difficult or impossible to pee), and anxiety disorder.During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 was cognitively intact. Resident 51's was dependent for toileting hygiene, lower body dressing, and chair/bed-to-chair transfer. The MDS indicated Resident 51 did not have an indwelling catheter.During a review of Resident 51's nursing progress notes, dated 05/14/2025, the progress notes indicated Resident 51 was sent to the hospital for abdominal pain.During a review of Resident 51's Admission/Readmission/ Initial Assessment, dated 5/17/2025, the Admission/readmission Initial Assessment indicated Resident 51 was readmitted to the facility from the hospital with an indwelling catheter.During a review of Resident 51's Physician's Orders, dated 5/18/2025, Resident 51 had an order for an indwelling catheter for obstructive uropathy (a blockage in the urinary tract that hinders urine flow, causing urine to back up and potentially damage the kidneys) from 5/18/2025 to 1/22/2026.During a review of Resident 51's Treatment Administration Record (TAR), dated May 2025, the TAR indicated to secure Resident 51's indwelling catheter and monitor the drainage for signs of infection.During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 had an indwelling catheter.During a review of Resident 51's medical records from May 2025 to January 2026, Resident 51's medical records did not indicate a Significant Change MDS was completed.During a concurrent interview and record review on 1/30/2026 at 9:12 a.m. with the MDS Coordinator, the RAI Manual, dated 10/2024 was reviewed. The RAI Manual indicated, a Significant Change Status Assessment (SCSA) is necessary when, it is determined that there has been a significant change (either improvement or decline) in a resident's condition from their baseline, the resident's condition is not expected to return to baseline within two weeks, and for a resident who frequently leaves and reenters the facility, and reentry is anticipated within the next 30 days. The MDS Coordinator stated, she thought a significant change MDS assessment was not completed for Resident 51 because the indwelling catheter did not impact Resident 51's activity of daily living. The MDS Coordinator stated, after reviewing the RAI Manual guidelines, a significant change in status assessment should have been made because Resident 51 came back with a significant condition that was a decline from the baseline.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2001, indicated, A significant change of condition is a major decline or improvement in the resident's status that:Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (in not self-limiting);Impacts more than one area of the resident's health status;Requires interdisciplinary review and/or revision to the care plan; andUltimately is based on the judgement of the clinical staff and guidelines outlined in the Resident Assessment Instrument.During a review of the facility's P&P titled, Resident Assessment Instrument, dated 2001, indicated, the Assessment Coordinator must ensure that the Interdisciplinary Assessment Team conducts timely resident assessments and reviews on the following schedule within 14 days of the resident's admission to the facility and when there has been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment and care screening too) reflected the presence of an indwelling urinary catheter for one of one sampled resident (Resident 51).This failure had the potential to negatively affect the resident's care planning and clinical decision-making.Findings:During a review of Resident 51's admission Record, the admission record indicated Resident 66 was admitted to the facility on [DATE]. Resident 66's diagnoses included but are not limited to polyneuropathy, urinary tract infection (UTI- an infection in the bladder/urinary tract), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), depression (a serious mood disorder that causes persistent sadness and loss of interest in daily activities, affecting how a person thinks, feels, and behaves, and can lead to physical problems), obstructive and reflux uropathy (a blockage in your body that makes it difficult or impossible to pee), and anxiety disorder.During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 was cognitively intact. Resident 51's was dependent for toileting hygiene, lower body dressing, and chair/bed-to-chair transfer. The MDS did not indicate the resident had an indwelling catheter.During a review of Resident 51's Physician's Orders, dated 5/18/2025, the Physician's Orders indicated the resident had an indwelling catheter from 5/18/2025 to 1/22/2026.During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 had an indwelling catheter.During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 had did not have indwelling catheter.During a review of the Admission/readmission Initial Assessment, dated 6/27/2025, the Admission/readmission Initial Assessment indicated that Resident 51 had an indwelling catheter present on assessment for obstructive uropathy (a condition in which the flow of urine is blocked).During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 had an indwelling catheter.During a concurrent interview and record review on 1/30/2026 at 9:12 a.m. with MDS Coordinator (MDS), Resident 51's Treatment Administration Record (TAR), dated June 2026 was reviewed. The TAR indicated, Resident 51 had an indwelling catheter on 6/24/2025. The MDS Coordinator stated that the MDS for 6/24/2025 for Resident 51 was not properly documented and no modification to the MDS was submitted or done.During a review of the of the facility's policy and procedure (P&P) titled, MDS Error Calculation, revised 9/2010, the P&P indicated if an error is found in a record that has already been accepted by the internet-based charting system, procedures must be implemented to either modify or deactivate the information in the system within 14 days from the discovery of the error.

Based on observation, interview, and record review, the facility failed to obtain a physician's order regarding the use of incentive spirometer (IS, a tool that helped lungs breathe better) for one of one sampled resident (Resident 27). This violation had the potential to compromise Resident 27's health and safety.Findings: During a review of Resident 27's admission Record (AR), the AR indicated Resident 27 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain problem caused by body chemistry, often linked to respiratory infection [an illness affecting breathing]) and dementia (a progressive state of decline in mental abilities). During a review of Resident 27's History and Physical (H&P) dated 1/4/2026, the H&P indicated Resident 27 could make needs known but could not make medical decisions. During a review of Resident 27's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 1/6/2026, the MDS indicated Resident 27 had severely impaired cognition (ability to understand). The MDS indicated Resident 27 required setup assistance with eating. The MDS indicated Resident 27 required moderate assistance (helper did less than half the effort) with oral hygiene, toilet hygiene, personal hygiene, and bed-to-chair transferring. The MDS indicated Resident 27 required maximal assistance (helper did more than half the effort) with showering/bathing. During a concurrent observation and interview on 1/27/2026 at 9:24 AM with Resident 27 at bedside, the IS mouthpiece was placed on the flat top surface of the nightstand. Resident 27 stated Resident 27 used the IS for breathing exercises daily. During an observation on 1/27/2026 at 12:38 PM at Resident 27's bedside, the IS mouthpiece was placed on the flat top surface of the nightstand. During a concurrent observation and interview on 1/28/2026 at 1:44 PM with the Infection Preventionist Nurse (IPN) at Resident 27's bedside, the IS mouthpiece was placed on the flat top surface of the nightstand. The IPN stated the IS was for Resident 27 to exercise breathing. During a concurrent interview and record review on 1/29/2026 at 3:35 PM with the IPN, Resident 27's active Order Summary Report (OSR) was reviewed. There was no physician's order for the use of IS. The IPN stated there should be a physician's order for the use of the IS prior to providing the IS to Resident 27. The IPN stated it was not acceptable to have the IS at Resident 27's bedside without a physician's order. The IPN stated the licensed nurse should follow up with the physician for the IS order for Resident 27. The IPN stated the licensed nurse should assess Resident 27 for any cough, respiratory distress, lung sounds, breathing, and oxygen saturation (the amount of oxygen in the blood). The IPN stated the licensed nurse should inform the physician about Resident 27's assessment and have the physician decide whether to continue the IS or not. During an interview on 1/30/2026 at 8:46 AM with the Director of Nursing (DON), the DON stated the licensed nurse should have obtained the physician's order prior to starting the IS treatment because it was the standard of nursing practice. The DON stated the licensed nurse should check the physician's order to ensure the order was current and active. During a review of the facility's Policy and Procedure (P&P) titled Incentive Spirometer, revised 10/2024, the P&P indicated to obtain a physician's order as needed for the IS. During a review of the facility's P&P titled Professional Standard of Care, revised 1/2025, the P&P indicated all employees should perform services in accordance with the accepted professional standard of care, ensuring competence, safety, and regulatory compliance.

Based on interview and record review, the facility Administrator (ADM) and Director of Nursing (DON) failed to report an injury of unknown origin (IUO- injury in which the cause cannot be determined due to lack of witnesses and resident injured unable to express how the injury occurred) to officials including the State Survey Agency (SSA) and adult protective services (APS), immediately, but no later than 24 hours, and according to the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating for one of two sampled residents (Resident 1). This failure had the potential for IUO to occur to other residents without appropriate reporting and investigation. Findings: During a review of Resident 1 ' s Admission Record (AR), the AR indicated the facility initially admitted Resident 1 on 3/7/2024 and was readmitted on [DATE] with diagnoses that included unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently) and generalized muscle weakness (weakness of muscles caused by lack of exercise, ageing, injury, or disease). During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 3/6/2025, the MDS indicated Resident 1 had severely impaired cognition (ability to think, remember, and function). The MDS indicated Resident 1 was dependent (helper does ALL the effort. Resident does none of the effort to completely the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear, and tub/shower transfers. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs, but provides less than half the effort) with upper body dressing, personal hygiene, rolling left and right (in bed), sitting to lying, sitting to standing, chair/bed-to-chair transfers, and walking 10 feet. During a review of Resident 1 ' s Resident Incident Investigation Report Form (RIIRM) dated 2/21/2025, the RIIRM indicated Resident 1 was, Suddenly noted a small skin discoloration under right lower eye. The RIIRM indicated Resident 1 was unable to communicate what happened. The RIIRM indicated the Resident 1 ' s right lower eye discoloration was, More than likely, self-inflicted by Resident 1. During a review of Resident 1 ' s situation-background-assessment-recommendation (SBAR- a written communication tool that helps provide essential, concise information, usually during crucial situations) Communication (SBAR) Form, dated 2/21/2025, timed at 1:03 pm, the SBAR form indicated licensed vocational nurse (LVN) 2 wrote Resident 1 was noted to have a self-inflicted small discoloration to right lower eye possibly upon striking (attempting to hit) out at staff. During an interview on 3/11/2025, timed at 3:25 pm, with LVN 2, LVN 2 stated 2/21/2025 between 9 am and 10 am, Resident 1 was agitated and trying to hit an unknown certified nurse assistant (CNA). LVN 2 stated Resident 1 attempted to hit and kick LVN 2 as well. LVN 2 stated Resident 1 was crying and rubbing Resident 1 ' s eyes, Aggressively. LVN 2 stated LVN 2 did not noticed any redness to Resident 1 ' s right eye that morning. LVN 2 stated Resident 1 stopped crying at some point after 12 pm, before LVN 2 ' s shift was over at 3 pm. LVN 2 stated the unknown CNA came up to LVN 2 and informed LVN 2 Resident 1 had redness under Resident 1 ' s right eye. LVN 2 stated LVN 2 did not know what caused the discoloration. LVN 2 stated LVN 2 did not actually know what happened to Resident 1 ' s right undereye because LVN 2 did not witness Resident 1 fall or hit anything. LVN 2 thought Resident 1 ' s right under eye discoloration happened due to rubbing Resident 1 ' s eyes, and was making an educated guess using LVN 2 ' s critical thinking skills. LVN 2 stated LVN 2 reported the incident to Resident 1 ' s sister and the DON. During a telephone interview on 3/11/2025, timed at 3:53 pm, with CNA 1, CNA 1 stated on 2/21/2025, Resident 1 was crying and rubbing Resident 1 ' s eyes a lot. CNA 1 stated around 11 am or 12 pm, CNA 1 went into to Resident 1 ' s room and noticed Resident 1 ' s right eye was red. CNA 1 stated CNA 1 did not witness Resident 1 fall or hit anything. CNA 1 stated CNA 1 report Resident 1 ' s right eye redness to LVN 2. During an interview on 3/11/2025, timed at 5:11 pm, with the DON, the DON stated on 2/21/2025, LVN 2 informed the DON Resident 1 had discoloration around the right eye. The DON stated the DON attempted to find out what happened when Resident 1 ' s sister visited Resident 1 that afternoon but Resident 1 could not answer. The DON stated they (the facility) did not know what happened to Resident 1 to cause the right eye discoloration unless it was caused by rubbing Resident 1 ' s eyes. The DON stated what happened to Resident 1 was an IUO. The DON stated IUO was supposed to be reported to the department of public health so it could be investigated for resident safety. The DON stated at the time of the interview, the DON was going to report the incident to the SSA, now, as well as local law enforcement, and the ombudsman. During an interview on 3/11/2025, timed at 5:40 pm, with the ADM, the ADM stated if staff identified a resident injury that was undetermined, it was supposed to be reported because it could be abuse. The ADM stated what happened to Resident 1 was an IUO, and should be reported to the ombudsman, department of public health, and local law enforcement. During a review of the P&P titled, Abuse Investigation and Reporting, revised 11/2024, the P&P indicated the facility promptly reports all resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. The P&P indicated an alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source [ .] will be reported immediately but not more than 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled bathrooms (Bathroom Room [BR] 1) had a functioning call light. This failure had the potential to result in residents being unable to notify staff for assistance. Findings: During a concurrent observation and interview on 12/17/2024 at 12:07 PM with Certified Nursing Assistant 1 (CNA 1) in BR 1, the call light button was observed to not stay on (pushed down) when pressed. CNA 1 stated the call light does not stay on and stated the risk of not having a working call light button was that the staff would not know if the resident would need help in the bathroom. During an interview on 12/17/2024 at 12:15 PM with the Maintenance Worker (MW), the MW stated the call light button was not staying in place when pushed down and stated if the call light does not work then the resident would not be able to call staff for assistance. During an interview on 12/18/2024 at 11:05 AM with the Director of Nursing (DON), the DON stated the call light button in the bathroom should stay on (down) when pushed. The DON stated if the call light was not working in BR 1 staff would not know if residents would need assistance. During a review of the facility's policy and procedure (P&P) titled Answering the Call Light, revised 10/2010, the P&P indicated staff to report defective call lights to the nurse supervisor promptly.

Based on observation, interview, and record review, the facility failed to attempt the use of appropriate alternatives to siderails before its installation for two of two sampled residents (Residents 9 and 39 ). These failures placed Residents 9 and 39 at risk for entrapment and injury from the use of siderails. Findings: a. During a review of Resident 39's Admission Records (AR), the AR indicated Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression (loss of pleasure or interest in activities for long periods of time) and compression fracture (occurs when one or more bones in the spine weaken and crumple) of first lumbar vertebrae. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool) dated 9/30/2024, the MDS indicated Resident 39 had intact cognition (ability to understand) and required partial/moderate assistance (helper did less than half the effort) with oral hygiene, upper body dressing and personal hygiene. Resident 39 required maximum assistance (helper did more than half the effort) with toileting, shower, and lower body dressing. During a review of Resident 39's Order Summary Report (OSR) dated 9/14/2024, the OSR indicated Resident 39 had an order for bilateral 1/4 side rails for bed mobility. During a concurrent observation and interview on 11/19/2024 at 10:18 am with Licensed Vocational Nurse 2 (LVN 2) inside Resident 39's room, Resident 39 was in bed, lying on his back with 1/4 siderails up on both sides of the bed. LVN 2 stated Resident 39 was alert and oriented. During a concurrent interview and record review on 11/20/2024 at 12:32 pm with Registered Nurse Supervisor (RNS), Resident 39's medical records (chart) and PointClickCare (PCC, a cloud-based software) were reviewed. The RNS stated there were no documented evidence that appropriate alternatives were attempted and did not meet the needs of Resident 39 before the siderails were installed. RNS stated other options appropriate for mobility for Resident 39 included the use of trapeze. RNS stated the facility should have tried other least restrictive appropriate options before the installation of siderails to prevent the risk of entrapment and injury to Resident 39. b. During a review of Resident 9's AR, the AR indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness on one side of the body). During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9 had severely impaired cognition and dependent (helper did all of the effort, resident did none of the effort to complete the activity) with oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 9 had an indwelling catheter (thin, sterile tube inserted into the bladder to drain urine into a bag outside the body). During a review of Resident 9's OSR dated 6/12/2024, the OSR indicated Resident 9 had an order for bilateral 1/4 siderails for bed mobility. During a concurrent observation and interview on 11/19/2024 at 10:25 am with LVN 2 inside Resident 9's room, Resident 9 was in bed, lying on his back with 1/4 siderails up on both sides of the bed. LVN 2 stated Resident 9 was confused. During a concurrent interview and record review on 11/20/2024 at 12:32 pm with RNS, Resident 9's medical records and PCC were reviewed. RNS stated, there were no documented evidence that appropriate alternatives were attempted and did not meet the needs of Resident 9 before the siderails were installed. RNS stated Resident 9 had contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of upper extremities and not able to use the siderails for turning and repositioning. RNS stated the facility should have tried other least restrictive appropriate options before the installation of siderails to prevent risk of entrapment and injury to Resident 9. During an interview on 11/21/2024 at 11:28 am with the facility's Director of Nursing (DON), the DON stated least restrictive alternatives should have been attempted and did not meet the resident's needs prior to installation and use of side rails for the safety of Residents 9 and 39. During a review of the facility's Policy and Procedure (P&P) titled, Bed Safety and Bed Rails, revised August 2022, the P&P indicated, The use of bed rails or side rails (including temporary raising the side rails for episodic use during care) is prohibited unless the criteria for use have been meet, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for three of four sampled residents (Residents 1, 26 and 36). These failures had the potential for complications related to tube feedings for Residents 1, 26 and 36. Findings: a. During a review of Resident 1's Admission Records (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included gastrostomy (a surgical opening fitted with a device to allow feedings/medication to be administered directly to the stomach), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness on one side of the body). During a review of Resident 1's untitled Care Plan (CP), dated 8/1/2022, the CP indicated Resident 1 had the potential for skin breakdown related to new G-tube stoma (the opening in the skin where the gastrostomy tube or G-tube is inserted into the stomach). The CP interventions included to provide G-tube stoma treatment as ordered, to cleanse the site with normal saline (NS), pat dry and apply a t-drain sponge (a pre-cut sponge that fits snugly around catheters, tubes and designed to keep moisture away from the site). During a review of Resident 1's Order Summary Report (OSR) dated 7/5/2023, the OSR indicated Resident 1 had an order for licensed staff to clean the gastrostomy site with NS, pat dry, and cover with T-drain dressing daily. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/22/2024, the MDS indicated Resident 1 had severely impaired cognition (ability to understand) and dependent (helper did all of the effort, resident did none of the effort to complete the activity) with eating, oral and toileting hygiene, shower, upper and lower body dressing and personal hygiene. The MDS indicated Resident 1 was on feeding tube for nutrition. During a concurrent observation and interview on 11/19/2024 at 10:02 am with Licensed Vocational Nurse 2 (LVN 2) inside Resident 1's room, Resident 1 was sitting in a reclining chair. Resident 1's skin around the G-tube stoma was red and the site was not covered. LVN 2 stated the G-tube stoma should be covered with a T-drain sponge dressing as ordered by the physician to minimize skin breakdown and prevent infection around the G-tube site. During an interview on 11/20/2024 at 10:39 am with the Treatment Nurse (TN), TN stated Resident 1's GT site and stoma would be cleansed with NS, pat dry, covered with T-drain sponge dressing and secured with a tape to prevent pulling and tugging. The TN stated GT site should be covered to absorb leaks or drainage around the GT site to prevent infection. During an interview on 11/21/2024 at 11:35 am with the Director of Nursing (DON), the DON stated, Resident 1's GT site/stoma needed to be covered with a T-drain sponge dressing to absorb drainage and prevent infection around the site. During a review of the facility's Policy and Procedure (P&P) titled, Gastrostomy/jejunostomy Site Care, revised 10/2022, the P&P indicated, Verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed. b. During a review of Resident 36's AR, the AR indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), gastrostomy, and dementia (a progressive state of decline in mental abilities). During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36 had severely impaired cognition and dependent with eating, oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 1 was on feeding tube for nutrition, During a concurrent observation and interview on 11/19/2024 at 10:12 am with LVN 2 inside Resident 36's room, Resident 36 was not in the room. Resident 36's GT tubing was hanging on the pole with the tubing end exposed and not covered. LVN 2 stated the GT tubing end should have a cap when not in use and not left exposed to prevent tubing contamination and cause infection to the resident. During an interview on 11/21/2024 at 11:35 am with the Director of Nursing (DON), the DON stated, all tubing/catheter ends needed to be capped when not in use or disconnected from the resident to prevent entry of bacteria on the port and cause infection to the resident. During a review of the facility's P&P titled, Enteral Feedings-Safety Precautions, revised 11/2024, the P&P indicated, Cap the feeding tubing when disconnected from the G-tube. 40037 c. During a review of Resident 26's AR, the AR indicated Resident 26 was admitted to the facility on [DATE], with diagnoses that included gastrostomy and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 26's MDS dated [DATE], the MDS indicated Resident 26 had unclear speech, sometimes understood others, and sometimes made self-understood. Resident 26 was dependent (helper does all the effort) in toileting hygiene and chair/bed-chair transfer. During a review of Resident 26's OSR dated 11/1/2024, the OSR indicated, Every shift continuous water via GT Administer 40ml/hr. (milliliter/hour) for 20 hours using enteral pump for a total of 800ml in 24 hours. On at 12 pm, off at 8 am or until total volume is complete. During an observation on 11/19/2024 at 12:48 pm, in Resident 26's room, Resident 26 was sitting up in bed having lunch. The enteral pump was at the bedside with 100 ml's of water left inside the water bag. There was no infusion of water at this time. During an observation on 11/19/2024 at 2:41 pm, in Resident 26's room, Resident 26 was in bed sleeping. The enteral pump was not started with the water infusion. During a concurrent interview, Licensed Vocational Nurse 3 (LVN 3) stated, LVN 3 turned the GT feeding pump off at 8 am and did not start the infusion of water afterwards. LVN 3 stated, LVN 3 did was not aware that Resident 26 had a physician's order for a water infusion at 40ml/hr. for 20 hours which should start at 12 pm. LVN 3 stated, per the physician's order, LVN 3 should start the water infusion at 40ml/hr. at 12 pm. LVN 3 stated, LVN 3 did not follow the physician's order for Resident 26. LVN 3 stated, it was important to provide water to Resident 26 to keep the resident hydrated to avoid electrolytes imbalance. LVN 3 stated, the nurse should review the physician's order and carry it out. During an interview with the Director of Nursing (DON) on 11/19/2024 at 2:52 pm, the DON stated, nurses should follow the physician's order to provide water at 40ml/hr. via the enteral pump for 20 hours for 24 hours. The DON stated, this was to prevent Resident 26 from dehydration (body loses more fluid than intake) and for resident safety and quality of care. A review of the facility's Policy and Procedure (P&P) titled Enteral Nutrition revised 11/2018, the P&P indicated Adequate nutritional support through enteral nutrition is provided to residents as ordered. The decision to continue or discontinue the use of the feeding tube is made through collaboration between the interdisciplinary team, the provider, and the resident. The nurse conforms that orders for enteral nutrition are complete including: instructions for flushing [solution, volume, frequency, timing and 24-hour volume.])

Based on observation, interview, and record review, the facility failed to ensure the residents had an environment free from accident hazards(risks) for two of five sampled residents (Residents 7 and 53) by failing to: a. Ensure Resident 7's bilateral 1/4 siderails were padded as ordered by the physician. b. Ensure Resident 53's floor mat (used to reduce fall related trauma if a patient gets up from bed, loses balance, and falls to the floor) was close to the bed and the resident's bed lowered at the lowest position. These failures had the potential to result in accidents and hazards for Residents 7 and 53. Findings: a. During a review of Resident 7's Admission Records (AR), the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc disorder with myelopathy (a condition where the spinal cord is compressed), spondylosis (age-related wear and tear of the spinal disks), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizure [sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking and loss of consciousness]). During a review of Resident 7's untitled Care Plan (CP) dated 2/20/2021, the CP indicated, Resident 7 had a seizure disorder. The CP interventions included for staff to apply bilateral padded side rails for seizure precautions. During a review of Resident 7's untitled CP dated 5/24/2021, the CP indicated Resident 7 had a potential for actual impairment to skin integrity. The CP interventions included for staff to pad the bed rails, wheelchair arms or any other source of potential injury. During a review of Resident 7's Order Summary Report (OSR) dated 1/25/2023, the OSR indicated Resident 7 had an order for padded side rails for seizure precautions. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 10/19/2024, the MDS indicated Resident 7 had severely impaired cognition (ability to understand) and dependent (helper did all of the effort, resident did none of the effort to complete the activity) with oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a concurrent observation on 11/19/2024 at 10:48 am inside Resident 7's room, Resident 7 was in bed, lying on her back with 1/4 siderails up on both sides of the bed. The siderails were not padded. During a interview on 11/20/2024 at 11:28 am with Licensed Vocational Nurse 1 (LVN 1) inside Resident 7's room, LVN 1 stated, Resident 7's siderails needed to be padded on both sides of the bed for resident's safety during seizure activity. During an interview on 11/21/2024 at 11:27 am with the facility's Director of Nursing (DON), the DON stated siderails were ordered for residents with seizure to prevent harm and injury during seizure activity. During a review of the facility's Policy and Procedure (P&P) titled, Bed Safety, revised December 2007, the P&P indicated, To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, siderails, headboard, footboard, and bed accessories), the facility shall identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.) 40037 b. During a review of Resident 53's Admission Record, the admission record indicated Resident 53 was admitted to the facility on [DATE], with diagnoses that included muscle weakness and lack of coordination. During a review of Resident 53's Admission/Readmission Initial Assessment, dated 10/25/2024, the Admission Assessment indicated, Resident 53's fall risk assessment score was 14. A total score of 10 or above represents a high risk for falls. During a review of Resident 53's Minimum Data Set (MDS, a resident assessment tool), dated 10/28/2024, the MDS indicated, Resident 53 had clear speech, rarely/never understood others, and rarely/never made self-understood. The MDS further indicated Resident 53 required substantial/maximal assistance (helper does more than half the effort) for toilet hygiene and chair/bed-to-chair transfer. During a review of Resident 53's Order Summary Report dated 11/1/2024, the Order Summary indicated, Low bed with gym mats as least restrictive measure due to fall risk. During an observation on 11/19/2024 at 9:46 am, while in Resident 53's room, Resident 53 was lying in bed awake. Resident 53's bed was in a high position and the floor mats were at each side of Resident 53's bed. The floor mat on the right side of Resident 53's bed was two feet away from the edge of the bed. During a continued observation and concurrent interview on 11/19/2024 at 10:12 am, in Resident 53's room, there was no change in Resident 53's bed position lever and floor mats. Licensed Vocational Nurse 3 (LVN 3) stated, Resident 53's bed was not at its lowest position and the right floor mat was too far away from Resident 53's bedside. LVN 3 stated, if Resident 53 fell on the right side, Resident 53 would not land on the floor mat. LVN 3 stated, Resident 53 was newly admitted to this facility and had a history of falls. LVN 3 stated, Resident 53's bed should be placed at the lowest position, and the floor mats should be placed close to Resident 53's bedside so Resident 53 could land on the floor mat to cause less of an impact on the body if there is a fall. LVN 3 stated, these measures were to prevent the resident from sustaining injuries after a fall. During a review of the facility's Policy and Procedure (P&P) titled Fall Risk Assessment, revised 11/2023, the P&P indicated The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents' (Residents 16 and 55) Minimum Data Set (MDS - a federally mandated resident assessment tool) reflected an accurate assessment, by failing to: a. Ensure Resident 16's discharge destination was coded correctly. Resident 16 was discharged to a Skilled Nursing Facility (SNF - care provided by trained registered nurses in a medical setting under a doctor's supervision) and was coded in the MDS assessment as being discharged to home or community. b. Ensure Resident 55's diagnosis was coded accurately. These deficient practices resulted in an inaccurate reporting to the Centers for Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) Services agency and had the potential for Residents 16 and 55 not to receive interventions to address their specific care concerns. Findings: a. During a review of Resident 16's Admission Record (AR), the AR indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) and muscle weakness. During a review of Resident 16's History and Physical (H&P), dated 2/23/2023, the H&P indicated Resident 16 did not have a diagnosis of PTSD. During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16 had active diagnosis of PTSD. During a review of Resident 16's MDS dated [DATE], the MDS indicated, Resident 16 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 16 was dependent (helper did all the effort and lifted or held trunk or limbs) to staff for oral/toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 16 had active diagnosis of PTSD. During a concurrent observation and interview on 11/19/2024 at 12:13 pm, Resident 16 was sitting on his wheelchair outside Resident 16's room. Resident 16 stated I do not have any trauma in the past. During an interview on 11/20/2024 at 2:04 pm, with the facility's Minimum Data Set Nurse (MDSN), the MDSN stated Resident 16 did not have any previous or active diagnosis of PTSD. The MDSN stated, she did not know why it was coded in the system and an error of the previous MDSN. The MDSN stated Resident 16's MDS assessment should have been coded accurately to give correct information to the Centers for Medicare and Medicaid services. b. During a review of Resident 55's AR, the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses that included essential hypertension (elevated blood pressure without a known cause) and anemia (decrease in the total amount of red blood cells in the blood). During a review of Resident 55's Physician's Order (PO) dated 9/10/2024, timed 11:25 am, the PO indicated to discharge Resident 55 to SNF with medications and personal belongings. During a review of Resident 55's Progress Notes (PN) dated 9/10/2024, timed 2:27 pm, the PN indicated Resident 55 was discharged to SNF with all personal belongings and medication. During a review of Resident 55's MDS dated [DATE], the MDS indicated Resident 55 was discharged to home/community. During an interview on 11/20/2024 at 11:47 pm, with the facility's Social Services Director (SSD), the SSD stated Resident 55 was discharge to SNF on 9/10/2024 and not to home or community. During a concurrent interview and record review of Resident 55's MDS dated [DATE] on 11/20/2024 at 12:52 pm, with the facility's MDSN, the MDSN stated Resident 55 was coded in the MDS as discharged to home/community. The MDSN stated, Resident 55 was discharged to SNF and not to home/community on 9/10/2024. The MDSN stated, Resident 55's MDS assessment needed to be coded discharged to SNF and not to home/community. The MDSN stated Resident 55's MDS assessment needed to be coded accurately to give accurate information to CMS. During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessments, dated 11/2019, P&P indicated the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducted timely and appropriate resident assessments and reviews according to the following requirements: OBRA required assessments conducted for all residents in the facility, such as initial assessment - conducted within fourteen days of th resident's admission to the facility and discharge assessment - conducted when an resident was discharged from the facility.

Based on interview and record review, the facility failed to provide information regarding Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents when individuals are not able to make their own healthcare decisions) for two of two sampled residents (Residents 11 and 25) in accordance with the facility's Policy and Procedure (P&P) titled Advance Directives. This failure had the potential for the facility staff to provide services and treatment against the residents' choices. Findings: a. During a review of Resident 11's Admission Record (AR), the AR indicated the facility admitted Resident 11 on 10/9/2021 and readmitted on [DATE] with diagnoses that included dependence on supplemental oxygen and gastrostomy (creation of an artificial external opening into the stomach for nutritional support) status. During a review of Resident 11's Minimum Data Set Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/9/2024, the MDS indicated Resident 11 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated, Resident 11 required total dependence (helper does all of the effort) with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent interview and record review of Resident 11's medical records (chart) on 11/19/2024 at 2:27 pm with Social Services Director (SSD), the SSD stated there was no Advance Directive Acknowledgement Form in Resident 11's chart. The SSD stated AD Acknowledgement form needed to be initiated and formulated upon Resident 11's admission. b. During a review of Resident 25's AR, the AR indicated the facility admitted Resident 25 on 2/6/2020 with diagnoses that included essential hypertension (elevated blood pressure without a known cause) and gastrostomy status. During a review of Resident 25's MDS dated [DATE], the MDS indicated Resident 25 had severely impaired cognition for daily decision making. The MDS indicated, Resident 25 required total dependence with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear and personal hygiene. During a concurrent interview and record review of Resident 25's chart on 11/19/2024 at 2:31 pm with SSD, the SSD stated there was no Advance Directive Acknowledgement Form in Resident 25's chart. The SSD stated AD Acknowledgement form needed to be initiated and formulated upon Resident 25's admission. During an interview on 11/19/2024 at 2:51 pm with the facility's Director of Nursing (DON), the DON stated the AD Acknowledgement form needed to be in the resident's chart for accessibility and to identify Resident 25's wants and wishes. During a review of the facility's P&P titled, Advance Directives, dated 11/2023, the P&P indicated upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate advance directive if he she chooses to do so. The P&P indicated prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The P&P indicated information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for four of four sampled residents (Residents 7, 9,12 and 23). These deficient practices had the potential for Residents 7, 9,12 and 23 not to receive necessary care or receive delayed services, placing the residents at risk for falls or injury. Findings: a. During a review of Resident 12's Admission Record (AR), the AR indicated Resident 12 was initially admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain) affecting left non-dominant side and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 12's Fall Risk Assessment (FRA - method of assessing a patient's likelihood of falling) dated 11/2/2022, the FRA indicated Resident 12 was assessed as high risk for fall due to intermittent confusion, unable to assess gait/balance and presence of predisposing disease condition. During a review of Resident 12's untitled Care Plan (CP) dated 4/11/2023, the Care Plan indicated Resident 12 was at risk for fall secondary to history of falls, impaired balance and recent cerebrovascular accident (CVA, blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel).The CP interventions indicated for nursing staff to keep the resident's call light within easy reach and encourage the resident to call for assistance. During a review of Resident 12's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/16/2024, the MDS indicated Resident 12 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 12 was dependent (helper did all the effort and lifted or held trunk or limbs) to staff for oral/toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During an observation on 11/19/2024 at 10:15 am, in Resident 12's room, Resident 12 was awake, lying in bed. Resident 12's call light was hanging on the left side rail of the bed. During a concurrent observation and interview on 11/19/2024 at 10:16 am, with the facility's Infection Prevention Nurse (IPN), the IPN stated, Resident 12 was unable to reach the call light because it was hanging on the left side rail. The IPN stated Resident 12's call light needed to be within reach for Resident 12 to use to call the staff if Resident 12 needed help in case of emergency or if the resident needed assistance from the facility staff. b. During a review of Resident 23's AR, the AR indicated Resident 23 was admitted to the facility on [DATE] with diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and lack of coordination. During a review of Resident 23's untitled CP dated 11/1/2024, the CP indicated Resident 23 was at risk for fall secondary to paraplegia. The CP interventions indicated for nursing staff to keep the resident's call light and bed controls within easy reach, answer the call light in a timely manner and encourage the resident to call for assistance. During a review of Resident 23's MDS dated [DATE], the MDS indicated Resident 23 had moderately impaired cognition for daily decision making. The MDS indicated Resident 23 was dependent to staff for oral/toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During an observation on 11/19/2024 at 10:01 am, in Resident 23's room, Resident 23 was awake and lying in bed. Resident 23's call light was hanging at the left side rail of the bed. Resident 23 stated, I cannot reach my call light. During a concurrent observation and interview on 11/19/2024 at 10:02 am, with the facility's IPN, the IPN stated Resident 23's call light needed to be within reach for Resident 23 to use to ask for help and assistance. During an interview on 11/19/2024 at 10:40 am with the facility's Director of Nursing (DON), the DON stated, the call light needed to be within reach for the residents to use so that staff could assist in a timely manner. 40438 c. During a review of Resident 7's AR, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc disorder with myelopathy (a condition where the spinal cord is compressed), spondylosis (age-related wear and tear of the spinal disks), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). During a review of Resident 7's untitled CP dated 8/11/2022, the CP indicated Resident 7 required to use bilateral (both sides) 1/4 partial padded bedside rail for seizure precautions. The CP interventions indicated to place the call light and frequently used items within reach and to answer call light promptly. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had severely impaired cognition and dependent with oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a concurrent observation and interview on 11/19/2024 at 10:48 am with Licensed Vocational Nurse 1 (LVN 1) inside Resident 7's room, Resident 7's call light was on the floor. LVN 1 stated Resident 7's call light should be placed close and next to the resident to use when assistance was needed. d. During a review of Resident 9's AR, the AR indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness on one side of the body). During a review of Resident 9's untitled CP dated 10/9/2023, the CP indicated Resident 9 was at risk for falls secondary to cerebrovascular accident (CVA, or stroke, caused by interrupted blood flow to the brain) with hemiplegia and hemiparesis. The CP interventions included to keep the resident's call light and bed controls within easy reach. During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9 had severely impaired cognition and dependent with oral and toileting hygiene, shower, upper and lower body dressing, and personal hygiene. During a concurrent observation and interview on 11/19/2024 at 10:25 am with LVN 2 inside Resident 9's room, Resident 9's call light was under the bed and the cord was tangled in between the bed and the siderails. LVN 2 stated Resident 9's call light should be placed within reach of the resident to be able to call staff when help was needed. During an interview on 11/21/2024 at 11:22 am with the Director of Nursing (DON), the DON stated, the resident's call light or pad sensor should be placed next to the resident's strong arm and hand so that the resident could call for assistance and staff could assist the resident timely. During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, dated 10/2010, the P&P indicated when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. The P&P indicated to answer the resident's call light as soon as possible.

Based on observation, interview, and record review, the facility failed to ensure the Low Air Loss (LAL) mattress (Alternating Pressure Mattress which provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure injury [PI- a localized damage to the skin and underlying soft tissue usually over a bony prominence]) was set up accurately based on the resident's weight for one of two sampled residents (Resident 10). This failure had the potential risk for Resident 10 to develop PI. Findings: During a review of Resident 10's Admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control). During a review of Resident 10's Order Summary Report (OSR) dated 11/1/2024, the OSR indicated Resident 10 had an order for LAL mattress for wound management. During a review of Resident 10's Weight Summary (WS), the WS indicated on 11/12/2024, Resident 10 weighed 162 lbs. During a review of Resident 10's quarterly Minimum Data Set (MDS, a resident assessment tool) dated 11/15/2024, the MDS indicated Resident 10 had clear speech, sometimes understood others, and sometimes made self-understood. The MDS indicated Resident 10 was dependent (helper does all of the effort) for toileting hygiene and chair/bed-chair transfer. During an observation and interview on 11/19/2024 at 10:33 am, in Resident 10's room, Resident 10 was lying in bed on a LAL mattress and the LAL mattress controller (model-Proactive 4000 series) had a weight indicator at 280 pounds (lbs.) During an observation and interview on 11/19/2024 at 2:41 pm, in Resident 10's room, Resident 10 was lying in bed sleeping. Resident 10's LAL mattress controller indicated 280 lbs. During a concurrent interview, Licensed Vocational Nurse 3 (LVN 3) stated, Resident 10's LAL was set at 280 lbs. and Resident 10's actual weight was 162 lbs. LVN 3 stated, Resident 10 was bed bound and had history of PI. LVN 3 stated, the LAL set up for Resident 10 should be based on Resident 10's weight for wound management to prevent recurrence of PI. During an interview on 11/20/2024 at 9:43 am with the facility's Treatment Nurse (TN), the TN stated, staff should set Resident 10's LAL mattress by weight per manufacturer's recommendation so that the mattress would alternate and provide proper relief of body's pressure points to prevent possible PI to Resident 10. During a review of the Proactive Operation Manual for Resident 10's LAL mattress, the manual indicated Users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from health care professional. During a review of the facility's Policy and Procedure (P&P) titled Support Surface Guidelines, revised 9/2013, the P&P indicated Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed.

Based on interview and record review, the facility failed to prevent a resident who was a high risk for falls, and needed one-on-one supervision (one staff supervising one resident) when up in a therapeutic recliner chair (an armchair with the capability to lower the back and raise the foot part) from falling and sustaining injuries by failing to: 1. Provide one-on-one supervision at all times while Resident 1 was lying in the therapeutic recliner chair as indicated in the resident's care plan for one of three sampled residents (Resident 1). Certified Nursing Assistant (CNA) 1 left Resident 1 unattended in the facility dining room while the resident was lying in the reclining chair. Resident 1 stood up and fell face down on the ground. This deficient practice required Resident 1 to be transferred to the general acute care hospital (GACH) where Resident 1 was admitted to the intensive care unit (a department of a hospital in which patients who are dangerously ill are kept under constant observation). Resident 1's injury resulted in small bilateral (both sides) frontal (front) lobe subarachnoid (the middle of three membranes that cover the central nervous system) hemorrhages (bleeding), a 5 millimeter (mm; unit of measurement) thick hemorrhage along the anterior falx (back of the eye), nasal (nose) bone fractures (break in a bone), opacified left maxillary [MEDICATION(S)] (swelling in the nose area) and left frontal (front of head) scalp swelling and hematoma (a pool of clotted blood in an organ, tissue, or body space, usually caused by a broken blood vessel). Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on [DATE], and readmitted to the facility on [DATE] with diagnoses that included traumatic (relating to physical injury) subdural hemorrhage (a collection of blood in the brain as a result of a severe head injury), bilateral [CONDITION(S)] (abnormal pressure in the eye that can cause blindness), [CONDITION(S)] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), [CONDITION(S)] (a type of dementia caused by brain damage with symptoms that included memory loss and difficulties with thinking, problem-solving or language), unsteadiness, and history of falls. A review of a handwritten care plan initiated on [DATE], indicated that Resident 1 constantly yelled and screamed for the resident's deceased mother and for people that were not there . and disturbed other residents. The care plan interventions included to get Resident 1 up in the wheelchair and place resident by the Nursing Station or the Dining Room with supervision and attempt a one-on-one with the resident. A review of Resident 1's record titled, Fall Risk Assessment, dated [DATE], indicated Resident 1 scored 14 (a score which indicated Resident 1 was a high risk for falls) indicating Resident 1 was a high risk for fall. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated [DATE], indicated Resident 1 had severe impairment in cognitive (ability to make decisions of daily living) skills, required extensive (staff providing weight-bearing support) two-persons plus physical assistance with transfer and walking in between locations within a room. The MDS indicated Resident 1 had impaired functional limitation in range of motion (the full movement potential of a joint, usually its range of flexion and extension) to both lower extremities (hips, knees, ankles, and feet). The MDS indicated Resident 1's balance during transitions (shifts) and walking, required staff assistance for stability. A review of Resident 1's record titled, Licensed Nurses Progress Notes dated [DATE] timed at 4 a.m., indicated at around 11:05 p.m. ([DATE]) CNA 1 attempted to put Resident 1 in bed and Resident 1 became very agitated and was yelling and screaming for her deceased mother, waking up Resident 1's roommate. The progress notes indicated Resident 1 was transferred to a therapeutic recliner chair and placed at the Nursing Station for close supervision to prevent her from disturbing other residents. The progress notes indicated Resident 1 continued to yell at the Nursing Station, subsequently, CNA 1 moved Resident 1 to the Dining Room where CNA 1 stayed with the resident. The Licensed Nurse Progress Notes dated [DATE] and timed at 4 a.m., indicated that on the same date ([DATE]) at around 12:05 a.m., CNA 1 called Licensed Vocational Nurse (LVN) 1 to the Dining Room and LVN 1 found Resident 1 lying on the floor next to the recliner chair. The progress notes indicated Resident 1's recliner chair was reclined with the foot part elevated. The progress notes indicated CNA 1 had left Resident 1 while asleep on the recliner chair to get a blanket and throw out the trash. The progress notes indicated CNA 1 witnessed (from approximately 10 feet away) Resident 1 got up and fall next to the reclining chair, when CNA 1 was coming back to the Dining Room. The progress notes indicated Resident 1 sustained a laceration (tearing of soft body tissue) on the left temporal (side of the head) area with swelling to the left eye and a bloody nose. The progress notes indicated another charge nurse (unknown) called [DATE] emergency services (person trained to give emergency medical care to people who are seriously ill with the aim of stabilizing them before they are taken to the hospital) and Resident 1 was transferred to the GACH. A review of Resident 1's GACH records titled History and Physical (H and P) dated [DATE] and timed at 11:27 a.m., indicated Resident 1 had a witnessed fall while standing without assistance and landed on the left side. The H and P indicated Resident 1 was admitted for further care in the GACH's intensive care unit. A review of Resident 1's GACH record indicated the result of the computed tomography (CT, a combination of X-rays and a computer to create pictures of your organs, bones, and other tissues) of the head dated [DATE], indicated Resident 1 had small bilateral frontal lobe subarachnoid hemorrhages, 5 millimeter thick hemorrhage along the anterior falx, nasal bone fractures, opacified left maxillary [MEDICATION(S)] and left frontal scalp swelling and hematoma. During an interview, on [DATE] at 1 p.m., the Director of Nursing (DON) stated that on [DATE] at 11 p.m., Resident 1 was yelling and screaming in her room and in the facility hallway upsetting other residents. The DON stated CNA 1 left the resident unsupervised in the Dining Room to get a blanket when Resident 1 fell asleep. The DON stated that when CNA 1 returned to the Dining Room, Resident 1 was out of the recliner chair, stood up, and fell on the floor. The DON stated CNA 1 should have asked another staff member to get the blanket, to ensure a staff member always remained with Resident 1 while in the Dining Room. During a telephone interview, on [DATE] at 6:25 a.m., LVN 1 stated Resident 1 was yelling during the night shift (11 p.m. to 7 a.m.) on [DATE]. LVN 1 stated the resident was placed at the Nurses' Station. LVN 1 stated CNA 1 moved Resident 1 to the facility's Dining Room because Resident 1 continued to yell and scream. LVN 1 stated Resident 1 eventually fell asleep after all the lights were turned off. LVN 1 stated CNA 1 left Resident 1 in the Dining Room unsupervised, to throw something out and get a blanket. LVN 1 stated when CNA 1 returned to the Dining Room, CNA 1 saw Resident 1 standing up, tried to walk, and then fell . LVN 1 stated Resident 1 had a laceration (cut) to the left side of the forehead. LVN 1 stated Resident 1 needed to be watched (monitored) because she might get up. During a telephone interview, on [DATE] at 6:30 a.m., CNA 1 stated that on [DATE] at 11 p.m., Resident 1 was restless, screaming and yelling. CNA 1 stated that CNA 1 and an unnamed coworker tried to place Resident 1 back in bed, but Resident 1 continued to scream and yell. CNA 1 stated other residents complained about Resident 1's screaming and yelling. CNA 1 stated she took Resident 1 to the Nursing Station. CNA 1 stated Resident 1 denied pain, feeling hungry or feeling thirsty. CNA 1 stated Resident 1 was transferred to the Dining Room when she started to scream and yell again. CNA 1 stated she remained with Resident 1 until the resident fell asleep and then left Resident 1's side to throw something out and get a blanket. CNA 1 stated that upon her return to the Dining Room, Resident 1 was getting up from the recliner chair. CNA 1 stated she witnessed Resident 1 started to walk and fell on the floor face down. CNA 1 stated she did not call for another staff member before leaving Resident 1 in the Dining Room because she did not want to wait until another staff member was available. CNA 1 stated the linen closet was down the hall. During a telephone interview with the director of nurses (DON) on [DATE] at 4 p.m., when asked about Resident 1's care plan (constantly yelling and screaming) dated [DATE], the DON stated that a one-on-one with the resident indicated a person managing the resident at all times, like a sitter. The DON stated that when Resident 1 fell from the reclining chair on [DATE], Resident 1 had a sitter (CNA 1). The DON stated the sitter left Resident 1 to go to the linen closet which was not too far away from Resident 1. The DON stated there were no other witnesses to Resident 1's fall incident on [DATE]. A review of the facility's policy and procedure titled, Fall Prevention Program, dated ,d+[DATE], indicated if a resident is at risk for falls, it would be identified in the care plan. All precautions would be implemented to protect the resident according to the fall prevention program. The policy indicated the care plan interventions should include the treatment prescribed by the physician and interdisciplinary recommendations, if any. The care plan should also include the following interventions but not limited to close observation and increase supervision.