Every finding on record at Bartram Crossing

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary conditions and proper food storage practices in the nourishment room on the 300 hallway, by failing to 1) Have a plate warming unit that was free of brown liquid residue, 2) Have a microwave free of food splatter, dried residue, and debris on the interior surfaces, including the top, sides, and base of the unit, and 3) Label and date bread stored in the cabinet above the microwave. These failures had the potential to negatively impact all residents who received food from the nourishment room. The findings include:On 3/25/2026 at 2:11 PM, an observation of the 300-hallway nourishment room revealed a cabinet containing a plate warming unit with visible accumulation of brown liquid residue, debris, and black particulate matter on the cabinet floor beneath the unit. The microwave was observed to have visible food splatter, dried residue, and debris on the interior surfaces, including the top, sides, and base of the unit. An opened loaf of bread was observed stored in the cabinet above the microwave with no date marking to indicate when the item was opened. (Photographic evidence obtained)On 3/26/2026 at 11:03 AM, another observation of the 300-hallway nourishment room was made. The plate warming unit continued to have a residue and debris beneath it and dried food residue and debris on the interior surfaces. The opened loaf of bread stored in the cabinet above the microwave had no date marking. On 3/26/2026 at 11:28 AM, the plate warming unit was observed and continued to have visible accumulation of dark residue, debris, and buildup along the interior surfaces and base of the unit. (Photographic evidence obtained)During an interview with the General Manager of the kitchen on 3/26/2026 at 3:02 PM, he stated that nourishment rooms are cleaned and maintained by dietary staff; however, no tracking log or documentation was available to demonstrate routine cleaning or monitoring of the nourishment rooms.During an interview with Dietary Aide D on 3/26/2026 at 4:08 PM, she stated that staff are responsible for cleaning nourishment rooms, including appliances such as microwaves and ensuring food items are monitored; however, there is no set schedule, and tasks are completed if there is time.During an interview with Dietary Aide E on 3/26/2026 at 4:45 PM, he stated that staff are responsible for checking expiration dates, labeling items, and cleaning nourishment room equipment including microwaves, refrigerators, and other appliances.A review of the facility's policy and procedure titled Service Guidelines, Policy DIET-059, last reviewed 11/2025, revealed the Food and Nutrition Services Department shall operate using guidelines for sanitation and infection control of food production and service. Additionally, a review of the facility's policy titled Food Safety (HACCP), Policy DIET-032, last reviewed 11/2025, revealed the facility maintains a comprehensive food safety system that includes proper handling, preparation, storage, and sanitation practices, as well as ongoing staff training related to food safety and cleaning procedures. (Copy obtained)

Based on observations, interviews, and record review, the facility failed to provide resident dignity by leaving a urinary catheter collection bag uncovered for one (Resident #13) of five residents observed with urinary catheters, from a total sample of 42 residents.The findings included:On 03/23/2026 at 12:29 PM, Resident #13 was observed lying in bed, eyes closed, with lower extremity in orthopedic boot, elevated on pillow. Her urinary catheter collection bag was observed uncovered and hanging on the bed frame with clear yellow urine visible in the bag and tubing visible to anyone walking past her room. (Photographic evidence obtained)Record review for Resident #13 revealed she was admitted to the facility on [DATE], with an initial admission date on 07/22/2022. Her diagnoses included obstructive reflux uropathy, dysuria and peripheral vascular disease. A review of the quarterly minimum data set (MDS) quarterly assessment, dated 01/08/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severe impairment. Resident #13 required supervision or touching assistance for eating and indwelling catheter due to always being incontinent of urinary and frequently incontinent of bowels.Review of Resident #13's Care Plan included a focus, and goals related to the risk for complication related to infection: Urinary Tract Infection (UTI) and indwelling catheter with diagnosis Neurogenic Bladder. (Copy obtained)Review of Resident #13's current physician's orders revealed the following: provide catheter care every shift and as needed (5/22/2025); ensure indwelling catheter drainage bag is below the level of the bladder and catheter collection tubing is free from kinks and ensure catheter anchoring device is in place every shift and as needed (5/22/2025); change catheter drainage bag in the evening every 30 day(s) follow protocol and as needed (5/22/2025); indwelling catheter 16 Fr with 10 milliliter (mL) balloon every shift (6/2/2025); Foley catheter to bedside bag Neurogenic bladder every shift (7/7/2025); and Enhanced Barrier Precautions (EBP).On 03/24/2026 at 9:10 AM, Resident #13 was observed in bed with lower extremity in orthopedic boot elevated on a pillow. Her finished breakfast tray was on the overbed table in front of her. Her urinary catheter collection bag was observed uncovered and hanging on the bed frame with clear yellow urine visible in the bag and tubing visible to anyone walking past her room. The resident was asked if she was comfortable with her catheter collection bag uncovered and facing the door. She replied, As far as I know, I can't see anything. (Photographic evidence obtained)On 03/25/2026 at 3:44 PM, Resident #13 was observed from the hallway. Her door was open, and she was lying in bed, eyes closed, with lower extremity in orthopedic boot, elevated on pillow. Her urinary catheter collection bag was observed hanging on the bed frame uncovered, with clear yellow urine in the collection bag and tubing, visible to anyone walking past her room. (Photographic evidence obtained)On 03/25/2026 at 3:47 PM, Licensed Practical Nurse (LPN) F was asked, what the facility policy was related to the positioning of urinary catheter bags. She replied, Bags should be below the bladder. When asked if it was okay for Resident #13's catheter collection bag to be uncovered and facing the door. LPN F replied, No, it should be covered.During an interview with the Director of Nursing (DON) on 03/25/2026 at 03:47 PM, the DON stated, Urinary catheter bags should be positioned on the other side of the bed and not in view of people passing.On 3/26/2026 at 11:16 AM, LPN B was asked how she monitored care plan interventions, including infection control standards for catheter care. LPN B replied, Ensure the urinary catheter is in the right position/in the privacy bag. She explained that if the bag is facing [NAME] on the bed, it has to be placed on the other side of the bed (out of sight from anyone walking past the room) and when in the wheelchair, the catheter bag should be placed in a privacy bag.

Based on a review of the facility's policy titled QAPI (Quality Assurance and Performance Improvement) Plan, facility and resident records and staff interviews, the facility failed to have an effective QAPI process that utilized adverse incident data to identify root cause analyses (RCAs), develop effective performance improvement activities to prevent recurrence of an avoidable injury after one (Resident #2) of seven residents reviewed for falls fell in the presence of Certified Occupational Therapy Assistant (COTA) A while not wearing a physician's ordered leg brace during a therapy session. She suffered a nondisplaced fracture of the proximal tibia/fibula (upper end of the lower leg bones under the knee), a tear of the body and posterior horn of the medial meniscus (fibrocartilage band that spans the inner knee joint), hemarthrosis (bleeding into the joint cavity), substantial pain, fear of using the right leg. The QAPI committee was not involved in identifying a root cause of the incident or developing a timely and effective performance improvement plan (PIP) or corrective action plan to prevent future similar occurrences. As a result, ten days later (11/20/25), Resident #1, with a known fall history and identified as a high fall risk, was left unattended on the toilet by Physical Therapy Assistant (PTA) B and fell. She struck her head and suffered a subarachnoid hemorrhage of the right posterior temporal lobe (a medical emergency characterized by bleeding between the brain and its protective membranes occurring in the rear side of the brain near the temple) requiring admission to an acute care hospital. The failure to develop measures needed to ensure the safety and protection of other residents had the potential to affect all 97 residents should an injury incident occur. Immediate Jeopardy (IJ) at a scope and severity of L (widespread) was identified at 1:47 PM on 12/8/25.On 11/20/25, Immediate Jeopardy began.On 12/10/25 at 3:00 PM, the Administrator was notified of the IJ determination. IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on 12/10/25.The findings include:Cross reference F600 and F689.1.A review of the facility's policy titled QAPI (Quality Assurance and Performance Improvement) Plan (BC ADMIN-058 effective 05/2017 last reviewed/updated 05/2025), revealed:The scope of the QAPI program encompasses all segments of care and services provided by [facility's name] that impact clinical care, quality of life, resident choice and care transitions with participation from all departments. The purpose of the plan includes a proactive approach for caring, and states that to achieve this, all employees will participate in ongoing QAPI efforts. Feedback, data systems and monitoring include tracking, investigating and monitoring adverse events every time they occur, and action plans implemented through the plan. The QAPI team will review sources of information to determine if gaps or patterns in the system of care that could result in quality problems; or if there are opportunities to make improvements. Based on the result of the review of the information, the QAPI team will prioritize opportunities for improvement, taking into consideration the importance of the issues (high risk, high frequency, and/or problem prone). The QAPI team will determine which problems will become the focus for a performance improvement project (PIP). The PIP Team is entrusted with a mission to look into a problem area and come up with plans for correction and/or improvement. The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes and implications for change. The approach comprehensively assesses all involved systems to prevent future events and promote sustained improvement. (Photographic evidence obtained)A review of a facility report authored by the Risk Manager (RM) on 11/21/25 revealed that on 11/10/25 at 2:00 PM, the therapy department notified the Unit Manager (UM) that Resident #2 had fallen while practicing a laundry task with COTA A. She was filling a basket attached to her walker with laundry. The basket started to fall. When COTA A attempted to adjust it, Resident #2 lost her balance and fell to the floor. Resident #2 complained of right knee pain and sustained a right forearm skin tear. An MRI (Magnetic Resonance Imaging - a non-invasive medical test that uses strong magnets, radio waves, and a computer to create detailed pictures of your body's organs, tissues, and skeletal system) on 11/11/25, revealed a nondisplaced fracture of the proximal tibia and fibula (upper end of the lower leg bones under the knee), tear of the body and posterior horn of the medial meniscus (fibrocartilage band that spans the inner knee joint), moderate hemarthrosis (bleeding into the joint cavity), and mild subcutaneous edema (swelling) around the knee. The facility investigation concluded that Resident #2 was not wearing her physician-ordered hinge brace locked in extension at the time of the accident.A review of a second facility report authored by the RM on 11/21/25 revealed that on 11/20/25, ten days after Resident #2's accident, Certified Nursing Assistant (CNA) V answered a call light for room [ROOM NUMBER]. CNA V discovered Resident #1 on the bathroom floor. Advanced Registered Nurse Practitioner (ARNP) Y evaluated the resident and observed a hematoma (bruise) to her left scalp and abrasion and hematoma to the left ear. She was sent to the Emergency Room. The facility's initial investigation revealed that PTA B had placed Resident #1 on the toilet, placed her call light across her lap and told her to pull it when she was finished. He left the room but did not see a nurse or CNA to tell them that Resident #1 was on the toilet. The PTA did not see the sign on the door indicating that Resident #1 was a fall risk. A computed tomography (CT) scan at the hospital revealed development of trace subarachnoid hemorrhage in the right posterior temporal lobe sulci (a medical emergency characterized by bleeding between the brain and its protective membranes) and she was admitted to the hospital. A facility tour on 12/8/25 at 10:15 AM revealed a system using door symbols, such as red stars and blue water droplets and red construction paper taped to the door concealing white paper underneath. The white paper had time slots for staff initials when they visited the room. Residents were observed throughout the facility using wheelchairs and walkers with plastic sleeves containing orange or blue pieces of construction paper.A medical record review for Resident #2 found she was admitted on [DATE]. Her admitting diagnosis was aftercare following joint replacement surgery. Resident #2 required assistance with activities of daily living (ADLs) and supervision or touch assistance for transfers. Additional diagnoses included but were not limited to osteoporosis (bone disease making the bones weak and brittle), muscle weakness, presence of a right artificial hip joint and unsteadiness on feet. Active discharge planning was occurring for her to return to the community. Resident #2 was care-planned on 10/17/25 for discharge with a goal of returning home, walking safely and being independent. She was care-planned for the risk of complications associated with decreased ADL self-performance related to decreased mobility and weakness. The goal was to maintain self-performance levels as evidenced by no decline through the next review date. Interventions included ambulation and transfer support as needed. The care plan also referred to a passport tip sheet that contained information relevant to the resident's needs. On 10/31/25, Resident #2 saw her orthopedic physician for a follow-up appointment. He noted weight bearing status for her right lower extremity (RLE) was weight bearing as tolerated (WBAT) with a walker and with a hinged knee brace locked in extension with all weight bearing. On 10/31/25 ARNP E ordered the recommended brace in the electronic record. A review of Resident #2's OT (occupation therapy) and PT (physical therapy) Precautions found the brace was not added to either until 11/19/25 (nine days after her fall). (Photographic evidence obtained)Registered Nurse (RN) I authored a nursing progress note dated 11/10/25 revealing that Resident #2 fell while practicing a laundry activity resulting in an inability to manipulate her right knee. The Interdisciplinary Team (IDT) met on 11/11/25 to discuss Resident #2's fall. Notes reflected a discussion that Resident #2 was supposed to wear her brace during weight-bearing, but it was not in place at the time of the fall. The therapist was educated on maintaining balance, and education on balance, and the use of the brace was provided to the resident.A review of Resident #2's passport (a tip sheet used by the facility as part of the care plan that provides easy access to information related to the resident's transfer status, ambulation support, bed mobility and guest care. They are housed in a plastic sleeve, color coded [blue for standard, and orange for fall in facility and fall risk] and affixed to the resident's wheelchair or walker for easy access and travel with the resident) found it was dated 11/3/25 and included instructions for the leg brace. (Photographic evidence obtained) 2.A record review for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses included unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, fall on same level from slipping, tripping and stumbling without subsequent striking against object, malignant neoplasm (a dangerous and potentially life-threatening cancerous tumor) of unspecified bronchus or lung, secondary neoplasm of brain, long term use of anticoagulants (blood thinners), history of TIAs (transient ischemic attack or mini-stroke), and unspecified severe protein calorie malnutrition.The minimum data set (MDS) Discharge Return Anticipated assessment, dated 11/20/25, revealed required partial/moderate staff assistance with toileting, bed mobility, and toilet transfers and was receiving physical therapy and occupational therapy.Resident #1 was care planned on 11/1/25 (revised 11/21/25) for her risk for falls and/or injury related to falls, related to medical conditions. It noted a prior fall with family present on 11/17/25. (Photographic evidence obtained)A Skilled Nursing admission Fall Risk assessment dated [DATE], established that Resident #1 was at risk for falls with total score of 52.0 (High).A review of Resident #1's medical record revealed an active physician's order for a Fall Risk Protocol, dated 11/3/25, for frequent rounding for safety checks and red rounding for safety awareness every shift (11/3/25), and toe-touch weight bearing to the RLE (right lower extremity) (11/3/25). An order dated 11/20/25 instructed staff to transfer the resident to the (hospital) emergency room for further evaluation and treatment status post unwitnessed fall with head injury.A nursing progress note dated 11/17/25 at 10:07 AM, revealed that Resident #1 fell while family was attempting to transfer her into a car for a scheduled appointment. On 11/20/25 at 12:21 PM, Licensed Practical Nurse (LPN) X noted Resident #1 fell in her bathroom and sustained a hematoma )bruise), abrasion, and a small laceration to the ear. She was sent to a local emergency room for further evaluation. Hospital records dated 11/20/25 revealed that Resident #1 was admitted to the hospital after being found on the floor in the bathroom. A CT scan (computed tomography, a test that uses X-rays and a computer for diagnostic testing) was performed and revealed a subarachnoid hemorrhage in the right posterior temporal lobe of the brain.The QAPI committee did not meet after the incident with Resident #2 or Resident #1.A facility training record review found that on 11/18/25, eight days after Resident #2's fall and two days before Resident #1's fall, an all-staff meeting was conducted to review braces, splints, and falls. PTA B was not in attendance. Training was conducted from 11/20/25 through 11/22/25 on the facility's safety protocol and bathroom safety best practice (stating NEVER leave high fall risk residents unattended on the toilet). PTA B was not in attendance. Training was conducted for the Rehabilitation Department on 11/24/25 on high fall risk residents. Twenty rehab staff were in attendance, but PTA B was not there. (Photographic evidence obtained) During an interview with the Director of Rehabilitation (DOR) on 12/9/25 at 12:03 PM, she said when Resident #2 was with COTA A doing laundry, she stepped back with her right leg, which she was not supposed to do. Resident #2 suffered a mild tibial plateau fracture. The orthopedic doctor recommended the brace on 10/31/25, but there was a breakdown and the order never made it into the therapy records. Resident #1 had a prior fall on 11/17/25. On the day of the most recent fall, PTA B transferred Resident #1v to the toilet and left, leaving her unsupervised. Unfortunately, she fell. Resident #1 sustained a hematoma and a small subarachnoid hemorrhage, was transferred out, and did not return.An interview was conducted with the Risk Manager on 12/9/25 at 3:30 PM. She said when an incident occurred where there was potential for injury, staff reported it to her. During morning meetings, if an incident contributed to a potential injury, a root cause analysis (RCA) meeting was held within 24 to 48 hours. The UM, DON, RM, Administrator, nurse and CNA involved, and any witnesses attended that meeting. This meeting was separate from QAPI meetings; the QAPI/QA (Quality Assurance) committee was not involved. If, during the investigation, she identified that corrective action was needed, they developed a corrective action plan (CAP) and started educating staff. This process was informal and could be done verbally or via email. After the incidents with Residents #2 and #1, they held an all-staff meeting and provided relevant education. After Resident #2's fall, a RCA was conducted and miscommunication about the brace was the concern. When asked about the QA committee's involvement in post-incident efforts, she said there was a QAPI meeting in November, but a performance improvement project (PIP) had not been developed yet, so it was not reviewed. Meetings were monthly and new PIPs would be reviewed at the next meeting (in December). The Medical Director and all key personnel attended the QA meetings. She continued explaining that Resident #1 fell on [DATE] and immediately went to the hospital where she was diagnosed with a hematoma. PTA B admitted to leaving Resident #1 in the bathroom with the call light in her lap. There was a star and red rounding sheet posted on her door, and PTA B should have known the policy that stand-by supervision was required for all fall risk residents. A risk meeting was conducted on 11/21/25 and an RCA was established. No PIP was developed in response. Instead, education on the fall policy was provided. Education was still ongoing and all staff would be trained at the meeting next week. When asked if the QA committee was involved or had reviewed this incident she said, no, but it would be involved next week. When asked how the facility utilized its QA committee, the RM explained that the committee reviewed PIPs after they were developed. The Medical Director was not involved in PIP development. The PIPs were presented to the QA committee at the next scheduled meeting. The committee really did not give input or recommend changes; they just provided a review of quality measures. An interview was conducted with the Administrator on 12/10/25 at 10:50 AM. He said he was the QAPI chairperson. Monthly meetings were conducted with all required members. Outside of those, the IDT conducted daily clinical meetings. They collaborated and figured out best actions to take when an issue arose such as whether an RCA or further investigation was needed. They then scheduled an RCA meeting and brought in the appropriate department to address areas of concern. He, the RM, DON, UM, therapy department, ADON (Assistant Director of Nursing), and CNAs involved attended the meetings. Once the RCA was done, the team worked on education as a first step and put together a PIP. This was not completed formally. Depending on the severity of the issue, they reviewed the concern, and reviewed RCA and PIP progress at the next QA meeting. The committee determined whether improvements had been made or if the PIP was it a toad, and if so, what changes were needed. The Administrator was advised of the purpose of the QA committee; that it was the entity responsible for conducting RCAs and developing PIPs in response to adverse incidents. He expressed understanding and said both incidents would be reviewed at the next meeting, on 12/16/25. When asked again, he confirmed the QA committee had not been involved with either incident. He explained that the Medical Director's availability was a barrier to ad hoc meetings and the team wanted to get a jump start on a plan. He acknowledged after Resident #2's fall and fracture, that facility efforts were unsuccessful as evidenced by a second unavoidable injury accident involving a therapy aide. When asked about the governing body's (GB) oversight of the QAPI process, the Administrator said at least one member of the GB attended each QAPI meeting via virtual meeting. Either the Chief Medical Officer, Chief Operating Officer, Chief Executive Officer, or the Chief Nursing Officer attend. When asked if the GB members were aware that the RCA and PIPs were being created without the involvement of the QA committee, he confirmed that they were, citing again that the facility wanted to jump right in immediately and not wait after an incident occurred.An interview was conducted with the Medical Director (MD) on 12/10/25 at 1:15 PM. He said he was notified immediately after each injury/incident occurred. The facility did an RCA and PIP. The MD said he met every morning with nurse managers, care managers and the DOR to discuss residents and issues. A smaller group later met to discuss incidents and determine how they could have happened. The MD confirmed he was a QA committee member and participated in monthly and post-incident QAPI activities. The QAPI process requirements were shared with him. Acknowledging the QAPI process was not being followed as intended, the MD suggested this Agency representative share recommendations with the facility, give them time to correct, then conduct a revisit.

Based on a review of facility and resident records, resident and staff interviews, and a review of facility policies titled Abuse, Neglect and Exploitation, Fall and Injury Reduction Best Practice Guidelines, and Bathroom Safety Best Practice, the facility failed to ensure sufficient safeguards and supervision to protect residents' right to be free from neglect by failing to ensure rehabilitation department staff were aware of, and implemented, care plan interventions to prevent two residents (Residents #2 and #1) from unavoidable falls with major injury, out of a total of seven residents reviewed for falls. On 11/10/25, the facility neglected to ensure that Resident #2 was wearing her physician-ordered hinged knee brace, locked in extension, while bearing weight on her right leg during a therapy session with Certified Occupational Therapy Assistant (COTA) A. The resident stepped back on her unsupported leg and fell, resulting in a nondisplaced fracture of the proximal tibia/fibula (upper end of the lower leg bones under the knee), a tear of the body and posterior horn of the medial meniscus (fibrocartilage band that spans the inner knee joint), hemarthrosis (bleeding into the joint cavity), substantial pain, fear of using the right leg, and a delayed discharge home. Ten days later, on 11/20/25, Resident #1, with a known fall history and identified as a high fall risk, was left unattended on the toilet by Physical Therapy Assistant (PTA) B and fell. She struck her head and suffered a subarachnoid hemorrhage of the right posterior temporal lobe (a medical emergency characterized by bleeding between the brain and its protective membranes occurring in the rear side of the brain near the temple) requiring admission to an acute care hospital. PTA B failed to recognize posted fall risk signage and a requirement for stand-by supervision while toileting and did not inform the resident's nurse or certified nursing assistant (CNA) that she was in the bathroom alone before leaving to treat another resident. The facility failed to ensure sufficient supervision and implement interventions to keep Residents #1 and #2 safe. This had the potential to place all 14 residents who required orthotic devices (devices used to support, align or correct movable body parts) at the time of survey and all 75 residents on active therapy caseload, at risk for a negative outcome or injury.Immediate Jeopardy (IJ) at a scope and severity of J (Isolated) was identified at 1:47 PM on 12/8/25.On 11/20/25, Immediate Jeopardy began.On 12/10/25 at 3:00 PM, the Administrator was notified of the IJ determination. IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on 12/10/25.The findings include:Cross reference F689 and F867.1. An interview was conducted with Resident #2 on 12/8/25 at 10:57 AM. She was in bed with a full-length brace on her right leg. A wheelchair and a walker were in the room. The plastic sleeve on the back of her wheelchair contained an orange passport that instructed TTWB (toe-touch weight bearing), RLE (right lower extremity), wheelchair, assistance with transfers, and a hinged brace locked in extension. Resident #2 said she had been in the facility approximately two months and was receiving both OT (occupational therapy) and PT (physical therapy). She had two hip replacement surgeries before admission. The day before she was supposed to get out of here, she was doing laundry with the OT aide. It got out of hand. She said she fell and broke her knee. The basket on her walker tipped as she was putting laundry in it and the walker fell over. She stepped back to get out of the way but there was nothing to hold on to, so she fell straight backwards. This caused a fracture in her shin bone and great pain in the knee. She was walking perfectly up to that point and did not have an order for a brace. She now has a brace on the knee. She did not wear a brace before the fall. The accident set her discharge back a month. She was walking some in therapy again but being super cautious as she did not want to fall again. She wasn't pushing it. When asked about the clear pouch on her wheelchair, Resident #2 confirmed it included doctor's orders, what she should and shouldn't do and the brace instructions.A review of a facility report authored by the Risk Manager (RM) on 11/21/25 revealed that on 11/10/25 at 2:00 PM, the therapy department notified the Unit Manager (UM) that Resident #2 had fallen while practicing a laundry task. According to COTA A, the resident was filling a basket attached to her walker with laundry. The basket started to fall. When COTA A attempted to adjust it, Resident #2 lost her balance and fell to the floor. Resident #2 complained of right knee pain and was unable to passively or actively manipulate her right knee. She also sustained a right forearm skin tear. The UM notified Advanced Registered Nurse Practitioner (ARNP) Y, who ordered an x-ray. X-ray results revealed no findings of a fracture or dislocation. On 11/11/25, ARNP J saw the resident and ordered a magnetic resonance imaging (MRI). The MRI results were received on 11/13/25 and revealed a nondisplaced fracture of the proximal tibia and fibula, a tear of the body and posterior horn of the medial meniscus, moderate hemarthrosis, and mild subcutaneous edema (swelling) around the knee. The facility's investigation concluded that Resident #2 was not wearing her physician-ordered hinge brace, locked in extension, at the time of the accident.A review of a second facility report authored by the RM on 11/21/25 revealed that on 11/20/25, ten days after Resident #2's accident, Certified Nursing Assistant (CNA) V answered a call light for room [ROOM NUMBER]. CNA V discovered Resident #1 on the bathroom floor. She had fallen. Resident #1 was assessed by nursing staff and placed back in bed for further evaluation. ARNP Y was called to Resident #1's bedside, evaluated her, observed a hematoma (bruise) to her left scalp and an abrasion and hematoma to her left ear. She was sent to the emergency room for further evaluation and treatment. The facility's initial investigation revealed that PTA B had placed Resident #1 on the toilet, placed her call light across her lap and told her to pull it when she was finished. He left the room but did not see a nurse or CNA to tell them that Resident #1 was on the toilet. The PTA did not see the sign on the door indicating that Resident #1 was a fall risk. A computed tomography (CT) scan revealed development of trace subarachnoid hemorrhage in the right posterior temporal lobe sulci (a medical emergency characterized by bleeding between the brain and its protective membranes) and she was admitted to the hospital. On 11/21/25, PTA B was taken off the schedule pending the outcome of the investigation. He never returned to work.A facility tour on 12/8/25 at 10:15 AM revealed name plaques on resident room doorways that had symbols, such as red stars and blue water droplets. Some rooms also had red construction paper taped to the door concealing white paper underneath. The white paper was a rounding sheet with time slots for staff initials when they visited the room. Residents were observed throughout the facility using wheelchairs and walkers that had plastic sleeves attached to them. The sleeves held orange or blue pieces of construction paper.A medical record review for Resident #2 found she was admitted on [DATE]. Her admitting diagnosis was aftercare following joint replacement surgery. Her significant change minimum data set (MDS) assessment, dated 11/18/25, revealed she was admitted from a short-term general hospital. She had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Resident #2 required assistance with activities of daily living (ADLs) and supervision or touch assistance for transfers. Additional diagnoses included but were not limited to osteoporosis (bone disease making the bones weak and brittle), muscle weakness, presence of a right artificial hip joint and unsteadiness on feet. Active discharge planning was occurring for her to return to the community. Resident #2 was care-planned on 10/17/25 for discharge with a goal of returning home, walking safely and being independent. She was care-planned for the risk of complications associated with decreased ADL (activities of daily living) self-performance related to decreased mobility and weakness. The goal was to maintain self-performance levels as evidenced by no decline through the next review date. Interventions included ambulation and transfer support as needed. The care plan also referred to a passport tip sheet that contained information relevant to the resident's needs. Resident #2 had a physician's order dated 10/17/25 for occupational and physical therapy four times per week. On 10/31/25, Resident #2 saw her orthopedic physician for a follow-up appointment. His notes referred to femoral neck (part of the thighbone) weakness and a history of a total hip arthroplasty (procedure for treating femoral neck fractures). Resident #2's weight bearing status for her right lower extremity (RLE) was weight bearing as tolerated (WBAT) with a walker and with a hinged knee brace locked in extension with all weight bearing until her quad strength returned.ARNP E entered a physician's order into Resident #2's record on 10/31/25 for Weight bearing: RLE NWB (non-weight bearing); hinged knee brace locked in extension when weight bearing, every shift. An internal medicine progress note authored by ARNP Y on 11/5/25 noted the hinged brace was to help with buckling. In a note dated 11/7/25, ARNP E reported that Resident #2 stated she had been walking more than 100 feet with her walker with therapy. A Social Services note, dated 11/7/25, revealed that Resident #2 was discharging home alone with home health services on 11/11/25.Registered Nurse (RN) I authored a nursing progress note on 11/10/25 revealing that a therapist notified him that Resident #2 had a fall while practicing a laundry activity. She was filling a basket, lost her balance and fell to the floor. Resident #2 was wearing a gait belt and non-skid socks but was unable to manipulate her right knee. A second note that same day documented that an x-ray was performed and was negative for acute findings. On 10/11/25, Resident #2 was care planned for a risk for falls after sustaining a fall with right knee pain. A revision on 11/13/25 added magnetic resonance imaging (MRI) results diagnosed a fracture of the proximal tibia and fibula.A review of the resident's physician's orders revealed that on 11/11/25, Oxycodone Hydrochloride (an opioid pain reliever) 5 milligrams (mg) every four hours as needed was ordered for moderate to severe pain.A review of the medication administration records (MARs) revealed that Resident #2 received the medication for pain levels between 4 (moderate discomfort) and 10 (the most pain possible) 12 times over the next five days.On 11/11/25, ARNP J noted that Resident #2 was seen in preparation for discharge and advised that she had a fall. Her right knee buckled and she was reporting pain at a level 10 out of 10 total points ever since. An x-ray was negative for acute osseous findings but Resident #2 was unable to move the right lower extremity without excruciating pain. Tenderness was present even when touching that knee and discharge was postponed. An Interdisciplinary Team (IDT) progress note dated 11/11/25, revealed that the team met to discuss Resident #2's fall. Notes revealed a discussion that Resident #2 was supposed to wear her brace during weight-bearing exercises, but it was not in place at the time of the fall. The therapist was educated on maintaining balance, and education on balance, and the use of the brace was provided to the patient. A new order was received for a STAT (immediate) MRI of the knee, with rest, ice, compression and elevation. Injections provided for inflammation. MRI results were received on 11/13/25 with Orthopedic instructions for Resident #2 to remain non-weight bearing for two more weeks. (Photographic evidence of progress notes was obtained)A review of Resident #2's passport (a tip sheet used by the facility as part of the care plan that provides easy access to information related to the resident's transfer status, ambulation support, bed mobility and guest care. They are housed in a plastic sleeve, color coded [blue for standard, and orange for fall in facility and fall risk] and affixed to the resident's wheelchair or walker for easy access and travel with the resident) found it was dated 11/3/25, seven days before the fall. It included instructions for Brace locked in extension, hip precautions, no hip extension, external rotation or abduction [moving the leg from midline away from the body], walking backwards or pivoting on the RLE (right lower extremity). Uses wheelchair and walker and needs minimal caregiver assistance with transfers. (Photographic evidence obtained)A review of Resident #2's OT and PT Precautions found neither included the instructions for the brace until 11/19/25 (nine days after her fall), when the revision Hinged brace on at all times except skin checks and bathing. Locked in extension during weight bearing and when not weight bearing was added. (Photographic evidence obtained) 2.A record review for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses including unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, fall on same level from slipping, tripping and stumbling without subsequent striking against object, malignant neoplasm (a dangerous and potentially life-threatening cancerous tumor) of unspecified bronchus or lung, secondary neoplasm of brain, long term use of anticoagulants (blood thinners), history of TIAs (transient ischemic attack or mini-stroke), and unspecified severe protein calorie malnutrition. The MDS Discharge Return Anticipated assessment dated [DATE] revealed that Resident #1 had a BIMS score of 11/15, indicating moderately impaired cognition. She required partial/moderate staff assistance with toileting, bed mobility, and toilet transfers and was receiving physical therapy and occupational therapy.Resident #1 was care planned on 11/1/25 (revised 11/21/25) for her risk for falls and/or injury related to falls, related to medical conditions. Has a history of fall with family present on 11/17/25. Interventions to prevent falls included, but were not limited to, assessing footwear, observing for unsteadiness, clutter free environment and assessing her per facility policy. (Photographic evidence obtained)A Skilled Nursing admission Fall Risk Assessment, dated 11/3/25, established Resident #1 at risk for falls with a total score of 52.0 (High).A review of Resident #1's medical record revealed an active physician's order, dated 11/3/25, for Xarelto (blood thinner) 10 mg every evening for atrial fibrillation. She also had a Fall Risk Protocol, dated 11/3/25, for frequent rounding for safety checks. Keep bed in low position except when rendering care every shift, red rounding for safety awareness every shift (11/3/25), and toe touch weight bearing to the RLE (11/3/25). Physical Therapy 5 times weekly for 8 weeks was ordered on 11/4/25. An order dated 11/20/25 instructed staff to transfer Resident #1 to [hospital name] emergency room for further evaluation and treatment status post unwitnessed fall with head injury.A nursing progress note, dated 11/17/25 at 10:07 AM, revealed that Resident #1 and two of her family members were outside the facility attempting to transfer her into a car so the resident could be taken to a scheduled follow-up appointment. One family member came back into the facility to request transfer assistance into the car. When the staff arrived at the car, the resident was observed on the ground in a kneeling position. The resident stated she did not fall, she sat on the ground. Resident #1's family member stated she witnessed the resident lower herself to the ground. An Occupational Therapist was nearby and assisted Resident #1 up off the ground and back into the wheelchair. Resident #1 did not complain of any pain or distress and had no apparent injury. The staff suggested that the resident come back into the facility to be assessed by a nurse. The family declined and stated the resident was going to visit the orthopedic physician. ARNP Y was notified.On 11/20/25 at 12:21 PM, Licensed Practical Nurse (LPN) X noted that after being observed on the floor in her bathroom, an assessment revealed a small hematoma to the left side of Resident #1's forehead, an abrasion to the left forearm and shoulder, and a small laceration behind the left ear. The resident verbalized generalized pain and was observed crying. ARNP Y was onsite, notified of the fall incident, and arrived to assess Resident #1 before she was assisted up to a wheelchair and back into bed. ARNP Y ordered staff to send Resident #1 to a local emergency department for further evaluation due to her head injury and because she was receiving Xarelto. A hospital physician's progress note dated 11/20/25 at 3:58 PM revealed that Resident #1 was admitted to the hospital on [DATE], Condition: Guarded. Found on floor in the bathroom on November 20, 2025, with hematoma to the left scalp as well as behind the left ear. The left ear has an abrasion. She was on Xarelto for Deep Vein Thrombosis (a dangerous blood clot formation in a deep vein, usually the leg) prophylaxis following her right femoral neck surgery. She will need a stat CT (computed tomography, a test that uses X-rays and a computer for diagnostic testing) of her head. Hospital records further revealed the CT revealed a subarachnoid hemorrhage in the right posterior temporal lobe of the brain.A review of facility training records found that on 11/18/25, eight days after Resident #2's fall and 2 days before Resident #1's fall, an all-staff meeting was conducted to discuss braces, splints, immobilizers, slings, boots and falls. PTA B was not in attendance. Training was conducted from 11/20/25 through 11/22/25 on the facility's safety protocol and bathroom safety best practice (stating NEVER leave high fall risk residents unattended on the toilet). PTA B was not in attendance. Training was conducted for the Rehabilitation Department on 11/24/25 on high fall risk residents. Twenty Rehab staff were in attendance, but PTA B was not there. (Photographic evidence obtained) LPN G was interviewed on 12/8/25 at 10:40 AM. She explained that the sleeved information on residents' wheelchairs included details about transfer status, mobility aides and orthotic devices. The therapy department updated the information as needed. If she found a discrepancy, she would check the physician's orders, report to the UM and request a correction. She would then notify the certified nursing assistants (CNAs). Most residents with orthotic devices came from the hospital with them; otherwise, nursing reported new orders to therapy to enter the order into the electronic record and for fitting. The therapy department's electronic recordkeeping system was connected to the electronic medical records system, so therapy staff had access to all residents' care plan interventions. It is a nice system.On 12/08/25 at 10:48 AM, an interview was conducted with CNA W. She was asked if the facility provided any training/in-service education on abuse/neglect. She stated, Yes. She was asked to name some forms of neglect. She stated, Leaving patients wet, if they call you and need to toilet and you say give me a few minutes and you come back in an hour, not changing their bed sheets as scheduled. She was asked how she knew residents' plans of care, including any precautions required. She stated she could look at their doors because the facility used multiple different signs that meant different things, or she could look in the electronic medical record. She could also go to the wall where [RN I's] office was; everyone's folder was there. Lifting or ambulation status could be found on the resident's passport hanging on the wheelchair. She knew which residents were at high risk of falling because there would be a Target red rounding sheet of red paper on the door where staff could initial that they laid eyes on the resident every hour. A red star by the door meant the resident had fallen and they were now a high fall risk. She also made sure call lights were within the residents' reach. CNA W explained that the facility's process for toileting a resident who was a fall risk was, If they are a fall risk you can't leave them, you must be in the restroom with them at all times.On 12/08/2025 at 11:07 AM, an interview was conducted with RN U. She stated she had been trained in abuse/neglect and cited not attending to resident needs as one example of neglect. She said the facility had a falling star system in place. Also, nurses could check to see what medications residents received that would put them at risk for falls. They could also refer to the hospital AHCA form 3008 (a medical certification for long term care) that notes fall risk and weight-bearing status, and how much assistance the residents needed for transfers and care. During the initial nursing assessment, each resident's status was assessed. When asked why she might review a resident's care plan, she stated, To know how to take care of them, how to talk to them, what kind of care you need to provide. When asked what resources the facility had to access resident restrictions or needed devices, she answered the POC (point of care) for the CNAs is one way; there they can see any changes in resident needs. Also, the red paper on the door means the resident should be checked every hour by any staff member. Red rounding; that means fall risk. There is also a passport that hangs on the back of the resident's wheelchair with information about fall precautions, any assistive devices and other safety measures. She concluded by explaining the facility's policy for toileting a resident who required assistance was to make sure to use a gait belt, and you are not supposed to leave them; you must always stay with them.In an interview with LPN X on 12/09/25 at 12:19 PM, she was asked to explain her understanding of the resident passport. She said when a resident was receiving rehab, therapy staff updated it to let staff know what limitations and restrictions existed. Staff might expect to see how the resident transferred, whether they required a mechanical lift, what assistive devices they used and their weight-bearing status. Therapy updated the passports with changes. Her role in preventing falls included red rounding, which you see on the door, and frequent rounding. When a resident needed assistance with toileting, staff checked the passport to make sure they were not a two-person assist. Staff transferred residents by whichever means was appropriate; let them have their privacy by standing outside the door by the bathroom, and made sure they had their light to pull when they were finished. We leave nobody on the toilet alone. She was asked if she recalled a fall incident that occurred on 11/20/25 with Resident #1. She stated, Yes. She recalled standing in the hallway at her cart when she saw a therapist standing in the hallway looking around, like he was trying to decide what to do. The call light was going off in the room where he was standing. At that time the therapist left and the CNA was coming around the corner. The CNA asked LPN X, Who put this lady on the toilet? The CNA went back into the room and by the time LPN X reached the room, the CNA was with the resident in the bathroom; the resident was on the floor. On 12/09/25 at 2:40 PM an interview was conducted with CNA V. She stated she received education on abuse/neglect and provided the following examples of neglect: Not changing them, ignoring them, and not bathing them. She knew what level of care the residents needed, including any precautions or restrictions they had, from shift report, talking to the nurse, the electronic plan of care and the resident folders behind the nursing desk. She knew which residents were at risk for falls because they had a wrist band, neighborhood watch (eyes) on the door, or they had a star on their door. They got that information in report also. The facility process for toileting a resident who was a fall risk was to supervise them going to the toilet. She left their bathroom door open but closed the door to the room so she could see them and give them privacy. We never leave a person on the toilet by themselves; they must always be in reach. CNA W recalled a fall incident that occurred with Resident #1 on 11/20/25. She stated she was not working with her that day; she was working in room [ROOM NUMBER]. She came around the corner and saw her call light was on. She walked over to her room and saw LPN X down the hall. When she asked the nurse who put Resident #1 on the toilet, LPN X said therapy was in the room with her. When CNA V went in, there was no one there. CNA V then saw Resident #1 on the floor in the bathroom. She went to the door and yelled for the nurse to come because the resident was on the floor. She asked LPN X if the therapist told her Resident #1 was left on the toilet; LPN X said, No. CNA V explained that he had not told her either. CNA V was asked if this resident had a passport at the time of the fall. She stated, Yes, it was light blue. She also confirmed there was red rounding signage on the resident's door at that time.PTA D was interviewed on 12/8/25 at 3:00 PM. He explained that the evaluating therapist created the residents' passports upon initial evaluation. The passport color was changed from blue (standard) to orange in cases involving falls. The passport was put in place immediately and was typically used by the CNAs; this was especially for the PRN (as needed), 2nd and 3rd shift CNAs, as they had little to no contact with the therapy team. For the first therapy day, the resident's chart was pulled up by the treating therapist or aide. It included a diagnosis, weight-bearing status, and functional status. Assistive devices including braces were noted, and if under a doctor's order would be listed as a precaution. He was not sure who transcribed physician's orders for braces into the medical record, but therapy staff saw those on the daily schedule. Braces and immobilizers usually came with the resident from the hospital and were sometimes noted on the passport. They should be but would also be listed under precautions and in the electronic medical record (EMR), which all therapy staff had access to. An interview was conducted with the Lead COTA (LC) on 12/8/25 at 3:25 PM. She explained that an evaluating therapist saw newly admitted residents the morning after admission. The results went into therapy under precautions. When the daily therapy schedule was printed, those precautions were printed on the schedule. When the resident walked in, staff had all of the precautions. Staff were expected to read that before they worked with the resident. Passport was a system meant for CNAs, nurses or other therapists like as-needed staff who had not worked with the resident. Or, if a call bell rang and you assisted a resident who you did not know, the information traveled with the resident. You can't say, I didn't know what to do with the person. It is right there. The evaluating therapist completes the passport at the time of the initial evaluation. The star and red covered paper on resident doors are for falls and red rounding. Staff initial every time they lay eyes on residents during red rounding. Everyone, with no exception, must have stand-by assistance with toileting. If a resident feels like they need that (private) space, the nurse must determine if the resident is safe to sit alone. So, if you are not safe, then taking you to the toilet and leaving you there alone is not safe to do. If a patient goes to an appointment post-surgery or post-injury, therapy sends a packet to the doctor. The packet asks for weight bearing status, braces or orthotic schedules, etc. The form comes back to the Unit Manager, is scanned into and shows up on the [EMR]. The information is forwarded to the Director of Rehab (DOR) and to all therapy leads. The lead then updates the information in the precautions. When asked about Residents #1 and #2, the LC recalled that Resident #1 went to the hospital after her second fall. She was frail with little appetite and had to be handled with kid gloves. She fell first with family in the parking lot, so they changed her passport from blue to orange to alert that a fall had occurred. Then she fell from her bathroom toilet. [PTA B] is not negligent. She had asked him to assist her onto the toilet. Instead of standing there, he left. He could have called or used the call bell. [Resident #1] went to the intensive care unit. Resident #2 was with [COTA A] when she lost her balance and fell. He was attempting a laundry task with her. Her passport had the leg brace on it; it was to be on all the time. [COTA A] did not read the passport. [Resident #2] sustained two small fractures and was non-weight bearing for two weeks. Sometimes passports go unnoticed, but therapy issues constant reminders to check them. It was about knowing the passport was there, not paying attention, and not realizing the brace wasn't on. The LC said her [NAME] was, When in doubt, don't do it! Better off being safe. During an interview with COTA A on 12/9/25 at 11:46 AM, he confirmed that the daily therapy schedule received each morning had all resident information on it. He stated he could also see the resident's transfer status in the [EMR]. The passport information was supposed to be consistent. He said he worked with Resident #2 once before. The day of the event was supposed to be her last day of therapy. On the day of the fall, they were going over a simulated laundry activity. The basket that hooked onto the top and side of her walker came loose. As he was fixing the basket, she stepped back onto her right leg, lost her balance and fell. She had her gait belt on, but he couldn't get to her fast enough. Prior to fall, she had good balance and was walking. The leg brace was not on the daily notes or the schedule and was not on the resident. Usually, the evaluating therapist put that information into the system. After the incident, within about a week, an all-staff meeting was held. They went over the incident and went over it one-on-one with the DOR. The DOR was interviewed on 12/9/25 at 12:03 PM. She stated the OT or PT initiated the passports which went in the sleeve on the back of the wheelchairs. Those contained basic information such as how a resident transferred and orthotic devices in use. The same information went in the therapy evaluation under precautions, which could also be seen in the EMR. When a therapist or assistant got a resident the first time, they got information regarding needed support and devices from the precautions or the initial evaluation. They could also review the passport. Resident #2 was with COTA A doing laundry and was scheduled to discharge the next day. The laundry simulator basket hook came loose and when COTA A went to move the basket, Resident #2 stepped back with her right leg, which she wasn't supposed to do due to her hip. She immediately complained of knee pain. X-rays were all negative, but that knee was swollen and painful. Then a mild tibial plateau fracture was discovered. She had gone to her orthopedic doctor on 10/31/25; he recommended she wear a brace, as her right knee was buckling, but there was a breakdown. The physician's order for the brace was supposed to be scanned into email for the DOR. Unfortunately, that precaution didn't show up on the daily schedule like it was supposed to. As for Resident #1, she had a prior fall while with family on 11/17/25. The day of the most recent fall, PTA B went to get Resident #1 for therapy, but she said she needed to go to the bathroom first. PTA B transferred her to the toilet and stepped into the hall to find a CNA, but the nurse couldn't find the CNA. He laid the call light across Resident #1's lap, asked her to use the call light and not get up, and left. Unfortunately, she fell. Reports are that the call light went on immediately. The nurse saw the PTA exit the room and described his behavior as kind of frantic; he was rushing like he had too many places to go. Resident #1 sus

Based on a review of facility and resident records, resident and staff interviews, and a review of the facility policy titled Fall and Injury Reduction Best Practice Guidelines and the Bathroom Safety Best Practice guidelines, the facility failed to ensure residents received adequate supervision and assistive devices to prevent unavoidable falls for two (Residents #2 and #1) of seven residents reviewed for falls.On 11/10/25 when Resident #2 was not wearing her physician-ordered hinged knee brace, she attended a therapy session with Certified Occupational Therapy Assistant (COTA) A. During the session she stepped back on her unsupported leg and fell, resulting in a nondisplaced fracture of the proximal tibia/fibula (upper end of the lower leg bones under the knee), a tear of the body and posterior horn of the medial meniscus (fibrocartilage band that spans the inner knee joint), hemarthrosis (bleeding into the joint cavity), substantial pain, fear of using the right leg, and a delayed discharge home. Ten days later, on 11/20/25, Resident #1, with a known fall history and identified as a high fall risk, was left unattended on the toilet by Physical Therapy Assistant (PTA) B and fell. She struck her head and suffered a subarachnoid hemorrhage of the right posterior temporal lobe (a medical emergency characterized by bleeding between the brain and its protective membranes occurring in the rear side of the brain near the temple) requiring admission to an acute care hospital. PTA B failed to recognize posted fall risk signage and a requirement for stand-by supervision while toileting and did not inform Resident #1's nurse or certified nursing assistant (CNA) that she was in the bathroom alone before leaving to treat another resident. Failure to ensure therapy orders were current and therapy staff were aware of care plan safety interventions had the potential to place all 14 residents who required orthotic devices (devices used to support, align or correct movable body parts) and all 75 residents on active therapy caseload at risk for injury.Immediate Jeopardy (IJ) at a scope and severity of J (Isolated) was identified at 1:47 PM on 12/8/25.On 11/20/25, Immediate Jeopardy began.On 12/10/25 at 3:00 PM, the Administrator was notified of the IJ determination. IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on 12/10/25.The findings include:Cross reference F600 and F867.1. An interview was conducted with Resident #2 on 12/8/25 at 10:57 AM. She was in bed with a full-length brace on her right leg. A wheelchair and a walker were in the room. The plastic sleeve on the back of her wheelchair contained an orange passport that instructed TTWB (toe-touch weight bearing), RLE (right lower extremity), wheelchair, assistance with transfers, and a hinged brace locked in extension. Resident #2 said she had been in the facility approximately two months and was receiving both OT (occupational therapy) and PT (physical therapy). She had two hip replacement surgeries before admission. The day before she was supposed to get out of here, she was doing laundry with the OT aide. It got out of hand. She said she fell and broke her knee. The basket on her walker tipped as she was putting laundry in it and the walker fell over. She stepped back to get out of the way but there was nothing to hold on to, so she fell straight backwards. This caused a fracture in her shin bone and great pain in the knee. She was walking perfectly up to that point and did not have an order for a brace. She now has a brace on the knee. She did not wear a brace before the fall. The accident set her discharge back a month. She was walking some in therapy again but being super cautious as she did not want to fall again. She wasn't pushing it. When asked about the clear pouch on her wheelchair, Resident #2 confirmed it included doctor's orders, what she should and shouldn't do and the brace instructions.A review of a facility report authored by the Risk Manager (RM) on 11/21/25 revealed that on 11/10/25 at 2:00 PM, the therapy department notified the Unit Manager (UM) that Resident #2 had fallen while practicing a laundry task. According to COTA A, the resident was filling a basket attached to her walker with laundry. The basket started to fall. When COTA A attempted to adjust it, Resident #2 lost her balance and fell to the floor. Resident #2 complained of right knee pain and was unable to passively or actively manipulate her right knee. She also sustained a right forearm skin tear. The UM notified Advanced Registered Nurse Practitioner (ARNP) Y, who ordered an x-ray. X-ray results revealed no findings of a fracture or dislocation. On 11/11/25, ARNP J saw the resident and ordered a magnetic resonance imaging (MRI). The MRI results were received on 11/13/25 and revealed a nondisplaced fracture of the proximal tibia and fibula, a tear of the body and posterior horn of the medial meniscus, moderate hemarthrosis, and mild subcutaneous edema (swelling) around the knee. The facility's investigation concluded that Resident #2 was not wearing her physician-ordered hinge brace, locked in extension, at the time of the accident.A review of a second facility report authored by the RM on 11/21/25 revealed that on 11/20/25, ten days after Resident #2's accident, Certified Nursing Assistant (CNA) V answered a call light for room [ROOM NUMBER]. CNA V discovered Resident #1 on the bathroom floor. She had fallen. Resident #1 was assessed by nursing staff and placed back in bed for further evaluation. ARNP Y was called to Resident #1's bedside, evaluated her, observed a hematoma (bruise) to her left scalp and an abrasion and hematoma to her left ear. She was sent to the emergency room for further evaluation and treatment. The facility's initial investigation revealed that PTA B had placed Resident #1 on the toilet, placed her call light across her lap and told her to pull it when she was finished. He left the room but did not see a nurse or CNA to tell them that Resident #1 was on the toilet. The PTA did not see the sign on the door indicating that Resident #1 was a fall risk. A computed tomography (CT) scan revealed development of trace subarachnoid hemorrhage in the right posterior temporal lobe sulci (a medical emergency characterized by bleeding between the brain and its protective membranes) and she was admitted to the hospital. On 11/21/25, PTA B was taken off the schedule pending the outcome of the investigation. He never returned to work.A facility tour on 12/8/25 at 10:15 AM revealed name plaques on resident room doorways that had symbols, such as red stars and blue water droplets. Some rooms also had red construction paper taped to the door concealing white paper underneath. The white paper was a rounding sheet with time slots for staff initials when they visited the room. Residents were observed throughout the facility using wheelchairs and walkers that had plastic sleeves attached to them. The sleeves held orange or blue pieces of construction paper.A medical record review for Resident #2 found she was admitted on [DATE]. Her admitting diagnosis was aftercare following joint replacement surgery. Her significant change minimum data set (MDS) assessment, dated 11/18/25, revealed she was admitted from a short-term general hospital. She had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Resident #2 required assistance with activities of daily living (ADLs) and supervision or touch assistance for transfers. Additional diagnoses included but were not limited to osteoporosis (bone disease making the bones weak and brittle), muscle weakness, presence of a right artificial hip joint and unsteadiness on feet. Active discharge planning was occurring for her to return to the community. Resident #2 was care-planned on 10/17/25 for discharge with a goal of returning home, walking safely and being independent. She was care-planned for the risk of complications associated with decreased ADL (activities of daily living) self-performance related to decreased mobility and weakness. The goal was to maintain self-performance levels as evidenced by no decline through the next review date. Interventions included ambulation and transfer support as needed. The care plan also referred to a passport tip sheet that contained information relevant to the resident's needs. Resident #2 had a physician's order dated 10/17/25 for occupational and physical therapy four times per week. On 10/31/25, Resident #2 saw her orthopedic physician for a follow-up appointment. His notes referred to femoral neck (part of the thighbone) weakness and a history of a total hip arthroplasty (procedure for treating femoral neck fractures). Resident #2's weight bearing status for her right lower extremity (RLE) was weight bearing as tolerated (WBAT) with a walker and with a hinged knee brace locked in extension with all weight bearing until her quad strength returned.ARNP E entered a physician's order into Resident #2's record on 10/31/25 for Weight bearing: RLE NWB (non-weight bearing); hinged knee brace locked in extension when weight bearing, every shift. An internal medicine progress note authored by ARNP Y on 11/5/25 noted the hinged brace was to help with buckling. In a note dated 11/7/25, ARNP E reported that Resident #2 stated she had been walking more than 100 feet with her walker with therapy. A Social Services note, dated 11/7/25, revealed that Resident #2 was discharging home alone with home health services on 11/11/25.Registered Nurse (RN) I authored a nursing progress note on 11/10/25 revealing that a therapist notified him that Resident #2 had a fall while practicing a laundry activity. She was filling a basket, lost her balance and fell to the floor. Resident #2 was wearing a gait belt and non-skid socks but was unable to manipulate her right knee. A second note that same day documented that an x-ray was performed and was negative for acute findings. On 10/11/25, Resident #2 was care planned for a risk for falls after sustaining a fall with right knee pain. A revision on 11/13/25 added magnetic resonance imaging (MRI) results diagnosed a fracture of the proximal tibia and fibula.A review of the resident's physician's orders revealed that on 11/11/25, Oxycodone Hydrochloride (an opioid pain reliever) 5 milligrams (mg) every four hours as needed was ordered for moderate to severe pain.A review of the medication administration records (MARs) revealed that Resident #2 received the medication for pain levels between 4 (moderate discomfort) and 10 (the most pain possible) 12 times over the next five days.On 11/11/25, ARNP J noted that Resident #2 was seen in preparation for discharge and advised that she had a fall. Her right knee buckled and she was reporting pain at a level 10 out of 10 total points ever since. An x-ray was negative for acute osseous findings but Resident #2 was unable to move the right lower extremity without excruciating pain. Tenderness was present even when touching that knee and discharge was postponed. An Interdisciplinary Team (IDT) progress note dated 11/11/25, revealed that the team met to discuss Resident #2's fall. Notes revealed a discussion that Resident #2 was supposed to wear her brace during weight-bearing exercises, but it was not in place at the time of the fall. The therapist was educated on maintaining balance, and education on balance, and the use of the brace was provided to the patient. A new order was received for a STAT (immediate) MRI of the knee, with rest, ice, compression and elevation. Injections provided for inflammation. MRI results were received on 11/13/25 with Orthopedic instructions for Resident #2 to remain non-weight bearing for two more weeks. (Photographic evidence of progress notes was obtained)A review of Resident #2's passport (a tip sheet used by the facility as part of the care plan that provides easy access to information related to the resident's transfer status, ambulation support, bed mobility and guest care. They are housed in a plastic sleeve, color coded [blue for standard, and orange for fall in facility and fall risk] and affixed to the resident's wheelchair or walker for easy access and travel with the resident) found it was dated 11/3/25, seven days before the fall. It included instructions for Brace locked in extension, hip precautions, no hip extension, external rotation or abduction [moving the leg from midline away from the body], walking backwards or pivoting on the RLE (right lower extremity). Uses wheelchair and walker and needs minimal caregiver assistance with transfers. (Photographic evidence obtained)A review of Resident #2's OT and PT Precautions found neither included the instructions for the brace until 11/19/25 (nine days after her fall), when the revision Hinged brace on at all times except skin checks and bathing. Locked in extension during weight bearing and when not weight bearing was added. (Photographic evidence obtained) 2.A record review for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses including unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, fall on same level from slipping, tripping and stumbling without subsequent striking against object, malignant neoplasm (a dangerous and potentially life-threatening cancerous tumor) of unspecified bronchus or lung, secondary neoplasm of brain, long term use of anticoagulants (blood thinners), history of TIAs (transient ischemic attack or mini-stroke), and unspecified severe protein calorie malnutrition. The MDS Discharge Return Anticipated assessment dated [DATE] revealed that Resident #1 had a BIMS score of 11/15, indicating moderately impaired cognition. She required partial/moderate staff assistance with toileting, bed mobility, and toilet transfers and was receiving physical therapy and occupational therapy.Resident #1 was care planned on 11/1/25 (revised 11/21/25) for her risk for falls and/or injury related to falls, related to medical conditions. Has a history of fall with family present on 11/17/25. Interventions to prevent falls included, but were not limited to, assessing footwear, observing for unsteadiness, clutter free environment and assessing her per facility policy. (Photographic evidence obtained)A Skilled Nursing admission Fall Risk Assessment, dated 11/3/25, established Resident #1 at risk for falls with a total score of 52.0 (High).A review of Resident #1's medical record revealed an active physician's order, dated 11/3/25, for Xarelto (blood thinner) 10 mg every evening for atrial fibrillation. She also had a Fall Risk Protocol, dated 11/3/25, for frequent rounding for safety checks. Keep bed in low position except when rendering care every shift, red rounding for safety awareness every shift (11/3/25), and toe touch weight bearing to the RLE (11/3/25). Physical Therapy 5 times weekly for 8 weeks was ordered on 11/4/25. An order dated 11/20/25 instructed staff to transfer Resident #1 to [hospital name] emergency room for further evaluation and treatment status post unwitnessed fall with head injury.A nursing progress note, dated 11/17/25 at 10:07 AM, revealed that Resident #1 and two of her family members were outside the facility attempting to transfer her into a car so the resident could be taken to a scheduled follow-up appointment. One family member came back into the facility to request transfer assistance into the car. When the staff arrived at the car, the resident was observed on the ground in a kneeling position. The resident stated she did not fall, she sat on the ground. Resident #1's family member stated she witnessed the resident lower herself to the ground. An Occupational Therapist was nearby and assisted Resident #1 up off the ground and back into the wheelchair. Resident #1 did not complain of any pain or distress and had no apparent injury. The staff suggested that the resident come back into the facility to be assessed by a nurse. The family declined and stated the resident was going to visit the orthopedic physician. ARNP Y was notified.On 11/20/25 at 12:21 PM, Licensed Practical Nurse (LPN) X noted that after being observed on the floor in her bathroom, an assessment revealed a small hematoma to the left side of Resident #1's forehead, an abrasion to the left forearm and shoulder, and a small laceration behind the left ear. The resident verbalized generalized pain and was observed crying. ARNP Y was onsite, notified of the fall incident, and arrived to assess Resident #1 before she was assisted up to a wheelchair and back into bed. ARNP Y ordered staff to send Resident #1 to a local emergency department for further evaluation due to her head injury and because she was receiving Xarelto. A hospital physician's progress note dated 11/20/25 at 3:58 PM revealed that Resident #1 was admitted to the hospital on [DATE], Condition: Guarded. Found on floor in the bathroom on November 20, 2025, with hematoma to the left scalp as well as behind the left ear. The left ear has an abrasion. She was on Xarelto for Deep Vein Thrombosis (a dangerous blood clot formation in a deep vein, usually the leg) prophylaxis following her right femoral neck surgery. She will need a stat CT (computed tomography, a test that uses X-rays and a computer for diagnostic testing) of her head. Hospital records further revealed the CT revealed a subarachnoid hemorrhage in the right posterior temporal lobe of the brain.A review of facility training records found that on 11/18/25, eight days after Resident #2's fall and 2 days before Resident #1's fall, an all-staff meeting was conducted to discuss braces, splints, immobilizers, slings, boots and falls. PTA B was not in attendance. Training was conducted from 11/20/25 through 11/22/25 on the facility's safety protocol and bathroom safety best practice (stating NEVER leave high fall risk residents unattended on the toilet). PTA B was not in attendance. Training was conducted for the Rehabilitation Department on 11/24/25 on high fall risk residents. Twenty Rehab staff were in attendance, but PTA B was not there. (Photographic evidence obtained) LPN G was interviewed on 12/8/25 at 10:40 AM. She explained that the sleeved information on residents' wheelchairs included details about transfer status, mobility aides and orthotic devices. The therapy department updated the information as needed. If she found a discrepancy, she would check the physician's orders, report to the UM and request a correction. She would then notify the certified nursing assistants (CNAs). Most residents with orthotic devices came from the hospital with them; otherwise, nursing reported new orders to therapy to enter the order into the electronic record and for fitting. The therapy department's electronic recordkeeping system was connected to the electronic medical records system, so therapy staff had access to all residents' care plan interventions. It is a nice system.On 12/08/25 at 10:48 AM, an interview was conducted with CNA W. She was asked how she knew residents' plans of care, including any precautions required. She stated she could look at their doors because the facility used multiple different signs that meant different things, or she could look in the electronic medical record. She could also go to the wall where [RN I's] office was; everyone's folder was there. Lifting or ambulation status could be found on the resident's passport hanging on the wheelchair. She knew which residents were at high risk of falling because there would be a Target red rounding sheet of red paper on the door where staff could initial that they laid eyes on the resident every hour. A red star by the door meant the resident had fallen and they were now a high fall risk. She also made sure call lights were within the residents' reach. CNA W explained that the facility's process for toileting a resident who was a fall risk was, If they are a fall risk you can't leave them, you must be in the restroom with them at all times.On 12/08/2025 at 11:07 AM, an interview was conducted with RN U. She said the facility had a falling star system in place. Also, nurses could check to see what medications residents received that would put them at risk for falls. They could also refer to the hospital AHCA form 3008 (a medical certification for long term care) that notes fall risk and weight-bearing status, and how much assistance the residents needed for transfers and care. During the initial nursing assessment, each resident's status was assessed. When asked why she might review a resident's care plan, she stated, To know how to take care of them, how to talk to them, what kind of care you need to provide. When asked what resources the facility had to access resident restrictions or needed devices, she answered the POC (point of care) for the CNAs is one way; there they can see any changes in resident needs. Also, the red paper on the door means the resident should be checked every hour by any staff member. Red rounding; that means fall risk. There is also a passport that hangs on the back of the resident's wheelchair with information about fall precautions, any assistive devices and other safety measures. She concluded by explaining the facility's policy for toileting a resident who required assistance was to make sure to use a gait belt, and you are not supposed to leave them; you must always stay with them.In an interview with LPN X on 12/09/25 at 12:19 PM, she was asked to explain her understanding of the resident passport. She said when a resident was receiving rehab, therapy staff updated it to let staff know what limitations and restrictions existed. Staff might expect to see how the resident transferred, whether they required a mechanical lift, what assistive devices they used and their weight-bearing status. Therapy updated the passports with changes. Her role in preventing falls included red rounding, which you see on the door, and frequent rounding. When a resident needed assistance with toileting, staff checked the passport to make sure they were not a two-person assist. Staff transferred residents by whichever means was appropriate; let them have their privacy by standing outside the door by the bathroom, and made sure they had their light to pull when they were finished. We leave nobody on the toilet alone. She was asked if she recalled a fall incident that occurred on 11/20/25 with Resident #1. She stated, Yes. She recalled standing in the hallway at her cart when she saw a therapist standing in the hallway looking around, like he was trying to decide what to do. The call light was going off in the room where he was standing. At that time the therapist left, and the CNA was coming around the corner. The CNA asked LPN X, Who put this lady on the toilet? The CNA went back into the room and by the time LPN X reached the room, the CNA was with the resident in the bathroom; the resident was on the floor. On 12/09/25 at 2:40 PM an interview was conducted with CNA V. She knew what level of care the residents needed, including any precautions or restrictions they had, from shift report, talking to the nurse, the electronic plan of care and the resident folders behind the nursing desk. She knew which residents were at risk for falls because they had a wrist band, neighborhood watch (eyes) on the door, or they had a star on their door. They got that information in report also. The facility process for toileting a resident who was a fall risk was to supervise them going to the toilet. She left their bathroom door open but closed the door to the room so she could see them and give them privacy. We never leave a person on the toilet by themselves; they must always be in reach. CNA W recalled a fall incident that occurred with Resident #1 on 11/20/25. She stated she was not working with her that day; she was working in room [ROOM NUMBER]. She came around the corner and saw her call light was on. She walked over to her room and saw LPN X down the hall. When she asked the nurse who put Resident #1 on the toilet, LPN X said therapy was in the room with her. When CNA V went in, there was no one there. CNA V then saw Resident #1 on the floor in the bathroom. She went to the door and yelled for the nurse to come because the resident was on the floor. She asked LPN X if the therapist told her Resident #1 was left on the toilet; LPN X said, No. CNA V explained that he had not told her either. CNA V was asked if this resident had a passport at the time of the fall. She stated, Yes, it was light blue. She also confirmed there was red rounding signage on the resident's door at that time.PTA D was interviewed on 12/8/25 at 3:00 PM. He explained that the evaluating therapist created the residents' passports upon initial evaluation. The passport color was changed from blue (standard) to orange in cases involving falls. The passport was put in place immediately and was typically used by the CNAs; this was especially for the PRN (as needed), 2nd and 3rd shift CNAs, as they had little to no contact with the therapy team. For the first therapy day, the resident's chart was pulled up by the treating therapist or aide. It included a diagnosis, weight-bearing status, and functional status. Assistive devices including braces were noted, and if under a doctor's order would be listed as a precaution. He was not sure who transcribed physician's orders for braces into the medical record, but therapy staff saw those on the daily schedule. Braces and immobilizers usually came with the resident from the hospital and were sometimes noted on the passport. They should be but would also be listed under precautions and in the electronic medical record (EMR), which all therapy staff had access to. An interview was conducted with the Lead COTA (LC) on 12/8/25 at 3:25 PM. She explained that an evaluating therapist saw newly admitted residents the morning after admission. The results went into therapy under precautions. When the daily therapy schedule was printed, those precautions were printed on the schedule. When the resident walked in, staff had all of the precautions. Staff were expected to read that before they worked with the resident. Passport was a system meant for CNAs, nurses or other therapists like as-needed staff who had not worked with the resident. Or, if a call bell rang and you assisted a resident who you did not know, the information traveled with the resident. You can't say, I didn't know what to do with the person. It is right there. The evaluating therapist completes the passport at the time of the initial evaluation. The star and red covered paper on resident doors are for falls and red rounding. Staff initial every time they lay eyes on residents during red rounding. Everyone, with no exception, must have stand-by assistance with toileting. If a resident feels like they need that (private) space, the nurse must determine if the resident is safe to sit alone. So, if you are not safe, then taking you to the toilet and leaving you there alone is not safe to do. If a patient goes to an appointment post-surgery or post-injury, therapy sends a packet to the doctor. The packet asks for weight bearing status, braces or orthotic schedules, etc. The form comes back to the Unit Manager, is scanned into and shows up on the [EMR]. The information is forwarded to the Director of Rehab (DOR) and to all therapy leads. The lead then updates the information in the precautions. When asked about Residents #1 and #2, the LC recalled that Resident #1 went to the hospital after her second fall. She was frail with little appetite and had to be handled with kid gloves. She fell first with family in the parking lot, so they changed her passport from blue to orange to alert that a fall had occurred. Then she fell from her bathroom toilet. [PTA B] is not negligent. She had asked him to assist her onto the toilet. Instead of standing there, he left. He could have called or used the call bell. [Resident #1] went to the intensive care unit. Resident #2 was with [COTA A] when she lost her balance and fell. He was attempting a laundry task with her. Her passport had the leg brace on it; it was to be on all the time. [COTA A] did not read the passport. [Resident #2] sustained two small fractures and was non-weight bearing for two weeks. Sometimes passports go unnoticed, but therapy issues constant reminders to check them. It was about knowing the passport was there, not paying attention, and not realizing the brace wasn't on. The LC said her [NAME] was, When in doubt, don't do it! Better off being safe.During an interview with COTA A on 12/9/25 at 11:46 AM, he confirmed that the daily therapy schedule received each morning had all resident information on it. He stated he could also see the resident's transfer status in the [EMR]. The passport information was supposed to be consistent. He said he worked with Resident #2 once before. The day of the event was supposed to be her last day of therapy. On the day of the fall, they were going over a simulated laundry activity. The basket that hooked onto the top and side of her walker came loose. As he was fixing the basket, she stepped back onto her right leg, lost her balance and fell. She had her gait belt on, but he couldn't get to her fast enough. Prior to fall, she had good balance and was walking. The leg brace was not on the daily notes or the schedule and was not on the resident. Usually, the evaluating therapist put that information into the system. After the incident, within about a week, an all-staff meeting was held. They went over the incident and went over it one-on-one with the DOR. The DOR was interviewed on 12/9/25 at 12:03 PM. She stated the OT or PT initiated the passports which went in the sleeve on the back of the wheelchairs. Those contained basic information such as how a resident transferred and orthotic devices in use. The same information went in the therapy evaluation under precautions, which could also be seen in the EMR. When a therapist or assistant got a resident the first time, they got information regarding needed support and devices from the precautions or the initial evaluation. They could also review the passport. Resident #2 was with COTA A doing laundry and was scheduled to discharge the next day. The laundry simulator basket hook came loose and when COTA A went to move the basket, Resident #2 stepped back with her right leg, which she wasn't supposed to do due to her hip. She immediately complained of knee pain. X-rays were all negative, but that knee was swollen and painful. Then a mild tibial plateau fracture was discovered. She had gone to her orthopedic doctor on 10/31/25; he recommended she wear a brace, as her right knee was buckling, but there was a breakdown. The physician's order for the brace was supposed to be scanned into email for the DOR. Unfortunately, that precaution didn't show up on the daily schedule like it was supposed to. As for Resident #1, she had a prior fall while with family on 11/17/25. The day of the most recent fall, PTA B went to get Resident #1 for therapy, but she said she needed to go to the bathroom first. PTA B transferred her to the toilet and stepped into the hall to find a CNA, but the nurse couldn't find the CNA. He laid the call light across Resident #1's lap, asked her to use the call light and not get up, and left. Unfortunately, she fell. Reports are that the call light went on immediately. The nurse saw the PTA exit the room and described his behavior as kind of frantic; he was rushing like he had too many places to go. Resident #1 sustained a hematoma and a small subarachnoid hemorrhage, was transferred out, and did not return.A review of the facility's policy titled Fall and Injury Reduction Best Practice Guidelines (BC ADMIN-035 Effective/Last Reviewed/Updated 05/2025), revealed:The policies and procedures are intended to promote fall and injury reduction activities during the daily care of residents. All newly admitted residents are to be considered a fall risk until evaluated. Guest passports are to be used as a means of communication regarding resident transfer status. For toileting, all residents with a STOP sign in their room require staff to remain at arm's length/line of sight inside the bathroom. Do not leave high risk residents unattended on the toilet. Assist the resident back to bed before you leave. (Photographic evidence obtained)A review of the facility's Bathroom Safety Best Practice guidelines instructed staff to never leave high

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility, by failing to 1) Date mark numerous open bundles of bread on the bread rack, 2) Clean grease buildup inside and around the door area of the convection oven, and 3) Clean food debris stuck on and around the safety guard of the mixer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 05/22/2024 at 7:00 AM. During the tour, the bread rack adjacent to the juice machine was observed with four open bundles of bread with no date markings. The inside door area and oven floor of the convection oven next to the steamer was covered with food grime and grease build-up. The mixer located next to the prep table was observed with food debris stuck on and around the safety guard. During the same tour, a test tray left the kitchen on the 100 hallways cart at 7:45 AM. The 100 hallways received their food cart at 7:46 AM. This surveyor received the test tray at 8:10 AM. Milk received on the food tray had a temperature of 56 F. The milk was discarded. At 8:20 AM, one milk carton pulled from a plastic bin with no ice, filled with other cartons of milk sitting on top of a cart and used for the tray line, tested at 62 F. All milk in the plastic bin was discarded. (Photographic evidence obtained) A tour of the kitchen was conducted on 05/23/2024 at 10:30 AM. New observations of eight open bundles of bread were observed on the bread rack with no date markings. The same observations as were made on 05/22/2024, were made again of the inside door area and oven floor of the convection oven covered with food grime and grease build-up, and the mixer located next to the prep table with food debris stuck on and around the safety guard. (Photographic evidence obtained) An interview was conducted with Cook A on 05/23/2024 at 10:17 AM. She stated when bread was opened, used, and placed back on the bread rack, it was closed tightly and placed on the rack. The cooks were responsible for cleaning the kitchen and food service equipment. The ovens were cleaned nightly. She acknowledged cleaning the oven once. She stated a staff member from the hospital came to the facility and deep cleaned the ovens; she was not sure when. The mixer was cleaned after each use by the staff member who used it, maybe once a week. An interview was conducted with the Executive Chef on 05/23/2024 at 11:00 AM. He stated the facility policy for date marking bread was to label, date, and discard after three days. Bread should be sealed tight, labeled and dated with a date used first sticker. Kitchen and food service equipment was wiped down nightly, sprayed and scrubbed every two weeks. The mixer was used maybe three times weekly and cleaned after each use. During an interview with the Certified Dietary Manager (CDM) on 05/23/2024 at 11:23 AM, the CDM confirmed the facility policy for date marking was to seal and label with date opened. Bread was discarded if not properly resealed. The cooks, chef, and the CDM were responsible for cleaning the kitchen and food service equipment. General cleaning was done weekly and deep cleaning was completed monthly. The cook and chef were responsible for cleaning the mixer after each use and deep cleaned weekly and monthly. A review of the facility's policy and procedure titled Work Area and Equipment Sanitation (last reviewed 12/2022), revealed: Food Service maintains a high standard of cleanliness of equipment, work areas, and floor. Each employee is responsible for cleaning his/her own work area and equipment. (Copy obtained) Reference: FDA (U.S. Food and Drug Administration) Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 5/24/2024): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on record reviews, interviews, and facility policy and procedure review, the facility failed to notify the resident, the resident's representative, and the office of the Long-Term Care Ombudsman of the resident's transfer and the reasons for the transfer in writing for one (Resident #1) of three residents reviewed for hospitalization . The findings include: A review of Resident #1's medical record found he was admitted from an acute care hospital to the facility on [DATE]. He had diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, Human Immunodeficiency Virus (HIV), unspecified Atrial fibrillation, Peripheral Vascular Disease (PVD) and benign prostatic hyperplasia without lower urinary tract symptoms. Resident #1's medical record revealed that he had his wife designated as his primary emergency contact and responsible party. A review of the resident's nursing progress notes revealed that on 9/20/23 at 2:09 pm, Employee E, Registered Nurse (RN)/Unit Manager (UM) was summoned by the therapist who was performing exercises in the resident's room. Resident #1 was unable to perform his exercises due to bleeding sores all over his body. Upon assessment, the resident's upper thigh had more wounds and they were profusely bleeding. Resident #1 complained of itching and kept scratching his sores. He was using napkins to stop the bleeding site. The resident was not following instructions and kept picking the sores. The doctor was made aware and ordered the resident sent to the hospital for evaluation and proper management. The wife was notified and became upset. She refused for the husband to go to the referred hospital because they had had a bad experience, and they did not receive good service in the past. The Director of Nursing (DON), Assistant Director of Nursing (ADON) and Medical Director were notified and decided to send the resident to the hospital from where he was admitted to the facility. The note indicated, At this time, we are not able to meet the resident's needs. He requires more monitoring and proper management. (Copy obtained) The DON was interviewed on 10/12/23 at 5:27 pm who stated she contacted the hospital discharge planner. She confirmed Resident #1 physically left the faciity on [DATE]. She stated the facility contacted the hospital to advise them they could not meet the resident's needs because of the bleeding, and it was then the hospital advised the facility that the resident was being admitted . The DON stated the facility also notified the resident's wife of the discharge. She was asked to provide a copy of the discharge summary or Nursing Home Transfer and Discharge Notice AHCA form 3120-0002. She stated the resident received the discharge forms. On 10/12/23 at 5:46 pm, the DON and Social Services Director (SSD) returned with a blank Nursing Home Transfer and Discharge Notice AHCA form 3120-0002. They were asked if it was the form the surveyor requested. The purpose of the form was explained to staff. The SSD stated they would need to contact medical records. On 10/12/23 at 6:01 pm, the DON stated they were not able to locate a discharge summary or Nursing Home Transfer and Discharge Notice AHCA form 3120-0002 for Resident #1. She confirmed Resident #1 was not readmitted to the facility and stated they were unsure of his current location. She confirmed he should have received the form and stated there isn't a separate policy to address hospital transfers. A phone interview was conducted with Resident #1's wife on 11/3/23 at 10:06 am. She stated the facility informed her that her husband was being transferred to the hospital for treatment on 9/20/23. She was not aware that they were not allowing him to return until she received a call from the hospital the following day. She stated she never received a phone call or any paperwork from the facility regarding a bed-hold or discharge. She stated the hospital informed her that the facility refused to accept the resident back because he was HIV positive and bleeding profusely from his wounds. She stated the resident had MRSA which left him with the sores on his body. However, he does not have HIV and should have been allowed to return to the facility for wound care. The wife stated the resident was discharged home from the hospital after the facility continuously refused to accept him back. She stated no one from the facility has contacted her regarding the resident's status nor had she received anything from them since he was discharged . On 11/3/23 at 10:36 am, a phone interview was conducted with the Ombudsman. She stated as of today, she has not received a notice of discharge for Resident #1 from the facility. She added that she has made attempts to make herself available to the facility for transfer and discharge training. Review of the facility's policy for Notice of Transfer and Discharge (policy BC ADM-005) effective 6/13 and last review/update on 6/23 revealed: Purpose: To develop a process to notify a Guest/Resident about a Notice of a Transfer and or Discharge from facility. a. The transfer is necessary for the Guest/Resident's welfare and the Guest/Resident/Elder's needs cannot be met in the facility; 2. The Guest/Resident and/or representative (sponsor) will be provided with the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the Guest/Resident is being transferred or discharged ; d. The name, address, and telephone number of the state long-term care ombudsman; A resident has the right to request an ombudsman to review the notice. If the resident request notice to be reviewed by the local ombudsman the facility will transmit the request to review within 24 hours to the local district office. In emergency discharge situation a request for ombudsman review will be transmitted to the ombudsman by telephone or in person. (Copy obtained)

Based on record reviews, interviews, and facility policy and procedure review, the facility failed to provide written information prior to hospital transfer that notified the resident/resident representative of the facility's bed hold policy for one (Resident #1) of three residents reviewed for hospital transfer. The findings include: A review of Resident #1's medical record found he was admitted from an acute care hospital to the facility on [DATE]. He had diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, Human Immunodeficiency Virus (HIV), unspecified Atrial fibrillation, Peripheral Vascular Disease (PVD) and benign prostatic hyperplasia without lower urinary tract symptoms. Resident #1's medical record revealed that he had designated his wife as his primary emergency contact and responsible party. A discharge minimum data set (MDS) assessment with a reference date of 9/20/23, indicated unplanned discharge, return anticipated. Cognitive skills for decision making: moderately impaired. The activities of daily living (ADL) section revealed Resident #1 required supervision with bed mobility, transfers, locomotion on/off the unit, walking in the room/corridor, toilet use and personal hygiene. Resident was coded No for risk of pressure ulcers/injuries and unhealed pressure ulcers/injuries. The brief interview for mental status (BIMS) was not assessed. (Copy obtained) Resident #1 was care planned on 9/17/23 with focuses on bleeding due to use of anti-coagulants, impaired skin, HIV infection, and decreased ADL self-performance. Goals included reduced risk for signs and or symptoms of abnormal bleeding and no skin breakdown/impairment by next review date. Interventions included medications as ordered, report to MD any signs/symptoms of abnormal bleeding, turning and repositioning during care rounds, and weekly skin sweeps and monitor. (Copy obtained) A review of the resident's nursing progress notes revealed that on 9/20/23 at 2:09 pm, Employee E, Registered Nurse (RN)/Unit Manager (UM) was summoned by the therapist who was performing exercises in the patient's room. Resident #1 was unable to perform his exercises due to bleeding sores all over his body. Upon assessment, the resident's upper thigh had more wounds and they were profusely bleeding. The resident complained of itching and kept scratching his sores. He was using napkins to stop the bleeding site. The resident was not following instructions and kept picking the sores. The doctor was made aware and ordered the resident sent to the hospital for evaluation and proper management. The wife was notified and became upset. She refused for the husband to go to the referred hospital because they had had a bad experience, and they did not receive good service in the past. The Director of Nursing (DON), Assistant Director of Nursing (ADON) and Medical Director were notified and decided to send the resident to the hospital from which he was admitted to the facility. The note indicated, At this time, we are not able to meet the resident's needs. He requires more monitoring and proper management. (Copy obtained) A phone interview was conducted with Resident #1's wife on 11/3/23 at 10:06 am. She stated the facility informed her that her husband was being transferred to the hospital for treatment on 9/20/23. She was not aware that they were not allowing him to return until she received a call from the hospital the following day. She stated she never received a phone call or any paperwork from the facility regarding a bed-hold or discharge. She stated the hospital informed her that the facility refused to accept the resident back because he was HIV positive and bleeding profusely from his wounds. She stated the resident had MRSA which left him with the sores on his body. However, he does not have HIV and should have been allowed to return to the facility for wound care. The wife stated the resident was discharged home after the facility continuously refused to accept him back. She stated no one from the facility has contacted her regarding the resident's status nor had she received anything from them since he was discharged . Further review of Resident #1's record revealed there was no bed hold notice provided to the resident or representative notifying them of the facility's bed hold policy, the duration the bed would be held in his absence, or any daily room rate should the resident/representative choose to hold a bed while hospitalized . An interview was conducted with Employee G, the Business Office Manager (BOM) on 11/3/23 at 12:13 pm, who stated the resident was not contacted regarding a bed hold for his transfer on 9/20/23. The BOM stated she was not sure why the bed hold was not done. She stated typically when a resident goes out to the hospital, the business office will contact the resident or their family and follow up with admissions to see if the resident will be returning to facility. She again stated she was not sure why the resident was not contacted about a bed hold. She stated the business office, or the nurse manager will usually communicate with the patient or responsible party. The BOM stated the bed-hold can be signed upon admission; however, the business office may still follow-up with residents when they go out to the hospital. She again confirmed there was no bed-hold for Resident #1 and that it would have been appropriate for him to receive the bed-hold upon being transferred to the hospital. During an interview with the Administrator on 11/3/23 at 1:49 pm, he stated the resident wasn't allowed to return due to his excessive bleeding. He stated he and the DON spoke to the discharge planner at the hospital regarding their concerns. He felt the hospital did not accurately assess the resident and instead were inappropriately attempting to send him back to the facility. He felt the hospital needed to see the resident's bleeding. He acknowledged the facility refused to accept the resident back. He stated under normal circumstances Resident #1 would have been allowed to return; however, due to the excessive bleeding, they felt it was not safe for him to return to the facility. The administrator stated he was not sure if a bed hold was issued. He stated that would have come from the business office. Review of the facility's policy on bed holds which is included in all admissions packet revealed: K. Bed Holds. You may need to be absent from the Skilled Nursing Facility temporarily for hospitalization or therapeutic leave. You may request that we hold your bed during this time. This is known as a bed hold. You shall be given notice of the bed hold option at the time of admission and upon hospitalization or therapeutic leave. (Copy obtained) Review of the facility's policy for Bed Holds and Notice Acknowledgement (policy BC ADM-001) effective 6/23 and last review/update on 7/23 revealed: Policy: Facility will follow Florida Policy on Bed Holds and Notice Acknowledgement. D. Facility Bed Hold Policy - The facility will reserve the bed of a resident who has been transferred to a hospital or who otherwise leaves the facility with the expectation of returning in the near future, as long as payment is made in advance to reserve the bed in accordance with the facility's bed hold charge. The resident/responsible party agrees that in the event of such temporary leave from the facility the facility shall reserve the bed until such time that the advance payment ceases to cover the bed hold or the facility is notified by the resident/responsible party that the bed should no longer be reserved. The facility will similarly reserve the bed, as long as payment is made in advance in anticipation of pending admission. The facility bed hold charge is FULL Price per day. (Copy obtained)

Based on record reviews and interviews, the facility failed to permit a resident to return after a transfer to the hospital for one (Resident #1) of three residents reviewed for transfer/discharge. The findings include: A review of Resident #1's medical record found he was admitted from an acute care hospital to the facility on [DATE]. He had diagnoses including, but not limited to, encounter for orthopedic aftercare following surgical amputation, acquired absence of other right toes, Human Immunodeficiency Virus (HIV), unspecified Atrial fibrillation, Peripheral Vascular Disease (PVD) and benign prostatic hyperplasia without lower urinary tract symptoms. A telephone interview was conducted with the hospital discharge planner on 10/12/23 at 10:26 am regarding Resident #1. She stated the resident was previously sent to the hospital on 9/18/23 and returned to the facility the same day. Resident #1 returned to the hospital emergency department on 9/20/23 at approximately 3:30 pm for observation. The resident was there less than 30 minutes when the doctor said he was stable and that there was no medical reason for him to remain at the hospital. She said when they contacted the facility's Director of Admissions and Administrator, they declined to accept the resident back. She stated neither could provide a clear reason why they wouldn't readmit the resident. She stated the hospital made attempts to find a long-term acute care center for the resident, but he didn't qualify for admission. As a result, the resident remained at the hospital until the doctor ordered him to be discharged home with home health. Resident #1's medical record revealed that he had designated his wife as his primary emergency contact and responsible party. A discharge minimum data set (MDS) assessment with a reference date of 9/20/23, indicated unplanned discharge, return anticipated. Cognitive skills for decision making: moderately impaired. The activities of daily living (ADL) section revealed Resident #1 required supervision with bed mobility, transfers, locomotion on/off the unit, walking in the room/corridor, toilet use and personal hygiene. Resident was coded No for risk of pressure ulcers/injuries and unhealed pressure ulcers/injuries. The brief interview for mental status (BIMS) was not assessed. (Copy obtained) Resident #1 was care planned on 9/17/23 with focuses on bleeding due to use of anti-coagulants, impaired skin, HIV infection, and decreased ADL self-performance. Goals included reduced risk for signs and or symptoms of abnormal bleeding and no skin breakdown/impairment by next review date. Interventions included medications as ordered, report to MD any signs/symptoms of abnormal bleeding, turning and repositioning during care rounds, and weekly skin sweeps and monitor. (Copy obtained) A review of the resident's nursing progress notes revealed that on 9/20/23 at 2:09 pm, Employee E, Registered Nurse (RN)/Unit Manager (UM) was summoned by the therapist who was performing exercises in the resident's room. Resident #1 was unable to perform his exercises due to bleeding sores all over his body. Upon assessment the resident's upper thigh had more wounds and they were profusely bleeding. The resident complained of itching and kept scratching his sores. He was using napkins to stop the bleeding site. The resident was not following instructions and kept picking the sores. The doctor was made aware and ordered the resident sent to the hospital for evaluation and proper management. The wife was notified and became upset. She refused for the husband to go to the referred hospital because they had had a bad experience, and they did not receive good service in the past. The Director of Nursing (DON), Assistant Director of Nursing (ADON) and Medical Director were notified and decided to send the resident to the hospital from where he was admitted to the facility. The note indicated, At this time, we are not able to meet the resident's needs. He requires more monitoring and proper management. (Copy obtained) An interview was conducted with Employee E, RN/UM on 10/12/23 at 4:06 pm. She confirmed Resident #1 was sent to the hospital on 9/20/23. She stated it was his second time going to the hospital after being admitted on [DATE]. He was sent to the hospital on 9/18/2023 for excessive bleeding and returned to the facility that same day. However, he wasn't readmitted after the hospitalization on [DATE] because the facility could not meet his needs due to the profuse bleeding. She stated the hospital didn't treat the resident and every time they would touch him, he would bleed. The resident was confused and was picking at his skin and the facility was worried about infections. She stated there was no discharge paperwork because the resident went out to the hospital. She confirmed the resident had not returned to the facility. An interview was conducted with the Social Services Director/Discharge Planner (SSD) on 10/12/23 at 5:07 pm, who was familiar with Resident #1. She stated he went out to the hospital twice, adding he went once and came back. Then he went back and was admitted . The SSD stated she had been out and did not see him for a full assessment. She stated if a resident is transferred to the hospital, it's anticipated that they will return to the facility. She then retrieved a Nursing Home Transfer and Discharge Notice AHCA form 3120-0002 and stated that the resident should have one on file. She then left the room to look for the form. An interview was conducted on 10/12/23 at 5:27 pm with the Director of Nursing (DON), who stated she contacted the hospital discharge planner. She confirmed Resident #1 physically left the faciity on [DATE]. She stated the facility contacted the hospital to advise them they could not meet the resident's needs because of the bleeding, and it was then the hospital advised the the facility that the resident was being admitted . The DON stated the facility also notified the resident's wife of the discharge. She was asked to provide a copy of the discharge summary or Nursing Home Transfer and Discharge Notice AHCA form 3120-0002. She stated the resident received the discharge forms. On 10/12/23 at 5:46 pm, the DON and SSD returned with a blank Nursing Home Transfer and Discharge Notice AHCA form 3120-0002. They were asked if it was form requested by the surveyor. The purpose of the form was explained to staff. The SSD stated they would need to contact medical records. On 10/12/23 at 6:01pm, the DON stated they were not able to locate a discharge summary or Nursing Home Transfer and Discharge Notice AHCA form 3120-0002 for Resident #1. She confirmed Resident #1 was not readmitted to the facility and stated they were unsure of his current location. She confirmed he should have received the form and stated there isn't a separate policy to address hospital transfers. A phone interview was conducted with Resident #1's wife on 11/3/23 at 10:06 am. She stated the facility informed her that her husband was being transferred to the hospital for treatment on 9/20/23. She was not aware that they were not allowing him to return until she received a call from the hospital the following day. She stated she never received a phone call or any paperwork from the facility regarding a bed-hold or discharge. She stated the hospital informed her that the facility refused to accept the resident back because he was HIV positive and bleeding profusely from his wounds. She stated the resident had MRSA which left him with the sores on his body. However, he does not have HIV and should have been allowed to return to the facility for wound care. The wife stated the resident was discharged home after the facility continuously refused to accept him back. She stated no one from the facility has contacted her regarding the resident's status nor had she received anything from them since he was discharged . An interview was conducted with Employee G, the Business Office Manager (BOM) on 11/3/23 at 12:13 pm, who stated that Resident #1 was not contacted regarding a bed hold for his transfer on 9/20/23. She stated she was not sure why the bed hold was not done. She stated typically when a resident goes out to the hospital, the business office will contact the resident or their family and follow up with admissions to see if the resident will be returning to facility. The BOM again stated she was not sure why the resident was not contacted about a bed hold. She stated the business office, or the nurse manager will usually communicate with the patient or responsible party. She stated the bed-hold can be signed upon admission; however, the business office may still follow-up with residents when they go out to the hospital. She again confirmed there was no bed-hold for Resident #1 and that it would have been appropriate for him to receive the bed-hold upon being transferred to the hospital. During a follow up interview with the DON on 11/3/23 at 12:35 pm, she again confirmed that Resident #1 was sent to the hospital for treatment for excessive bleeding. She stated the resident needed a higher level of care for his wounds. She stated the facility felt the hospital needed to appropriately assess the resident's condition instead of returning him to the facility. She confirmed that the bed hold was not discussed again, adding the resident needed a higher level of care. She stated they asked the family to provide a private sitter for the resident, but they could not. She stated the facility also made attempts to provide a private sitter to keep the resident safe; however, they also were unsuccessful. She stated the resident needed one-to-one care and that the facility did not have the staff to support that. During an interview with the Administrator on 11/3/23 at 1:49 pm, he stated that Resident #1 wasn't allowed to return due to his excessive bleeding. He stated he and the DON spoke to the discharge planner at the hospital regarding their concerns. He felt the hospital did not accurately assess the resident and instead were inappropriately attempting to send him back to the facility. He stated they felt the hospital needed to see the resident's bleeding. The administrator acknowledged the facility refused to accept the resident back. He stated under normal circumstances he would have been allowed to return; however, due to the excessive bleeding, they felt it was not safe for him to return to the facility. He stated he was not sure if a bed hold was issued. He stated that would have come from the business office. Further record review revealed the facility failed to enter a bed hold during Resident #1's hospitalization . Per billing census, a stop billing was entered on 9/20/2023.

Based on observations, interviews, and record reviews, the facility failed to ensure proper sanitation and food storage practices were adhered to in order to prevent the outbreak of foodborne illnesses. The findings include: During a tour of the kitchen on [DATE] at 10:52 AM with Certified Dietary Manager (CDM) E, he stated he had been employed at the facility for approximately one year. At this time, he identified Food Service Utility Worker F as the primary dishwasher. He stated he completed weekly kitchen audits and all outdated and damaged food should be discarded. An observation of one of the kitchen freezers revealed an open pack of ground turkey labeled use by [DATE]. When asked about this, the CDM acknowledged it was out of date and stated, It's not on the menu. There was also an unopened package of veggie burgers labeled use by [DATE]. The CDM stated the burgers weren't open and were there just in case a vegetarian was admitted into the facility. As the tour of the kitchen continued, a box labeled red potatoes was observed sitting on a shelf in the kitchen. Upon opening the top of the box, small flying insects immediately exited the box into the air. Several of the flying insects were covering some of the potatoes inside of the box and some of the potatoes were rotten. The CDM looked into the box, observed the conditions, reached into the box, retrieved the rotten potatoes, and discarded them in a nearby garbage can. During an observation of the dishwasher on [DATE] at 11:37 AM, a sign was observed posted next to the dishwasher identifying it as a low-temperature machine. Food Service Utility Worker F was asked to test the sanitation level of the dishwasher. He stated he had never done this before and was unsure of how to perform the test. When asked for the sanitation log and who was responsible for performing this test, he replied there was no log, and no one had been performing the test. At this time the CDM interjected and stated the dishwasher was a high-temperature machine and did not require sanitation testing. He stated the rinse temperature should reach 180 degrees. Food Service Utility Worker F began testing the dishwasher running a few items through. Initially, the rinse temperature did not register, so he restarted the process. Again, the rinse temperature did not register. (Photographic evidence obtained) Food Service Utility Worker F stated this had happened in the past. He was asked what he did when this occurred. He replied, I wait until it starts working. After he waited a few more minutes, he attempted to test the dishwasher again by running through more items. This time the rinse temperature registered at 158 degrees Fahrenheit (F). (Photographic evidence obtained) At 11:46 AM, the CDM was asked what should be done. He stated he should call maintenance, as they were responsible for the dishwasher, but neither he nor Food Service Utility Worker F contacted anyone at that time. Food Service Utility Worker F stopped using the dishwasher and turned it off. The tour of the kitchen continued. At 11:56 AM, flying insects were observed near the prep station next to the fryers. The CDM denied seeing the insects. Again, insects were observed in the area and again the CDM denied the observation. While checking the coolers in the kitchen, 19 expired cartons of chocolate milk were observed in the stand-up cooler near the serving station. The CDM confirmed the observation, acknowledging that the items were all expired. During an interview with the CDM on [DATE] at 12:06 PM, he was asked about the expired chocolate milk and who was responsible for ensuring that items in the cooler were within the appropriate date range. He stated it should be checked nightly by the nighttime staff. As the tour of the kitchen continued, the surveyor returned to the dishwasher. Food Service Utility Worker F turned on the dishwasher and ran through more items. At this time the rinse temperature registered at 160 degrees F. (Photographic evidence obtained) The CDM stated he would contact maintenance. At this time he was advised to discontinue use of the dishwasher and not use items that were washed while the rinse temperature was not registering. On [DATE] at 12:13 PM, Maintenance Director H and Food Service Utility Worker F were observed at the dishwasher. They began testing the dishwasher and again the rinse temperature did not register. On [DATE] at 3:03 PM, the CDM advised that he had contacted the dishwasher service company to diagnose and repair the dishwasher. At this time he was again advised that he could not use the dishwasher or anything previously washed when the rinse temperature was not registering. He was advised at this time that he would need to use disposable dishware for meals until the repairs had been made. He nodded and replied, Oh, okay. On [DATE] at 4:37 PM, the kitchen staff were observed preparing dinner using regular dishware. The CDM was immediately notified of this and asked why disposable dishware was not being used. He stated he didn't understand, and he assumed the surveyor was referring to the dishes that would be used for breakfast the next day. At 4:44 PM, the kitchen staff were observed preparing meals on black paper plates. The plates were uncovered and were being placed on the counter before being transferred to the meal delivery cart. (Photographic evidence obtained) At 4:48 PM, after observing several plates on the counter, the CDM was asked about the black paper plates with no covers. He was specifically asked how the food would hold its temperature until it was received by the residents. He initially asked what he should do, then he asked if he could use the tray domes on the rack. When asked whether they had been washed in the dishwasher after lunch, he replied that they had. Again, he was advised that for sanitation purposes, items that had been washed in the dishwasher while the rinse temperature was not registering could not be used for food service. On [DATE] at 9:33 AM, the facility provided a service order receipt for the dishwasher repair dated [DATE] at 6:37 PM. The notes on the service order receipt read, Found bad Final Rinse temperature sensor. The receipt also advised that the unit was to operate at set point of booster heater to 180 degrees plus 10 degrees F during final rinse operation. (Photographic evidence obtained) A review of the instruction manual on the CLe-Series Dishwashers F Rev. C ([DATE]) revealed the machine could be operated as a low- or high-temperature machine. Per page 25, the minimum temperature for the final rinse cycle using high temperature sanitizing was 180 degrees F (82 degrees C). (Photographic evidence obtained)

Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, by failing to ensure that two (Residents #23 and #73) of 25 sampled residents received care as ordered by the physician. Resident #73 had orders for follow up with oncology due to a history of [CONDITION(S)], and Resident #23 had orders for laboratory diagnostic tests. These orders were not carried out. The findings include: 1. On 06/21/22 at 3:41 PM, Resident #23 stated she did not always get her prescribed cream. Staff told her they didn't have it on hand and would use her personal Vaseline ointment instead. A review of Resident #23's clinical record revealed she was admitted on [DATE] with a re-entry on 7/20/19. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/1/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating she was cognitively intact. She also required extensive assistance for bed mobility, transfers and toileting. A Nursing Progress Note, dated 6/3/22, indicated the certified nursing assistant (CNA) noted that the resident had a small amount of brownish drainage from her left breast with no complaints of pain noted. A Nursing Progress Note, dated 6/4/22, read, Received report this morning from nurse that resident had some brown discharge from left nipple, assessed patient, noted with her blouse sticking to the nipple, noted blood coming out. Called physician (MD). New orders to apply [MEDICATION(S)] ointment twice daily (BID) and may need a mammogram in future. An Internal Medicine Progress Note, dated 6/19/22, indicated that Resident #23 complained of some bleeding from her right and left breast; some pain worse when staff were transferring her using a Hoyer (mechanical) lift. The resident had missed an appointment with oncology. The note continued, stating bleeding was observed from the breast; resident has a history of [CONDITION(S)]. Discussed with nurse to arrange follow-up for the resident-she had missed a couple times already. (Copy obtained) In an interview on 6/23/22 at 2:23 PM, Resident # 23 stated she was aware that she had [CONDITION(S)] and she was supposed to have surgery, but every time she tried to go to her appointments there was no transportation, therefore, she missed most of her appointments. She added that she believed her condition had worsened since she was pain and had discharge from her left breast. She lifted her blouse and revealed an allevyn foam dressing on the left nipple. The dressing was dated 6/20/22. She stated she had spoken to her physician regarding the need to get assistance scheduling her oncology appointment, but she had not received any feedback. In an interview with Licensed Practical Nurse (LPN) D on 6/23/22 at 2:27 PM, she was asked to explain the process for making resident appointments. She stated the person who received the appointment order, entered it in the resident's electronic medical record. After the order was entered, the individual responsible for scheduling made the appointment. When asked if Resident #23 had any appointments, she stated this resident normally made her own appointments. LPN D was asked who/which staff member was responsible for following up to ensure that the resident scheduled the appointments as ordered. LPN D stated, I am not sure. I will ask the unit manager. She checked the resident's record and stated, There are no orders for appointments. She was asked to review Resident #23's physician's progress note. LPN D confirmed that the nurse who was informed of the issue should have entered the order in the electronic medical record. When asked about the drainage and the dressing on the resident's breast, LPN D stated,I am not aware of any drainage. The resident has orders for [MEDICATION(S)] under her breast, and I have not put it on today. There is no dressing order. She added that she would get with the physician and the unit manger for order clarification and then schedule the appointment. In an interview with LPN C/Unit Manager on 6/23/22 at 2:30 PM, he confirmed that there were no appointment orders or appointments scheduled for Resident #23. He stated he would follow up as soon as possible. When asked about the dressing on the resident's breast, he stated he was not aware that the resident had any drainage from her breast. He added that he would follow up with the resident. In an interview with the Director of Nursing (DON) on 6/23/22 at 2:46 PM, she was asked who was responsible for reviewing residents' charts. She stated the 11:00 PM - 7:00 AM shift nurses were expected to review the progress notes nightly and transcribe/carry out the orders if they had not been completed. When asked about Resident # 23, The DON stated this resident made her own appointments. When asked if there was a process in place to ensure that the resident scheduled the appointments as ordered, she stated she would follow up with the unit manager since she did not see any orders in the electronic medical record. On 6/23/22 at 4:04 PM, a follow-up interview was conducted with the DON. She stated Resident #23 was agreeable to having the facility book her an appointment. She confirmed that there was no order for the allevyn dressing, but the resident wanted it on. New orders were obtained for the dressing. A Nursing Progress Note, dated 6/23/22, read,Per physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . I called the physician and order given for patient to have oncology consult for the left breast nipple drainage as well as in-house wound care nurse to evaluate. (Copy obtained) 2. A review of Resident #73's clinical record revealed an admission on 9/15/14 with a re-entry on 2/27/16. Her primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Her secondary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the June 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan revealed that Resident #73 required extensive to total assistance with Activities of Daily Living (ADL). Resident #73 was being followed by a psychiatry services with the most recent visit conducted on 6/16/22. Plan: Continue medication [MEDICATION(S)] for depression, [MEDICATION(S)] for anxiety, dextromethorphan-[MEDICATION(S)] for PBA, and [MEDICATION(S)] for poor appetite. A Nursing Progress Note, dated 6/3/22, indicated that a CNA reported vaginal bleeding in brief, writer checked the brief and resident had slight bleeding coming from the vaginal area. Writer notified the physician and order given for vaginal ultrasound. Writer was informed that the mobile imaging company did not perform those ultrasounds. Physician notified of updates. Physician mentioned to just monitor area. An Internal Medicine Progress note, dated 6/18/22, read , Resident is stable. Lab work Monday. In an interview with LPN B on 6/23/22 at 1:55 PM, she was asked for the recent laboratory results for Resident #23. She provided results dated 1/25/22. She checked the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked about the physician's progress note dated 6/18/22, she stated the night shift nurses were supposed to conduct chart audits and enter any orders in the electronic medical record. She stated the laboratory orders were also entered in the lab requisition book for the laboratory staff to sign after obtaining a specimen. LPN B proceeded to check the lab requisition book and stated there were no lab draws requested for Resident #73 on 6/20/22. In an interview with the DON on 6/23/22 at 3:06 PM, she was asked about Resident #73's labs indicated in the physician's progress note. She stated the physician would have put the orders in the electronic medical record. She added that at times physicians also gave verbal orders to the nurses. She mentioned that she would contact the physician to follow up. On 6/23/22 at 4:08 PM, a follow-up interview was conducted with the DON. She stated the physician stated he thought he had put the order in the electronic medical record. She added that new orders were received to have the labs carried out on 6/23/22. .

Based on interviews and record reviews, the facility failed to review gradual dose reduction recommendations for one (Resident #73) of five residents selected for [CONDITION(S)] drug review from a total sample of 25 residents. The findings include: A review of Resident #73's clinical record revealed an admission on 9/15/14 with a re-entry on 2/27/16. Diagnoses included [CONDITION(S)] following unspecified [CONDITION(S)] disease affecting unspecified cite, anxiety disorder, and major depressive disorder. A review of the June 2022 Physician's Order Sheets revealed active physician's orders for the following: [MEDICATION(S)] 20 milligrams (mg) every day (QD) for depression, [MEDICATION(S)] 2.5 mg every 12 hours for [CONDITION(S)] (DVT - blood clot), [MEDICATION(S)] 400 mg one time a day for poor appetite, Dextromethorphan-[MEDICATION(S)] 20-10 mg every 12 hours for pseudobablor affect PBA (sudden episodes of uncontrollable and inappropriate laughing or crying), and [MEDICATION(S)] 15 mg BID (twice daily) for anxiety. A review of the active care plan revealed that the resident was demonstrating generalized dissatisfaction with life, depressed mood, anxious feelings toward surroundings including staff and other residents, and often being short-tempered and frustrated with staff. [Resident #73] also has the potential for complications related to [CONDITION(S)] drug use. A review of the pharmacy recommendations, dated 3/29/22, revealed a recommendation for: Antidepressant gradual dose reduction attempt for [MEDICATION(S)] 20 mg QD since February, 2016. The guideline further read, All agents falling within the psychoactive category (without regard to indication) fall under gradual dose reduction guidelines. This includes agents within the antidepressant category. (Copy obtained) Another recommendation, dated 5/29/22, read, Federal guidelines state psychopharmacological drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in two different quarters with one month between attempts, then annually thereafter when used to manage behavior, stabilize mood, or treat psychiatric disorders. This resident has been taking the following anxiolytic without GDR: [MEDICATION(S)] 15 mg twice a day (BID) since 3/24/2017. (Copy obtained) A review of Resident #73's Medication Administration Record (MAR) for April 2022 through June 2022, revealed [MEDICATION(S)] 20 milligrams (mg) and [MEDICATION(S)] 15 mg BID for anxiety, were administered every day. (Copy obtained) In an interview with the Director of Nursing (DON) on 6/23/22 at 4:00 PM, she confirmed that Resident #73 received [MEDICATION(S)] 20 milligrams (mg) and [MEDICATION(S)] 15 mg BID for anxiety. She also confirmed that the GDR recommendations were not reviewed by the physician. A reviewed the facility's policy and procedure titled [CONDITION(S)] PRN (As Needed) Medication (Effective May 2017 and last Reviewed on May 2022), revealed, In accordance with State and Federal Guidelines, revised regulation 483.45 (e) [CONDITION(S)] Drugs states that based on a comprehensive assessment of a resident, the facility must ensure that: Residents who use [CONDITION(S)] drugs receive gradual dose reductions, and behavior interventions, unless clinically contraindicated.

Based on observations, resident and staff interviews, and resident and facility record reviews, the facility failed to maintain complete and accurate medical records for one (Resident #74) of two residents reviewed for non-pressure skin conditions, from a total of 25 residents in the sample. The findings include: An observation was conducted of Resident #74 on 06/21/22 at 1:29 PM. Multiple bruises were present on both forearms, and he had a dime-sized skin tear on the right forearm above his wrist. When he was asked what happened, Resident #74 replied he did not know; perhaps it was from his hospital bracelet. Observation confirmed a plastic snap-on medical identification bracelet secured loosely around his right wrist. On 06/22/22 at 11:07 AM, Resident #74 was observed in an activity on the 300 hall. The skin tear to his right forearm was visible and open to the air. The identification bracelet was still on the same wrist. Resident #74 reported the nurses were applying a salve to the area, and he would ask them to place the next bracelet on his left arm. An interview was conducted with Certified Nursing Assistant (CNA) A on 06/23/22 at 9:39 AM. She confirmed Resident #74 was assigned to her today on the 7:00 AM to 3:00 PM shift. She reported CNAs looked at residents' skin daily and reported any issues such as redness, discoloration, blisters, etc., to the nurse. CNA A stated Resident #74 was cognitively intact and pretty mobile but sometimes had involuntary movements due to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked about the skin tear, CNA A said she was unaware of it but would go look. She confirmed that the bruising and the skin tear should have been reported to the nurse. CNA A went to Resident #74, looked at the area, returned and confirmed its presence. She said she would tell the nurse and proposed removing the wrist band and placing it on his bed and place another one on his wheelchair to prevent further skin tears. Resident # 74 was observed again on 06/23/22 at 11:54 AM. The skin tear was still visible, and the medical identification bracelet was now on the arm of his wheelchair. Resident #74 had a quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 6/11/22. He had a brief interview for mental status score (BIMS) of 14 out of a possible 15 points, reflecting that he was cognitively intact. He had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section M reflected Resident #74 had no skin issues. Resident #74 was care planned on 6/13/22 for the potential for impaired skin due to his immobility with a goal to have no skin impairment though the next review period. The interventions included to inspect his skin during bathing and to notify the nurse immediately of any new areas. Notify the resident or responsible party of any new areas. (Photographic evidence obtained) Resident #74 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Complete a skin note. If skin is not intact, complete a change in condition-skin form. (Photographic evidence obtained) A review of the Treatment Administration Record (TAR) for May 2022 and June 2022 found the weekly skin checks were checked off as having been performed as ordered on June 1, 8 and 15, 2022. (Photographic evidence obtained) Corresponding nursing progress notes were authored on 6/1/22 and 6/15/22. Each noted Resident #74 presented with no new skin issues identified. There was no note for 6/8/22. Progress notes for the months leading up to June were reviewed with no mention of the area. (Photographic evidence obtained) A Skilled Nursing Facility Daily Nursing Documentation note, dated 6/21/22, found section C. #2 Integumentary (skin) asked if the patient had any skin impairment. The answer was No. (Photographic evidence obtained) An interview was conducted with Licensed Practical Nurse (LPN) B, assigned to Resident #74 on the 7:00 AM to 3:00 PM shift at 2:53 PM on 06/23/22. She stated she believed Resident #74 was on a blood thinner. The bruising to his forearms was fairly normal as he had very thin, fragile skin. Skin checks were performed daily on the evening shift for this resident. Any open or reddened areas, skin tears or bruises were to be recorded on the skin report. Skin checks were also noted on the Treatment Administration Record (TAR). Anything significant was written in a skin note. LPN B was told about the skin tear. She stated she did not know about it; when it occurred, or why it was not documented. CNA A had just reported it to her, but she had not gotten to Resident #74 yet, as she was passing medication. LPN B said she would always make a note for any new skin issue, clean it up, notify the physician and follow protocols. She confirmed a note should have been authored when the injury occurred. An interview was conducted with Unit Manager C on 06/23/22 at 4:00 PM. He was asked about resident skin assessments. He pointed out the posted schedule and explained they were to be conducted and documented weekly for every resident per the assigned schedule. All new issues were to be documented. Unit Manager C was asked if he was aware of Resident #74's skin tear, and if he knew when it may have occurred. He replied that he did not know when it occurred. He had seen the wound today and recognized it was not new. He said it should have been documented when it was identified. He acknowledged the highly visible wound was overlooked on multiple shifts by multiple licensed staff over an undetermined period of time. He had no explanation as to why the area was not documented. A review of the facility's policy and procedure Skin Care Protocol (#BC NUR-039 revised 05/2022) revealed: Purpose: The purpose of this policy is to: 1. Maintain optimal skin integrity . 2. Protect skin and tissue against adverse effect of external mechanical force . Policy: Skin of all individuals at risk is systematically inspected upon admission and daily . Procedure: .4. Document wound assessment and interventions daily in the medical record . The policy did not address the facility's weekly skin sweep protocol.

Based on observation, record reviews, and interviews, the facility failed to follow resident's person-centered care plans for prevention of falls for one (Resident #2) out of 3 residents reviewed for falls. The findings include: A review of Resident #2's clinical record revealed she was admitted to the facility on [DATE]. A review of Resident #2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the 5-day Material Data Set (MDS) dated [DATE], revealed she had a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognitive response. A review of the progress note dated 04/23/2021, revealed, Resident was found with over bed table under TV and wheelchair parked in front of table. Resident was lying on floor on right side of body in front of wheelchair. Range of motion and mental status within normal limits. A review of Resident #2's care plan indicated that she was a fall risk. Interventions included, alarms as ordered and a reacher for resident to avoid reaching so low. During an interview on 05/05/2021 at 2:09 PM with Employee B, Registered Nurse (RN) Unit Manager, she confirmed that Resident #2 sustained a fall on 04/23/2021. She stated that the post-fall huddle included the intervention to order Resident #2 a reacher to avoid reaching too low. When asked if Resident #2 had a bed and chair alarm, she stated, no, she's never had any alarms. When asked about Resident #2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/05/2021 at 3:00 PM, Resident #2 was observed sitting in her wheelchair next to the bed. There were no bed or chair alarms observed. During an interview with Resident #2 on 05/05/2021 at 3:05 PM, she confirmed that she did not have any bed or chair alarms.

Based on observation, record review and interview, the facility failed to carry out physician's orders for one (Resident #253) of one resident reviewed for the care area of [MEDICAL CONDITION], from 33 residents sampled. The findings include: On 12/16/20 at 1:45 PM, an observation and interview with Resident #253 was conducted. She was observed sitting in her wheelchair. Her left leg was [MEDICAL CONDITION] (swollen) but was not elevated. During the interview she stated, I fell at home and I broke my leg. I had surgery on my hip. I am here to get better. I think this leg is supposed to be wrapped. They are not doing anything to it. A review of the residents medical record revealed she was admitted to the facility on [DATE] with a [MEDICAL CONDITION] femur. A review of the physician's orders revealed an active order to apply an ace wrap compression bandage to bilateral (both) lower extremities in the morning and take them off at bedtime. The order also instructed staff to elevate bilateral lower extremities. This order was written on 12/16/20. An observation and interview with Resident #253 on 12/17/20 at 2:00 PM, revealed she had no ace wrap bandages on her lower extremities as ordered. She stated, No one is doing anything to my left leg. I think the swelling on my left leg is not getting any better. It is not painful but it is swollen. An interview with the Licensed Practical Nurse (Employee D) on 12/17/20 at 2:15 PM revealed, I did not see a treatment order for (Resident #253). She doesn't get any treatment for [REDACTED]. On 12/17/20 at 2:40 PM, the Unit Manager, Registered Nurse E was made aware of the above information. She verified Resident #253 did not have on ace wrap compression bandages to her bilateral lower extremities as ordered. She also verified the facility had not followed the physician's order. She stated, She has ace wrap compression orders for her legs. I will notify the physician. He is here today.

Based on observations, interviews, review of the medical record, and review of the Respiratory Care-Oxygen Therapy Policy and Procedure, the facility failed to follow physician's orders [REDACTED].#51) of 33 sampled residents. The findings include: A record review was conducted for Resident #51 which noted an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the current Medication Administration Record [REDACTED]. On 12/15 at 9:00 AM, the resident was observed lying in bed. He had oxygen infusing via nasal cannula. He reported it was set at 2 L and he used it. An observation was conducted of Resident #51 on 12/16 at 3:54 PM in his room. He was lying in bed watching TV. He had an air mattress and oxygen at 2 L via nasal cannula was infusing. An observation was conducted of Resident #51 on 12/17 at 10:39 AM lying in bed visiting with his wife. He was wearing a nasal cannula with 2 L of oxygen infusing via oxygen concentrator. On 12/17/20 at 02:18 PM the resident was observed lying in bed. He reported he had finished therapy. He was observed wearing a nasal cannula and receiving oxygen at 2 L per minute. An interview was conducted with Employee A, Licensed Practical Nurse (LPN), on 12/17 at 3:30 PM. The LPN was asked if the resident was still receiving oxygen. She replied, Yes, he had his oxygen on today. After reviewing the MAR, the LPN confirmed the oxygen was discontinued on 12/8/2020. Employee A proceeded to call the Advanced Registered Nurse Practioner (ARNP), and received an order for [REDACTED]. The LPN reviewed several physician's notes and did not see an order to continue the oxygen. She confirmed there was no order for oxygen to be administered after 12/8/2020. A review of the Respiratory Care-Oxygen Therapy policy and procedure, dated May 2017, noted oxygen therapy is administered as ordered by the physician or as an emergency measure until a physician's orders [REDACTED].

Based on record review and interviews, the facility failed to ensure an accurate, complete medical record for one (Resident #51) of six residents sampled for unnecessary medications, from a sample of 33 residents. Apical pulses were not documented for [MEDICATION NAME] with parameters before administration on the Medication Administration Record (MAR). The findings include: A record review was conducted for Resident #51, which noted an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the current MAR noted [MEDICATION NAME] 125 mcg (micrograms)give 2 tablets by mouth everyday for [MEDICAL CONDITION], dated 11/28/2020. [MEDICATION NAME] is not to be administered before taking an apical pulse and if below 60, [MEDICATION NAME] should be held. Apical pulses were not documented on the MAR An interview was conducted with Employee A, Licensed Practical Nurse (LPN) on 12/17/2020 at 3:30 PM. She was asked where apical pulses were documented for the [MEDICATION NAME], and she reported apical pulses were taken at the time of administration, but she did not document them. She proceeded to look in the computer and changed the keying in so apical pulses could be documented with the medications. She confirmed the apical pulses were not documented in the computer, and there were parameters for administering [MEDICATION NAME]. A review of the RNpedia noted on it's website: WARNING: Monitor apical pulse for 1 min before administering; hold dose if pulse < 60 in adult or < 90 in infant; retake pulse in 1 hr. If adult pulse remains < 60 or infant < 90, hold drug and notify prescriber. Note any change from baseline rhythm or rate.

Based on record review and staff interviews, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent the development of pressure ulcers to the heels and failed to implement preventive measures timely for one (Resident #2) of three sampled residents with pressure ulcers. The findings include: A record review for Resident #2 revealed a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. He was alert, oriented, and required limited assistance with activities of daily living. The initial nursing assessment dated [DATE] indicated a surgical incision to the right hip with staples and no other skin impairment. The discharge plan included the resident's return to the Assisted Living Facility (ALF). On 2/23/18, he underwent a revision of the right hip due to a lack of progress in healing and limited range of motion. He returned to the facility on [DATE]. A review of the initial nursing assessment dated [DATE] revealed a surgical incision to right hip with staples and bilateral (both) heels that were dry and scaly. On 3/8/18, the wound care nurse documented that the resident was found with a flat brown resolving blister to the left heel which measured 3cm (centimeters) x 3.5cm. The right heel had an intact, dark, fluid-filled blister measuring 3.4cm x 5cm. Skin Prep and a [MEDICATION NAME] dressing was ordered every other day. Posey heel boots (offloading devices) were found in his room and were applied to both feet. The wound note for 3/15 indicated the left heel was nearly resolved with a small brown area remaining. The right heel blister was intact and measured 3.8cm x 4.5cm. The wound note for 3/22/18 revealed the left heel was resolved. The right heel found with unstageable, dark flat skin, was now a pale gray intact area. New treatment orders for [MEDICATION NAME] and [MEDICATION NAME] dressing every other day were received. A review of the discharge plan revealed that Resident # 2 would return to the Assisted Living Facility (ALF) were he was paying to hold his room. On 3/23, the nurse came from the ALF to assess his progress and gave approval to return. On 3/24, the right heel had serosanguinous drainage, and on 3/26 was observed with clear yellow drainage, and treatment to include daily dressing changes. On 4/9/18, his discharge to the ALF was cancelled due to the worsening heel ulcer. On 4/20/18, the right heel was unstageable and had dark, soft, loose eschar. On 5/3/18, a new area was found on the right lateral foot with two reddened areas and intact black eschar. The attending physician ordered a wound care consult with the surgeon. Further review of Resident #2's clinical record revealed that the resident was seen by the surgeon on 5/9/18, he ordered venous and arterial studies. The report of the venous study dated 5/11/18 found no abnormality, and the arterial study showed mild flow impairment. A review of the wound notes showed the right heel wound and the wound on the right lateral leg were not improving. On 5/31/18, a Snap [DEVICE] was put in place to the right lateral leg wound due to excessive drainage. The resident was observed with increased [MEDICAL CONDITION] and redness to both lower legs. He developed [MEDICAL CONDITION] to the right leg. A consult was ordered with an Infectious Disease (ID) specialist. The ID specialist saw the resident on 6/28/18. He recommended offloading pressure to the legs and an intravenous antibiotic ([MEDICATION NAME]) to treat the infection. Resident #2 was complaining of increased pain of the legs due to wounds and infection. The Medication Administration Record [REDACTED]. On 7/2/18, his daughter came for a visit, and requested to visualize the wounds. After looking at the wounds and observing the [MEDICAL CONDITION] and redness, she requested that the facility send him to the hospital for an evaluation. The attending physician was present and wrote the order for transfer. Resident #2 was admitted to the hospital with [REDACTED]. An interview was conducted with the Wound Care Nurse (WCN), a Licensed Practical Nurse (LPN), on 7/19/18 at 2:57 pm. She was asked who notified Resident #2's daughter when the heel ulcers were found. She stated she called her cell phone on 3/8/18, however there was no answer. She was asked if she left a message to inform the daughter, and she stated she did not recall and had not documented leaving a message. When asked if she had attempted to call again, she was not sure. She stated the daughter was a physician and visited in the evening, and she always spoke to the staff. She was asked if the daughter attended the care plan meeting on 3/8/18. She said the daughter came to discuss discharge planning, and voiced her concern regarding weight loss and pain medication possibly causing cognitive impairment. The plan included resident #2's return to the ALF. A review of the care plan meeting notes for 3/8/18 revealed discussion of discharge planning, weight loss and concern of pain medication affecting cognition, but there was no documentation regarding presence of heel ulcers. The WCN was asked if Resident #2 complained of heel pain, and she stated yes, and she would ensure he was medicated an hour prior to the dressing changes. The WCN was asked if Resident #2 was admitted with any pressure ulcers, and she replied, No. She was asked what the protocol was for preventing heel ulcers, and she stated to float heels off the bed and use of Posey heel boots when in bed, ensure appropriate footwear, and inspect heels daily. Review of the care plan dated 2/27/18 identified the potential for impaired skin related to decreased mobility. The goal was no skin breakdown/impairment by next review on 5/21/8. The interventions did not include float heels off mattress, use of Posey heel boots when in bed, or to assess for appropriate footwear. The care plan was not updated to reflect development of heel ulcers until 6/15/18, three months after their discovery. The entry on 6/15/18 stated that Resident #2 had an unstageable right heel ulcer noted on 3/5/18 and had a Snap [DEVICE] initiated and Posey boots to be utilized while in bed. During the interview, the WCN was asked how often wounds were assessed and measured. She replied weekly. When asked who staged the wounds upon admission, she stated that she did. When asked if a regsitered nurse (RN) accompanied her when the wounds were asssed and staged, she replied, No. She stated that she had a wound care certification, therefore she was permitted to assess and stage wounds. When asked if the Nurse Practice Act allowed LPNs to assess and stage wounds, she stated that she could because she had the certification. An interview was conducted with the resident's daughter on 7/16/18 at 1:23 pm. When asked if her father was admitted with pressure ulcers she stated, No. She stated her father was admitted after a [MEDICAL CONDITION] for therapy and expected return to the community. During his stay, he developed an unstageable ulcer to the right heel. He also developed [MEDICAL CONDITION] of the right and left leg. He was treated with antibiotics, but they did not resolve the infections. The wound worsened, had a foul odor and became infected. She requested he be sent to the hospital, but the facility insisted they could provide the care. She spoke to the attending physician and had her write an order to transfer her father to the hospital. She stated he was found to be septic upon his admission to the hospital. She was also upset that she was not notified when the heel ulcer was discovered. She found out when she observed a nurse changing the dressing. She asked the nurse how often the dressing was changed, and she said on the night shift. The dressings were never dated, so she did not know when the dressing was changed. When she asked how the wound was doing, she was told it was healing, even when she saw for herself it had worsened and had an odor. She felt management dismissed her concerns. She said when she spoke to management about how the wound developed; she was told it was because her father was diabetic and had dementia. She stated he was supposed to have a boot on the heel, but when she came in he did not have it in place and it could not be found.

Based on record review and staff and resident interviews, the facility failed to provide adequate supervision to prevent a fall with significant injury for one (Resident #1) of three sampled residents with falls. The findings include: A record review for Resident #1 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. On 6/8/18, she underwent a total hip replacement and open reduction of the right distal fracture. The C-spine was treated non-surgically with a hard, cervical neck collar, and she had a cast to the right arm fracture. She was alert and oriented, and had been living independently at home with her husband when she fell . The goal was to return home after therapy was completed. A review of the initial nursing assessment dated [DATE] revealed she required extensive assistance with all activities of daily living except eating, for which she required set-up of the meal tray. She was continent of bowel and bladder, and required assistance on and off the toilet. Upon admission, her orders included non-weight bearing status on the right leg and [MEDICATION NAME] (narcotic pain medication) 10/352 mg (milligrams) every four hours around the clock to manage her pain. On 6/13/18 at approximately 12:00 am, Resident #1 put her call light on and requested to be put on the bedside commode. The nurse responded to the light and transferred her onto the commode. The nurse was aware at the time that Resident #1 had a right [MEDICAL CONDITION], her right arm was in a cast and she had a hard cervical neck collar on for C-1 spinal fracture. She was left alone on the bedside commode with the call light. The nurse asked the resident if she needed assistance to be cleaned and changed, and resident #1 responded that she would need assist from the Certified Nursing Assistant (CNA), as she preferred a female staff to assist with personal care, and the nurse was male. After the nurse left the room he documented that he notified the CNA that Resident #1 would need assistance. The nurse heard a loud noise and cry for help. Resident #1 was found on the floor, complaining of right hip pain. The nurse summoned the supervisor, the resident was assessed, the physician was notified, and she was transferred to the hospital. She was initially sent to the hospital closest to the facility, however, after x-rays determined she had a displaced trochanteric [MEDICAL CONDITION] femur, she was transferred to the hospital where she had previously had surgery. An interview was conducted by phone with Resident #1 on 7/16/18 at 1:05 pm. She was asked about the fall at the facility on 6/13/18. She stated she was admitted there for therapy after a fall at home. She had a right [MEDICAL CONDITION] with replacement, had fractured her right arm, and had a fracture in her neck at C-1. She stated that on the first night she was there she requested to go to the bathroom. She was placed on a bedside commode near the bed. She remembered it was late at night. The nurse gave her the call light, and told her to put the light on when she was ready. She put on the call light, but no one responded. She stated that she waited so long her hip was causing great pain. She said she could not stand it anymore and tried to shift her position, when she ended up falling off the commode. She then began screaming for help. Finally, when the staff came in the room they asked what I had done. She stated she was in so much pain. They called 911 and sent me to hospital. The hospital they sent me to was not the hospital where I had surgery. I had x-rays at that hospital, and when they found I had another fracture, I was transferred to the hospital where I had my hip replacement. She stated that because of the fall, causing a second fracture to the hip, the recovery has been very slow and she was still non-weight bearing on that leg. A review of the interim care plan dated 6/12/18 revealed she was at risk for falls, however no interventions regarding safety precautions or that Resident #1 was non-weight bearing on the right leg, had a cast to her right arm and had a hard cervical neck collar, were in place. She was also determined to be at risk for orthopedic complications. The checklist indicated fall precautions, therapy to evaluate and treat, and administer medications as ordered. No fall precaution interventions were documented. An interview was conducted with the Director of Nursing (DON) on 7/19/18 at 12:47 pm. She was asked if an investigation had been conducted regarding the fall for Resident #1. She stated that Resident #1 was admitted on [DATE] after a fall at home. She sustained right hip and arm fractures and a fracture to the C-1 spine. She stated that Resident #1 was alert and oriented, and was aware of how to use the call light to ask for assistance. The investigation revealed that Resident #1 had put on her call light and requested to be put on the bedside commode. The nurse answered the light and transferred her to the commode; he gave her the call light, and asked if she would need assistance cleaning herself when she was finished. She told him she would need the CNA to assist her, as she preferred a female to assist with personal care. The nurse on that unit was a male nurse. The nurse did not go back and check on her until he heard a loud noise and her cry for help. She was found on the floor and was complaining of hip pain. The investigation determined that the nurse was at fault and should not have left the resident alone. The DON was asked for the name and phone number of the nurse on duty that night, and she stated that he was no longer employed by the facility. An interview was conducted with the Fall Prevention Specialist on 7/19/18 at 2:30 pm. When asked what her role was at the facility, she stated she oversaw the fall prevention program and she reviewed all fall risk assessments for all residents upon admission. She reviewed the fall program for each resident to ensure safety measures were in place. She was also involved in all investigations of falls, to determine how the falls occurred, whether interventions were in place and what additional measures needed to be initiated. When asked if she had investigated Resident #1's fall, she stated yes. She also performed root cause analysis of the falls, reported findings to administrative staff, developed a plan of action and reported findings at performance improvement committee meetings. She was asked what had been determined as the cause of Resident #1's fall, and she replied that the nurse should not have left Resident #1 alone on the commode.

Based on record review and staff and family interviews, the facilty failed to notify the resident representative related to the discovery of a pressure ulcer for one (Resident #2) of three sampled residents with pressure ulcers. The findings include: A record review for Resident #2 revealed a [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. He was alert, oriented, and required limited assistance with activities of daily living. The initial nursing assessment dated [DATE] indicated a surgical incision to the right hip with staples and no other skin impairment. The discharge plan included returning to the Assisted Living Facility (ALF). On 2/23/18, he underwent revision of the right hip due to lack of progress in healing and limited range of motion. He returned to the facility on [DATE]. Review of the initial nursing assessment dated [DATE] revealed a surgical incision to right hip with staples and bilateral heels that were dry and scaly. On 3/8/18, the wound nurse documented that he was found with a flat brown resolving blister to his left heel that measured 3cm (centimeters) x 3.5cm. The right heel had an intact, dark, fluid-filled blister which measured 3.4cm x 5cm. Skin Prep and a [MEDICATION NAME] dressing was ordered every other day. Posey boots (heel offloading devices) were found in his room and were applied to both feet. The wound nurse documented that she attempted to call the daughter's cell phone, but there was no answer. An interview was conducted with the wound nurse on 7/19/18 at 2:57 pm. When asked when Resident #2's daughter was notified when pressure ulcers to the heels were found, she stated she called her cell phone on 3/8/18, however there was no answer. She was asked if she left a message to inform the daughter, and she stated she did not recall and had not documented leaving a message. When asked if she had attempted to call again, she stated not that was documented. Also on 3/8/18, a care plan meeting was held with the interdisciplinary team, and the resident's daughter wanted to discuss discharge planning. The plan included Resident #2 returning to the ALF. The daughter voiced her concern regarding weight loss and pain medication possibly causing cognitive impairment. There was no documentation that the heel wounds were addressed with the daughter at the meeting. An interview was conducted with the daughter on 7/16/18 at 1:23 pm. When asked if her father was admitted with pressure ulcers she stated, no. She stated her father was admitted after a [MEDICAL CONDITION] for therapy and then was expected to return to the community. During his stay, he developed an unstageable ulcer to the right heel. He also developed [MEDICAL CONDITION] of the right and left leg. He was treated with antibiotics but they did not resolve the infections. The wound worsened, had a foul odor and became infected. The resident's daughter requested he be sent to the hospital, but the facility staff insisted that they could provide the care. The resident's daughter spoke to the attending physician, and had her write an order to transfer her father to the hospital. She stated he was found to be septic once admitted to the hospital. The resident's daughter was also upset that she was not notified when the heel ulcer was discovered. She found out when she observed a nurse changing the dressing. She asked the nurse how often the dressing was changed and the nurse replied on the night shift. The dressings were never dated, so she did not know when the dressing was changed. When she asked how the wound was doing, she was told it was healing, even when she saw for herself it had worsened and had an odor. She felt management dismissed her concerns. She said when she spoke to management about how the wound developed, she was told it was because her father was diabetic and had dementia. She stated he was supposed to have a boot on the heel, but when she came in he did not have it in place and it could not be found.