Every finding on record at Bentleys Extended Care

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #2) was free from physical abuse when Certified Nurse Aide (CNA) C covered and twisted the resident's mouth when he/she cried during a shower, which resulted in bruising to the resident's face. The sample was 3. The census was 49.Review of the facility's Abuse Prevention Program policy, undated, showed:-Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms;-Policy Interpretation and Implementation:-As part of the resident abuse prevention, the administration will:--Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior;-Establish and implement a Quality Assurance and Performance Improvement (QAPI) review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. Review of the facility's Abuse Investigating and Reporting policy, undated, showed:-Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported;-Role of the Administrator: The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation;-Role of the Investigator:--The investigator will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process;-Reporting:--All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies;---The local/State ombudsman;---Law enforcement officials;---The facility Medical Director;--The resident and/or representative will be notified of the outcome immediately upon conclusion of the investigation. Review of Resident #2's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/31/26, showed:-Moderate cognitive impairment;-Felt down, depressed, or hopeless half or more of the days;-No behaviors exhibited;-Upper and lower extremity impairment on one side;-Dependent on assistance for bathing;-Diagnoses included depression, high blood pressure, stroke, and hemiplegia (paralysis to one side) or hemiparesis (weakness to one side). Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident had impaired cognitive function or impaired thought processes related to memory loss;--Interventions included cue, reorient and supervise as needed;-Focus: The resident was/had the potential to be physically and verbally aggressive related to anger, depression, history of attempting to harm others, poor impulse control, and throwing objects;--Interventions included:---Communication: Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff member when agitated;---When the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away, and approach later.----Staff responsible for interventions included nursing staff;-Focus: The resident had a mood/behavior problem related to depression, ineffective coping behaviors. The resident had yelling behaviors, negative verbalizations, frequent complaints/expresses dissatisfaction, and depressed mood;--Interventions included monitor, record, and report to medical physician as needed mood patterns signs and symptoms of depression, anxiety, sad mood, as per facility behavior monitoring protocols;-Focus: The resident had depression related to current health status;--Interventions included monitor, document, report as needed any signs and/or symptoms of depression, including hopelessness, anxiety, verbalizing negative statements, repetitive anxious or health-related complaints, and tearfulness. Review of the resident's progress notes showed:-On 5/11/26 at 4:00 P.M., the Director of Nurses (DON) documented the resident reported to this DON that a CNA had put their hand over his/her mouth because he/she was crying. The CNA had already left facility prior to resident's report. The resident was alert and oriented times three (oriented to person, place and time);-On 5/12/26 at 3:30 P.M., staff documented an incident follow up for the reported incident. Light purplish discoloration noted to right side of mouth. The resident denied pain. Review of the facility's investigation showed:-An Incident Investigation Report, undated, showed:--Date and time of incident: 5/11/26, between 7:00 A.M. and 11:30 A.M.;--Location: Shower room;--Incident description: The resident alleged he/she was in the shower room and CNA D put his/her hand over the resident's mouth and twisted the resident's mouth because he/she was crying;---Individuals involved: The resident and CNA C (alleged perpetrator);---Witnesses: None to the incident. CNA B was in the shower room for a period of time while resident and CNA C were in there. Statement attached;--Evidence collected: The resident had a bruise to right side of mouth. Photos taken of bruise on 5/12/26 and 5/14/26;--Conclusion: After reviewing statement and the physical findings, the resident's allegations appear to be substantiated;-A typed statement from the resident, undated, showed the resident said CNA C grabbed his/her mouth. The resident had bruises. CNA C said the resident could cry all he/she wanted, then grabbed the resident's mouth and twisted it;-A handwritten statement from CNA B, dated 5/14/26, in which CNA B documented he/she walked in the shower room and heard someone crying. He/She observed the resident getting his/her shower done and CNA C gave the shower. When CNA B asked the resident why he/she was crying, the resident said, I just want to die, about three times. CNA B left the shower room;-Two photographs of the resident, undated, showed a purple bruise, approximately one inch long, to the right side of the resident's mouth. Observation on 5/19/26 at 9:01 A.M., showed the resident with yellow, black, and blue bruises to the right side of his/her mouth and chin. He/She had bruising around his/her left eye socket. During an interview, the resident said the bruising around his/her eye was from when he/she fell out of bed a couple weeks ago. The bruising by his/her mouth was from CNA C grabbing and pinching his/her mouth last week while the resident received a shower. CNA C did this because the resident was crying. There was no one else in the shower room when this occurred. The resident said his/her mouth hurts. During an interview on 5/20/26 at 10:31 A.M., CNA C said he/she provided a shower to the resident on the morning 5/11/26. During the shower, the resident cried and repeated he/she wanted to die, which was the resident's normal behavior when he/she doesn't want to do something. When this happens, CNA C tells the resident if he/she keeps crying, it was going to take longer. CNA C tried to wipe the resident's face and mouth, and the resident tried to grab and squeeze CNA C's hand. CNA C denied squeezing, pinching, or twisting the resident's mouth. He/She had no idea how the resident got bruising to his/her mouth. The resident did not have any bruising on his/her face during the shower provided by CNA C. CNA C had never been instructed on how to handle the resident's behaviors by walking away, asking for assistance, or reporting it to the nurse. CNA B was on the other side of the curtain in the shower room when CNA C showered the resident. CNA B asked who CNA C was showering because he/she heard the resident crying, and CNA B pulled back the curtain so he/she could see. CNA B did not assist with the shower. During an interview on 5/20/26 at 11:50 A.M., CNA B said on 5/11/26, he/she entered the shower room to get supplies and heard a resident crying and saying he/she wanted to die. CNA B checked to see who it was, and saw it was the resident. This was normal behavior for the resident. CNA C was finishing up the resident's shower and was drying and dressing the resident. CNA B asked CNA C why the resident was crying, and the resident said because he/she didn't like taking the shower. CNA B only saw the resident crying and the CNA getting the resident dried off and dressed. CNA B denied being educated on specific behaviors and how to handle the resident. The resident was alert and knows what's going on. He/She just liked to cry when he/she didn't like something. A new bruise around the resident's mouth showed up last week, a day or so after the shower incident. During an interview on 5/20/26 at 11:03 A.M., the resident's Power of Attorney (POA) aid the resident was cognitive and knew what was going on around him/her. The facility notified the POA of an abuse allegation. He/She was unaware of the bruise to the resident's mouth from the alleged abuse and had not received any updated reports since he/she was notified of the incident. He/She was unaware of the outcome of the facility's investigation. During an interview on 5/20/26 at 12:37 P.M., the DON said it was not appropriate for staff to continue performing care against a resident's expressed wishes, including crying. It was never appropriate for staff to cover a resident's mouth. The resident always cried when he/she did not like what was going on. When CNA B saw the resident was upset during the shower on 5/11/26, the DON expected CNA B to have notified the nurse about the resident being upset. Staff should follow the resident's care plan when caring for the resident's behaviors. Staff should also adhere to the facility's abuse and neglect policies. The facility conducted an investigation, which concluded that abuse occurred. The resident was consistent in reporting what happened when asked several times, and he/she was able to demonstrate how CNA C covered and twisted his/her mouth, which lined up with the bruising observed by the resident's mouth. The bruising showed up the next day, after the incident. The facility's abuse and neglect policy and procedures should be followed. During an interview on 5/19/26 at 8:36 A.M., CNA C said he/she was not aware of an abuse allegation involving the resident. The resident was alert and knows what was going on. He/She had behaviors and cried if he/she did not like what was going on. He/She required two staff to assist with care. During an interview on 5/19/26 at 1:47 P.M. Administrator said CNA C was told to leave the facility prior to the alleged abuse reported by resident #2 due to CNA C having a verbal confrontation with the DON about scheduling. After CNA C had been told to leave, the resident reported the alleged abuse. CNA C was terminated for the verbal altercation with the DON and the abuse to the resident. During an interview on 5/20/26 at 1:08 P.M., the Administrator said the resident had behaviors and was known to cry when he/she didn't want to do something or didn't like something. When the resident cries during a shower, CNAs should complete the resident's shower and let the nurse know about the crying incident. It was never appropriate for staff to put their hands over a resident's mouth for any reason. CNA B should have assisted CNA C when he/she saw the resident crying and/or at least let the nurse know about the incident. All residents should be free from abuse and facility staff should follow the facility's policies and procedures for abuse. She reviewed the investigation findings and confirmed that abuse occurred. She expected staff to follow the facility's policy and procedures for abuse. 3014047

Based on interview and record review, the facility failed to ensure Nurse Aides (NAs) employed by the facility were not charged for a competency evaluation program. The census was 52. Review of the facility's Certified Nurse Aide (CNA) Training Program Assistance Agreement, dated 2025, showed:- Student collectively referred to as Parties or individually as a Party;-Whereas, the Student desires to participate in a CNA Training Program Assistance, and whereas, the facility is willing to provide the necessary training and educational materials to the student for the purpose of obtaining a CNA certification;-Now, therefore, in consideration of the mutual covenants and promises contained herein, the parties agree as follows;-CNA Training Program Assistance Scope and Duration; --The facility shall offer assistance to a comprehensive CNA training program, through a provider, that covers the necessary theoretical knowledge and practical skills required to become a CNA;-Training program fees:--The Student shall pay the training program fees as outline by the Facility;---Tuition for the CNA Program is set at $720.00, payable in installments of $140.40 per pay period until the entire amount is fulfilled. It is important to note that in the event that the student does not complete the course, no refund will be issued, and the course completion will not be granted until cost to facility has been reimbursed;--The fees are non-refundable unless otherwise specified by the Facility. 1. Review of the facility's list of active employees and personnel files, showed three NAs employed by the facility, one of whom was enrolled in a certification program outside of the facility. Review of NA G's employee file, showed:-Active employee;-No documentation of enrollment in CNA certification course. During an interview on 4/29/26 at 9:46 A.M., NA G said he/she had been working in laundry at the facility for about a year. At the beginning of April 2026, he/she moved into the NA position at the facility to see if he/she would like it. The facility offered to pay the cost of the CNA program with a repayment plan of around $100 or so to come out of his/her check until the cost of the CNA program is paid off. At this time, he/she was not enrolled in the CNA program and had not received money to pay for the program. Review of NA L's employee file showed:-Active employee, hire date of 3/6/26;-A CNA Training Program Assistance Agreement, signed 4/21/26. 2. During an interview on 4/29/26 at 1:24 P.M., CNA M said he/she was hired as an NA in 2024. The facility had him/her pay for his/her CNA certification program and he/she is a CNA now. 3. During an interview on 4/29/26 at 8:04 A.M., the Administrator said the facility did not have a program to complete clinical hours for NAs who are in the process of becoming certified. The facility assisted NAs with the cost of the CNA program to help them. For NAs interested in becoming certified, the facility offered to pay for the certification program upfront, and then they had the NA sign an agreement to reimburse the facility for the cost of the program over a 12-week period. 2993082

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to re-order anti-seizure medication for one resident (Resident #1) within 72 hours of its last available dose, per facility policy, resulting in the resident missing doses of the medication on two days. Facility staff failed to administer two of the resident's other anti-seizure medications for one day and the resident had a seizure the next day. The sample was 4. The census was 52.Review of the facility's Medication Administration policy, dated 2/2020, showed: -Policy Statement: To administer all medications safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis;-If medication is ordered but not present, call the pharmacy or supervisor to obtain the medication. Review of the facility's Ordering Medications policy, dated 2/2020, showed:-Policy Statement: Medications and related products are ordered from the long-term care pharmacy on a timely basis;-Procedures: Refill requests should be sent 72 hours prior to the last dose. Review of the facility's Following Physician Orders policy, dated 1/2026, showed:-Policy Statement: It is the policy of the community to ensure that all Licensed Professional Nurses (Registered Nurse (RN), License Practical Nurse (LPN), Licensed Vocational Nurse (LVN)) and other healthcare professionals, follow physician orders in accordance with State and Federal regulations, and their respective practice acts;-Procedure: All physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical records. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/3/26, showed:-Cognitively intact;-Diagnoses included epilepsy (seizure disorder), spinal cord injury, and quadriplegia (paralysis of all four limbs). Review of the resident's care plan, in use at the time of survey, showed:-Focus: Resident has a seizure disorder related to disease process, spinal cord injury/disease, and epilepsy;-Goal: The resident will be free from injury from seizure activity;-Interventions included give medications as ordered and monitor, document for effectiveness and side effects. Review of the facility's Leave of Absence sheet, showed on 4/5/26 at 9:15 A.M., a family member signed the resident out of the facility with an anticipated time of return at 5:00 P.M. Review of the resident's physician order summary (POS), controlled drug receipts, and Medication Administration Record (MAR) from April 2026, showed:-A physician order, dated 4/2/25, for lamotrigine (Lamictal, used to treat seizures) oral tablet 150 mg, give one tablet by mouth two times a day related to other epilepsy. Scheduled for 8:00 A.M. and 8:00 P.M.;--The MAR showed on 4/5/26, 8:00 A.M. and 8:00 P.M. doses missed due to resident absent from facility without medication;-A physician order, dated 4/2/25, for levetiracetam (used to treat seizures) oral tablet 750 mg, give one tablet by mouth two times a day related to other epilepsy. Scheduled for 8:00 A.M. and 800 P.M.; --The MAR showed on 4/5/26, 8:00 A.M. and 8:00 P.M. doses missed due to resident absent from facility without medication;-A physician order, dated 4/2/25, for lacosamide (used to treat seizures) oral tablet 200 milligrams (mg), give one tablet by mouth two times a day related to other epilepsy. Scheduled for 8:00 A.M. and 8:00 P.M.;--Controlled drug receipts and disposition form, showed on 4/4/26, one tablet given and 0 tablets remained;--The MAR showed on 4/5/26, 8:00 A.M. and 8:00 P.M. doses missed due to resident absent from facility without medication;--The MAR showed on 4/6/26, 8:00 A.M. and 8:00 P.M. doses missed, see progress notes. Review of the resident's progress notes, showed:-On 4/6/26 at 9:18 A.M., an order administration note: On order, nurse notified. The note did not specify which medication was on order;-On 4/6/26 at 10:24 A.M., an order administration note: Not available, nurse notified. The note did not specify which medication was unavailable;-On 4/6/26 at 8:16 P.M., a health status note: Resident observed having twitching and drooling, unresponsive to verbal stimuli, eyes open but not following at approximately 7:10 P.M. Resident has history of seizures. Nurse and Certified Nurse Aide (CNA) implemented seizure precautions. Convulsions lasted around five to ten minutes. Resident began to follow nurse with eyes and speak slowly. Around 15 minutes later convulsions began again lasting five to seven minutes. Nurse called Emergency Medical Services (EMS) to transport resident to hospital for observation. Physician and Power of Attorney (POA) notified;-No documentation to show staff notified the physician of the resident's missed anti-seizure medications on 4/5/26 or 4/6/26, prior to the resident's seizure on 4/6/26. Review of the resident's hospital Discharge summary, dated [DATE], showed resident with a history of hypertension (high blood pressure), hydrocephalus (buildup of spinal fluid in the brain causing pressure) status post ventriculoarterial shunt (drain for hydrocephalus) with multiple revision, central cord syndrome secondary to cervical syrinx (fluid filled cyst within the spinal cord), seizure disorder, who was admitted on [DATE] for breakthrough seizure. Presented from skilled facility after reportedly experiencing a 10-minute seizure followed by a shorter episode, with EMS noting he/she had not received his/her antiepileptic medications for two to three days due to supply issues at the facility. Neurology was consulted and confirmed the breakthrough seizure was likely due to medication noncompliance. Review of the resident's physician note, dated 4/13/26 at 4:23 P.M., showed the resident had uncontrolled seizure secondary to list dose of medication. Apparently, lamotrigine dose missed. During an interview on 4/29/26 at 11:19 A.M., the resident said he/she had poor short-term memory. He/She called a family member during the interview. The family member said he/she was not aware the resident had not received his/her 8:00 A.M. dose of seizure medications on 4/5/26, prior to the resident leaving the facility for the day. The family was not given the resident's medications to administer while the resident was out of the facility with them. The family member only found out from the hospital that the resident had missed his/her seizure medication. During an interview on 4/29/26 at 1:51 P.M., Certified Medication Technician (CMT) C said he/she was not aware the resident left the building on 4/5/26 until CMT C went to complete the 8:00 A.M. medication pass then found the resident was not in the facility. He/She notified the nurse of the resident's missed medications. He/She did not know when the resident returned to the facility and was told the resident was gone all day. He/She did not remember if he/she looked for the resident for the 8:00 P.M. med pass because he/she thought the resident was gone. He/She did not check the Leave of Absence sign out sheet. Medications should be administered up to one hour prior and one hour after a scheduled dose. The resident's lacosamide ran out and CMT C recorded it was unavailable on 4/4/26. He/She thought the lacosamide refill was automatically reordered. During an interview on 4/29/26 at 2:25 P.M., LPN A said the facility had an automatic weekly medication cycle refill for all non-narcotic and non-controlled medications. Lacosamide is a controlled medication and needs to be reordered 72 hours prior to its last dose. A dose of lacosamide should never be missed. If the medication was missed, the CMT should have notified the nurse and the nurse should have called the pharmacy to follow up on when the medication would be delivered. The nurse should then notify the Director of Nursing (DON) and/or physician for further instructions, if the pharmacy was unable to deliver the medication. He/She was not aware the resident missed all doses of his/her seizure medications on 4/5/26. The medications should have been sent with the resident or given to the resident prior to him/her leaving the facility for the day. During an interview on 4/30/26 at 6:52 A.M., LPN D said he/she worked the 3:00 P.M. to 11:00 P.M. shift on 4/5/26. The resident returned to the facility that day at around 5:00 P.M., during the facility's dinner meal service. He/She was not made aware by the CMT that the resident did not receive any of his/her seizure medications all day. He/She did not know why the CMT did not administer the morning seizure medications, or send them with the resident before he/she left the facility. LPN D did not know why staff did not administer the resident's 8:00 P.M. seizure medications on 4/5/26, because the resident was in the facility at that time. On 4/6/26, after the resident started having seizures, the CMT reported the resident was out of lacosamide and had missed several doses. The CMT said he/she reordered lacosamide on 4/4/26 but it had not arrived. This was not communicated in report from the day shift nurse on 4/6/26. During an interview on 4/30/26 at 11:41 A.M., RN E said he/she worked the 7:00 A.M. to 3:00 P.M shift on 4/5/26. At the beginning of the shift, he/she informed the CMT to make sure residents leaving the facility for the holiday on 4/5/26 had received their medications. He/She saw the resident at around 8:00 A.M., getting ready to go out. The family filled out the Leave of Absence sign out sheet. RN E was not made aware that the resident was out of lacosamide and had not received his/her morning medications that day. During an interview on 4/30/26 at 12:43 P.M., the resident's physician, Physician F, said he/she was not aware the resident had missed all his/her medications on 4/5/26, including three seizure medications (lacosamide, lamotrigine, and levetiracetam). He/She was not aware the resident missed an additional dose of lacosamide on 4/6/26 due to it not being refilled on time. He/She became aware of this after the resident returned from his/her hospitalization for seizure activity. The PCP expected facility staff to make sure resident's medications did not run out. He/She expected staff to follow physician orders and to administer medications per physician order. Missed seizure medications could cause residents to have seizures. During an interview on 4/30/26 at 1:25 P.M., the Director of Nursing (DON) said on 4/6/26, she was made aware the resident missed doses of his/her lacosamide. She found the lacosamide was not reordered in a timely manner. The CMT is responsible for notifying the nurse if a medication was not available. The nurse should call the pharmacy and check when the medication would be delivered, then notify the DON and/or the physician of missing medication for further instructions or orders. On 4/5/26, the resident left the facility and was sent out without receiving any of his/her medications for the day. The DON did not know when the resident returned, but the sign out sheet showed the resident was expected to return at 5:00 P.M. The DON did not know why the CMT did not administer the resident's 4/5/26 evening medication when he/she was back in the facility. It is possible the missed seizure medications could cause a seizure, but the hospital did not run labs to verify if this is what caused the resident's seizures. 2976795

Based on interview and record review, the facility failed to ensure Registered Nurse (RN) B assessed a resident and notified one resident's physician after Certified Nursing Assistant (CNA) G informed the RN the resident complained of pain and could not stand or walk, which was a change in condition for the resident (Resident #11). Facility staff did not assess the resident or call the physician for at least six hours after the change of condition was noticed. When the resident was evaluated at the hospital, he/she was diagnosed with a wrist fracture. The resident sample was 18. The census was 52. Review of the facility Change in a Resident's Condition or Status policy, revised 12/2016, showed:-Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g , changes in level of care, etc.)-Policy Interpretation and Implementation:-The nurse will notify the resident's Attending Physician or physician on-call when there has been a(an):-Accident or incident involving the resident;-Discovery of injuries of an unknown source;-Significant change in the resident's physical/emotional/mental condition;-A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or impacts more than one area of the resident's health status;-Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider;-The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility Pain Assessment and Management policy, revised 3/2015, showed:-Purpose: The purpose of this procedure is to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain;-General Guidelines:-Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain. Effectively recognizing the presence of pain. Identifying the characteristics of pain. Addressing the underlying causes of pain;-Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new or worsening pain;-Recognizing Pain: Verbal expressions such as groaning, crying, screaming. Facial expressions such as grimacing, frowning, clenching of the jaw. Changes in gait (walking), skin color and vital signs. Guarding (A behavior where a person protects or guards a specific body part, indicating they may be experiencing pain. Oten due to the inability to verbally express discomfort.), rubbing or favoring a particular part of the body. Difficulty eating or loss of appetite;-Possible Physiological Signs of Pain: Increased blood pressure; tachycardia (rapid heart rate); increased respiration; diaphoresis (sweating);-Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level;-Pain management interventions shall reflect the sources, type and severity of pain;-Pain management interventions shall address the underlying causes of the resident's pain;-Documentation: Document the resident's reported level of pain with adequate detail as necessary and in accordance with the pain management program;-Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. Review of the facility RN job description, undated, showed:-Provide direct nursing care in accordance with established policies, procedures ad protocols of the healthcare organization;-Primary Responsibilities:-Implements and monitors patient care plans. Monitors, records and communicates patient condition as appropriate;-Serves as a primary coordinator of all disciplines for well-coordinated patient care;-Works in a constant state of alertness and safe manner;-May perform point of care testing according to policies and procedures;-Will demonstrate an understanding of patient needs, ensuring that each patient feels informed and understood, as well as heard. You are passionate about providing superior quality care and you are an inventive problem solver who thrives in a dynamic environment;-Registered Nurse put the patient first, helping to improve quality of life for our residents, providing high-quality care and doing well by what is right;-Initial and on-going systemic patient assessment;-Timely and accurate documentation using appropriate systems;-Promoting continuous quality improvement. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/17/25 and located in the resident's electronic medical record (EMR), showed:-Adequate hearing and vision;-Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Severe cognitive impairment;-Rejection of Care - Presence and Frequency: Did the resident reject evaluation of care: No;-Independent - Resident completes the activity by themselves with no assistance from a helper: Sit to stand, chair/bed-to-chair transfer, toilet transfer, walk 10 feet (once standing, the ability to walk at least 10 feet in a room, corridor, or similar space), 50 feet with two turns (once standing, the ability to walk at least 50 feet and make two turns), 150 feet (once standing, the ability to walk at least 150 feet in a corridor or similar space;-Diagnoses of Alzheimer's disease, and non-Alzheimer's dementia;-Pain Presence: No. Review of the resident's care plan, located in the EMR, showed:-12/11/24, Focus: Impaired cognitive function/dementia or impaired thought processes. Goal: Will maintain current level of cognitive function. Interventions: Encourage resident to participate in activities planned by the facility. Administer medications as ordered;-12/11/24, Focus: Elopement risk/wanderer. Goal: Safety will be maintained. Interventions: Distract resident from wandering by offering diversions. Monitor for fatigue and weight loss. Provide structured activities: toileting, walking inside/outside;-4/30/25, Focus: Risk for falls due to ambulating (walking) unassisted, wandering behavior, poor safety awareness. Goal: Will be free of falls/free of major fall related injury. Interventions: Educate on the importance of maintaining a safe environment, free of potential of fall hazards. Assist with placement of proper footwear as needed for safer ambulation and transfers;-12/11/25, Focus: Current Functional Performance. Goal: Functional status will progress towards personal discharge. Interventions: Locomotion on unit - independent. Toilet use - extensive assist of one person. Transfer - independent. Walk in in room/corridor - independent. During an interview on 2/23/26 at 12:30 P.M., CNA F said he/she took care of the resident on 1/30/26 on the day shift (7:00 A.M. - 3:00 P.M.). The resident was confused and up and walking independently all over the facility which was normal for him/her. The resident did not have any falls that day he/she was aware of, did not complain of pain, did not have swelling on his/her left wrist and had no bruising that he/she observed. During an interview on 2/23/26 at 1:05 P.M., CNA G said the resident was normally confused. He/She knew who he/she was, and knew family members, but did not know where he/she was or time/date. The resident was independent for transfers and walking. CNA G worked on 1/30/26 on the day shift and although he/she was not assigned to take care of the resident, he/she remembered the resident walking around the facility without any problems. On 1/31/26, he/she was not assigned to take care of the resident, but he/she was in the dining room between 8:00 A.M. and 9:00 A.M. when he/she noticed the resident was not there. He/She went to the resident's room and found him/her sitting on the toilet. The resident was weak and could not stand up or walk. The resident said his/her leg was sore. CNA G asked the resident if he/she had fallen, and the resident said no. CNA G did not notice swelling to the left wrist or any bruising at that time. He/She found CNA E to help transfer the resident off the toilet and into a wheelchair. After taking the resident to the dining room in the wheelchair for breakfast, he/she went and told RN B something was wrong with the resident. The resident couldn't stand up or walk, and normally he/she could, and the resident was complaining of pain in his/her leg. The RN said he/she would take a look at the resident. CNA G went back to the dining room to finish feeding residents. The resident ate about 20%, when normally he/she eats about 75%. The resident did not appear to be in constant pain while he/she sat in the wheelchair, only when he/she tried to stand up. After breakfast, CNA G wheeled the resident to the nurse's station and left him/her there. Around 3:00 P.M. that day, CNA G asked some of the evening staff coming in if the resident had fallen the evening before, and they said no. During a telephone interview on 2/27/26 at 9:00 A.M., CNA E said he/she was assigned to take care of the resident on 1/31/26. The resident is very confused, which is normal for him/her. The resident is normally independent for transfers and walking. The night shift gets the resident up and ready for the day, so when he/she arrived to work around 7:00 A.M. that morning, the resident was not in bed and was not in his/her room, which is not unusual. The first time he/she saw the resident was when CNA G asked for help getting the resident off the toilet. They went to the resident's room where the resident sat on the toilet. The resident said he/she could not get up because his/her bottom and/or leg was hurting. CNA E did not notice swelling of the left wrist or bruising on the resident's bottom or sides at that time. After taking the resident to the dining room in the wheelchair, CNA G said he/she was going to tell RN B about the resident not being able to stand and complaining of pain. CNA E did see the RN take the resident's vitals at the nurse's station after breakfast. After lunch, CNA E and CNA G took the resident to the bathroom in the wheelchair. The resident still could not stand up. They transferred the resident to the toilet and cleaned him/her up and took him/her back to the nurse's station. CNA E did not notice any swelling of the left wrist or bruising at that time. The resident sat in the wheelchair all day. CNA E did not speak to RN B about the resident because CNA G spoke to the RN that morning. Review of the resident's progress note's, located in the EMR, showed:-1/31/26, 7:00 A.M. - 3:00 P.M.: No observations, or assessments including pain and vital signs (blood pressure, pulse, respirations, temperature) documented by RN B; -1/31/26 at 3:34 P.M., Licensed Practical Nurse (LPN) H (evening shift nurse 3:00 P.M. - 11:00 P.M.) documented: Day shift nurse informed this nurse that the resident's CNA informed him/her this morning that they discovered resident in his/her restroom on the toilet unable to walk or stand. They placed him/her in a wheelchair and rolled him/her to the nurse's station. This nurse observed resident with swelling to left wrist and unable to bear weight on his/her legs. He/She is complaining of pain to back and right hip. Upon further assessment, resident found to have bruising to the right arm and side. Resident said, I fell right here, pointing to his/her knees. I asked him/her what happened after he/she fell, and he/she said, I got on the toilet. DON (Director of Nursing), PCP (primary care physician), and POA (power of attorney) notified;1/31/26 at 4:30 P.M. LPN C (evening shift nurse) documented: Upon start of shift, nurse in building informed this nurse that resident had bruising and swelling to left wrist and is unable to bear weight on either leg. The nurse informed the change in health occurred prior to arrival during previous day shift (7:00 A.M.-3:00 P.M.). Upon assessment, this nurse noted visible bruising and swelling to left wrist and hand. Resident guarding area, showing signs of pain and discomfort. This nurse spoke with NP (nurse practitioner) and resident's family informing them of health status change. This nurse called EMS (emergency medical services) to transport resident to hospital for further evaluation. Awaiting update. Review of the resident's medical administration record (where a nurse or Certified Medication Technician (CMT) documents routine and PRN (as necessary) medications are administered) located in the EMR and dated 1/1/26 through 1/31/26, showed:-6/3/24, Acetaminophen (Tylenol) 500 milligrams (mg) one by mouth every eight hours as needed for pain: No documentation showing the medication had been administered on 1/31/26. Review of the facility investigation dated 2/2/26, showed:-2/2/26 the DON documented: After learning about an incident with a resident, I called the nurse (RN B) that was on duty on 1/31/26 for the day shift (7:00 A.M.-3:00 P.M.). The nurse was an agency nurse. I asked the nurse was he/she made aware of any incident regarding resident. The nurse said there were several residents sitting at the nurse's station in wheelchairs. Nurse said he/she was not aware of resident's baseline status. I asked nurse if anyone had reported that resident fell, and he/she said he/she did not recall and when he/she heard something regarding a fall, it was at shift change and the relieving nurse had arrived. Spoke to CNA (CNA G) on staff on 1/31/26 day shift. CNA said that resident would not get off the toilet by himself/herself, and he/she had to assist resident into a wheelchair. I asked CNA if he/she noticed any bruising or swelling on resident and CNA said no. I asked CNA did he/she let the nurse know about the resident's change in condition, and CNA said he/she did inform the nurse on duty. I asked CNA to write a statement;-Review of CNA G's written statement dated 2/2/26, showed: On Saturday January 31, 2026, I noticed the resident had not eaten breakfast, so I went to check on him/her and he/she was in the restroom on the toilet. I tried to help him/her get dressed and stand up. The resident said, Oh baby I can't, my leg hurts. I told him/her okay give me one minute and went to get another aide. We both stood him/her up with a gait belt (applied around a resident's waist to provide balance and support during a transfer), pulled his/her pants on and helped pivot him/her to a wheelchair. Resident ate his/her breakfast. I took him/her to the nurse's station and told the nurse the resident said his/her leg was sore, so I put him/her in a wheelchair. During an interview on 2/23/26 at 3:09 P.M., LPN H said he/she worked the night shift on 1/30/26 at 11:00 P.M. and left around 7:00 A.M. on 1/31/26. There were no reports about the resident falling, having pain or a change in condition during that shift. When he/she came back to work on 1/31/26 around 3:00 P.M., he/she noticed the resident sat in a wheelchair at the nurse's station. That was unusual because the resident was usually up and walking around the entire facility. LPN H went over to look at the resident and noticed the resident's left wrist was huge, very swollen and reddish in color. The resident was wearing a short-sleeved shirt, and it was very noticeable. The resident guarded the wrist when he/she tried to assess it. LPN H tried to help the resident stand up, but the resident moaned and could not stand. LPN H asked the resident if he/she had fallen, and the resident said he/she had. RN B told him/her staff had brought the resident to the nurse's station that morning and told him/her the resident could not walk. The RN said he/she had not assessed the resident because he/she was busy doing other things. The resident was sitting at the nurse's station so there was no reason as to why the RN could not have assessed the resident. LPN H looked in the progress notes, and the RN had not documented anything about the resident. LPN H called the physician's exchange and left a message for the physician to call back. He/She left before the physician returned the call because the facility had scheduled both him/her and LPN C to work. Since he/she had to work the midnight shift that night, he/she went home. LPN C took the call from the physician. The resident was still at the facility when he/she went home. During a telephone interview on 3/4/26 at 9:40 A.M., LPN C said he/she was familiar with the resident. Normally, the resident is confused and independent for self-transfer and walking. When LPN C came to work on 1/31/26 around 3:00 P.M., RN B sat at the nurse's station and did not say anything to him/her about the resident, but LPN H was already at the facility, so he/she did not know if RN B had mentioned anything to LPN H or not. The resident sat in a wheelchair at the nurse's station wearing a shirt that did not cover the left wrist. LPN C could see the resident's left wrist was purple and swollen. When he/she assessed the left wrist, the resident guarded it. The resident's legs were crossed. When he/she asked the resident if he/she could try to stand, the resident uncrossed his/her legs and had a notable tremor and his/her facial expression changed as if he/she were in pain. LPN H had called the physician but had left by the time the physician called back. LPN C informed the physician of the resident's condition change, and the physician gave the order to send the resident to the hospital for an evaluation. LPN C notified the resident's family as well. If he/she had been on duty on the day shift and a CNA told him/her a resident that normally transfers and walks independently could no longer do that, he/she would assess the resident, check vitals and range of motion, notify the physician and document it all in the progress note. The LPN's progress note dated 1/31/26 at 4:30 P.M., was reviewed. When he/she documented Nurse in building he/she referred to LPN H. When he/she documented the nurse informed the change in health occurred prior to arrival during previous day, he/she meant to write previous shift. Review of the resident's hospital records dated 1/31/26, showed:-Arrival Date/Time: 1/31/26 at 4:43 P.M.;-History of Present Illness: Fall - Patient is pleasantly demented who presented to the emergency department (ED) for evaluation after reported fall. Patient is accompanied by family who indicates he/she received a phone call this afternoon about 4:30 P.M. indicating patient had sustained an unwitnessed fall. Patient was noted to have some swelling on his/her left wrist;-Physical Exam:-Blood Pressure: 173/86 (normal is 120/80);-Mild swelling and redness of the distal (anatomically located far from a point of reference) left wrist;-Comments: Patient is pleasantly confused but at his/her normal neurological baseline per family;-Radiology:-Soft tissue swelling around the wrist with probable nondisplaced (the bone is broken but remains in its original position without any significant shift or misalignment) distal radial (the bone on the thumb side of the wrist) fracture;-Medical Decision Making:-Patient placed in a plaster splint and will be discharged home;-discharged [DATE] at 9:32 P.M. Review of the resident's progress note's dated 1/31/26 at 11:56 P.M. showed, LPN H documented: Received update from hospital. Resident was being discharged and will be going home with family. Review of the resident's hospital records dated 2/1/26, showed:-Arrival Date/Time: 2/1/26 at 5:59 P.M.;-Unwitnessed fall;-Chief Complaint: Tailbone (coccyx) pain;-History of Present Illness:-Patient presenting after a fall yesterday, resulting in increased difficulty bearing weight and coccyx pain. Patient arriving in a splint. He/She was seen in the ED yesterday and a non-displaced distal radius fracture was identified. The fall was unwitnessed and occurred during the day shift. The evening shift nurse found the patient sitting at the edge of his/her wheelchair at the nursing station, where he/she had been all day. Upon returning home from the hospital last night, he/she refused to bear weight on his/her right leg, making it difficult to get him/her out of the car. He/She also experienced back pain when attempting to sit on the commode. He/She did not return to the long-term facility after his/her discharge yesterday, but went home with family. He/She does not typically use a cane or walker for mobility. He/She reported pain in his/her right leg yesterday while in the ED. He/She has significant memory issues, sometimes failing to recognize familiar people. He/She experiences pain in his/her lower back and buttocks. He/She was administered Tylenol for pain management;-Blood Pressure: 124/81;-General: He/She is not in acute distress and is not ill-appearing or toxic-appearing;-Musculoskeletal: Left wrist in OCL (a type of plaster splint used to immobilize an injury such as a fracture or soft tissue damage). Right upper leg pain with ROM (range of motion) testing;-Radiology:-Impression: Acute compression fracture (a fracture or break in the vertebrae (bones in the spine) of the L2 (the second lumbar (lower back) vertebrae);-Hospital Course:-Spine surgery was consulted, and after discussion with family, the decision was made for nonoperative management of the L2 compression fracture with a custom TLSO brace (spinal brace), activity as tolerated, and initiation of physical and occupational therapy in the brace. For the distal left radius fracture, initial splinting was performed, but due to repeated removal by patient, a short arm fiberglass cast was placed to ensure immobilization;-Therapy assessments noted significant deficits in mobility, transfers, and ADLs (activities of daily living);-Start taking these medications: Tylenol 650 mg every six hours as needed and hydrocodone-acetaminophen (a combination of an opioid (narcotic pain medication) and Tylenol for moderate to severe pain) 5 mg-325mg one tablet every eight hours as needed for pain;-discharged : 2/6/26 at 4:24 P.M. Review of the resident's progress note's, showed:-2/2/26 at 2:37 P.M., the DON documented: This nurse called the hospital for update on resident. Social Worker at hospital said the resident was originally seen in ER (emergency room) and was discharged shortly after with a left wrist fracture and sent home with a splint. Resident then returned two hours later due to increased back pain and was found to have an acute (sudden) L2 vertebrae of the spine and is using a TLSO brace and receiving therapy. Social Worker said family currently touring other facilities;-2/2/26 at 3:50 P.M.: Resident initially sent to hospital for evaluation. Resident is not returning to this facility so no plan of care updates post fall were done. During an interview on 2/25/26 at 9:10 A.M. LPN R said the resident's normal is that he/she is confused, oriented to person only, and independent with dressing, transfers and ambulation. The resident was up and walking constantly throughout the day. LPN R was not working on 1/31/26. Had he/she been working that day and the CNA told him/her the resident was having pain, could not stand or walk, that would have been a change in condition. LPN R would have obtained a set of vitals, assessed the resident's range of motion, skin and pain level. He/She would have notified the resident's physician as well. He/She would have documented everything in the resident's progress notes. Even if he/she were an agency nurse and had never taken care of the resident before, he/she would have listened to the staff that know the resident and completed the assessments and notified the physician. During an interview on 2/25/26 at 9:25 A.M., CNA J said he/she was familiar with resident. The resident's cognition would come and go. His/Her long-term memory was better than his/her short-term memory. He/She would probably not even know he/she had just eaten if he/she were not in the dining at the table with the food in front of him/her. The resident was independent with transfers and waking around the facility. If he/she had found the resident and the resident could not stand or walk, he/she would have informed the nurse that it was not normal for the resident and something was wrong. Normally the charge nurse will go and assess the resident if there is a change in condition. During an interview on 2/25/26 at 10:00 A.M., the DON said the resident could normally transfer himself/herself and walk independently throughout the facility. She expects the nurses to pay attention when a CNA tells them there is something wrong with a resident. If the resident could no longer do that, it would be a change in condition that warranted an assessment by the nurse. Nurses have to prioritize their duties by what is being presented to them. The nurse should have talked to the staff about the resident's baseline and obtained a set of vitals, assessed the resident's range of motion, pain. If the resident was exhibiting signs of pain like grimacing or guarding or if there was swelling/bruising, the nurse should have called the physician and documented the assessments and the physician's response. She was aware the resident was sent to the hospital on 1/31/26, but it was not until 2/2/26 that she learned the resident had a fractured wrist and L2. When she learned that, she called RN B and got his/her statement and asked CNA G to write a statement. She expects staff to follow the facility policies. During a telephone interview on 3/2/26 at 4:10 P.M., the facility Medical Director he would have expected RN B to have assessed the resident when the CNA told him/her the resident could no longer stand or walk. He would have the RN to have assessed the resident, called the physician and documented that information in the resident's EMR. He would have expected the RN to follow the facility change of condition and pain policies. 2732741

Based on observation, interview and record review, the facility failed to ensure each resident fall was thoroughly investigated/evaluated to determine the cause of the fall and failed to implement new interventions and/or modify existing interventions to prevent future falls or reduce the potential of injury or serious injury from future falls. In addition, the facility failed to ensure residents' care plans were updated to reflect current fall interventions and failed to have an updated system in place to communicate fall interventions to staff. Three residents with a history of falls were sampled and problems were identified with all three. (Residents #3, #9 and #7). The census was 57.Review of the facility Assessing Falls and Their Causes policy, undated, showed:-Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall;-Preparation: 1. Review the resident's care plan to assess for any special needs of the resident; 2. Identify the resident's current medication and active medical condition; 3. Assemble the equipment and supplies as needed;-General Guidelines: 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes; 2. Approximately 50% of residents fall annually and 10% of these falls result in serious injury; 3. Fear of falling may limit an individual's participation in activities; 4. Falling may be related to underlying clinical conditions and functional decline, medication side effects, and/or environmental risk factors; 5. Residents must be assessed in a timely manner for potential causes of falls;6. Relevant environmental issues should be addressed promptly;-After a Fall (included):c. Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details.1. Review of Resident #3's quarterly Minimum data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 5/21/25, and located in the electronic medical record (EMR), showed:-Makes Self Understood: Rarely/never understood;-Ability To Understand Others: Rarely/never understands;-Short-term Memory: Memory problem;-Long-term Memory: Memory problem;-Cognitive Skills for Daily Decision Making: Severely impaired-never/rarely made decisions;-Functional Abilities: Independent-Resident completes the activity by themselves with no assistance from a helper: Roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, walk 10, 50 and 100 feet;-Diagnoses: Alzheimer's Disease, Non-Alzheimer's Disease (dementia), anxiety and psychotic disorder;-Any Falls Since Admission/Entry or Reentry or Prior Assessment: Yes;-Number of Falls Since Admission/Entry or Reentry or Prior Assessment: Two falls with no injury.Review of the resident's care plan, located in the EMR, showed:-Focus (no date): Communication problem related to poor cognition due to advanced dementia. Goals: The resident will have needs met with staff assistance daily. Interventions (no dates): Anticipate and meet needs;-Focus (no date): Impaired cognitive function/dementia or impaired thought processes related to dementia. Goals: Staff will identify and anticipate needs in effort to show cognitive function decline. Interventions (no dates): Communicate with resident/family/caregivers regarding residents' capabilities and needs. Provide the resident with necessary assistance, stop and return if agitated;-Focus (no date): High risk for falls related to confusion. Unaware of safety needs. Goals: Will not sustain serious injury. Interventions (no dates): Low air loss mattress with raised sides to help resident identify edges of bed. Anticipate and meet resident's needs. Educate resident/family/caregivers about safety reminders and what to do if a fall occurs. The resident needs a Broda chair (mobile recliner) for comfort to reduce restlessness. Utilize a low bed to lower risk of fall and serious injury.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed: 7/4/25 at 8:30 P.M., received phone call from resident's roommate that resident fell and was on the floor. Went to resident's room and resident was laying on his/her side on the floor next to his/her bed.Review of the resident's progress note's, located in the EMR, showed:-7/4/25 at 9:23 P.M.: Nurse made aware the resident was on the floor. When staff arrived in resident's room, resident was found on side of bed. Resident was wrapped in blanket and blood was noted on the floor and on the resident's person. Hematoma (a localized collection of blood outside of blood vessels, often caused by trauma or injury) noted to left side of face and above his/her brow. Laceration noted to top of scalp with active bleeding. Order to send resident to hospital;-7/8/25 at 3:45 P.M.: At 1:30 P.M., called to shower room by staff who stated resident was walking through doorway and tripped over his/her own feet and before staff could reach resident, he/she fell to the floor on his/her right side. No injuries noted.Review of the resident's Fall Risk Evaluation dated 7/8/25, and located in the EMR, showed resident is at risk to fall. Review of the resident's progress note, dated 7/15/25 at 7:33 P.M., showed: Nurse was called to TV room for resident on the floor. Resident was observed on the floor next to a chair. Assessed for injuries and none found CNAs stated resident was walking and tripped over the chair legs and fell onto floor.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-7/15/25 at 4:00 A.M.: Nurse was called to TV room for resident on the floor. Resident was observed on the floor next to chair;-7/31/25 at 9:15 A.M.: Nurse and Certified Medication Technician (CMT) saw resident get up from his/her dining chair, got twisted in his/her feet and tripped and fell.Review of the resident's progress note's, showed:-7/31/25 at 5:52 P.M.: Nurse and CMT saw resident getting up from dining room chair and tripped over his/her own feet and fell onto the floor. No injuries noted;-8/10/25 at 11:24 P.M., showed the resident was observed on his/her right side in a fetal position during last rounds on the 3:00 P.M. - 11:00 P.M. shift. Assessment completed and no injuries noted. Resident unable to state why or how he/she got on the mat. Resident assisted back to bed. Bed in low position and call light in reach.Review of the resident's care plan showed no intervention for fall mats.Review of the resident's Fall Risk Evaluation dated 8/11/25, showed the resident is at risk to fall. Review of the resident's annual MDS, dated [DATE], showed:-Cognitive Skills for Daily Decision Making: Severely impaired-never/rarely made decisions;-Functional Abilities: Independent: Roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, walk 10, 50 and 100 feet;-Any Falls Since Admission/Entry or Reentry or Prior Assessment: Yes;-Number of Falls Since Admission/Entry or Reentry or Prior Assessment: Two falls with no injury.Review of the resident's physician's order sheet (POS) located in the EMR, showed:-8/29/25: Be sure bed is in lowest position and floor mats on floor while resident is in bed.Review of the resident's care plan showed no intervention for floor mats while resident is in bed. Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:9/25/25 at 1:45 P.M.: Loud noise heard. Upon entering the dining room. When walked in, witnessed resident on the floor bleeding with laceration to the right side of forehead.Review of the resident's progress note's, showed:-9/25/25 at 2:29 P.M.: A loud noise heard upon entering the dining room. When walked in witnessed resident on the floor bleeding with laceration to the right side of forehead. Area cleansed, two-centimeter (cm) laceration. Pressure dressing applied. New order sent to send resident to emergency room for treatment;-9/25/25 at 11:18 P.M.: Returned to facility from hospital. Sutures noted to laceration on forehead and area to be monitored and removed in five days. Review of the resident's Fall Risk Evaluation dated 9/25/25, showed the resident is at risk to fall. Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-10/7/25 at 2:53 P.M.: Family brought in soft helmet requesting resident to wear. Physician in agreement. New order, soft helmet at all times as tolerated. May remove for activities of daily living care and skin checks.Review of the resident's care plan showed no intervention for a soft helmet at all times.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-11/7/25 at 10:00 P.M.: During rounds at 10:00 P.M., CNA (Certified Nursing Assistant) found resident halfway on the floor mat and halfway on the bed. Resident was assessed by nurse. No skin injuries from fall. The incident report did not show if the bed was in the lowest position or if the resident was wearing the soft helmet.Review of the resident's progress notes showed no documentation regarding the resident being found on the floor as documented on the 11/7/25 at 10:00 P.M. Incidents by Incident Type report.Review of the resident's Fall Risk Evaluation dated 11/17/25, showed the resident is at risk to fall. Review of the resident's significant change in status MDS, dated [DATE], showed:-Cognitive Skills for Daily Decision Making: Severely impaired-never/rarely made decisions;-Functional Abilities: Partial/moderate assistance - helper does less than half the effort: Roll left and right. Substantial/maximal assistance - helper does more than half the effort: Sit to lying, lying to sitting on side of bed, sit to stand. Dependent - helper does all of the effort: chair/bed-to-chair transfer. Not applicable - Not attempted and the resident did not perform this activity: Walk 10, 50 and 100 feet;-Any Falls Since Admission/Entry or Reentry or Prior Assessment: Yes;-Number of Falls Since Admission/Entry or Reentry or Prior Assessment: One fall with no injury, One fall with injury (skin tears, abrasions, lacerations, superficial bruises, hematoma and sprains).Review of the resident's progress note, dated 12/2/25 at 12:05 P.M., showed the Social Service Director spoke to family during recent visit regarding decreasing use of soft helmet. Family agreeable to removing it during the daytime but would like the resident to have it while in bed to reduce self-injury risk.Review of the resident's POS, showed:-12/2/25: Alternating low air loss mattress with raised edges for comfort, pressure relief and to identify edges of bed;-12/2/25: Soft helmet while in bed and may remove as needed for activities of daily living (ADLs) care and skin checks. Review of the resident's care plan showed no intervention for a soft helmet while in bed. Observation on 12/9/25, showed:-At 7:59 A.M., the resident was out of the room. A low air loss mattress with raised sides was on the bed. There were two floor mats in the bathroom;-At 8:12 A.M., the resident sat in a Broda chair in the dining room wearing a soft helmet at the feeding assistance table;-At 12:47 P.M., the resident sat in a Broda chair in the dining room. The resident was not wearing the soft helmet;-At 2:10 P.M., the resident lay in bed with his/her eyes closed. The bed appeared to be low to the floor, but there were no fall mats on the floor and the resident was not wearing the soft helmet. Two fall mats were observed in the bathroom. Observation on 12/10/25, showed:-At 7:32 A.M., the resident sat in the Broda chair in the TV room across from the nurse's station. He/She was wearing the soft helmet;-At 10:07 A.M,, the resident sat in the TV room. The soft helmet had been removed. A request was made by the surveyor for staff to lay the resident down in bed for a skin assessment;-At 10:27 A.M., the surveyor entered the resident's room. The resident had been transferred to bed, but there were no staff present in the room. The bed was in the low position and one floor mat sat on each side of the bed. The resident was not wearing the soft helmet. After waiting several minutes for staff to arrive, the surveyor went to the nurse's station and asked the Director of Nurses (DON) which staff were going to complete the skin assessment. The DON and CNA A went with the surveyor at that time to complete the skin assessment. During an interview on 12/10/25 at 12:04 P.M., CNA B said he/she had worked at the facility since 7/2025. He/She was assigned to take care of the resident yesterday and today. His/Her shift began at 7:00 A.M. and ends at 3:00 P.M. When he/she first started working at the facility, there was a folder at the nurse's station that showed what type of care/interventions each resident required. He/She left the interview to find the folder, returned a few minutes later and said he/she could not find the folder. Most of the time, the nurses will tell staff what kind of care a resident needs. Yesterday, the resident was already up in the Broda chair when CNA B arrived. He/She laid the resident down yesterday after lunch. He/She did not put the helmet on the resident because he/she was told the resident only wore the helmet at night. He/She did not know the physician's order showed the helmet was to be worn while in bed with no stipulation that it was to be worn only at night. He/She did walk off and forget to put the mats on the floor after laying the resident down. Today when he/she arrived, the resident was in bed. The resident had the fall mats on the floor next to the bed and was wearing the soft helmet. During an interview on 12/10/25 at 1:34 P.M., the DON said she started at the facility on April 28, 2025, but did not become the DON until about a month after in May. Since she has been there, the only interventions the facility put into place in response to the resident's falls were the fall mats and the soft helmet the family brought in. This should have been added to the care plans. She expected staff to ensure the mats were on the floor and the soft helmet was on when the resident was in bed.2. Review of Resident #9's admission MDS, dated [DATE], and located in the EMR, showed:-Makes Self Understood: Usually understood;-Ability To Understand Others: Sometimes understands;-Moderately impaired cognition;-Cognitive Skills for Daily Decision Making: ;-Functional Abilities: Independent: Roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, walk 10 and 50 feet;-Diagnoses: Cancer (with or without metastasis), malnutrition and schizophrenia (a psychotic disorder);-Any Falls Since Admission/Entry or Reentry: No.Review of the resident's care plan, located in the EMR, showed:-Focus (no date): Functionally independent with some ADLs at this time. Diagnosis of cancer and on Hospice. Please accommodate my ADL needs as they change. Goals: Will remain independent with ADLs. Interventions (no dates): Limited assistance for bed mobility and transfers;-Focus (no date): Has had an actual fall. Goal: The resident's injured areas will resolve without complication. Interventions (no dates): For no apparent acute injury, determine and address causative factors of the fall. Monitor/document/report to physician any signs/symptoms of pain, bruises, change in mental status. New onset of confusion, sleepiness, inability to maintain posture, agitation;-Fall mats were not documented as an intervention. Review of the resident's POS showed no order for fall mats as an intervention to prevent injuries.Review of the resident's Fall Risk Evaluation dated 5/29/25, showed the resident is at risk to fall. Review of the resident's progress note dated 7/2/25 at 6:30 P.M., and located in the EMR, showed: Nurse called to resident's room. Upon entering room, resident was on the floor next to his/her bed. Resident said he/she tried to sit on the bed and missed the bed, sitting on the floor instead.Review of the resident's quarterly MDS, dated [DATE], showed:-Makes Self Understood: Usually understood;-Ability To Understand Others: Sometimes understands;-Moderately impaired cognition;- Functional Abilities: Independent: Roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, walk 10 and 50 feet;-Any Falls Since Admission/Entry or Reentry or the Prior Assessment: Yes;-Number of Falls: Two falls with no injuries.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-7/4/25 at 4:30 P.M.: Nurse called to resident room. Upon entering resident was on the floor next to his/her bed.Review of the resident's progress notes showed no documentation about the resident being found on the floor on 7/4/25 at 4:30 P.M.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-8/7/25 at 2:20 P.M.: Resident found on the floor by this nurse and Hospice nurse.Review of the resident's progress note, dated 8/7/25 at 2:20 P.M., showed the resident was found on the bathroom floor by the nurse and Hospice nurse. Resident was lying on his/her right side and said he/she hit his/her head on the right side. Resident was assisted back to the wheelchair. Upon assessment, bruising noted in his/her head on the right side and along his/her right arm. He/She also had a skin tear measuring 1 cm by 1.5 cm.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-8/11/25 at 10:35 P.M.: CNA reported to charge nurse the resident was found on the floor lying on his/her side in the fetal position.Review of the resident's progress note, dated 8/11/25 at 10:45 P.M., showed CNA reported to nurse that during rounds resident was found on the floor in his/her room lying in the fetal position. This nurse asked the resident what happened, and he/she said that he/she was reaching for his/her drink and his/her wheelchair rolled from underneath him/her. Nurse educated resident on using his/her call light and locking his/her wheelchair prior to reaching for items and/or transferring from one surface area to another.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-8/19/25 at 10:05 P.M.: This nurse was called to resident room for resident on the floor. Upon entering, resident found on the floor slouched over in front of wheelchair.Review of the resident's progress note, dated 8/19/25 at 11:55 P.M., showed the nurse was called to the resident's room for a report of the resident being on the floor. Upon entering the room resident was found on the floor slouched over in front of his/her wheelchair. Resident said he/she fell asleep and fell over onto the floor out of his/her chair. Resident assisted into bed, assessed for injury in which a laceration was found to forehead and cleaned up. No further intervention was determined needed.Review of the resident's Fall Risk Evaluation dated 9/1/25, showed the resident at risk to fall.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-9/27/25 at 1:30 A.M.: At 1:30 A.M. this morning, resident was found on the floor next to his/her bed. Resident stated he/she rolled out of bed while sleeping. Floor mat was in place. Physician was notified after this Registered Nurse (RN) obtained vitals and assessed the resident, as well as cleaned his/her scalp wounds. Resident denies headache or discomfort other that when this RN was cleaning the wounds with a small three-inch laceration to the right scalp area and also noted an abrasion to that area. Ice pack was placed 20 minutes on, 20 minutes off. Will continue to monitor closely.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-10/3/25 at 7:45 A.M.: Called to resident room by staff. Upon entering room, resident noted to be lying on his/her back on the floor of the bathroom. Resident was dressed with shoes on. No injuries noted. Wheelchair was near and unlocked. Review of the resident's progress note dated 10/3/25 at 4:44 P.M., showed at 7:45 A.M., called to resident's room by staff. Upon entering room, resident noted on his/her back on the floor of the bathroom. Resident was dressed with shoes on. Wheelchair was near and unlocked. Resident said he/she was trying to pick up his/her dirty shorts from off the floor when he/she fell over. No injuries noted. Reminded resident to use call light to call for assistance.Review of the resident's Fall Risk Evaluation dated 10/3/25, showed the resident is at risk to fall. Review of the resident's quarterly MDS dated [DATE], showed:-Makes Self Understood: Usually understood;-Ability To Understand Others: Sometimes understands;-Moderately impaired cognition;- Functional Abilities: Independent: Roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, walk 10 and 50 feet;-Any Falls Since Admission/Entry or Reentry or the Prior Assessment: Yes;-Number of Falls: Two falls with no injuries.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-11/13/25 at 5:50 P.M.: Staff called this nurse. Resident was on floor in front of bathroom door lying on his/her right side with wheelchair nearby.Review of the resident's progress note dated 11/13/25 at 7:10 P.M., showed at 5:50 P.M., this nurse was called to the resident's room by staff. Upon entering resident's room, resident noted to be lying on the floor on his/her right side in front of the bathroom door by the air conditioner unit. Wheelchair near resident was unlocked. Resident said he/she was trying to turn the heat on and fell over. Resident has a bruise to right shoulder and an abrasion to right ear.Review of the resident's Fall Risk Evaluation dated 11/14/25, showed the resident is at risk to fall. Observation on 12/10/25, showed:-At 9:22 A.M., the resident was dressed and lay in bed. His/Her eyes were closed. He/She did not have fall mats next to the bed. Observation of the resident's bathroom showed two fall mats leaning against the wall;-At 10:14 A.M., the resident lay in bed. No fall mats were on the floor next to the resident's bed. During an interview on 12/10/25 at 12:20 P.M., CNA C said he/she had been taking care of the resident for the past three or four days. The resident requires one person assistance to transfer. Once the resident is in the wheelchair, he/she is independent. There used to be a folder at the nurse's station that would show what kind of care/interventions a resident requires, but he/she had not seen it in a while. The nurses usually tell staff what kind of care a resident requires. The nurses did tell him/her the resident is a fall risk. This morning the resident was already up when he/she came to work. Yesterday, the resident did have fall mats next to his/her bed when he/she came to work. Throughout the day, he/she does not think the resident uses the floor mats. He/She thinks they are only used at night. No one had told him/her whether the resident needed the fall mats or not when the resident is in bed. 3. Review of Resident #7's quarterly MDS dated [DATE], located in the EMR, showed:-Makes Self Understood: Usually understood;-Ability To Understand Others: Usually understands;-Severely impaired cognition;-Mobility Device; Wheelchair;-Functional Abilities: Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity: Roll left and right, and sit to lying. Substantial/maximal assistance - Helper does more than half the effort: Lying to sitting on side of bed, and sit to stand. Dependent - Helper does all of the effort: Chair/bed-to-chair transfer and walk 10 feet;-Diagnoses of high blood pressure, Non-Alzheimer's Dementia and depression;-Has the resident had any falls since admission/entry or reentry or the prior assessment: No.Review of the resident's care plan located in the EMR, showed:-Focus (no date): Impaired cognitive function/dementia or impaired thought processes. Goals: Will improve/maintain cognitive function. Interventions (no dates): Communicate with the resident/family/caregivers regarding residents capabilities and needs. Cue, reorient and supervise as needed;-Focus (no date): The resident had an actual fall with no injury on 7/28/25. Goals: Will resume usual activities without further incident. Will be encouraged to ask for assistance when transferring. Interventions: Continue interventions on the at-risk plan.Review of the facility Incidents by Incident Type report dated 7/1/25 through 12/10/25, showed:-7/28/25 at 7:00 A.M.: Resident's aide called RN to the room after he/she found the resident on the floor. Resident was on the left side of his/her bed and lying on his/her left side at the time. Resident denied pain and remained alert and oriented times four (person, place, time, situation). Fall plan initiated;-The report did not show if the resident was in bed with side rails up or down prior to being fond on the floor or if he/she was up in a chair. Review of the resident's progress note's, showed no documentation related to the resident being found on the floor on 7/28/25 at 7:00 A.M. Review of the resident's Fall Risk Evaluation dated 10/20/25, showed the resident was at risk to fall. Observation on 12/9/25, showed:-At 8:28 A.M., showed the resident lay in bed with three-quarter length side rails up on both sides of the bed;-At 12:50 P.M., the resident sat in a Broda chair in the dining room.Observation on 12/10/25 at 7:51 A.M., showed the resident lay in bed with his/her eyes closed and three-quarter length side rails up on both side of the bed.During an interview on 12/10/25 at 1:34 P.M., the DON said she did not have any more information regarding the resident being found on the floor on 7/28/25, other than what was documented on the Incidents by Incident Type report. She does not know if the resident was in bed or in a chair prior to the fall. If the resident was in bed, she does not know if the side rails were up or down, if the resident climbed over the side rails or scooted to the foot of the bed. 4. During an interview on 12/10/25 at 10:53 A.M., with the DON and Administrator, the DON said she started at the facility on April 28, 2025, but did not become the DON until about a month after in May. The facility had QIPMO (Quality Improvement Program Missouri. An organization that provides education on best practices to improve care delivery and outcomes for nursing homes) at the facility from 11/18/25 through 11/20/25. QIPMO identified resident falls and fall interventions as a concern and told her each resident fall needed to be investigated, and have an intervention added. She was not aware of that prior to the mock survey. The Administrator said after QIPMO exited on 11/20/25, the facility scheduled staff meetings to address resident falls. The first meeting was scheduled and completed this morning, and all nursing staff will be in-serviced. The DON said there are no post-fall investigations for Resident #3, Resident #9 and Resident #7's falls. The only information she had is what was on the Incidents by Incident Types report and/or what was in the progress notes. Going forward, staff will be required to complete a post-fall investigation in the resident's EMR explaining exactly what happened and they will be required to add an immediate intervention. They recently started weekly Interdisciplinary Team meetings where they will be reviewing several issues including resident falls. Currently, she communicates daily with the nurses about any changes or new interventions and the nurses are to pass it along to CNAs during shift report. There is a folder at the nurse's station for staff that identifies what kind of care a resident requires and/or fall interventions that are in place, although it has been a long time since it was updated so she is not sure if it is current. She obtained the folder which showed Resident #3 was up ad lib (walking independently) and there were no fall interventions identified. There was no information in the folder regarding Resident #9 and Resident #7. 2630308

Based on interview and record review, the facility failed to ensure one resident's (Resident #11's) pain was addressed when he/she experienced a change of condition. On 1/31/26 at approximately 9:00 A.M., the resident complained of pain and could not stand or walk as he/she usually could. Certified Nursing Assistant (CNA) G informed Registered Nurse (RN) B. RN B did not assess the resident's pain, contact the physician or administer any pain medication. Facility staff did not address the resident's pain or call the physician, until approximately 1/31/26 at 3:00 P.M. when the evening shift started work, which was at least six hours after the resident's pain was first noticed. When the resident was evaluated at the hospital, he/she was diagnosed with a wrist fracture. The resident sample was 18. The census was 52.Review of the facility Change in a Resident's Condition or Status policy, revised 12/2016, showed:-Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g , changes in level of care, etc.)-Policy Interpretation and Implementation:-The nurse will notify the resident's Attending Physician or physician on-call when there has been a(an):-Accident or incident involving the resident;-Discovery of injuries of an unknown source;-Significant change in the resident's physical/emotional/mental condition;-A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or impacts more than one area of the resident's health status;-Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider;-The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility Pain Assessment and Management policy, revised 3/2015, showed:-Purpose: The purpose of this procedure is to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain;-General Guidelines:-Pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain. Effectively recognizing the presence of pain. Identifying the characteristics of pain. Addressing the underlying causes of pain;-Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new or worsening pain;-Recognizing Pain: Verbal expressions such as groaning, crying, screaming. Facial expressions such as grimacing, frowning, clenching of the jaw. Changes in gait (walking), skin color and vital signs. Guarding (A behavior where a person protects or guards a specific body part, indicating they may be experiencing pain. Oten due to the inability to verbally express discomfort.), rubbing or favoring a particular part of the body. Difficulty eating or loss of appetite;-Possible Physiological Signs of Pain: Increased blood pressure; tachycardia (rapid heart rate); increased respiration; diaphoresis (sweating);-Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level;-Pain management interventions shall reflect the sources, type and severity of pain;-Pain management interventions shall address the underlying causes of the resident's pain;-Documentation: Document the resident's reported level of pain with adequate detail as necessary and in accordance with the pain management program;-Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. Review of the facility RN job description, undated, showed:-Provide direct nursing care in accordance with established policies, procedures ad protocols of the healthcare organization;-Primary Responsibilities:-Implements and monitors patient care plans. Monitors, records and communicates patient condition as appropriate;-Serves as a primary coordinator of all disciplines for well-coordinated patient care;-Works in a constant state of alertness and safe manner;-May perform point of care testing according to policies and procedures;-Will demonstrate an understanding of patient needs, ensuring that each patient feels informed and understood, as well as heard. You are passionate about providing superior quality care and you are an inventive problem solver who thrives in a dynamic environment;-Registered Nurse put the patient first, helping to improve quality of life for our residents, providing high-quality care and doing well by what is right;-Initial and on-going systemic patient assessment;-Timely and accurate documentation using appropriate systems;-Promoting continuous quality improvement. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/17/25 and located in the resident's electronic medical record (EMR), showed:-Adequate hearing and vision;-Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Severe cognitive impairment;-Rejection of Care - Presence and Frequency: Did the resident reject evaluation of care: No;-Independent - Resident completes the activity by themselves with no assistance from a helper: Sit to stand, chair/bed-to-chair transfer, toilet transfer, walk 10 feet (once standing, the ability to walk at least 10 feet in a room, corridor, or similar space), 50 feet with two turns (once standing, the ability to walk at least 50 feet and make two turns), 150 feet (once standing, the ability to walk at least 150 feet in a corridor or similar space;-Diagnoses of Alzheimer's disease, and non-Alzheimer's dementia;-Pain Presence: No. Review of the resident's care plan, located in the EMR, showed:-12/11/24, Focus: Impaired cognitive function/dementia or impaired thought processes. Goal: Will maintain current level of cognitive function. Interventions: Encourage resident to participate in activities planned by the facility. Administer medications as ordered;-12/11/24, Focus: Elopement risk/wanderer. Goal: Safety will be maintained. Interventions: Distract resident from wandering by offering diversions. Monitor for fatigue and weight loss. Provide structured activities: toileting, walking inside/outside;-4/30/25, Focus: Risk for falls due to ambulating (walking) unassisted, wandering behavior, poor safety awareness. Goal: Will be free of falls/free of major fall related injury. Interventions: Educate on the importance of maintaining a safe environment, free of potential of fall hazards. Assist with placement of proper footwear as needed for safer ambulation and transfers;-12/11/25, Focus: Current Functional Performance. Goal: Functional status will progress towards personal discharge. Interventions: Locomotion on unit - independent. Toilet use - extensive assist of one person. Transfer - independent. Walk in in room/corridor - independent. During an interview on 2/23/26 at 1:05 P.M., CNA G said the resident was normally confused. He/She knew who he/she was, and knew family members, but did not know where he/she was or time/date. The resident was independent for transfers and walking. CNA G worked on 1/30/26 on the day shift and although he/she was not assigned to take care of the resident, he/she remembered the resident walking around the facility without any problems. On 1/31/26, he/she was not assigned to take care of the resident, but he/she was in the dining room between 8:00 A.M. and 9:00 A.M. when he/she noticed the resident was not there. He/She went to the resident's room and found him/her sitting on the toilet. The resident was weak and could not stand up or walk. The resident said his/her leg was sore. CNA G asked the resident if he/she had fallen, and the resident said no. CNA G did not notice swelling to the left wrist or any bruising at that time. He/She found CNA E to help transfer the resident off the toilet and into a wheelchair. After taking the resident to the dining room in the wheelchair for breakfast, he/she went and told RN B something was wrong with the resident. The resident couldn't stand up or walk, and normally he/she could, and the resident was complaining of pain in his/her leg. The RN said he/she would take a look at the resident. CNA G went back to the dining room to finish feeding residents. The resident ate about 20%, when normally he/she eats about 75%. The resident did not appear to be in constant pain while he/she sat in the wheelchair, only when he/she tried to stand up. After breakfast, CNA G wheeled the resident to the nurse's station and left him/her there. During a telephone interview on 2/27/26 at 9:00 A.M., CNA E said he/she was assigned to take care of the resident on 1/31/26. The resident is very confused, which is normal for him/her. The resident is normally independent for transfers and walking. The night shift gets the resident up and ready for the day, so when he/she arrived to work around 7:00 A.M. that morning, the resident was not in bed and was not in his/her room, which is not unusual. The first time he/she saw the resident was when CNA G asked for help getting the resident off the toilet. They went to the resident's room where the resident sat on the toilet. The resident said he/she could not get up because his/her bottom and/or leg was hurting. CNA E did not notice swelling of the left wrist or bruising on the resident's bottom or sides at that time. After taking the resident to the dining room in the wheelchair, CNA G said he/she was going to tell RN B about the resident not being able to stand and complaining of pain. CNA E did see the RN take the resident's vitals at the nurse's station after breakfast. After lunch, CNA E and CNA G took the resident to the bathroom in the wheelchair. The resident still could not stand up. They transferred the resident to the toilet and cleaned him/her up and took him/her back to the nurse's station. CNA E did not notice any swelling of the left wrist or bruising at that time. The resident sat in the wheelchair all day. CNA E did not speak to RN B about the resident because CNA G spoke to the RN that morning. Review of the resident's progress note's, located in the EMR, showed:-1/31/26, 7:00 A.M. - 3:00 P.M.: No observations, or assessments including pain and vital signs (blood pressure, pulse, respirations, temperature) documented by RN B;-1/31/26 at 3:34 P.M., Licensed Practical Nurse (LPN) H (evening shift nurse 3:00 P.M. - 11:00 P.M.) documented: Day shift nurse informed this nurse that the resident's CNA informed him/her this morning that they discovered resident in his/her restroom on the toilet unable to walk or stand. They placed him/her in a wheelchair and rolled him/her to the nurse's station. This nurse observed resident with swelling to left wrist and unable to bear weight on his/her legs. He/She is complaining of pain to back and right hip. Upon further assessment, resident found to have bruising to the right arm and side. Resident said, I fell right here, pointing to his/her knees. I asked him/her what happened after he/she fell, and he/she said, I got on the toilet. DON (Director of Nursing), PCP (primary care physician), and POA (power of attorney) notified;1/31/26 at 4:30 P.M. LPN C (evening shift nurse) documented: Upon start of shift, nurse in building informed this nurse that resident had bruising and swelling to left wrist and is unable to bear weight on either leg. The nurse informed the change in health occurred prior to arrival during previous day shift (7:00 A.M.-3:00 P.M.). Upon assessment, this nurse noted visible bruising and swelling to left wrist and hand. Resident guarding area, showing signs of pain and discomfort. This nurse spoke with NP (nurse practitioner) and resident's family informing them of health status change. This nurse called EMS (emergency medical services) to transport resident to hospital for further evaluation. Awaiting update. Review of the resident's medical administration record (where a nurse or Certified Medication Technician (CMT) documents routine and PRN (as necessary) medications are administered) located in the EMR and dated 1/1/26 through 1/31/26, showed:-6/3/24, Acetaminophen (Tylenol) 500 milligrams (mg) one by mouth every eight hours as needed for pain: No documentation showing the medication had been administered on 1/31/26. Review of the facility investigation dated 2/2/26, showed:-2/2/26 the DON documented: After learning about an incident with a resident, I called the nurse (RN B) that was on duty on 1/31/26 for the day shift (7:00 A.M.-3:00 P.M.). The nurse was an agency nurse. I asked the nurse was he/she made aware of any incident regarding resident. The nurse said there were several residents sitting at the nurse's station in wheelchairs. Nurse said he/she was not aware of resident's baseline status. I asked nurse if anyone had reported that resident fell, and he/she said he/she did not recall and when he/she heard something regarding a fall, it was at shift change and the relieving nurse had arrived. Spoke to CNA (CNA G) on staff on 1/31/26 day shift. CNA said that resident would not get off the toilet by himself/herself, and he/she had to assist resident into a wheelchair. I asked CNA if he/she noticed any bruising or swelling on resident and CNA said no. I asked CNA did he/she let the nurse know about the resident's change in condition, and CNA said he/she did inform the nurse on duty. I asked CNA to write a statement;-Review of CNA G's written statement dated 2/2/26, showed: On Saturday January 31, 2026, I noticed the resident had not eaten breakfast, so I went to check on him/her and he/she was in the restroom on the toilet. I tried to help him/her get dressed and stand up. The resident said, Oh baby I can't, my leg hurts. I told him/her okay give me one minute and went to get another aide. We both stood him/her up with a gait belt (applied around a resident's waist to provide balance and support during a transfer), pulled his/her pants on and helped pivot him/her to a wheelchair. Resident ate his/her breakfast. I took him/her to the nurse's station and told the nurse the resident said his/her leg was sore, so I put him/her in a wheelchair. During an interview on 2/23/26 at 3:09 P.M., LPN H said he/she worked the night shift on 1/30/26 at 11:00 P.M. and left around 7:00 A.M. on 1/31/26. There were no reports about the resident falling, having pain or a change in condition during that shift. When he/she came back to work on 1/31/26 around 3:00 P.M., he/she noticed the resident sat in a wheelchair at the nurse's station. That was unusual because the resident was usually up and walking around the entire facility. LPN H went over to look at the resident and noticed the resident's left wrist was huge, very swollen and reddish in color. The resident was wearing a short-sleeved shirt, and it was very noticeable. The resident guarded the wrist when he/she tried to assess it. LPN H tried to help the resident stand up, but the resident moaned and could not stand. LPN H asked the resident if he/she had fallen, and the resident said he/she had. RN B told him/her staff had brought the resident to the nurse's station that morning and told him/her the resident could not walk. The RN said he/she had not assessed the resident because he/she was busy doing other things. The resident was sitting at the nurse's station so there was no reason as to why the RN could not have assessed the resident. LPN H looked in the progress notes, and the RN had not documented anything about the resident. LPN H called the physician's exchange and left a message for the physician to call back. He/She left before the physician returned the call because the facility had scheduled both him/her and LPN C to work. Since he/she had to work the midnight shift that night, he/she went home. LPN C took the call from the physician. The resident was still at the facility when he/she went home. During a telephone interview on 3/4/26 at 9:40 A.M., LPN C said he/she was familiar with the resident. Normally, the resident is confused and independent for self-transfer and walking. When LPN C came to work on 1/31/26 around 3:00 P.M., RN B sat at the nurse's station and did not say anything to him/her about the resident, but LPN H was already at the facility, so he/she did not know if RN B had mentioned anything to LPN H or not. The resident sat in a wheelchair at the nurse's station wearing a shirt that did not cover the left wrist. LPN C could see the resident's left wrist was purple and swollen. When he/she assessed the left wrist, the resident guarded it. The resident's legs were crossed. When he/she asked the resident if he/she could try to stand, the resident uncrossed his/her legs and had a notable tremor and his/her facial expression changed as if he/she were in pain. LPN H had called the physician but had left by the time the physician called back. LPN C informed the physician of the resident's condition change, and the physician gave the order to send the resident to the hospital for an evaluation. LPN C notified the resident's family as well. If he/she had been on duty on the day shift and a CNA told him/her a resident that normally transfers and walks independently could no longer do that, he/she would assess the resident, check vitals and range of motion, notify the physician and document it all in the progress note. The LPN's progress note dated 1/31/26 at 4:30 P.M., was reviewed. When he/she documented Nurse in building he/she referred to LPN H. When he/she documented the nurse informed the change in health occurred prior to arrival during previous day, he/she meant to write previous shift. Review of the resident's hospital records dated 1/31/26, showed:-Arrival Date/Time: 1/31/26 at 4:43 P.M.;-History of Present Illness: Fall - Patient is pleasantly demented who presented to the emergency department (ED) for evaluation after reported fall. Patient is accompanied by family who indicates he/she received a phone call this afternoon about 4:30 P.M. indicating patient had sustained an unwitnessed fall. Patient was noted to have some swelling on his/her left wrist;-Physical Exam:-Blood Pressure: 173/86 (normal is 120/80);-Mild swelling and redness of the distal (anatomically located far from a point of reference) left wrist;-Comments: Patient is pleasantly confused but at his/her normal neurological baseline per family;-Radiology:-Soft tissue swelling around the wrist with probable nondisplaced (the bone is broken but remains in its original position without any significant shift or misalignment) distal radial (the bone on the thumb side of the wrist) fracture;-Medical Decision Making:-Patient placed in a plaster splint and will be discharged home;-discharged [DATE] at 9:32 P.M. Review of the resident's progress note's dated 1/31/26 at 11:56 P.M. showed, LPN H documented: Received update from hospital. Resident was being discharged and will be going home with family. Review of the resident's hospital records dated 2/1/26, showed:-Arrival Date/Time: 2/1/26 at 5:59 P.M.;-Unwitnessed fall;-Chief Complaint: Tailbone (coccyx) pain;-History of Present Illness:-Patient presenting after a fall yesterday, resulting in increased difficulty bearing weight and coccyx pain. Patient arriving in a splint. He/She was seen in the ED yesterday and a non-displaced distal radius fracture was identified. The fall was unwitnessed and occurred during the day shift. The evening shift nurse found the patient sitting at the edge of his/her wheelchair at the nursing station, where he/she had been all day. Upon returning home from the hospital last night, he/she refused to bear weight on his/her right leg, making it difficult to get him/her out of the car. He/She also experienced back pain when attempting to sit on the commode. He/She did not return to the long-term facility after his/her discharge yesterday, but went home with family. He/She does not typically use a cane or walker for mobility. He/She reported pain in his/her right leg yesterday while in the ED. He/She has significant memory issues, sometimes failing to recognize familiar people. He/She experiences pain in his/her lower back and buttocks. He/She was administered Tylenol for pain management;-Blood Pressure: 124/81;-General: He/She is not in acute distress and is not ill-appearing or toxic-appearing;-Musculoskeletal: Left wrist in OCL (a type of plaster splint used to immobilize an injury such as a fracture or soft tissue damage). Right upper leg pain with ROM (range of motion) testing;-Radiology:-Impression: Acute compression fracture (a fracture or break in the vertebrae (bones in the spine) of the L2 (the second lumbar (lower back) vertebrae);-Hospital Course:-Spine surgery was consulted, and after discussion with family, the decision was made for nonoperative management of the L2 compression fracture with a custom TLSO brace (spinal brace), activity as tolerated, and initiation of physical and occupational therapy in the brace. For the distal left radius fracture, initial splinting was performed, but due to repeated removal by patient, a short arm fiberglass cast was placed to ensure immobilization;-Therapy assessments noted significant deficits in mobility, transfers, and ADLs (activities of daily living);-Start taking these medications: Tylenol 650 mg every six hours as needed and hydrocodone-acetaminophen (a combination of an opioid (narcotic pain medication) and Tylenol for moderate to severe pain) 5 mg-325mg one tablet every eight hours as needed for pain;-discharged : 2/6/26 at 4:24 P.M. Review of the resident's progress note's, showed:-2/2/26 at 2:37 P.M., the DON documented: This nurse called the hospital for update on resident. Social Worker at hospital said the resident was originally seen in ER (emergency room) and was discharged shortly after with a left wrist fracture and sent home with a splint. Resident then returned two hours later due to increased back pain and was found to have an acute (sudden) L2 vertebrae of the spine and is using a TLSO brace and receiving therapy. Social Worker said family currently touring other facilities. During an interview on 2/25/26 at 9:10 A.M. LPN R said the resident's normal is that he/she is confused, oriented to person only, and independent with dressing, transfers and ambulation. The resident was up and walking constantly throughout the day. LPN R was not working on 1/31/26. Had he/she been working that day and the CNA told him/her the resident was having pain, could not stand or walk, that would have been a change in condition. LPN R would have obtained a set of vitals, assessed the resident's range of motion, skin and pain level. He/She would have notified the resident's physician as well. He/She would have documented everything in the resident's progress notes. Even if he/she were an agency nurse and had never taken care of the resident before, he/she would have listened to the staff that know the resident and completed the assessments and notified the physician. During an interview on 2/25/26 at 10:00 A.M., the DON said the resident could normally transfer himself/herself and walk independently throughout the facility. She expects the nurses to pay attention when a CNA tells them there is something wrong with a resident. If the resident could no longer do that, it would be a change in condition that warranted an assessment by the nurse. Nurses have to prioritize their duties by what is being presented to them. The nurse should have talked to the staff about the resident's baseline and obtained a set of vitals, assessed the resident's range of motion, pain. If the resident was exhibiting signs of pain like grimacing or guarding or if there was swelling/bruising, the nurse should have called the physician and documented the assessments and the physician's response. She was aware the resident was sent to the hospital on 1/31/26, but it was not until 2/2/26 that she learned the resident had a fractured wrist and L2. When she learned that, she called RN B and got his/her statement and asked CNA G to write a statement. She expects staff to follow the facility policies. During a telephone interview on 3/2/26 at 4:10 P.M., the facility Medical Director he would have expected RN B to have assessed the resident when the CNA told him/her the resident could no longer stand or walk. He would have the RN to have assessed the resident, called the physician and documented that information in the resident's EMR. He would have expected the RN to follow the facility change of condition and pain policies. 2732741

Based on observation, interview and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one resident (Resident #10) who chipped their tooth while at the facility. The sample was 10. The census was 54. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/18/25, showed the following: -Cognitively intact; -Dependent with transfers, dressing and wheelchair locomotion; -Diagnoses included diabetes, hemiplegia flaccid of left side (paralysis on left side of body), cerebral infarction (stroke) and nontraumatic intracranial hemorrhage (bleed in the brain), seizures, and malnutrition; -Oral/Dental status: blank. Review of the resident's care plan, dated 4/30/25, showed no documentation regarding the resident's oral care. Review of the resident's progress notes, showed: -Health status progress note, dated 10/21/2023 at 10:37 A.M., the resident reported his/her left front tooth broke off while eating a piece of candy. Partial tooth remains in socket; -Social services progress note, dated 11/22/2023 at 9:31 A.M., resident has a dental appointment scheduled on 1/23/2024 at 3:00 P.M.; -Health status progress note, dated 1/23/24 at 9:02 P.M., resident left for dentist appointment and returned without seeing dentist due to resident being unable to transfer to dental chair; -Physician progress note, dated 2/28/2025 at 1:42 P.M., resident complaining of a toothache. Tooth abscess diagnosed by physician and antibiotics ordered. Resident is scheduled to see the dentist. Physician attempted calling resident's next of kin with no answer. Staff to follow up notification with next of kin; -Health status progress note, dated 3/3/25 at 5:21 P.M., resident received antibiotic order from the physician for Amoxicillin (antibiotic) 500 milligrams (mg) twice a day for seven days for diagnosis of dental abscess, left message for family; -Physician progress note, dated 3/17/25 at 12:05 A.M., resident was treated for tooth abscess and had no complaints of tooth pain. Review of the resident's physician orders, dated 3/4/25, showed Amoxicillin oral capsule 500 mg, give one capsule by mouth two times a day for dental abscess for seven days. During an observation and interview on 4/28/25 at 9:29 A.M., the resident fiddled his/her tongue on the area of his/her front broken tooth while being interviewed. The resident denied pain and said the tooth feels funny. There was a slight lisp noticed at times when the resident spoke. The resident said his/her front tooth broke off over a year ago. The facility repeatedly said they were going to have a dentist look at it. He/She has pain and cannot bite into anything solid, like an apple. Also, he/she can only chew on the right side of his/her mouth due to pain on the left. He/She spoke with Social Worker (SW) C and Licensed Practical Nurse (LPN) A about the pain and broken tooth. LPN A has said that SW C is taking care of it. SW C made a dentist appointment about a year ago and when the resident arrived the dentist refused to see him/her because he/she could not get into a dental chair from the wheelchair. Since then, SW C has said he/she is working on getting him/her to a dentist and then said he/she will have a dentist come to the facility to see the resident, but so far nothing has been done. The broken front tooth hurts and he/she is embarrassed about the appearance of his/her teeth. He/She feels like the facility does not care about him/her and are putting him/her off and this makes the resident aggravated. The physician that makes rounds started the resident on an antibiotic for a tooth pain a few weeks ago, but he/she does not remember the physician coming to see him/her. During an interview on 4/29/25 at 9:36 A.M., SW C said when a resident needs dental services, an appointment should be made as soon as possible. He/She is responsible to make these appointments once he/she is made aware of resident dental needs from the resident, family or nursing staff. He/She generally asks all residents about their vision, dental, and podiatry needs during the quarterly review documented in the progress notes. The facility uses a Medicaid accepting dentist, or the dentist of the resident's choice. There was an incident when a resident was sent to the dentist, and they were not able to be seen because they could not get into the dental chair, so the appointment was rescheduled. He/She does not remember which resident this was. He/She does not think any residents are in need of dental care at this time and is unaware that a resident has been waiting for over a year to be seen by a dentist. He/She added, he/she thinks he/she knows which resident the surveyor may be asking about, Resident #10, but he/she is unaware of what is going on with the resident at this time. He/She remembers telling Resident #10 a dentist will be making rounds at the facility but that did not happen, and he/she does not remember why. He/She also remembers speaking with Resident #10's family around the end of the year 2024 about the resident's chipped off tooth, but he/she only remembers getting the first initial appointment and is not sure why this has not been followed up on. He/She said she has never asked Resident #10 about his/her tooth. Waiting a year to get a tooth fix is too long. During an interview on 4/29/25 at 9:54 A.M., the Administrator said if a resident is need of dental care SW C is responsible to make the appointments. SW C is made aware of dental issues from the resident, family, and staff. If a resident requires dental care the SW should notify the Director of Nursing (DON) or the nurse supervisor and let them know about the dental issue and then make the appointment. The appointment should be made as soon as possible. She expects SW C to follow up on appointments and make sure the resident has been seen or attempts made to have them seen and this should be documented in the progress notes. She is unaware a resident has been waiting over a year to see a dentist for a broken off tooth. She is also unaware the resident was on an antibiotic for an abscessed tooth on 3/4/25. During an interview on 4/30/25 at 9:02 A.M., the DON said she is aware of the resident's broken off tooth back on 10/21/23 and the dentist appointment was scheduled as soon as possible after the resident recovered from a broken hip and the first open appointment with a Medicaid dentist. The resident returned without seeing the dentist due to an issue with resident not being able to transfer to a dental chair. She was not aware the resident and family have requested several times to see the dentist. The SW is responsible to make dental appointments which the SW did for 1/23/24. The facility attempted to take care of the dental issues, but the resident has never complained about tooth pain or needing to see a dentist to her since returning from the dentist unseen. She was not aware the rounding physician ordered an antibiotic for an abscessed tooth. She does not know why the physician wrote in his/her notes the resident has an appointment with the dentist. She does not know if the tooth should be fixed because she does not know what they can do for him/her. During an interview on 4/30/25 at 9:47 A.M., LPN A said he/she was aware of the resident having a broken off tooth since 10/21/23 after eating a piece of candy. The dentist appointment was made for January 2024, after the resident hip healed from surgery, by SW C. He/She was aware the resident returned from the dentist without being seen because there was an issue with not being able to transfer resident into the dental chair. He/She has not spoken with the family or resident about a follow up dental appointment because SW C is responsible for it. The physician that rounds at the facility ordered an antibiotic about a month ago for an abscessed tooth. He/She is not sure which tooth it was for. The resident did not tell him/her about the tooth pain, the resident just told the physician. He/she found out about the abscessed tooth, after the physician ordered an antibiotic for the resident. He/She does not know which tooth, the physician did not specify. He/She does not know why the physician wrote in his/her notes the resident has an appointment with the dentist. The resident did tell him/her every now and then since the tooth broke off that the resident had tooth pain, but it is managed by the resident's scheduled pain medication ordered for his/her back. He/She did not follow up with the resident after the antibiotic was ordered to check the tooth or if the resident was having any pain from it. He/She never followed up because the resident can make his/her needs known. MO 00253231

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse when an allegation of physical abuse was made for one resident (Resident #1). On 2/1/25 at approximately 10:00 A.M., Registered Nurse (RN) A heard banging on the wall inside the resident's room, and someone yelling, Stop that, stop that, do it again, then a loud slap inside the resident's room and when he/she opened the resident's door he/she saw Certified Nurse Aide (CNA) B holding the resident against the wall. RN A notified the Director of Nurses (DON) of an allegation of abuse and the DON directed RN A not to send CNA B home. CNA B remained in the facility providing care to other residents for over five hours after the allegation was reported. The facility did not immediately begin an investigation into the allegation of abuse. Facility staff were not properly educated on the facility's policies of identifying and reporting abuse to ensure residents were free from abuse. The sample was 8. The census was 49. The Assistant Director of Nurses (ADON) and DON were notified on 2/1/25 at 6:45 P.M. of an Immediate Jeopardy (IJ) which began on 2/1/25. The IJ was removed on 2/4/25 as confirmed by surveyor onsite verification. Review of the facility's Abuse Prevention Program policy, revised December 2016, showed: -Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms; -Policy Interpretation and Implementation: -As part of our resident abuse prevention, the administration will: --Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; --Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents; --Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior; --Implement measures to address factors that may lead to abusive situations; --Identify and assess all possible incidents of abuse; --Investigate and report any allegations of abuse within timeframes as required by federal requirements; --Protect residents during abuse investigations. Review of the facility's Abuse Investigation and Reporting policy, revised July 2017, showed: -Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management; -Policy Interpretation and Implementation: --Role of the Administrator: -If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual; -The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/22/25, showed: -Adequate hearing; -Resident rarely/never understands; -Resident rarely/never understood; -Short and long term memory problem; -Severe impairment for decisions regarding tasks of daily life; -Rejection of care behavior occurred one to three days; -Physical behavioral symptoms occurred one to three days; -Substantial/maximal assist required for upper and lower body dressing, toileting, and personal hygiene; -Diagnoses include Alzheimer's disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks), anxiety, and depression. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Current functional performance; -Interventions included extensive assist/one-person physical assist for dressing, personal hygiene and toilet use. Extensive assist/two-person physical assist for dressing, personal hygiene, and toilet use; -Focus: The resident is resistive to care at times with activities of daily living (ADLs) care; -Focus: The resident is/has potential to be physically aggressive; -Interventions included assess and anticipate resident's needs. Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Give the resident as many choices as possible about care and activities. When the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, and if response is aggressive, staff to walk away calmly and reapproach later. During an interview on 2/1/25 at 1:07 P.M., RN A said at around 10:05 A.M. that morning, he/she heard a voice yelling in the resident's room. The voice sounded threatening and mean, and was yelling, Stop that, stop that, do it again! RN A heard bumping noises inside the room, then a loud slap. The voice yelled, See, I told you, don't do it again! RN A opened the door to the resident's room and saw the resident up against the wall with CNA B standing in front of him/her. The resident's back was to the wall and CNA B had his/her body pushed into the resident's, holding the resident's left arm with his/her right arm. The resident was not attempting to move. When asked if everything was ok, CNA B said yes, sat the resident down on the bed, and immediately left the room. RN A interviewed the resident by asking yes/no questions, but the resident was very confused and was unable to say much. RN A performed a skin assessment and when he/she attempted to check the resident's lower body, the drawstring on the resident's pants was tied so tight, he/she had to cut the string to assess the resident. After assessing the resident, RN A called the DON to inform him of what he/she observed. RN A asked to send CNA B home and the DON said no, the facility was too short on staff. The DON told RN A the resident is very combative and CNA B would never do this type of thing. The DON did not ask RN A for a written statement regarding what happened and said he/she would arrive at the facility soon. RN A left the building at 12:20 P.M., at which time, CNA B was still working in the facility and the DON had not arrived. Observation on 2/1/25 at 2:03 P.M., showed CNA B walked throughout the building, going in and out of resident rooms, providing care to residents. During an interview on 2/1/25 at 2:03 P.M., Licensed Practical Nurse (LPN) H said he/she came in around 12:15 P.M. The DON called him/her in because the nurse from day shift asked the DON to find someone to replace him/her on the schedule. LPN H was not informed of any allegations of abuse. If he/she was made aware of an allegation of abuse perpetrated by an employee, he/she would notify the DON and leave it up to the DON to determine if the employee should be sent home. He/She would not make the decision to send the employee home. The DON is responsible for investigating abuse allegations. During an interview on 2/1/25 at 2:33 P.M., CNA B said the day shift nurse called the DON and told him that he/she was being mean to the resident. The resident is not aggressive, but hits on people. CNA B was in the resident's room this morning, around 9:30 A.M., to get him/her changed and dressed for breakfast. The resident is pretty confused and kept going around the room. Two employees are usually needed to provide care to the resident, but CNA B can do it by him/herself because he/she knows the resident. CNA B told the resident he/she was wet and smelled like pee. He/She kept telling the resident to sit down to change him/her. The resident hit CNA B on the shoulder and CNA B said he/she did not hit the resident back. When the resident tried to hit him/her again, CNA B pushed the resident's arms back. He/She told the resident, Your licks don't hurt me, you need to stop. The resident kept swinging and CNA B pushed the resident's hands while he/she was swinging. CNA B put the resident against the wall so he/she couldn't bend over with CNA B while he/she was trying to pull his/her pants up. When asked to demonstrate how he/she spoke to the resident, CNA B raised his/her voice loudly. He/She said he/she uses a louder pitch to get the resident's attention. The nurse on the day shift was in the hall at the time, and must have heard this. Some people might think there is no way in hell someone should talk to a resident like this, but they don't do this every day and sometimes staff have to raise their voice for a resident to listen. Observation on 2/1/25 at 2:59 P.M., showed LPN H, Certified Medication Technician (CMT) I, and CNA B escorted the resident to his/her room for a skin assessment. LPN H and CMT I said the resident will hit staff. CNA B lifted the resident's shirt in the front and back. When staff attempted to fully remove the shirt for an observation of the resident's arms, the resident shook his/her head no, and wiggled his/her arms away from CNA B. The resident did not attempt to hit staff and left the room. During an attempted interview on 2/1/25 at 3:05 P.M., the resident was confused and was unable to answer specific questions regarding his/her care needs, interactions with staff, or treatment at the facility. During an interview on 2/1/25 at 3:05 P.M., CMT I said the DON called him/her earlier that day and asked which aide was assigned to the resident's hall, which was CNA B. The DON told CMT I the day shift nurse said CNA B was being mean to the resident. The DON did not say anything about sending CNA B home. The resident has Alzheimer's disease. He/She only gets aggressive when he/she has a bowel movement or is receiving care, and then he/she will sucker punch staff. CNA B is the only aide who can provide care to the resident by him/herself. Otherwise, two staff have to provide care so one person can distract the resident and the other person can do the care. During an interview on 2/1/25 at 3:29 P.M., the DON said at around 10:00 A.M., he got a call from RN A. RN A said he/she heard yelling and loud noises coming from the resident's room, like the heads of residents banging on the walls or something. RN A saw CNA B and the resident leaned against the wall while CNA B was getting the resident dressed. RN A wanted to send CNA B home on the basis of abuse and the DON said no, noises are not a good basis to send the employee home. Noises could come from anywhere. He told RN A he would look into it and called the facility. He talked to CMT I, who didn't know what was going on. He has not interviewed the resident or any other staff, yet. Management typically investigates abuse. They get statements from the parties involved and document as necessary. He lets the ADON do most of that, because he is still new and has only been working with the facility for three months. Abuse investigations are conducted in a timely fashion, and the DON did not provide specifics on the definition of timely. During an interview on 2/1/25 at 3:48 P.M., the ADON said the DON did not notify her of the abuse allegation until after 2:30 P.M., when LPN H called to notify her the Department of Health and Senior Services (DHSS) was in the building. The Assistant Administrator was not aware, either. Any employee alleged to have been the perpetrator of abuse should be suspended immediately, pending investigation, to keep all residents safe. CNA B should have been sent home the minute the DON was notified of an abuse allegation. Management should immediately be notified of abuse allegations. An abuse investigation should be started by management the moment they are made aware. Observation on 2/1/25 at 3:48 P.M., showed CNA B in the ADON's office. Review of CNA B's time punches, showed he/she clocked out at 4:42 P.M. During an interview on 2/1/25 at 4:06 P.M., CNA K said the resident has Alzheimer's disease. Staff have to be loud with him/her in order for him/her to understand what they need him/her to do. He/She needs assistance with changing and dressing and can get angry and hit staff when they assist with this. It takes two staff to provide care to the resident on some days. When the resident gets physically aggressive, staff should step back and leave the room. During an interview on 2/1/25 at 4:58 P.M., the Assistant Administrator said staff should engage residents in a normal tone of voice, or speak louder if the resident is hard of hearing. If a resident becomes combative and physically aggressive, staff should leave the room and should not physically engage with the resident. He wasn't notified of the abuse allegation until the ADON contacted him at 2:35 P.M. The day shift nurse reported a concern of abuse to the DON. The alleged incident occurred at 10:00 A.M. The Assistant Administrator should have been notified within 30 minutes to an hour of the DON being notified, and an investigation should have been started right away. The DON should have immediately suspended the CNA pending an investigation to protect the resident and other residents from potential abuse. CNA B should not have remained in the facility, providing care for other residents, for another five hours after the allegation of abuse was reported. During an interview on 2/1/25 at 8:37 P.M., the ADON said the resident was combative when first admitted to the facility, but he/she started anxiety medication and this has not been an issue for a long time. Approach is a lot for the resident. Staff should tell him/her what they want to do and speak to the resident in a low, normal tone of voice. Staff should not yell at the resident; he/she is not hard of hearing. If the resident becomes combative when receiving care, staff should leave and get assistance. Ongoing behaviors and combativeness should be reported to her, but she has not received any reports about this happening. It is not appropriate for staff to keep the resident against the wall when assisting him/her with toileting. Instead, the resident should be taken to the toilet, where he/she can sit down and staff can change him/her. Staff should be educated on the facility's abuse policies. During an interview on 2/1/25 at 2:27 P.M., Housekeeper J said If he/she overheard staff from another department yelling at a resident, or witnessed abusive behavior, he/she would have to wait to tell his/her supervisor. His/Her department does not get involved with what goes on in other departments. Each department handles their own issues. If he/she witnessed yelling or abuse on a weekend, he/she would unfortunately have to wait to speak to his/her supervisor on Monday. During an interview on 2/3/25 at 9:20 A.M., Housekeeper L said he/she has not received training about the facility's abuse policies recently. If he/she heard nursing staff yelling at a resident, or slapping noises coming from a resident's room, he/she would probably tell the nurse. It is not his/her place to get involved with nursing staff, so he/she would not intervene. During an interview on 2/3/25 at 11:29 A.M., the DON said he was not educated on the facility's abuse policies when he began his position with the facility in November 2024. After the abuse allegation was made on 2/1/25, he was in-serviced on the policy. All staff who have worked since the allegation was made, have not been in-serviced in a timely fashion. If any employee hears, witnesses, or suspects abuse, they should intervene first, make sure the resident is safe, then report it to management. During the interview, the DON reviewed the documentation being provided to staff to educate them on the facility's abuse policies. The documentation did not provide guidance for staff to ensure the resident is safe when abuse is suspected, before reporting it to management. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00248906

Based on observation, interview and record review, the facility failed to provide care and services to ensure residents were free from accident hazards. Certified Nurse Aide (CNA) B performed a Hoyer (mechanical lift) transfer for one resident (Resident #6) without the assistance of a second person, and the resident was struck in the face with the lift, causing injuries to his/her face. The employee failed to report the incident at the time it occurred, and staff failed to perform neurological assessments for 72 hours following the incident, in accordance with facility policy. In a separate incident, Certified Medication Technician (CMT) C performed a Hoyer transfer for the resident without the assistance of a second person, and failed to ensure the resident's physician-ordered fall mats were positioned at bedside before leaving the room. The resident fell from bed, hit his/her face, and required stitches in his/her forehead. In addition, staff failed to utilize appropriate techniques during a two-person Hoyer transfer, resulting in the machine tilting several times while the resident was in the lift. The sample was 8. The census was 49. Review of the facility's Hoyer Lift guidance, revised 9/9/15, showed: -Always have two people when completing transfer; -If there is room, the Hoyer lift is safer when the legs of the lift are wide open. If space allows, keep legs of lift open; -The primary person on the transfer starts to lift the resident slowly in the air. The second person is close to the resident at all times as well; -Once the resident is up, start to move the lift. The primary person steers the lift and makes sure the resident's feet don't hit the lift. The secondary person at the back of the resident is making sure the resident doesn't slide out and helps guide the resident correctly over the chair. Make sure the brakes are locked on the Hoyer lift before lowering the resident; -Align the resident over the wheelchair, slowly start lowering the resident. The secondary person needs to help guide resident and help achieve correct posture. Both staff should make sure that the lift does not hit the resident in head; -Two people are required at all times for safety with mechanical device. Review of the facility's Hoyer Safety Precautions document, undated, showed: -The weight must be centered over the base. When lifting, always keep patient centered over the base and facing the attendant who is operating the lifter; -To reduce the hazard of tipping over, spread adjustable base lifters (legs) to their widest position before lifting anyone. Review of the facility's Neurological Assessment policy, revised October 2010, showed: -Purpose: The purpose of this procedure is to provide guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition; -General Guidelines: --Neurological assessments are indicated: -Upon physician order; -Following an unwitnessed fall; -Following a fall or other accident/injury involving head trauma; -When indicated by resident's condition; -Steps in the procedure, included perform neurological checks with the frequency as ordered or per falls protocol; -Documentation: --The following information should be recorded in the resident's medical record: -The date and time the procedure was performed; -The name and title of the individual(s) who performed the procedure; -All assessment data obtained during the procedure; -The signature and title of the person recording the data; -Related documents: Neurological Evaluation Flow Sheet. Review of the facility's Post Fall 72-Hour Monitoring Report form, dated July 2008, showed: -This assessment should be completed at the following intervals for follow up for all falls. A fall that is unwitnessed or in which the head is struck, requires neurological checks. Initial assessment, followed by four 15-minute checks, two 30-minute checks, two hourly checks, and once per shift for 72 hours. 1. Review of Resident #6's medical record, showed: -Diagnoses included repeated falls, difficulty walking, generalized muscle weakness, dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life), anxiety and depression; -A physician order, dated 6/16/23, to be sure bed is in lowest position and fall mats on the floor while resident is in bed. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/2/24, showed: -Resident rarely/never understood; -Dependent for chair/bed-to-chair transfers. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has an activities of daily living (ADLs) self-care performance deficit related to generalized weakness and deconditioning (a decline in physical fitness and overall health that occurs due to a prolonged period of inactivity or reduced physical activity); -Interventions included the resident requires Hoyer mechanical lift with two staff assistance for transfers; -Focus: The resident is moderate risk for falls related to confusion, deconditioning; -Interventions included follow facility protocol; -Focus: The resident had an actual fall with serious injury on 1/24/25; -The care plan did not include the utilization of fall mats and a low bed as a fall intervention. Review of the resident's incident note, dated 1/15/25 at 7:24 A.M., showed Licensed Practical Nurse (LPN) D documented after clocking in at 10:40 P.M. (1/14/25), LPN D was made aware the resident had a small laceration to his/her forehead, bruise to the bridge of his/her nose, and a swollen top lip from the Hoyer lift. The aide (CNA B) reported that while putting the resident to bed on the evening shift, the Hoyer lift's pendulum swung back and struck the resident in the face. LPN D assessed the resident while he/she was in bed. The laceration and top lip were not actively bleeding. The laceration was cleaned and bandaged. Review of the resident's medical record, showed: -Health status notes documented on 1/16/24 at 4:00 P.M. and 7:11 P.M. for incident follow-up. Scabbed laceration to forehead, bridge of nose purplish bruised with swelling, top lip swollen. -No Post-Fall 72-Monitoring Report forms or neurological assessment (neurocheck) flow sheets following the incident on 1/14/25. During an attempted interview on 2/3/25 at 9:15 A.M., the resident was non-verbal and unresponsive to questions. During an interview on 2/3/25 at 10:41 A.M., LPN D said the resident is confused, does not talk, and requires a Hoyer lift for all transfers. On 1/14/25, LPN D came in for the night shift and CNA B, who worked the evening shift, reported the resident was injured during a Hoyer transfer. CNA B reported he/she was transferring the resident with the Hoyer lift at around 8:30 P.M., and the bar on the lift swung back and hit the resident in the face. CNA B did not report the incident to the nurse on evening shift. CNA B did not specify that he/she did the transfer by him/herself. All Hoyer transfers should be performed by two staff. During an interview on 2/3/25 at 2:17 P.M., the Assistant Director of Nurses (ADON) said on 1/14/25, CNA B transferred the resident by him/herself with the Hoyer lift, and the lift hit the resident in the head. CNA B did not give a straight answer when asked why he/she performed the transfer by him/herself. CNA B did not report the incident to the evening shift nurse like he/she should have and instead, reported the incident to the nurse on the night shift. Following the incident an in-service training on Hoyer transfers was conducted with nursing staff. Review of the facility's list of employees and in-service training records, showed: -On 1/16/25, 21 nursing staff, excluding the ADON and Director of Nurses (DON), were employed by the facility; -In-service attendance record, titled Transfers, dated 1/16/25, showed objectives included two-person transfers and mechanical lift transfers, with nine nursing staff in attendance and 11 nursing staff not in attendance. CNA B was not in attendance. During an interview on 2/3/25 at 3:15 P.M., the ADON said he/she could not find neurochecks completed for the resident following his/her head injury on 1/14/25. Neurochecks should have been completed for the 72 hours following the incident. During an interview on 2/4/25 at 1:32 P.M., Physician E said she is Resident #6's physician. She could not recall if she was notified of the incident on 1/14/25. She was not aware of the details of how the resident was injured on 1/14/25. When a resident has an injury like this, she always encourages staff to send the resident out to the hospital because facilities do not have the ability to perform a computed tomography scan (CT scan, uses a computer that takes data from several x-ray images of structures inside the body and converts them into pictures on a monitor) to rule out head injury. She expected staff to perform neurochecks for 72 hours after the resident was injured. 2. Review of Resident #6's incident note, dated 1/24/25 at 4:00 P.M., showed at 1:45 P.M., LPN O was called to the resident's room. Resident noted to be lying on the floor on his/her right side with blood coming from his/her head. Resident alert and oriented to self. 3.5 centimeters (cm) by (x) 1.0 cm x 0.8 cm laceration to forehead above right eyebrow. Staff reported resident was in bed prior to incident. Bed in lowest position. Neurochecks within normal limits. First aide provided. Vitals documented. Physician notified and resident sent out to hospital. Review of the resident's hospital Discharge summary, dated [DATE], showed: -Diagnoses included fall, injury of head, and facial laceration; -Laceration repair completed. Review of the resident's health status note, dated 1/25/25 at 3:15 A.M., showed resident returned from hospital. Intact sutures noted to right forehead above eyebrow. During an interview on 2/3/25 at 1:34 P.M., Certified Medication Technician (CMT) C said the resident is supposed to have fall mats when in bed, because he/she is a fall risk. On 1/24/25, CMT C used a Hoyer lift by him/herself to transfer the resident to bed. He/She knows Hoyer transfers require two people, but he/she was trying to help the aides. Once he/she got the resident in bed, she lowered the bed but he/she forgot to put down the resident's fall mats. He/She went on break and when he/she came back, someone found the resident on the floor with a busted head. The resident went out to the hospital and got stitches. During an interview on 2/3/25 at 2:17 P.M., the ADON said on 1/24/25, CMT C used the Hoyer lift to transfer the resident to bed by him/herself. He/She did not ensure the resident was straightened in bed and did not put down the resident's fall mats. The resident fell out of bed and hit his/her face, resulting in him/her getting stitches. Following the incident another in-service training on Hoyer transfers was conducted with nursing staff. Review of the facility's list of employees and in-service training records, showed: -On 1/24/25, 24 nursing staff, excluding the ADON and DON, were employed by the facility; -In-service attendance record, titled Transfers, dated 1/24/25, showed objectives included all Hoyer lifts require the use of two persons to transfer and do not transfer any resident that uses a Hoyer lift alone, with 15 nursing staff in attendance and nine nursing staff not in attendance. 3. Observation on 2/3/25 at 2:18 P.M., showed Resident #6 seated on top of a Hoyer pad in a wheelchair in his/her room. Nurse Aide (NA) F brought a Hoyer lift to the resident's room and positioned it in front of the resident. After securing the loops of the Hoyer pad to the bar on the lift, NA F began pumping the lever to lift the resident. NA G was on the other side of the room assisting the resident's roommate while NA F operated the lift. As NA F pumped the lever, the bar on the Hoyer lift bumped the resident's chin. NA G continued to pump the lever and NA G stopped him/her, suggesting they get a different Hoyer lift. NA F unhooked the Hoyer pad straps from the lift while NA G left the room to get the other Hoyer lift. At 2:24 P.M., NA G and NA F secured the loops of the Hoyer pad to the bar on the other Hoyer lift. NA G operated the machine and lifted the resident so he/she was approximately 20 inches above the bed. NA G positioned the Hoyer to the right side of the resident's bed. While the legs of the Hoyer lift were straight, not in an open position, NA G moved the lift back and forth while attempting to get the lift's legs fully underneath the resident's bed, banging against the bed and furniture, while the resident swung back and forth in the Hoyer pad. NA G did not lock the brakes on the Hoyer legs and used both of his/her hands to push the resident's body toward the center of the bed. The Hoyer lift tilted over and NA G pulled it back down to the ground. NA F began maneuvering the Hoyer lift back and forth, bumping into furniture. At 2:27 P.M., NA G left the room and NA F used both hands to push the resident's body so it was centered over the bed, causing the Hoyer to tilt. NA G re-entered the room and while the resident was suspended over the right side of the bed, NA F pressed a lever on the Hoyer and the resident rapidly dropped several inches, remaining in the sling, hovering over the bed. At 2:29 P.M., NA G left the room and NA F continued to move the Hoyer, banging into furniture. At 2:30 P.M., NA F stepped out into the hall, leaving the resident in the Hoyer, halfway over the right side of the bed. At 2:31 P.M., both aides re-entered the room. The Hoyer lift legs were straight as NA F moved the lift, and the Hoyer lift tilted. NA F pressed a lever on the lift and the resident dropped rapidly onto the right side of the bed. During an interview on 2/3/25 at 2:34 P.M., NA G said this is his/her first week working at the facility. He/She never received training at the facility about how to use the Hoyer lift and learned from watching others. NA F said he/she has been working with the facility for less than two weeks. He/She never received any training at the facility about how to use the Hoyer lift. No one at the facility has shown him/her how to use the Hoyer lift and he/she only knows from previous jobs. Review of the facility's in-service training record, titled Transfers, dated 1/24/25, showed both NA F and NA G were in attendance. 4. During an interview on 2/4/25 at 6:34 A.M., Registered Nurse (RN) N said all Hoyer transfers require two staff. Any incident that results in injury should be reported to the nurse immediately. If a resident has an unwitnessed fall or hits their head, the nurse should perform neurochecks. Neurochecks should be completed at the intervals indicated on the neurocheck flow sheet for 72 hours to ensure there is no head injury. A resident's specific care needs, such as transfer status and fall interventions, should be indicated on their care plan and communicated to staff in report. During an interview on 2/4/25 at 9:40 A.M. with the ADON and DON, the ADON said NAs get three days of orientation in which they learn how to perform transfers through a hands-on demonstration. After orientation, the NA spends three days on the floor being paired with another person, then they are released to work by themselves. A Hoyer transfer must be completed by two staff and both staff should remain in the room at all times. One person should operate the lift while the other person assists with positioning and ensuring the resident is safe. The legs of the Hoyer lift should be locked when the lift is positioned over the area where the resident will be transferred. Staff should ensure the resident is properly positioned over their wheelchair or bed before lowering the resident and the resident should be lowered slowly for safety. Staff should ensure a resident is securely and safety positioned in the center of their bed before leaving the room for safety purposes. Staff should ensure fall mats are positioned on the sides of the bed for residents who are a high fall risk. The DON said staff know if a resident is a fall risk by asking the nurse. The ADON said staff can also tell if a resident requires a fall mat by checking the resident's care plan. Resident #6 has physician orders for fall mats and this information should also be on his/her care plan. Care plans are updated by department heads. Any injuries should be reported to the nurse immediately. If a resident hits their head or has an unwitnessed fall, the nurse should complete a full neurological assessment. Neurochecks should be documented on the neurocheck flow sheet. Neurochecks must be completed at the intervals indicated on the flow sheet for 72 hours after the injury or unwitnessed fall to see if there are any neurological changes. During an interview on 2/4/25 at 11:06 A.M., the Assistant Administrator said he expected staff to report any injury to the nurse on shift at that time so the nurse could assess the resident right away. He expected nurses to document assessments as indicated on the neurological flow sheets for incidents involving head injury. Two staff should be present at all times during a Hoyer lift transfer. The Hoyer lift brakes should be locked when appropriate for safety. He expected staff to utilize proper techniques during a Hoyer transfer and to implement identified interventions, such as fall mats, for residents at risk for falls. A resident's individual fall interventions should be documented on a resident's care plan. MO00248702

Based on interview and record review, the facility failed to report an allegation of abuse involving one resident (Resident #1) to the State Survey Agency immediately and not later than two hours after the allegation was made. The sample was 8. The census was 49. Review of the facility's Abuse Investigation and Reporting policy, revised July 2017, showed: -Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management; -Policy Interpretation and Implementation: --Reporting: -All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies, included the State licensing/certification agency responsible for surveying/licensing the facility; -An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/22/25, showed: -Resident rarely/never understands; -Resident rarely/never understood; -Short and long term memory problem; -Severe impairment for decisions regarding tasks of daily life; -Substantial/maximal assist required for upper and lower body dressing, toileting, and personal hygiene; -Diagnoses include Alzheimer's disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks), anxiety, and depression. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Current functional performance; -Interventions included extensive assist/one-person physical assist for dressing, personal hygiene and toilet use. Extensive assist/two-person physical assist for dressing, personal hygiene, and toilet use; -Focus: The resident is resistive to care at times with activities of daily living (ADLs) care; -Focus: The resident is/has potential to be physically aggressive; -Interventions included when the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, and if response is aggressive, staff to walk away calmly and reapproach later. During an interview on 2/1/25 at 1:07 P.M., Registered Nurse (RN) A said at around 10:05 A.M. that morning, he/she heard a voice yelling in the resident's room. The voice sounded threatening and mean, and was yelling, Stop that, stop that, do it again! RN A heard bumping noises inside the room, then a loud slap. The voice yelled, See, I told you, don't do it again! RN A opened the door to the resident's room and saw the resident up against the wall with Certified Nurse Aide (CNA) B standing in front of him/her. The resident's back was to the wall and CNA B had his/her body pushed into the resident's, holding the resident's left arm with his/her right arm. The resident was not attempting to move. After CNA B left the room, RN A interviewed the resident by asking yes/no questions, but the resident was very confused and was unable to say much. After assessing the resident, RN called the Director of Nurses (DON) to inform him of what he/she observed. During an interview on 2/1/25 at 3:29 P.M., the DON said at around 10:00 A.M., he got a call from RN A. RN A said he/she heard yelling and loud noises coming from the resident's room, like the heads of residents banging on the walls or something. RN A saw CNA B and the resident leaned against the wall while CNA B was getting the resident dressed. RN A wanted to send CNA B home on the basis of abuse. He told RN A he would look into it. He did not report the allegation to the Department of Health and Senior Services (DHSS) because he needed to know more details. He did not know he needed to report all allegations of abuse to DHSS within two hours of being made aware of the allegation. During an interview on 2/1/25 at 3:48 P.M., the Assistant Director of Nurses (ADON) said she was not aware of the allegation of abuse until after 2:30 P.M. Any allegation of abuse should be reported immediately to the manager on duty and Assistant Administrator. All allegations of abuse should be reported to DHSS within two hours. During an interview on 2/1/25 at 4:58 P.M., the Assistant Administrator said he was not aware of the abuse allegation until 2:35 P.M. The nurse reported an allegation of abuse to the DON at 10:00 A.M. The Assistant Administrator should have been notified within 30 minutes to an hour of the DON being notified, and an investigation should have been started right away. Any allegation of abuse should be reported to DHSS within two hours of being made aware of the allegation. MO00248906

Based on interview and record review the facility failed to electronically submit to the Center of Medicaid and Medicare Services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for three quarters proceeding the annual survey. The census was 47. Review of the fiscal years Payroll Based Journal (PBJ) staffing report, showed the facility triggered for failing to submit data for: -Fiscal year quarter 1, 2024 (October 1 to December 31); -Fiscal year quarter 2, 2024 (January 1 to March 31); -Fiscal year quarter 3, 2024 (April 1 through June 30). During an interview on 10/24/24 at 12:31 P.M. the Assistant Administrator said it was his responsibility to submit the PBJ report to CMS. He was aware that the report needed to be sent and had not done so.

Based on observation, interview, and record review the facility failed to ensure the dignity of residents by failing to ensure staff members stayed off their cell phones during care (Residents #1, #22, #40 and #44), failing to ensure staff were seated next to the residents while feedings residents (Residents #9 and #20), and failing to ensure staff replaced silverware for a resident who dropped theirs (Resident #21). The sample was 12. The census was 47. Review of the facility's Quality of Life, Dignity policy, dated august 2009, showed: -Policy Statement: each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality; -Policy Implementation: residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self- esteem and self-worth. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of the facility's in-service for all nursing staff, dated 2/10/09, showed: -Cell phones cannot be on while you are on duty; -Using cell phones during working hours has become a problem. You may use your cell phone during break time or lunchtime. Anyone abusing this policy will receive a written reprimand. Continued abuse of this policy may result in termination. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/4/24, showed: -Severe cognitive impairment; -Diagnoses included dementia, anxiety, and major depressive disorder. Observation on 10/21/24, of the resident in the dining room, showed: -At 1:03 P.M., the resident sat at a table in the dining room. Nurse Aide (NA) E seated next to the resident at the table. NA E had his/her phone in his/her lap, and appeared to be texting; -At 1:04 P.M., NA E set down his/her phone, picked up a grape with his/her hand from the resident's plate, and fed the grape to the resident; -At 1:06 P.M., NA E looked down at his/her phone in his/her lap; -At 1:07 P.M., NA E grabbed a grape with one hand and fed it to the resident while scrolling on his/her phone with his/her other hand. NA E did not watch the resident as he/she fed the resident the grape; -At 1:10 P.M., NA E stood up from the table with his/her phone in his/her hand and walked away from the table. 2. Review of Resident #22's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses include diabetes and depression. Observation on 10/21/24 at 9:47 A.M., showed NA E seated on the resident's bed. The resident in his/her wheelchair next to the bed. NA E had his/her phone in his/her hand, held it up to his/her face, and appeared to be texting. NA E not interacting with the resident. During an interview on 10/21/24 at 11:02 A.M., the resident said he/she did not know why NA E was in his/her room on his/her phone. NA E was not in the room to help him/her, NA E just walked into his/her room and sat down without saying anything. He/She said it made him/her feel uncomfortable. 3. Review of Resident #40's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses include diabetes and Alzheimer's disease. Observation on 10/22/24, of the resident in the dining room, showed: -At 12:43 P.M., the resident seated at a table to eat lunch with NA E seated next to him/her. NA E had his/her phone in his/her lap and appeared to be texting; -At 12:45 P.M., NA E lifted his/her phone off his/her lap and appeared to be sending a text; -At 12:46 P.M., NA E grabbed the resident's spoon and gave the resident a bite of food; -At 12:47 P.M., NA E placed his/her phone flat on the table and appeared to be texting; -At 12:48 P.M., NA E grabbed the resident's spoon and gave the resident a bite while he/she looked down at his/her phone; -At 12:50 P.M., NA E grabbed his/her phone and appeared to be texting; -At 12:51 P.M., Certified Nursing Assistant (CNA) G walked over to the table and told NA E to get off his/her phone. As CNA G walked away NA E grabbed his/her phone from the table and placed it under the table and appeared to be texting. 4. Review of Resident #44's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included diabetes, anxiety, asthma and acute respiratory failure. During an interview on 10/22/24 at 9:26 A.M., the resident said that earlier in the morning, NA E had come into his/her room to provide care. NA E was on a phone call with his/her daughter the entire time he/she was being assisted and it made him/her feel uncomfortable. Licensed Practical Nurse (LPN) A came into his/her room and observed NA E on a phone call. LPN A told NA E to get off his/her phone. During an interview on 10/23/24 at 11:36 A.M., LPN A said he/she did walk into the resident's room on 10/22/24 and observe NA E on his/her phone, on a phone call while he/she provided care to the resident. He/She told NA E to get off his/her phone. 5. Review of Resident #9's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included dementia and major depressive disorder. Observation on 10/21/24 at 8:23 A.M., of the resident in the dining room, showed the resident seated in his/her wheelchair at a table. NA C walked up to the resident's table, stood over the resident, grabbed the resident's spoon, and gave the resident a bite of food. 6. Review of Resident #20's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included Alzheimer's disease and anxiety. Observation on 10/21/24, of the resident in the dining room, showed: -At 7:43 A.M., the resident seated at a table. NA C walked up to the resident, stood over the resident, and started to feed the resident; -At 7:43 A.M., NA C walked away from the resident; -At 7:44 A.M., NA C walked back to the resident, stood over the resident, and started to feed the resident; -At 8:32 A.M., NA C stood over the resident and fed him/her. 7. Review of Resident #21's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included dementia, dystonia (involuntary muscle contractions that cause repetitive or twisting movements), and chronic obstructive pulmonary disease (COPD, lung disease). Observation on 10/21/24, of the resident in the dining room, showed: -At 8:19 A.M., the resident dropped his/her spoon on the ground. The resident started to eat his/her eggs with his/her hands; -At 8:24 A.M., the resident began struggled to eat his/her eggs with his/her hands; -At 8:26 A.M., the resident struggled to wipe his/her hands on his/her clothing protector; -At 8:44 A.M., the resident propelled him/herself out of the dining room in his/her wheelchair without ever receiving assistance from staff to get new utensils. 8. During a resident council meeting on 10/22/24 at 2:35 P.M., five residents, whom the facility identified as alert and oriented, said staff are always on their cell phones. 9. During an interview on 10/23/24 at 11:19 A.M., CNA H said the facilities policy on cellphone usage is that no staff are allowed to be on their phones while working. Staff are allowed to use their phones on break. He/She would expect staff to follow the cell phone policy. It is not appropriate for staff to use their cell phones when feeding residents, or while providing care to a resident. It is not appropriate to stand up while feedings residents. 10. During an interview on 10/23/24 at 11:34 A.M., LPN A said staff are not allowed to use their phones during work. Staff are only allowed to use their cell phones in the break room or outside. He/She would expect staff to follow the facility's cell phone policy. It is not appropriate for staff to use their cell phones when feeding residents or while providing care to a resident. It is not appropriate to stand while feedings residents and that staff should be seated. 11. During an interview on 10/23/24 at 11:43 A.M., the Assistant Director of Nursing (ADON) said staff are only to use their cell phones in the break room or outside. Staff are not to use their phones in resident areas. She would expect staff to follow the facility's cell phone policy. It is not appropriate for staff to use their cell phones when feeding residents or while providing care to a resident. It is not appropriate to stand up while feedings residents and staff should be seated. 12. During an interview on 10/23/24 at 11:51 A.M., the Assistant Administrator said there is a zero-tolerance policy for staff using their cell phones in resident areas. Staff are to use their phones in the break room. He would expect all staff to follow the cell phone policy. It is not appropriate for staff to use their cell phones when feeding residents or while providing care to a resident. Is not appropriate to stand while feedings residents and staff should be seated.

Based on observation, interview, and record review, the facility failed to develop comprehensive care plans with resident-specific interventions to meet the resident's preferences and goals, and to address the resident's medical, physical, and psychosocial needs for five residents (Residents #31, #19, #20, #41, and #44). The sample was 12. The census was 47. Review of the facility's Care Plans - Comprehensive Person-Centered policy, revised [DATE], showed: -Policy Statement: A comprehensive, person-centered care plan that includes measurable outcomes and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -Policy Interpretation and Implementation: -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan will: -Include measurable objectives and timeframes; -Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; -Incorporate identified problem areas; -Incorporate risk factors associated with identified problems; -Build on the resident's strengths; -Reflect the resident's expressed wishes regarding care and treatment goals; -Reflect treatment goals, timetables and objectives in measurable outcomes; -Identify the professional services that are responsible for each element of care; -Aid in preventing or reducing decline in the resident's functional status and/or functional levels; -Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and -Reflect currently recognized standards of practice for problem areas and conditions; -Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan; -Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process; -Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making; -When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; -The IDT must review and update the care plan: -When there has been a significant change in the resident's condition; -When the desired outcome is not met; -At least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) assessment. 1. Review of Resident #31's medical record, showed diagnoses included stroke, bullous pemphigoid (an autoimmune skin disorder that causes blisters on the skin), local infection of the skin, urinary tract infection (UTI), diabetes, and high blood pressure. Review of the resident's electronic physician order sheet (ePOS), showed: -An order, dated [DATE], for ProSource oral liquid (high protein and calorie nutritional supplement), 30 milliliters (mL) by mouth twice daily for wound healing; -An order, dated [DATE], for alternating pressure mattress; -An order, dated [DATE], for mirtazapine (anti-depressant) oral tablet 15 milligrams (mg), one tablet by mouth at bedtime for poor appetite, -An order, dated [DATE], for urinary catheter 16 French (size) with 10 mL balloon (used to hold the urinary catheter in place) for wound healing; -An order, dated [DATE], to send to wound clinic for consult and treatment of wounds; -An order, dated [DATE], for soft heel boots to bilateral (both sides) lower extremities as tolerated, every shift; -An order, dated [DATE], for Med Pass 2.0 (fortified nutritional shake), 120 mL, four times a day for weight loss; -An order, dated [DATE] for regular diet, pureed texture, super cereal (calorie dense cereal) at breakfast, ice cream at lunch/dinner. Review of the resident's nutrition quarterly review, dated [DATE], showed: -Current diet order: Mechanical soft diet; -Snack/supplement orders: Med Pass supplement 120 mL three times daily, liquid protein 30 mL twice daily, super cereal at breakfast, ice cream at lunch/dinner; -Additional information: Significant weight loss of -25 pounds in six months. Continues with trend down. Poor appetite continues. Multivitamins/minerals in place for skin integrity support. Mirtazapine (antidepressant that also increases the appetite) 15 mg ordered, which may help aid in appetite stimulation. Assisted at meals with encouragement. Continue to encourage intakes at meals/supplements, continue to offer snacks and alternatives at meals as indicated, assistance at meals. Review of the resident's skin assessment, dated [DATE], showed: -Bullous pemphigoid wound to right upper extremity anterior (in front of); -Bullous pemphigoid wound to left lateral (to the side of) knee; -Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (dead tissue). May also present as an intact or open/ruptured blister) to left buttock; -Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed) to sacrum (triangular bone at the base of the spine). Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Upper extremity impairment on one side and lower extremity impairment on both sides; -Indwelling catheter in use; -Weight loss of 5% in the last month, loss of 10% in the last six months; -Mechanically altered diet received; -At risk of developing pressure ulcers; -Unhealed pressure ulcers: None; -Other ulcers, wounds, and skin problems: None. Review of the resident's medical record, showed the resident seen routinely by a wound clinic. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has unplanned/unexpected weight loss related to poor food intake; -Interventions: Give the resident supplements as ordered. Alert nurse/dietician if not consuming on a routine basis; -Focus: Potential for impaired skin integrity as evidenced by Braden scale (used to determine pressure ulcer risk); -Interventions included: Educate resident/representative about the proper usage of pressure reducing devices and monitor nutritional status; -Focus: The resident has bladder incontinence; -The care plan failed to identify the resident's intake of a mechanically altered diet; -The care plan failed to identify the resident's significant weight loss and specific interventions to address weight loss, including super cereal and ice cream with meals, and nutritional supplements administered as treatments; -The care plan failed to identify the resident's use of an indwelling catheter and interventions specific to catheter use; -The care plan failed to identify the resident's active, unhealed bullous pemphigoid wounds and pressure ulcers, and specific interventions to address his/her impaired skin integrity, including the use of a low air-loss mattress, soft heel boots, nutritional supplements, as well as monitoring and treatments completed by a wound clinic. Observation on [DATE] at 8:53 A.M., showed the resident seated upright in bed on an alternating pressure mattress. A catheter bag hung at the foot of the bed. Certified Nurse Aide (CNA) D stood next to the resident's bed and assisted to feed the resident pureed food from a divided plate. During an interview on [DATE] at 9:11 A.M., CNA I said the resident has a catheter. He/She stopped eating and had unplanned weight loss. He/She gets health shakes. He/She has wounds and wears boots on his/her feet for them. During an interview on [DATE] at 9:32 A.M., CNA G said the resident has a catheter. He/She does not eat anything and has lost weight. He/She receives a pureed diet and likes some foods, like bananas. He/She has several wounds and wears pressure relieving boots. During an interview on [DATE] at 10:11 A.M., Licensed Practical Nurse (LPN) A said the resident has a catheter and has had unplanned significant weight loss. He/she receives a pureed diet and only consumes about ,d+[DATE]% at meals. He/She has a lot of bullous pemphigoid wounds and two pressure ulcers for which he/she has an alternating pressure mattress and pressure relieving boots. He/She received nutritional supplements. These things should be on his/her care plan. 2. Review of Resident #19's medical record, showed diagnoses included major depressive disorder (MDD) and anxiety disorder due to known physiological condition. Review of the resident's hospital transfer orders to the receiving facility, dated [DATE], showed discharge diagnoses of dementia and suicidal ideation. Review of the resident's progress notes, from [DATE] through [DATE], showed: -On [DATE], the resident slipped and fell while ambulating in the hallway; -On [DATE], the resident noted with a skin tear from his/her recent fall; -On [DATE], the resident was witnessed sliding off the couch. Review of the resident's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Delusions exhibited; -Verbal behavioral symptoms directed and other behavioral symptoms not directed toward other exhibited one to three days; -No falls during review period. Review of the resident's progress notes from [DATE] through [DATE], showed: -On [DATE], the resident found on the floor. Witnesses said the resident was walking and tripped over his/her feet and fell to the floor; -On [DATE], the resident was witnessed to trip over his/her foot, losing his/her balance, and fell to the floor. A laceration noted to the resident's left eyebrow; -On [DATE], the resident turned and lost his/her balance, falling on the floor by the nurse's station. He/She was admitted to the hospital from [DATE] through [DATE] for a fractured femur (large bone of the upper leg); -On [DATE], the resident returned to the facility from the hospital. The resident stated he/she was dying and was uncooperative during an exam; -On [DATE], the resident confused, repeating the words, My mom and dad are dead, you want me to die. -On [DATE], the resident continues to fixate on scenarios concerning death and/or requesting his/her parents. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has potential of limited physical mobility related to decreased cognition and aging process: -Goal: The resident will maintain current level of mobility being able to walk independently through review date (OVERDUE); -Interventions: Ambulation - the resident is able to ambulate independently; -Focus: The resident has had an actual fall with (SPECIFY - no injury, minor injury, serious injury) poor balance; -Goal: The resident will resume usual activities without further incident through the review date (OVERDUE); -Interventions: Continue interventions on the at-risk plan; -Focus: The resident is at risk for falls related to gait/balance problems, unaware of safety needs; -Goal: The resident will not sustain serious injury through the review date (OVERDUE); -Interventions: Anticipate and meet the resident's needs. Follow facility protocol. Physical therapy evaluate and treat as ordered or as needed; -Focus: The resident has impaired cognitive function/dementia or impaired thought processes related to dementia; -Goal: The resident will maintain current level of cognitive function through the review date. The resident will remain oriented to person through the review date (OVERDUE); -Interventions included: Administer medications as ordered. Monitor/document for side effects; -Focus: The resident has a mood problem related to dementia; -Goal: The resident will have improved mood state evidenced by decreased signs/symptoms of anxiety through the review date (OVERDUE); -Focus: The resident has depression related to current health status; -Goal: The resident will exhibit indicators of depression, anxiety, or sad mood less than daily by review date. The resident will remain free of signs/symptoms of distress, symptoms of depression, anxiety or sad mood by/through review date (OVERDUE); -The care plan failed to be updated with measurable goals related to focus areas; -The care plan failed to identify the resident's falls on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], and the resident sustaining a hip fracture from the fall on [DATE], with interventions to decrease future falls. The care plan failed to identify the resident's decrease in mobility and use of wheelchair as a result of the hip fracture; -The care plan failed to identify the resident's history of suicidal ideation and current, ongoing thoughts regarding death and dying, and specific interventions that were found to be effective or ineffective in addressing his/her thoughts on dying. Observation on [DATE] at 9:28 A.M., showed the resident on his/her side in bed. During an attempted interview, the resident confused and repeatedly said he/she was dying. He/She said someone was trying to take his/her dress and repeatedly said he/she did not want to die. Observation on [DATE] at 8:37 A.M., showed the resident propelled into the dining room in his/her wheelchair. The resident said he/she was scared and someone died . He/She repeatedly said he/she was scared. During an interview, CNA I and Nurse Aide (NA) C said this is what the resident says all the time. Observation on [DATE] at 9:27 A.M., showed the resident propelled down the hallway talking to him/herself, saying he/she was dying. Observation on [DATE] at 12:23 P.M., showed the resident seated at a table in the dining room. He/She talked to him/herself and his/her tablemate, repeatedly saying he/she was dying. During an interview on [DATE] at 9:11 A.M., CNA I said the resident is very confused and obsessed with dying. He/She chants, Help me die, help me die, and says he/she is dying or his/her parent is dying. The resident has been doing this since CNA I began working with the resident in February 2024. Nothing helps the resident stop focusing on dying. The resident used to walk but a few months ago, the resident changed and started falling all the time. The resident broke his/her hip and now he/she is in a wheelchair. During an interview on [DATE] at 9:32 A.M., CNA G said the resident is totally confused. He/She constantly talks about dying, wanting to die to be with his/her parents, and asking to help him/her die. The resident has been this way since he/she came to the facility several years ago and nothing helps address this. The resident walked with a limp for years. A few months ago, he/she started falling more often and recently broke his/her hip. The resident is currently using a wheelchair. During an interview on [DATE] at 9:52 A.M., the Social Services Director said the resident perseverates on death. When the SSD started working with the facility three years ago, the resident did not talk about death as much, but this has progressively increased. The resident used to walk and was up for most of the day. A month or so ago, he/she fell and broke his/her hip and now he/she is in a wheelchair. During an interview on [DATE] at 10:11 A.M., LPN A said the resident is alert and oriented to self. He/She is frequently anxious and talks about dying a lot. His/Her talk about dying has increased since his/her overall decline and progression of dementia. Sometimes having a conversation with the resident helps, and sometimes it does not. He/She likes to have reassurance from someone. During an interview on [DATE] at 11:33 A.M., the Assistant Director of Nursing (ADON) said the resident is alert and oriented to self. He/She is confused and talks about him/her dying, people dying, and wanting to die. The resident has always been this way since admission. His/Her medication was changed recently, but he/she still expresses thoughts about dying. The resident used to walk independently, but now uses a wheelchair due to falling and breaking his/her femur. 3. Review of Resident #20's medical record, showed diagnoses included underweight, abnormal weight loss, hypothyroidism (underactive thyroid), Alzheimer's disease, dementia, unspecified psychosis, and anxiety. Review of the resident's ePOS, showed: -An order, date [DATE] for regular texture diet, no pork, super cereal at breakfast, and ice cream or pudding at lunch and dinner; -An order, dated [DATE], for Med Pass 2.0 three times a day related to abnormal weight loss. Review of the resident's annual MDS, dated [DATE], showed: -Resident rarely/never understood; -Rejection of care behavior not exhibited; -Supervision or touching assistance required for eating. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has nutritional problem or potential nutritional problem of abnormal weight loss related to poor cognition; -Goal: The resident will comply with recommended diet for weight reduction daily through review date (OVERDUE); -Interventions: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition factors. Invite the resident to activities that promote additional intake. Monitor/report to physician as needed signs/symptoms of malnutrition. Provide and serve supplements as ordered: Med Pass 2.0. Provide, serve diet as ordered. Monitor intake and record every meal. Registered Dietician to evaluate and make diet change recommendations; -The care plan failed to identify the resident's significant weight loss, use of a divided plate and dietary supplements of super cereal and ice cream with meals, and the resident's preference to eat with his/her hands and refusal of assistance during meals. Review of the resident's nutrition/dietary notes, showed: -On [DATE], the resident noted with significant weight loss of -5.1% in one month. Weight trend likely related to recent COVID positive cases last month. Med Pass 120 ml three times a day in place. Super cereal at breakfast, ice cream or pudding at lunch and dinner. Appetite varied depending on mood. Per conversation with nursing, resident will not let staff help with feeding, but have been trying a divided plate at meals. Stability guarded related to dementia disease progression and advanced age. Multiple interventions in place for nutrition support; -On [DATE], the resident noted with significant weight loss of -10.9% in six months. Resident feeds self, will not let staff help with feeding. Observation on [DATE] at 7:43 A.M., showed the resident seated in the dining room. NA C stood next to the resident and fed him/her for one minute, then walked away. The resident did not refuse feeding assistance. After NA C walked away, the resident began feeding him/herself, using his/her hands to eat. Observation on [DATE] at 12:51 P.M., showed the resident seated at a table in the dining room. The resident ate his/her food using his/her hands, dropping food onto the table and his/her lap. Observation on [DATE] at 9:29 A.M., showed the resident used his/her hands to eat breakfast from a divided plate in the dining room. The resident dropped food onto the table and floor. Observation on [DATE] at 12:49 P.M., showed the resident used his/her hands to eat lunch from a divided plate in the dining room. A bowl of ice cream next to the resident's plate. The resident dropped food onto the table and floor. Observation on [DATE] at 5:39 P.M., showed the resident seated in the dining room. Staff placed a table, bowl of ice cream, and utensils on the table in front of the resident. The resident used his/her hands to eat dinner, dropping food onto the table. During an interview on [DATE] at 9:11 A.M., CNA I said the resident has lost a tremendous amount of weight. He/She is very confused. His/her appetite is good, but he/she gets confused while eating. He/She likes ice cream with meals. He/She will not allow staff to assist him/her with eating. During an interview on [DATE] at 9:32 A.M., CNA G said the resident is very confused. He/She had lost a lot of weight. He/She gets ice cream with meals and a divided plate. He/She eats with his/her hands but misses his/her mouth and gets food all over him/herself. He/She refuses to let staff provide feeding assistance and will push staff away when they try. During an interview on [DATE] at 10:11 A.M., LPN A said the resident has had a significant weight loss. He/She has a good appetite and eats with his/her hands. He/She will not let staff assist him/her with eating. 4. Review of Resident #41's medical record, showed diagnoses included dementia, depression, high blood pressure, high cholesterol, peripheral vascular disease (PVD, a lack of blood flow to the arms and legs), and overweight. Review of the resident's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Clear speech; -Able to make self understood; -Able to understand others; -Severe cognitive impairment; -No impairment with hip, knee, ankle, foot; -No mobility devices needed; -Independent with toileting, showers, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, sit to lying, sit to stand, chair/bed to chair transfer, toilet transfer, and able to walk 150 feet once standing. Review of Physical Therapy Assistant Progress Note, dated [DATE], showed: -Current level of Function, max assistance of bed mobility, poor muscle strength, and maximum assistance of two with chair/bed to chair transfers; -Precautions: At risk for falls and mechanical lift for transfers. Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: Current Functional Performance; -Goals: the resident's functional status will progress towards personal discharge goal during stay; -Interventions: the resident is independent with bed mobility, dressing, locomotion off/on the unit, personal hygiene, toilet use, transfers, walk in corridor, and walk in room. Observation on [DATE] at 8:37 A.M. and 11:22 A.M., staff propelled the resident in his/her wheelchair to the day room. At 12:11 P.M., staff propelled the resident in his/her wheelchair to the dining room. At 1:10 P.M., staff propelled the resident in his/her wheelchair to their room. Observation on [DATE] at 10:16 A.M., showed staff assisted the resident to stand in the shower room on the 100 hall, by Certified Medication Technician (CMT) F, CNA H and Physical Therapy Assistant (PTA) L. CNA H said the resident needs assist of two for transfers, and staff use a mechanical lift to assist the resident out of the bed to wheelchair. Staff have dress, provide hygiene, and toilet the resident. 5. Review of Resident #44's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included asthma and acute respiratory failure. Review of the resident's ePOS, showed an order dated [DATE], for continuous oxygen at 2 liters via nasal canula (device used to deliver oxygen with into the nostrils). Review of the resident's care plan, dated [DATE], showed: -Problem: The resident has oxygen therapy; -Goal: The resident will have no symptoms of poor oxygen absorption through the review date; -Interventions: Give medications as ordered by physician. Monitor and document side effects and effectiveness of medications. Oxygen setting: oxygen via nasal cannula continuous at 2 liters; -The care plan did not include a concern or interventions of the resident removing his/her nasal canula. Observations on [DATE] at 8:53 A.M., [DATE] at 9:50 A.M., [DATE] at 9:23 A.M., [DATE] at 9:23 A.M., [DATE] at 2:56 P.M., and [DATE] at 9:15 A.M., showed the resident lay in bed with his/her nasal canula off. During an interview on [DATE] at 8:04 A.M., the resident said he/she uses oxygen whenever he/she needs it. During an interview on [DATE] at 10:40 A.M., LPN A said the resident has an order for continuous oxygen but does not always keep his/her nasal canula on. He/She would expect for the care plan to have interventions that reflect monitoring the resident to ensure he/she has his/her nasal canula in place. During an interview on [DATE] at 12:39 P.M., the ADON said the resident requires continuous oxygen and does not always keep his/her nasal canula on. She would expect interventions to be included on the resident's care plan for staff to follow when the resident does not want to wear his/her nasal canula. 7. During an interview on [DATE] at 11:33 A.M., the ADON said she is responsible for updating the care plans for all residents. She expects them to include services provided for the resident to attain their highest practicable physical, mental, and psychosocial well-being. She expects the care plans to include person-specific, measurable objectives and timeframes in order to evaluate the resident's progress toward their goals. She expects care plans to identify specific areas of concern, including significant weight loss, wounds, and catheter use. Care plans should specify interventions in place to assist the resident, including diet orders and dietary supplements, the use of pressure relieving devices, and ADL needs. 8. During an interview with the ADON and Assistant Administrator on [DATE] at 12:31 P.M., the Assistant Administrator said he expects care plans to include services provided for resident to attain resident's highest practicable physical, mental, and psychosocial well-being. He expects care plans to include person-specific, measurable objectives and timeframes in order to evaluate the resident's progress toward goals. The ADON and Assistant Administrator said care plans should be updated with changes in conditions. Care plans should be a true reflection of the resident and their care needs. 46888 49992

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents when staff failed to prevent residents' feet from dragging on the floor during staff-assisted propelling for two residents (Residents #41 and #32). Facility staff failed to use gait belts during assisted transfers for three residents (Residents #40, #20, and #41) and failed to ensure one resident with a history of falling from his/her wheelchair was appropriately repositioned in his/her chair (Resident #21). The sample was 12. The census was 47. The facility did not have a written policy regarding transfer protocols. 1. Review of Resident #41's medical record, showed diagnoses of dementia, depression, high blood pressure, high cholesterol, and overweight. Review of the resident's quarterly Minimum Data Set (MDS,) a federally mandated assessment instrument completed by the facility staff, dated 7/18/24, showed: -admitted [DATE]; -Clear speech; -Able to make self understood; -Able to understand others; -Severe cognitive impairment. Observation on 10/20/24 at 9:10 A.M., showed the resident propelled down the hall in a wheelchair toward the dining room by Certified Nursing Assistant (CNA) H. No leg rests were on the resident's wheelchair and the resident had difficulty keeping his/her legs elevated. The resident lowered his/her legs three times while being propelled, and his/her shoe touched the floor causing resistance. CNA H stopped the wheelchair and the resident lifted his/her legs to allow the staff to continue to propelling the wheelchair. During an interview on 10/21/24 at 11:42 A.M., the resident said he/she is not able to keep his/her legs up all the time when the staff propel him/her in the wheelchair. His/Her feet drop to the floor and it hurts sometimes. 2. Review of Resident's #32 medical record, showed diagnoses included depression, dementia, weakness, high blood pressure, and anemia. Review of the resident's admission MDS, dated [DATE], showed: -admitted [DATE]; -Clear speech; -Able to make self understood; -No cognitive impairment. Observation on 10/24/24 at 8:51 A.M., showed the resident being propelled in his/her wheelchair out of the dining room, toward his/her room by Nursing Assistant (NA) J. No leg rests were on the wheelchair and the resident had difficulty keeping his/her legs elevated. The resident lowered his/her legs two times while being propelled and his/her shoe touched the floor, causing resistance. CNA J stopped the wheelchair and the resident lifted his/her legs to allow the staff to continue to propelling the wheelchair. During an interview, the resident said his/her foot gets caught sometimes. 3. During an interview on 10/24/24 at 8:53 A.M., CNA G said that if a resident is unable to elevate their legs up while being propelled to the dining room, the staff should stop, get leg pedals, and tell the nurse. During an interview on 10/24/24 at 9:05 A.M., CNA I said that if a resident is unable to elevate their legs, he/she would propel the resident backwards in their wheelchair. During an interview on 10/24/24 at 12:33 P.M., the Assistant Director of Nursing (ADON) said that she would expect staff to use wheelchair leg pedals for those residents who are unable to elevate their legs and would expect the staff not to pull the residents backwards. 4. Review of Resident #40's medical record, showed diagnoses included diabetes, dementia and high blood pressure. Review of the resident's quarterly MDS, dated [DATE], showed: -admitted [DATE]; - Unclear speech; -Rarely/never understood. -Dependent on staff for care needs. During an observation on 10/21/2024 at 8:23 A.M., Licensed Practical Nurse (LPN) B entered the day room to assist the resident back in the chair. LPN B folded the resident's right arm, positioned it near the stomach, and used his/her left hand to grab the resident's right arm, then placed his/her right forearm under the resident's left arm, and lifted the resident. 5. Review of Resident #20's medical record, showed diagnoses included Alzheimer's disease, dementia, anxiety, and psychotic disorder. Review of the resident's fall risk evaluation, dated 8/14/24, showed the resident at risk for falls. Resident the resident's annual MDS, dated [DATE], showed: -Resident rarely/never understood; -Independent with mobility of sitting to standing. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is high risk for falls related to confusion; unaware of safety needs; -Interventions included follow facility fall protocol; -No documentation regarding the resident's transfer status. Observation on 10/21/24 at 8:38 A.M., showed the resident seated at a table in the dining room. CNA I stood on one side of the resident and CNA D stood on the other side of the resident. CNA D wore a gait belt around his/her torso. The CNAs attempted to lift the resident by grasping the resident's biceps and lifting up. The resident swung his/her arms away. Both CNAs used one hand to grasp each of the resident's biceps and their other hand to grasp the waistband of the resident's pants, then lifted the resident by his/her arms and pants to a standing position. A gait belt was not positioned around the resident during the transfer. 6. Observation on 10/22/24 at 10:16 A.M., showed Resident #41 seated in the shower room. Certified Medication Technician (CMT) F and CNA H placed the gait belt around the resident, under the arms, and using the gait belt and the residents' shorts, assisted the resident to stand. CNA H said that the resident requires assistance of two staff with standing, and a mechanical lift for getting the residents in and out of the wheelchair and in the bed. During an interview on 10/24/24 at 9:11 A.M., CNA I said the resident can transfer on his/her own. If staff have to assist the resident during a transfer, it is because the resident is being stubborn. When staff assist the resident with transfers, they should use a gait belt. During an interview on 10/24/24 at 9:32 A.M., CNA G said the resident is able to sit and stand on his/her own. Sometimes the resident might need a boost. During an interview on 10/24/24 at 10:11 A.M., LPN A said generally, the resident is independent with transfers. Sometimes, he/she requires minimal assistance from staff. 7. During an interview on 10/24/24 at 9:32 A.M., CNA G said when staff assist the resident with transfers, a gait belt should be used. It would not be appropriate to lift a resident by their arms due to potential for injury. During an interview on 10/24/24 at 10:11 A.M., LPN A said when staff assist residents with transfers, they must use a gait belt. It is not appropriate to transfer residents by pulling the resident by their arms or clothing due to potential injury. During an interview with the ADON and Assistant Administrator on 10/24/24 at 12:33 P.M., the ADON said any transfer assisted by staff requiring them to put hands on them, would require staff to use a gait belt. The gait belt should be around the resident's waist. 8. Review of Resident #21's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included dementia, dystonia(involuntary muscle contractions that cause repetitive or twisting movements) and chronic obstructive pulmonary disease (lung disease). Review of the resident's care plan, dated 9/30/24, showed: -Focus: The resident is at high risk for falls; -Goals: The resident will be free of falls through the review date. The resident's falls will be minimized/eliminated by the review date; -Interventions: Anticipate and meet the resident's needs. Ensure that the resident is wearing appropriate footwear (non-skid socks or shoes) when ambulating or mobilizing in wheelchair. Purposeful staff rounding. Staff will educate resident on fall prevention and give safety cues and reminders to ask for help when needed to prevent falls. Review of the resident's most recent fall risk assessment, dated 9/30/24, showed: -The resident had not had any falls in the past three months at the time of this assessment; -Score of five, which indicated the resident was not a high risk for falls. Review of the resident's progress notes on 10/21/24 at 9:21 A.M., showed: -The resident has had falls on the following dates: 5/16/24, 6/28/24, 7/2/24, 7/7/24, and 10/20/24. Observation on 10/21/24 at 7:18 A.M., showed the resident in the dining room at a table. The resident was leaning to the right side of his/her wheelchair. The resident was slouched down in his/her wheelchair. Observation on 10/21/24 at 11:19 A.M., showed the resident in his/her room sitting in his/her wheelchair. The resident was leaning over with his/her chest touching his/her legs. The resident's bedroom door was cracked. Observation on 10/22/24 at 10:38 A.M., showed the resident sitting in his/her wheelchair at the end of the 100 hallway. The resident was leaning over with his/her chest touching his/her legs. No staff were observed on the hallway. During an interview on 10/24/24 at 9:55 A.M., CNA G said the resident has a history of falls. He/She would expect staff to be conducting frequent rounds on the resident to ensure the resident was safe. He/She would expect for staff to reposition the resident in his/her wheelchair if he/she is observed leaning. During an interview on 10/24/24 at 10:38 A.M., LPN A said the resident has a history of falling. Some of the resident's falls have been from the wheelchair. The resident normally leans to the right when in his/her wheelchair. He/She would expect for staff to reposition the resident in his/her wheelchair if the resident is observed to be leaning. He/She would expect staff to be performing frequent checks on the resident to ensure the resident is safe. During an interview on 10/24/24 at 12:33 P.M., the ADON said the resident has a history of falls. She said the resident normally leans to his/her right side when in his/her wheelchair. She would not always expect staff to reposition the resident due to the resident's leaning to be normal for the resident. She would expect for staff to conduct frequent rounds on the resident to ensure the resident was safe from falling. 46888 49992

Based on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 47. Review of the facility's Staffing policy, revised, April, 2007, showed: -The facility provides adequate staffing to meet needed care and services of the resident population; -The facility maintains adequate staffing on each shift to ensure that the residents' needs and services are met; -Licensed RN and licensed nursing staff are available to provide and monitor the delivery of resident care services. Review of the facility's staffing sheets dated 10/1 through 10/21/24 showed no RN coverage for: 10/1, 10/2, 10/3, 10/4, 10/6, 10/8, 10/10, 10/11, 10/13, 10/14, and 10/19/24. During an interview on 10/23/24 at 9:05 A.M., the Assistant Director of Nursing (ADON) said she was aware that an RN is required eight hours a day, seven days a week. She is responsible for staffing. It was difficult to get RNs to work. She puts the request for an RN on the agency website, and no one picks up the shift. During an interview on 10/24/24 at 12:31 P.M., the Assistant Administer said he would expect staffing to be covered with an RN eight hours a day, seven days a week.

Based on interview and record review, the facility failed to establish a system of record for all controlled drugs with sufficient detail to enable an accurate reconciliation for two out of three medication carts reviewed. This had the potential to affect all residents with controlled substance orders. The census was 47. Review of the facility's Controlled Substances policy, revised December, 2012, showed: -The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II (a drug classification) narcotics and other controlled substances; -Nursing staff must count controlled medications at the end of each shift; The nurse coming on duty and the nurse going off duty must make the count together. Review of the Narcotic Count Sheets dated 10/1 through 10/19/24 on the 400 and 500 medication cart showed: -22 out of 57 shifts had no nurse initial on the shift change count; -28 out of 57 shifts only had one nurse initial on the shift change count. Review of the Narcotic Count Sheets dated 10/1 through 10/19/24 on the 100, 300, and 600 medication cart showed: -23 out of 57 shifts had no nurse initial on the shift change count; -28 out of 57 shifts only had one nurse initial on the shift change count. During an interview on 10/20/24 at 9:05 A.M., Certified Medicine Technician (CMT) F said he/ she is the main nursing staff member that signs the narcotic sheets. There should be two nursing staff members when counting narcotics, one off going staff member and one oncoming staff member, every shift, every day. He/She will count with another nursing staff member, but he/she cannot make someone sign the narcotic count when they have completed counting. During an interview on 10/20/24 at 9:10 A.M., Licensed Practical Nurse (LPN) A said there should be two staff members signing the narcotic book and completing the count, one off going and one oncoming staff member. This should be done every shift, every day. During an interview on 10/23/24 at 9:05 A.M., the Assistant Director of Nursing (ADON) said she expected the narcotics to be counted and documented by two different staff members, every shift, every day.

Based on observation, interview and record review, the facility failed to have a system in place to ensure drugs and biologicals stored in the medication room refrigerator were being stored at a proper temperature for one out of one medication rooms observed. The medication room refrigerator also had food and nutritional supplements stored with the medications. The census was 47. Review of the facility's Storage of Medications policy, revised, April, 2007, showed: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage and preparation area in a clean, safe, and sanitary manner; -Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secure location; -Medication must be stored separately from food and must be labeled accordingly. During an interview and observation on 10/20/24 at 9:05 A.M., the medication room had a small refrigerator that contained a thermometer hanging on the inside of the door, two boxes of insulin vials (treats diabetes), one box of tuberculin testing serum, a locked container that contained a box of Ativan (medication used to treat anxiety), several cartons of Nepro (a nutritional supplement), several cartons of Boost (a nutritional supplement), one carton of Med Pass (a nutritional supplement) and an undated, clear plastic bowl of applesauce covered with clear plastic wrap. Certified Medication Technician (CMT) F said he/she was not aware of any system in place or temperature log for the medication refrigerator. He/She was not aware food items for residents were not to be stored with the medications because it was always stored that way. During an interview on 10/20/24 at 9:10 A.M., Licensed Practical Nurse (LPN) A said there was no refrigerator log and he/he was not sure who was responsible to check the refrigerator. During an interview on 10/24/24 at 12:31 P.M., the Assistant Administrator and The Assistant Director of Nursing (ADON) said they did not have a system in place to check the refrigerator temperature in the medication room. They were not aware that medications should not be stored with food items.

Based on observation, interview, and record review, the facility failed to ensure facility staff performed appropriate hand hygiene during meal service which effected 15 residents (Residents #21, #36, #11, #39, #20, #1, #13, #14, #35, #37, #9, #43, #19, #41, and #17). The sample was 12. The census was 79. Review of the facility's handwashing/hand hygiene policy, dated August 2015, Showed: -Policy statement: this facility considers hand hygiene the primary means to prevent the spread of infections; -Policy implementation: all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap and water for the following situations: before and after direct contact with residents, before and after eating or handling food, before and after assisting a resident with meals. 1. Review of Resident #21's medical record, showed diagnoses included dementia, dystonia (involuntary muscle contractions that cause repetitive or twisting movements), and chronic obstructive pulmonary disease (COPD, lung disease). 2. Review of Resident #36's medical record showed diagnoses included Alzheimer's disease and depression. 3. Review of Resident #11's medical record showed diagnoses included acute respiratory failure. 4. Review of Resident #39's medical record showed diagnoses included diabetes and major depressive disorder. 5. Review of Resident #20's medical record showed diagnoses included Alzheimer's disease and anxiety. 6. Review of Resident #1's medical record showed diagnoses included dementia, anxiety, and major depressive disorder. 7. Review of Resident #13's medical record showed diagnoses included diabetes and dementia. 8. Review of Resident #14's medical record showed diagnoses included wheezing, shortness of breath, and dementia. 9. Review of Resident #35's medical record showed diagnoses included diabetes and major depressive disorder. 10. Review of Resident #37's medical record showed diagnoses included Alzheimer's disease and dementia. 11. Review of Resident #9's medical record showed diagnoses included dementia and paranoid schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). 12. Review of Resident #43's medical record showed diagnosis of Parkinson's disease (brain disorder causing unintended or uncontrolled movements). 13. Review of Resident #19's medical record showed diagnoses included major depressive disorder and anxiety. 14. Review of Resident #41's medical record showed diagnoses included dementia and major depressive disorder. 15. Review of Resident #17's medical record showed diagnoses included Alzheimer's disease and anxiety. 16. Observation on 10/21/24, of breakfast in the main dining room, showed: -At 7:32 A.M., Licensed Practical Nurse (LPN) B and Nurse Aide (NA) C repositioned Resident #21 in his/her chair by holding onto the resident's arms and pants. No hand hygiene performed; -At 7:33 A.M., NA C walked up to Resident #36 and assists the resident with his/her clothing protector; -At 7:35 A.M., NA C walked up to Resident #21, took the resident's cup from his/her hand, and placed it on the table. NA C grabbed onto the resident's wheelchair handle for support as he/she stood near the resident; -At 7:37 A.M., NA C walked to Resident #21 and grabbed the resident's silverware, unraveling it from the napkin. He/She then started to cut the resident's food; -At 7:38 A.M., NA C grabbed Resident #21's clothing protector and put it on him/her. He/She grabbed the resident's wheelchair handle as he/she started to walk away; -At 7:39 A.M., NA C grabbed Resident #11's silverware and started to cut up the residents food; -At 7:39 A.M., NA C walked up behind Resident #21's wheelchair and positioned the resident's wheelchair closer to the table; -At 7:40 A.M., NA C grabbed Resident #21's drink from the table and assists the resident with a drink; -At 7:42 A.M., NA C placed his/her hand on Resident #39's shoulder as he/she walked past the resident; -At 7:43 A.M., NA C grabbed Resident #20's spoon and gave the resident a bite of food; -At 7:44 A.M., NA C picked up Resident #1's silverware and started to cut the resident's food. NA C then went to Resident #20 and picked up his/her spoon and fed him/her a bite of food; -At 7:45 A.M., NA C grabbed Resident #13's wheelchair and propelled the resident to his/her spot at the table. NA C rubbed the resident's back as he/she walked away; -At 7:45 A.M., NA C grabbed and chair and pulled it up to the table next to Resident #14. He/She picked up the resident's drink to assist him/her with a drink; -At 8:12 A.M., NA C reached down and unlocked Resident #14's wheelchair with his/her hands, stood up, and propelled the resident out of the dining room door and walked back into the dining room; -At 8:17 A.M., NA C stood next to Resident #35. He/She picked up the resident's silverware and picked up the resident's piece of toast with his/her hand and spread jam on the toast. He/She then patted the resident's shoulder; -At 8:18 A.M., NA C walked back over to Resident #1 and placed his/her hand on the resident's wheelchair handle as he/she spoke to the resident; -At 8:20 A.M., NA C walked over to Resident #37 and gave the resident a hug; -At 8:23 A.M., NA C stood next to Resident #9 and grabbed the resident's wheelchair handle as he/she reached over the resident to grab the resident's drink; -At 8:23 A.M., NA C walked over to Resident #43 and picked up his/her silverware to assist the resident with cutting his/her food; -At 8:25 A.M., NA C walked over to Resident #9 and sat down next to him/her. He/She picked up the resident's drink and assisted the resident with a drink; -At 8:28 A.M., NA C stood up and propelled Resident #9 in his/her wheelchair out of the dining room; -At 8:29 A.M., NA C propelled Resident #9 into the sitting room, reached down, and locked the resident's wheelchair with his/her hands, then walked back into the dining room; -At 8:31 A.M., NA C placed his/her hands on the handles of Resident #1's wheelchair as he/she spoke with another staff member; -At 8:32 A.M., NA C grabbed Resident #20's spoon to give the resident a bite of food; -At 8:37 A.M., NA C wiped his/her nose with his/her hand; -At 8:38 A.M., NA C grabbed Resident #19's silverware off the table and cuts up the resident's food; -At 8:41 A.M., NA C patted Resident #19's shoulder; -At 8:41 A.M., NA C walked over to Resident #21 and unlocked the resident's wheelchair with his/her hands; -At 8:43 A.M., NA C held onto Resident #21's wheelchair handle as he/she spoke with the resident. He/She rubbed the resident's shoulder and then rubbed his/her eye with his/her right hand; -At 8:45 A.M., NA C stood next to Resident #19 and fed the resident. He/she itched his/her head with his/her right hand; -At 8:52 A.M., NA C grabbed Resident #41's wheelchair handles and pushed the resident out of the dining room; -At no time during the observation did NA C complete hand hygiene. 17. Observation on 10/21/24, of lunch in the dining room, showed: -At 12:37 P.M., Certified Nursing Assistant (CNA) D propelled Resident #17, in his/her wheelchair to a spot at the table, and put a clothing protector on the resident; -At 12:38 P.M., CNA D walked over to Resident #19 and assisted the resident with his/her clothing protector; -At 12:39 P.M., CNA D walked over to Resident #21 and assisted the resident with his/her clothing protector; -At 12:40 P.M., CNA D grabbed Resident #21's coffee cup and gave it to the resident. He/She then grabbed the resident's silverware and placed it in front of the resident; -At 1:03 P.M., NA E sat in a chair next to Resident #1 to assist the resident with eating. At 1:04 P.M., NA E held his/her phone in both hands texting. He/She then put down his/her phone, picked up a grape from the resident's plate with his/her right hand, and then fed the grape to the resident. At 1:06 P.M., NA E grabbed a grape from the resident's plate with his/her right hand and fed it to the resident. At 1:07 P.M., NA E grabbed a grape from the resident's plate with her right hand and fed it to the resident. At 1:09 P.M., NA E grabbed a grape from the resident's plate with her right hand and fed it to the resident; -During the observation, neither CNA D nor NA E completed hand hygiene. 18. During an interview on 10/24/24 at 8:25 A.M., CNA G said staff should wash their hands before going into the dining room and after touching each plate. Staff should also wash their hands anytime they touch anything. He/She would expect staff to follow the hand washing policy. 19. During an interview on 10/24/24 at 8:28 A.M., Certified Medication Technician (CMT) F said staff are expected to wash their hands or use hand sanitizer before coming into the dining room, before passing each plate, and every time they touch something. Hand hygiene is important to prevent cross contamination of germs. He/She would expect staff to be following the hand washing policy. 20. During an interview on 10/24/24 at 8:58 A.M., LPN A said staff are expected to wash their hands before they enter the dining room, after passing three plates, after feeding a resident, or if they touch something. Hand washing is important to prevent the spread of germs and contamination. He/She would expect staff to follow the hand washing policy. 21. During an interview on 10/24/24 at 12:37 P.M., the Assistant Director of Nursing (ADON) and Administrator said they would expect all staff to follow the hand hygiene policy and procedures. They would expect staff to wash or sanitize their hands before coming into the dining room, after each tray passed, and whenever they touch something.

42795 Based on observation, interview and record review, the facility failed to ensure staff used good infection control practices for one resident when providing wound care (Residents #38). The facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs can spread that requires gown and glove use during high contact resident care activities for certain residents) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with urinary catheters (a tube that drains the bladder) and wounds requiring treatments (Residents #38 and #31). In addition, the facility failed to provide tuberculosis (TB) testing for five residents out of five residents reviewed for TB testing (Resident #38, #11, #12, #14, and #22). The sample was 12. The census was 47. An EBP policy was requested but not provided by the facility. Review of the facility's Wound Care policy, revised October, 2010, showed: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing; -Steps in the procedure: -Use disposable cloth (paper towel is adequate) to establish a clean field on resident's overbed table; -Place all items to be used during your procedure on the clean field; -Arrange the supplies so they can be easily reached; -Wash and dry hands thoroughly; -Position the resident and place disposable cloth next to the resident under the wound to serve as a barrier to protect the bed linens and other body sites; -Put on exam glove, loosen tape and remove the dressing; -Pull glove over dressing and discard into appropriate receptacle; -Wash and dry hands thoroughly; -Put on gloves: -Gowns will only be necessary if soiling of your skin or cloth with blood, urine, feces, or other body fluids is likely; -Masks and eyewear will only be necessary if splashing of blood or other body fluids into the eyes; -Use no touch technique by using sterile tongue blades and applicators to remove ointments and creams form their containers; -Pour liquids solutions directly on gauze sponges on their papers; -Wear exam gloves for holding gauze to catching irrigation solutions that are pored directly over the wound; -Wash tissue around the wound that is usually covered by the dressing, tape, or gauze with antiseptic or soap and water; -Apply treatments as indicated; -Dress the wound and mark with initials, time and date and apply to the dressing. 1. Review of Resident #38's medical record showed: -Diagnosis that included adult failure to thrive, pressure wound (skin or soft tissue injury that develops with prolonged periods of pressure over specific areas of the body), diabetes, and stroke; -No care plan; -An order, dated 5/29/24, to cleanse coccyx (tailbone) wound with wound cleaner, pack with saline moistened Kerlix (a type of gauze dressing), cover with ABD pad (a large thick dressing) and secure. Change daily and as needed (PRN); -An order dated, 6/30/24, provide urinary catheter care every shift. Observation on 10/21/24 at 9:40 A.M., showed no EBP signage on the resident's door. The resident lay in bed, soiled with stool. Certified Nursing Assistant (CNA) G and Nursing Assistant (NA) J wore gloves and provided perineal care (care to the surface area between the thighs, extending from the pubic bone to tail bone) by turning the resident from side to side. Neither staff wore a gown. The resident had a urinary catheter that drained yellow urine. Licensed Practical Nurse (LPN) B entered the resident's room and said he/she was going to provide wound care. LPN B left the room and stood at the treatment cart. LPN B used hand sanitizer and began opening drawers on the treatment cart. LPN B placed sheet of parchment paper on top of the treatment cart. LPN B opened one drawer and removed an unpackaged Kerlix dressing that lay directly inside drawer, with his/her ungloved hands and placed it on the parchment paper. LPN B then opened another drawer and removed unpackaged 4x4 gauze with his/her ungloved hands and placed the 4x4 gauze on the parchment paper located on top of the treatment cart. LPN B then removed a pair of blue handled scissors from the top drawer of the treatment cart and began cutting the Kerlix dressing. LPN B did not clean the scissors prior to cutting the Kerlix dressing. LPN B removed the dressings with the parchment paper with ungloved hands and a box of gloves and entered the resident's room and placed the box of gloves and parchment paper with the dressings on the resident's bed. LPN B did not wear a gown. LPN B used hand sanitizer then applied gloves and removed the resident's coccyx dressing that was dated 10/20/24. LPN removed gloves and used hand sanitizer and applied clean gloves. LPN B cleansed the resident's coccyx wound with the 4x4's that were located on the parchment paper on the resident's bed. LPN B then removed the Kerlix dressing from the parchment paper and applied normal saline to the Kerlix and then packed the Kerlix into the resident's coccyx wound. LPN B removed his/her gloves and used hand sanitizer. LPN B then applied clean gloves and placed an ABD pad on top of the coccyx wound and secured with tape. LPN B did not label or date the resident's coccyx dressing. LPN B removed his/her gloves and left the room. CNA G and NA J finished getting the resident dressed and placed a Hoyer pad (a specialized transfer pad used for mechanical lifts) under the resident by turning him/her side to side. The resident was then transferred by CNA G and NA J with the use of a Hoyer lift and placed in a Broda chair (specialized reclining chair). CNA G, NA J, and LPN B did not wear a isolation gown while providing care. 2. Review of Resident #31's medical record, showed: -Diagnoses included stroke, bullous pemphigoid (an autoimmune skin disorder that causes blisters on the skin), local infection of the skin and subcutaneous tissue, and urinary tract infection; -A physician order, dated 5/29/24, for urinary catheter 16 French (size) with 10 milliliter (ml) balloon, for wound healing. Review of the resident's skin assessment, dated 10/18/24, showed: -Bullous pemphigoid wound to left lateral (to the side of) knee with serosanguineous (thin, watery, pale, red/pink drainage) exudate (drainage); -Bullous pemphigoid wound to left anterior (in front of) thigh with serosanguineous exudate; -Bullous pemphigoid wound to left medial (toward the middle or center) thigh with serosanguineous exudate; -Bullous pemphigoid wound to right upper extremity anterior with serosanguineous exudate; -Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough (dead tissue). May also present as an intact or open/ruptured blister) to left buttock with sanguineous (bloody) exudate; -Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed) pressure ulcer to sacrum (triangular bone at the base of the spine). Review of the resident's care plan, in use at the time of survey, showed no documentation regarding the use of EBP. Observation on 10/20/24 at 9:24 A.M., showed no signage regarding EBP outside of the resident's room. The resident in bed with his/her catheter bag hung from the foot of the bed, and rested on the floor. Observation on 10/21/24 at 8:53 A.M., showed no signage regarding EBP outside of the resident's room. The resident seated upright in bed while CNA D fed him/her breakfast. CNA D did not wear a gown or gloves while providing feeding assistance. Observation on 10/22/24 at 10:20 A.M., showed no signage regarding EBP outside of the resident's room. The resident on his/her back in bed while NA K provided a bed bath. NA K wore gloves and no gown while providing bathing assistance. Observation on 10/23/24 at 10:39 A.M., showed no signage regarding EBP outside of the resident's room During an interview on 10/23/24 at 11:36 A.M., CNA G said he/she was not aware of EBP and never heard of it. 3. During an interview on 10/23/24 at 11:44 A.M., LPN A said he/she was not aware of EBP and it is not currently in place. The nurse should wash their hands and apply clean gloves prior to touching the sterile dressings. Scissors that are used off the treatment cart should be cleaned prior to cutting any dressing because staff would not know it the person before you cleaned them. The dressings should be labeled with the nurses' initials and dated. 4. During an interview on 10/23/24 at 12:15 P.M., Certified Medicine Technician (CMT) F said he/she was not aware of EBP and has not been in-serviced on it. 5. During an interview on 10/24/24 at 11:24 A.M., the Assistant Director of Nursing (ADON) said she was aware of the EBP precautions requirement but has not implemented it in the facility yet. Staff have not been in-serviced and Resident #38 and #31 would be residents that would require EBP due to their wounds and urinary catheters. She would expect staff to wash their hands and apply gloves prior to touching clean dressings. She would expect staff to clean scissors with a bleach wipe prior to cutting a dressing. She would expect staff to label the dressing with their initial and with the date completed. 6. Review of the facility's TB policy, revised July, 2013, showed: -The facility shall screen all resident for TB infection and disease; -Individuals identified with active TB disease shall be isolated form other residents and ancillary staff, and transported to an appropriate care facility; -Screening new admissions or re-admissions: -The facility will screen referrals for admission or readmission for information regarding exposure to, or symptoms of TB and will check recent result (within 12 months) tuberculin skin test (TST), blood assay for Mycobacterium tuberculosis (organism that cause TB) (BAMT), or chest x-ray (CXR); -Any resident with documented negative TST, BAMT, or CXR with the previous 12 months will receive a baseline (two step) TST or (one step) BAMT on admission; -If the first step is negative a follow up TST will be administered one to three weeks after the initial test is read; -Asymptomatic (without symptoms) resident who have a known positive skin test or past history of TB, and have not had a CXR in the past six months, will receive a CXR before, or soon after admission; -The physician will screen each new admission for possible signs and symptoms of TB, including coughing, loss of appetite, fatigue, weight loss, night sweats, bloody sputum, hoarseness, fever, or chest pain. 7. Review of Resident #38's medical record showed: -An admitted [DATE]; -Diagnosis that included adult failure to thrive, pressure wound, diabetes, and stroke. -No documentation that resident was screened for TB or received a TST. 8. Review of Resident #11's medical record showed: -An admitted [DATE]; -Diagnosis that included sepsis (a systematic infection that affects the entire body) and acute (short duration) respiratory failure; -No documentation that resident was screened for TB or received a TST. 9. Review of Resident #12's medical record showed: -An admitted [DATE]; -Diagnosis that included, stroke, COVID-19, diabetes, and heart failure; -No documentation that resident was screened for TB or received a TST. 10. Review of Resident #14's medical record showed: -A admitted [DATE]; -Diagnosis that included diabetes, urinary tract infections (UTI), sepsis, yeast infection and heart failure; -No documentation that resident was screened for TB or received a TST. 11. Review of Resident #22's medical record showed: -An admitted [DATE]; -Diagnosis that included sepsis, long term use of antibiotics, enterocolitis (inflammation of the colon), cystitis (inflammation of the urinary bladder), and diabetes; -No documentation that resident was screened for TB or received a TST. 12. During an interview on 10/23/24 at 9:05 A.M., the ADON said she is expected to ensure that the resident TB screening and TST is completed. The residents are to receive a two-step TST on admission and then a one-step TST once yearly. If the resident has a history of TB or a previous positive result, then a CXR is obtained.

Based on interview and record review the facility failed to offer and vaccinate as desired, eligible residents for the pneumococcal (pneumonia) vaccine for 4 out of 5 residents sampled for immunizations (Resident #12, #11, #38, #22). The census was 47. Review of the facility's Pneumococcal Vaccine policy, revised August, 2016, showed; -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia or pneumococcal infections; -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated; -Assessments of pneumococcal vaccination status will be conducted within 5 working days of the resident's admission if not conducted prior to admission; -Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine; -Provisions of such education shall be documented in the resident's medical record; -Resident's and their representatives have the right to refuse vaccination; -If refused, appropriated entries will be documented in each resident's medical record indication the date of the refusals of the pneumococcal vaccination; -For residents who receive the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record; -Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 1. Review of Resident #12's medical record showed: -An admitted [DATE]; -Diagnosis that included, stroke, COVID-19, diabetes, and heart failure; -No documentation that resident was screened or received the pneumococcal vaccine. 2. Review of Resident #11's medical record showed: -An admitted [DATE]; -Diagnosis that included sepsis (a systematic infection that affects the entire body) and acute (short duration) respiratory failure; -No documentation that resident was screened or received the pneumococcal vaccine; 3. Review of Resident #38's medical record showed: -An admitted [DATE]; -Diagnosis that included adult failure to thrive, diabetes, and stroke; -No documentation that resident was screened or received the pneumococcal vaccine. 4. Review of Resident #22's medical record showed: -An admitted [DATE]; -Diagnosis that included sepsis, long term use of antibiotics, enterocolitis (inflammation of the colon), cystitis (inflammation of the urinary bladder), and diabetes; -No documentation that resident was screened or received the pneumococcal vaccine. 5. During an interview on 10/23/24 at 9:05 A.M., the Assistant Director of Nursing (ADON) said she is responsible for screening and checking the vaccine status of the residents. It is expected that the residents should be offered the pneumococcal vaccine if they do not have any contraindications and are eligible. Refusals of the vaccine are to be documented in the medical record. Education is also expected to be provided to the resident or residents responsible party for each type of immunization.

Based on interviews, record review, observations, and facility policy review, the facility failed to ensure resident-centered comprehensive care plans were developed, implemented, and revised to meet the needs of 13 (Residents #10, #96, #17, #44, #8, #14, #145, #2, #36, #30, #27, #35, and #29) of 29 residents reviewed for comprehensive care plans. The facility failed to develop and implement comprehensive care plans to address residents at risk for falls and residents with a history of multiple falls with injury. The facility also failed to develop and implement comprehensive care plans related to a risk for and current significant weight loss, diabetes monitoring and management, behaviors, chronic kidney disease and dialysis care, treatment, and monitoring, antipsychotic mediation use for a resident with a dementia diagnosis, monitoring of a diuretic medications, and monitoring and management of a resident on anticoagulant therapy. The facility census was 42. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.21 (Comprehensive Resident Centered Care Plan). The IJ began on 12/15/2022 when Resident #10 had a fall after their fall risk care plan was initiated on 09/20/2022. Resident #10 had 12 falls from 12/15/2022 to 04/30/2023, one of which resulted in a right hip fracture, and the facility did not identify new care plan interventions for fall prevention that addressed causal and contributing factors after falls in an effort to prevent further falls. The Administrator and Assistant Administrator (AA) were notified of the IJ and provided with the IJ template on 06/18/2023 at 9:50 AM. A Removal Plan was requested. The IJ was determined to be removed on 06/23/2023 after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of G. Findings included: Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, dated 2001 and revised in December 2016, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy indicated, 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her right to refuse treatment; d. Describe any specialized services to be provided as a result of PASARR [preadmission screening and resident review] recommendations; e. Include the resident's stated goals upon admission and desired outcomes; f. Include the resident's stated preferences and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; i. Build on the resident's strengths; j. Reflect the resident's expressed wishes regarding care and treatment goals; k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and o. Reflect currently recognized standards or practice for problem areas and conditions. Further review of the policy revealed, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS [Minimum Data Set]). 1. Review of Resident #10's Admission Record indicated the facility admitted the resident on 11/12/2018 with diagnoses including osteoarthritis (Most common form of arthritis characterized by the cartilage within a joint beginning to break down and the underlying bone changing. Most frequently in the hands, hips, and knees), paranoid schizophrenia, bipolar disorder, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and dementia. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #10 was independent with transfers, walking, and locomotion and was steady at all times when walking and during surface-to-surface transfers. The MDS indicated the resident had no falls since admission or the prior assessment. Review of Resident #10's care plan revealed a focus area, with an initiation date of 09/20/2022, that indicated the resident was at risk for falls. Interventions directed staff to assist the resident with ambulation and transfers, determine the resident's ability to transfer, evaluate fall risk on admission and as needed (PRN), and if a fall occurred, staff were to initiate frequent neuro [neurological] and bleeding evaluation per the facility protocol. Review of Resident #10's care plan revealed another focus area, with an initiation date of 11/21/2022, that indicated the resident was at high risk for falls due to Parkinson's disease and psychoactive medication use. Interventions directed staff to anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use the call light, educate the resident about safety reminders and what to do if a fall occurred, ensure that that the resident was wearing appropriate footwear, and ensure the resident was in a safe environment. Review of Resident #10's electronic medical record (EMR) indicated Resident #10's comprehensive care plan was due for review on 02/19/2023 but had not yet been reviewed. There had been no changes to the interventions in the focus areas created for fall risk on 09/20/2022 or 11/21/2022. Review of Resident #10's progress notes revealed the resident had five falls from 12/15/2022 to 01/18/2023. Resident #10 had two falls on 01/18/2023, which resulted in a right hip fracture. Resident #10 was readmitted on [DATE] following a hospitalization with a fractured right hip. Resident #10 then had seven more falls from 02/08/2023 to 04/30/2023. There was no root cause analysis to determine causal and contributing factors after each fall, and there were no new fall prevention interventions added to Resident #10's care plan to prevent further falls. 2. Review of Resident #96's Admission Record revealed the facility admitted the resident on 04/22/2023 with diagnoses including acute respiratory failure, adjustment disorder with mixed anxiety and depressed mood, macular degeneration, and age-related osteoporosis. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #96 transferred and walked with one-person limited assistance and used a wheelchair for mobility. According to the MDS, the resident had no falls in the two to six months prior to admission and had no falls since admission. Review of Resident #96's electronic medical record (EMR) on 06/13/2023 revealed there was no comprehensive care plan for the resident. Review of Resident #96's Initial Plan of Care, dated 04/22/2023, indicated the resident required assistance with mobility, turning, and transfers. The Initial Care Plan did not indicate the resident was at risk for falls or include interventions for fall prevention. Review of Resident #96's health status progress notes, dated 06/09/2023 and written by nursing staff, indicated that at 2:57 AM, Resident #96 fell forward out of their wheelchair after falling asleep, suffering a large hematoma to the right side of their forehead. Resident #96 was transported to the emergency room (ER). The resident returned from the ER at 11:30 AM with no further injuries noted. There was no root cause analysis to determine causal and contributing factors of the fall and no fall prevention interventions developed and care planned to prevent further falls for the resident. 3. Review of Resident #17's Admission Record revealed the facility admitted the resident on 03/06/2023 with diagnoses hypothyroidism (underactive thyroid), dementia, and congestive heart failure. Review of the Admission Record revealed there was no documented diagnosis of anorexia (a condition when pertaining to the elderly including a loss of appetite, decreased food intake or both). Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #17 required extensive assistance of one person with eating. According to the MDS, Resident #17 had a weight loss of 5% (percent) or more in the last month or 10% or more in the last six months and was not on a physician-prescribed weight loss regimen. The MDS also indicated Resident #17 was at risk for developing pressure ulcers. The resident was receiving hospice care. Review of Resident #17's electronic medical record (EMR) on 06/12/2023 revealed there was no comprehensive care plan for the resident. Review of the resident's Initial Plan of Care, dated 03/07/2023, revealed the resident required total assistance with eating. The Initial Plan of Care did not indicate the resident was at risk of weight loss or pressure injuries/ulcers. A review of Resident #17's weight record in the EMR revealed the resident weighed the following: - On 03/13/2023, 141.4 pounds - On 03/20/2023, 130.0 pounds, an 11.4-pound (8.06%) weight loss in seven days - On 03/27/2023, 128.0 pounds - On 04/10/2023, 120.4 pounds, a 21.0-pounds (14.85%) weight loss in 28 days - On 04/17/2023, 120.2 pounds A review of Resident #17's March 2023 and April 2023 meal intake records indicated the resident consumed 50-100% at each meal. There was no documentation indicating snack or nutritional supplements were offered or consumed. Review of Resident #17's hospice notes, dated 05/03/2023, revealed the resident had a diagnosis of anorexia as of 03/06/2023. The notes indicated facility staff reported to hospice staff that Resident #17 consumed about 25% of one to two meals per day. The notes indicated that Resident #17 had decreased intake, and weight loss was significant and ongoing. Review of Resident #17's nutrition/dietary progress notes, dated 05/26/2023, revealed the resident weighed 122.4 pounds and was down 23.8 pounds (16.3%) in the past quarter. The notes indicated the resident had no skin issues, per nursing assessment. The notes indicated the resident's weights were more stable in the last month and there were no recommended changes due to stable weight. Review of Resident #17's health status progress notes, dated 06/06/2023, indicated the hospice aide and nurse identified new, facility-acquired pressure ulcers on the resident's bilateral heels; an unstageable pressure injury on the left heel and a stage 3 pressure ulcer on the right heel. The hospice nurse notified the physician and family and obtained wound treatment orders. There was no care plan developed to address the resident's risk for weight loss with nutritional interventions or risk for pressure injuries/ulcers with interventions to prevent skin breakdown. 4. Review of Resident #44's Admission Record indicated the facility admitted the resident on 03/24/2023 with diagnoses including diabetes mellitus, depression, anemia, and Alzheimer's disease. Review of Resident #44's electronic medical record (EMR) revealed an entry tracking Minimum Data Set (MDS) was completed on 03/24/2023. No comprehensive admission MDS, which was due 14 days after the resident's admission, was completed. A discharge MDS was completed on 04/19/2023 (26 days after admission when Resident #44 was discharged to the hospital and did not return). Review of the discharge MDS, with an Assessment Reference Date (ARD) of 04/19/2023, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Review of Resident #44's EMR on 06/17/2023 revealed there was no comprehensive care plan for the resident. Review of Resident 44's Initial Plan of Care, dated 03/24/2023, indicated the resident required assistance with activities of daily living (ADLs) and was fed by staff. The Initial Plan of Care did not indicate the resident was diabetic or address how staff were to monitor and manage the resident's diabetes. Review of Resident #44's April 2023 medication administration record (MAR) revealed a physician's order, dated 03/24/2023, for Lantus insulin, 10 units, to be subcutaneously injected at bedtime. The MAR did not include a physician's order for blood sugar checks. Review of Resident #44's health status progress notes, dated 04/19/2023 and written by nursing staff, revealed Resident #44 was found unresponsive during routine activities of daily living (ADL) care, with a blood sugar of 24 milligrams (mg)/deciliter (dL). Resident #44 was transported to the emergency room and did not return to the facility. During an interview on 06/23/2023 at 4:05 PM, the Assistant Director of Nursing (ADON) stated Resident #44 was not in the facility long enough to have a completed comprehensive care plan. During an interview on 06/23/2023 at 4:06 PM, the Director of Nursing (DON) stated Resident #44 was not in the building long enough to have a completed comprehensive care plan. 5. Review of Resident #27's Admission Record indicated the facility admitted Resident #27 on 08/13/2020 with diagnoses including Alzheimer's disease, psychosis, dementia, and anxiety. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #27 received antipsychotic and antidepressant medication daily in the past seven days. Review of Resident #27's June 2023 medication administration record (MAR) revealed a physician's order, dated 08/14/2022, for sertraline hydrochloride (HCl), an antidepressant, to be administered once a day, related to dementia with behavioral disturbance. There was also a physician's order, dated 08/13/2022, for Seroquel, an antipsychotic medication, to be administered twice a day, related to psychosis. Review of Resident #27's comprehensive care plan revealed a focus statement, with an initiation date of 09/21/2022, that indicated the resident had a mood problem related to dementia. Interventions directed staff to administer medications as ordered, monitor/document side effects and effectiveness, and obtain behavioral health consultations as needed. Resident #27's comprehensive care plan did not include a focus area specifically related to psychotropic medication use. Review of Resident #27's electronic medical record (EMR) on 06/14/2023 revealed Resident #27's care plan was due for review on 01/23/2023 but had not yet been reviewed. 6. Review of Resident #35's Admission Record revealed the facility admitted the resident on 09/01/2021 with diagnoses including Parkinson's disease, edema, delusional disorder, depression, psychosis, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had a diagnosis of edema and used a diuretic medication daily in the past seven days. Review of Resident #35's June 2023 medication administration record (MAR) revealed a physician's order for Lasix, a diuretic medication, to be administered daily, related to edema. Review of Resident #35's comprehensive care plan revealed no focus area related to edema or diuretic use. Review of Resident #35's electronic medical record (EMR) revealed Resident #35's care plan was due for review on 11/10/2022 but had not yet been reviewed. 7. Review of Resident #29's Admission Record revealed the facility admitted the resident on 09/09/2019 with diagnoses including ataxia (poor muscle control that causes clumsy, involuntary movements), dementia, type two diabetes mellitus, atrial fibrillation (abnormal heartbeat), cardiac arrhythmia (problem with rate or rhythm of the heartbeat), and hypertension(high blood pressure). Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #29 received an anticoagulant medication daily in the past seven days. Review of Resident #29's June 2023 medication administration record (MAR) revealed a physician's order, dated 11/16/2022, for Eliquis, an anticoagulant medication, to be administered twice a day due to atrial fibrillation. Review of Resident #29's comprehensive care plan revealed no focus area related to anticoagulant medication use, including risk factors or current conditions the could put the resident at risk for bleeding or nursing interventions to reduce risk for bleeding. Review of Resident #29's electronic medical record (EMR) revealed Resident #29's care plan was due for review on 12/25/2022 but had not yet been reviewed. 40141 8. Review of Resident #8's Admission Record indicated the facility admitted the resident on 04/26/2023 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and cerebral infarction. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and transfers and was totally dependent on staff for toilet use; walking and locomotion did not occur during the review period. The MDS indicated the resident had no limitations in range of motion and used a wheelchair for mobility. According to the MDS, the resident did not have falls prior to or since admission. Review of Resident #8's electronic medical record (EMR) revealed no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 04/26/2023, revealed Resident #8 required assistance of one staff for mobility, turning, and transfers. The Initial Plan of Care did not indicate the resident was at risk for falls or include interventions to prevent falls. Review of incident notes, dated 05/29/2023 at 1:35 AM and written by nursing staff, revealed Resident #8 found on the floor in the resident's room. The notes indicated the resident said they were returning to bed from the bathroom when they fell . The notes indicated the resident was assessed and there were no visible injuries; however, range of motion to the left leg was not within normal limits. The resident was unable to straighten the left leg, and ice was applied to the left hip. The resident complained of pain, and pain medications were administered. The incident note indicated Resident #8 was transferred to the hospital. A health status progress note, dated 05/30/2023, indicated the resident's family member phoned the facility and reported the resident had a computed tomography (CT) scan and had a crack in the head of the femur. An admission summary progress note, dated 06/01/2023, indicated Resident #8 returned to the facility. The Admission Record was updated to indicate the resident had a diagnosis of nondisplaced intertrochanteric fracture of the left femur. There was no care plan developed to include fall prevention interventions to prevent further falls. 9. Review of Resident #14's Admission Record indicated the resident was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar) and dementia with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #14 had short-term and long-term memory problems and moderately impaired cognitive skills for daily decision-making based on the Staff Assessment for Mental Status (SAMS). The MDS indicated the resident was independent with bed mobility and transfers and required limited assistance with toilet use. The MDS indicated Resident #14 had no falls prior to or since admission or the prior assessment. Review of Resident #14's medical record revealed there was no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 04/26/2023, revealed Resident #14 was independent with mobility, turning, and transfers. The Initial Care Plan did not indicate the resident was at risk for falls and did not include interventions to prevent falls. Review of a health status progress note, dated 03/23/2023 at 4:16 PM and written by nursing staff, revealed the resident found on the floor at the entrance to the dining room. According to the note, the resident did not have any injuries; the resident was assisted to stand and ambulated to their room without difficulty. This fall was not reflected on the quarterly MDS assessment, dated 04/28/2023. Review of a health status progress note, dated 05/08/2023 at 10:44 AM and written by nursing staff, revealed Resident #14 slid out of a recliner chair. The note indicated the resident had no injuries. Review of a health status progress note, dated 05/30/2023 at 8:28 AM and written by nursing staff, revealed, purplish bruising to right outer eye, no swelling noted. The note indicated the resident stated they hit their head. According to the note, the resident's roommate stated the resident was moaning during the night and was on the floor, and the lady across the hall helped the resident up and into bed. Review of an incident note, dated 06/11/2023 at 6:12 PM and written by nursing staff, revealed Resident #14 was heard yelling and was found on the floor, with a blanket tangled between their legs and feet. The note indicated a large hematoma was found on the back of the resident's head and the hematoma was painful to touch. There was no care plan developed to include fall prevention interventions to prevent further falls after any of the resident's falls. 10. Review of Resident #145's Admission Record indicated the facility admitted the resident on 05/24/2023 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, Alzheimer's disease, and hypertension. Review of Resident #145's electronic medical record (EMR) revealed the resident's required admission Minimum Data Set (MDS) assessment had not been completed. Review of Resident #145's EMR revealed there was no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 05/24/2023, revealed Resident #145 required assistance of one staff for mobility, turning, and transfers. The Initial Care Plan did not indicate the resident was at risk for falls or include interventions to prevent falls. Review of incident notes, dated 05/29/2023 at 3:05 AM and written by nursing staff, revealed Resident #145 was found on the floor, in the hallway. The note indicated the resident had blood on the inside and outside of their nose and mouth. The resident denied pain but was sent to the hospital. A health status progress noted, dated 05/29/2023 at 2:46 PM and written by nursing staff, indicated Resident #145 returned to the facility with a diagnosis of closed fracture of the nasal bone. Review of a health status note, dated 06/03/2023 at 10:45 PM and written by nursing staff, revealed Resident #145 was found on the floor beside their bed and the resident told staff they were trying to reach something and slid out of the bed. The note indicated the resident had no injuries. A review of a health status note, dated 06/10/2023 at 1:50 PM and written by nursing staff, revealed Resident #145 was found on the floor next to their wheelchair. The resident told the nurse they slid out of the chair. The note indicated the resident had no injuries. There was no care plan developed to include fall prevention interventions to prevent further falls after any of the resident's falls. 11. Review of Resident #2's Admission Record indicated the resident admitted on [DATE] with diagnoses including unspecified mood disorder, stage 2 chronic kidney disease, and age-related cognitive decline. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required supervision from staff with bed mobility, transfers, and eating and limited assistance from staff with toilet use. The MDS did not indicate the resident had other behavioral symptoms not directed toward others. Review of Resident #2's medical record revealed there was no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 03/07/2023, revealed Resident #2 was independent with mobility, turning, and transfers and used a rolling walker. The Initial Care Plan did not indicate the resident picked at the skin on their face and did not include approaches related to skin picking. During an observation on 06/12/2023 at 11:36 AM, Resident #2 had a light-colored purplish discoloration with spotty red areas on the left cheek. The resident indicated they did not know what happened to their face. During an observation on 06/13/2023 at 1:16 PM, Resident #2 was in the dining room eating the noon meal. The slight discoloration to the left cheek remained. During an interview on 06/14/2023 at 8:52 AM, Nursing Assistant (NA) #4 indicated she did not know what happened to Resident #2's left cheek. During an interview on 06/14/2023 at 9:09 AM, the Restorative Aide (RA) indicated she did not know what happened to Resident #2's left cheek but stated the resident picked at the skin on their face constantly. During an interview on 06/14/2023 at 9:21 AM, NA #7 stated the resident sat and constantly picked at their face. NA #7 indicated they could stop the resident, but the resident would go right back to picking their face. NA #7 stated she did not know if the resident had a care plan that addressed skin picking. During an interview on 06/14/2023 at 12:40 PM, Licensed Practical Nurse (LPN) #2 stated the area to the left cheek was petechiae (pinpoint, round spots that form on the skin- caused by bleeding), and the resident constantly picked at their face. LPN #2 indicated she did not know if skin picking of the face was care planned but would consider it a behavioral symptom. During an interview on 06/14/2023 at 12:56 PM, the Assistant Director of Nursing (ADON) stated she did not consider the area a bruise. The ADON indicated the area to the left cheek was from the resident messing with their cheek. The ADON stated it was a behavior for the resident that obviously was not documented. During an interview on 06/14/2023 at 1:30 PM, the Director of Nursing (DON) stated the area on Resident #2's left cheek was from the resident picking at their skin. During an observation on 06/20/2023 at 11:00 AM, the resident was sitting in the television room picking at the skin on the left side of their face. There was discoloration with red areas and some small open areas. 12. Review of Resident #36's Admission Record indicated the facility admitted the resident on 04/18/2023 with diagnoses including hypertension, chronic pulmonary edema, and chronic kidney disease. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Review of Resident #36's medical record revealed there was no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 04/18/2023, revealed Resident #36 required assistance with mobility and transfers. Review of an admission summary in the progress notes, dated 06/05/2023 and written by nursing staff, revealed Resident #36 had a right upper chest tunneled dialysis catheter and was scheduled to receive hemodialysis on Tuesdays, Thursdays, and Saturdays. The resident's care needs related to hemodialysis were not addressed in a comprehensive care plan or added to the Initial Plan of Care. 13. Review of Resident #30's Admission Record indicated the facility admitted the resident on 03/11/2021 with diagnoses that included type 2 diabetes mellitus, cerebral infarction, chronic kidney disease, and hypertension. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was totally dependent on the assistance of two staff for transfers and toilet use and required extensive assistance with bed mobility and eating. According to the MDS, the resident had other behavioral symptoms not directed toward others. A review of Resident #30's care plan, that was last revised 10/12/2022, revealed the resident's care plan was due for review on 01/10/2023 but had not yet been reviewed. During an interview on 06/13/2023 at 3:53 PM, the ADON stated if a resident's care plan was not in the electronic medical record (EMR), then the resident only had a baseline care plan (Initial Plan of Care). The ADON said the MDS Coordinator was responsible for completing comprehensive care plans. During an interview on 06/14/2023 at 9:19 AM, NA #8 stated she received verbal report at shift change and checked in with the charge nurse for any updates. During an interview on 06/14/2023 at 11:55 AM, the RA said the facility was in the process of revising their patient care forms. The patient care forms included care information and instructions for resident care that the charge nurse provided to the aides and nursing assistants. The RA further stated there was nothing in writing for staff to refer that included instructions for specific resident care. During an interview on 06/14/2023 at 12:12 PM, NA #7 stated the charge nurse verbally notified the nursing assistants at shift change about the care residents required and if there were any changes in care. NA #7 thought there was a book at the nurses' station that outlined resident care requirements, but she did not know the location of the book. During an interview on 06/14/2023 at 12:32 PM, NA #8 stated the residents had care plans, but she was not sure when they were updated. She said she kept her own piece of paper with notes on it about the residents. NA #8 indicated the care plans were in a binder at the nurses' station. During an interview on 06/14/2023 at 12:21 PM, NA #4 stated the charge nurse verbally notified the nursing assistants at shift change about resident care requirements and let them know if there were any changes. NA #4 stated there was a report sheet that had resident care

Based on observations, interviews, and record review, the facility failed to determine causative factors of resident falls, implement and evaluate interventions to prevent falls, and develop an effective communication system that identified residents at risk for falls and provided care staff with interventions to prevent more falls for 4 (Residents #10, #8, #145, #96 and #14) of 4 residents reviewed for falls. Specifically, the facility failed to: - Determine causal factors and implement new interventions following multiple falls for Resident #10 that resulted in a fractured right hip. - Ensure a fall risk assessment was completed upon admission and investigate a fall that resulted in a fractured hip to determine causal factors for Resident #8. - Ensure a fall that resulted in a nasal bone fracture was investigated for causal factors for Resident #145. - Identify side rails as a possible fall risk, determine causal factors and implement new interventions to prevent further falls for Resident #96. -Determine causal factors and implement new interventions following multiple falls for Resident #14 that resulted in brusing to the right eye and a large hematoma on the back of the resident's head. - Develop an effective communication method that relayed information to staff in the prevention of resident falls. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care). The IJ began on 12/15/2022 when Resident #10 had a fall after their fall risk care plan was initiated on 09/20/2022. Resident #10 had 12 falls from 12/15/2022 to 04/30/2023, one of which resulted in a right hip fracture, and there were no attempts to determine the cause of Resident #10's falls, no evaluation of the effectiveness of fall interventions, and no new fall prevention interventions added to Resident #10's care plan following each fall in order to prevent further falls. The Administrator and Assistant Administrator (AA) were notified of the IJ and provided with the IJ template on 06/15/2023 at 3:44 PM. A Removal Plan was requested. The IJ was determined to be removed on 06/23/2023 after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of G. This deficient practice had the potential to affect all residents. Findings included: Review of the facility policy titled, Assessing Falls and Their Causes, dated 2001 and revised in October 2010, indicated, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. The policy indicated, in part: 1. Review the resident's care plan to assess for any special needs of the resident and 5. Residents must be assessed in a timely manner for potential causes of falls. 6. Relevant environmental issues should be addressed promptly. The policy further indicated, An incident report must be completed for resident falls. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing (DON) services no later than 24 hours after the fall occurs. The policy indicated, 1. Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. 2. Staff will evaluate chains of events or circumstances preceding a recent fall. 3. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found. The policy indicated, When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found. 2. Assessment data including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family as indicated. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. 1. Review of Resident #10's Admission Record indicated the facility admitted the resident on 11/12/2018 with diagnoses including osteoarthritis (Most common form of arthritis characterized by the cartilage within a joint beginning to break down and the underlying bone changing. Most frequently in the hands, hips, and knees), paranoid schizophrenia, bipolar disorder, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severely impaired cognition. The MDS indicated Resident #10 was independent with transfers, walking, and locomotion and was steady at all times when walking and during surface-to-surface transfers. The MDS indicated the resident had no falls since admission or the prior assessment. Review of Resident #10's care plan revealed a focus area, with an initiation date of 09/20/2022, indicated the resident was at risk for falls. Interventions directed staff to assist the resident with ambulation and transfers, determine the resident's ability to transfer, evaluate fall risk on admission and as needed (PRN), and if a fall occurred, staff were to initiate frequent neuro [neurological] and bleeding evaluation per the facility protocol. Review of Resident #10's care plan revealed another focus area, with an initiation date of 11/21/2022, that indicated the resident was at high risk for falls due to Parkinson's disease and psychoactive medication use. Interventions directed staff to anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use the call light, educate the resident about safety reminders and what to do if a fall occurred, ensure that that the resident was wearing appropriate footwear, and ensure the resident was in a safe environment. A review of Resident #10's electronic medical record (EMR) revealed fall risk assessments were completed on 09/10/2022, 12/10/2022, and 04/18/2023 indicating Resident #10 was at risk for falls. A review of Resident #10's Progress Notes revealed five falls occurred from 12/15/2022 to 01/18/2023. Resident #10 was noted to have two falls on 01/18/2023, which resulted in a right hip fracture. Resident #10 readmitted to the facility on [DATE] following a hospitalization with a fractured right hip. The Progress Notes revealed Resident #10 had seven more falls from 02/08/2023 to 04/30/2023. The Progress Notes related to Resident #10's falls included: - On 12/15/2022 at 5:23 PM, Resident #10 was found on the floor of the television room with no injuries noted. - On 12/22/2022 at 6:29 PM, Resident #10 was found on the floor in front of their wheelchair next to the bed. The wheelchair was unlocked. Resident #10 had on socks had no injuries were noted. - On 12/25/2022 at 8:38 AM, Resident #10 was found on the floor in front of their bed, but by the time we got back to the room, [Resident #10] had scooted to the bathroom attempting to get up. There were no injuries noted. - On 12/26/2022 at 5:21 PM, Resident #10 was found on the floor of their room with no injuries noted. The resident indicated she was trying to change clothes. - On 01/03/2023 at 2:45 PM, Resident #10 was found lying on the floor of a sitting area with no injuries noted. The wheelchair was behind the resident and was unlocked. - On 01/18/2023 at 12:41 PM, Resident #10 was found on the floor at the foot of their bed on their right side with no injuries noted. - On 01/18/2023 at 2:46 PM, Resident #10 was observed to be ambulating in their room unassisted, with difficulty, while holding their right leg. A small purplish bruise was discovered on Resident #10's right hip. A physician's order was obtained for a right hip x-ray. - On 01/18/2023 at 5:30 PM, Resident #10 was found on the floor in their room holding their right thigh and yelling out in pain. Three staff members transferred Resident #10 to the bed where staff noted Resident #10's right leg was visibly shortened. An order was obtained to send Resident #10 to the emergency room . - On 02/08/2023 at 2:00 PM (which was a late entry for 12:00 PM), Resident #10 returned to the facility following a hospital stay for a right hip fracture. - On 02/08/2023 at 2:45 PM, Resident #10 was found sitting on the floor at the foot of their bed with no injuries noted. - On 02/18/2023 at 9:36 PM, Resident #10 appeared drowsy while sitting in their wheelchair at 9:00 PM. Staff found Resident #10 on the floor next to their bed at 9:15 PM and transferred Resident #10 back to their wheelchair and brought the resident out to the nurses' station. No assessment for injuries was noted. - On 03/15/2023 at 9:34 PM, staff found Resident #10 on the floor next to their bed with no injuries noted. - On 04/10/2023 at 8:18 AM, Resident #10 was kneeling at their bedside, appears resident OOB [out of bed] without assist d/t [due to] to both side rails being up. Resident #10 was assessed with no injuries noted. - On 04/18/2023 at 8:30 PM, Resident #10 sat at the nurses' station at 8:15 PM and then fell at the nurse's station after attempting to stand up from the wheelchair sustaining a contusion to the forehead about the size of a half dollar. - On 04/20/2023 at 3:29 PM, staff heard Resident #10 yelling out at 12:20 PM. Resident #10 was found on the floor of the nurses' station with one wheel of their wheelchair unlocked, no injuries were noted. Resident #10 was holding their head and rolling back and forth. - On 04/30/2023 at 3:51 PM (this note was still a draft and not finalized), a staff member found Resident #10 on the floor with no injuries noted. During an interview on 06/15/2023 at 2:06 PM, the DON stated when someone fell or had an incident, she was notified and the next day she would put it in to risk management. The DON stated it was kind of like an incident report. The risk management gave a graph of information, such as how many falls occurred during a certain period. The DON indicated there was not a risk management team, it was a section in the computer that could be printed out to see the number of falls. A review of Resident #10's clinical record from 12/15/2022 through 06/15/2023 revealed no evidence the facility attempted to determine what may have caused or contributed to Resident #10's falls. A review of Resident #10's care plan with the focus area of the resident being at risk of falls, initiated on 09/20/2022, revealed no evidence the fall risk care plan was reviewed and revised to reduce the likelihood of another fall after each of the falls Resident #10 experienced. During an interview on 06/13/2023 at 4:45 PM, the Assistant Director of Nursing (ADON) stated all documentation related to resident falls was in the progress notes. The ADON said there were no incident reports, forms, or other fall details included elsewhere in the resident's EMR. During an interview on 06/14/2023 at 8:55 AM, Certified Medicine Technician (CMT) #19 stated the nurse aides were there to make sure Resident #10 did not try to stand up, and the nurses were responsible for any implemented fall risk interventions. She said if Resident #10 started to stand up, the certified nursing assistants (CNAs) would tell them to sit back down. During an interview on 06/14/2023 at 9:19 AM, Nursing Assistant (NA) #8 stated she received verbal report at shift change and checked in with the charge nurse for any updates on residents needs for care. NA #8 said Resident #10 tried to stand up occasionally. NA #8 stated she was not sure if Resident #10 had any falls or if they were a high fall risk. She said she would have to ask the nurse for that information. During an interview on 06/14/2023 at 11:55 AM, the Restorative Aide (RA) said the facility was in the process of revising their patient care forms. The patient care forms included care information and instructions for resident care that the charge nurse provided to the aides and nursing assistants. The RA further stated there was nothing in writing for staff to refer to that included instructions for specific resident care. The RA stated Resident #10 was not steady on their feet, constantly tried to stand up, and was a high fall risk. The RA stated there may be a tilt seat in Resident #10's wheelchair to prevent them from getting up, and staff also gave Resident #10 coloring books to take their mind off trying to stand up. The RA did not know of any other fall risk interventions in place for Resident #10. During an interview on 06/14/2023 at 12:12 PM, NA #7 stated the charge nurse verbally notified the nursing assistants at shift change about the care residents required and if there were any changes in care. NA #7 indicated she thought there was a book at the nurses' station that outlined resident care requirements, but she did not know the location of the book. NA #7 stated staff kept Resident #10 at the nurses' station for increased supervision because the resident was a high fall risk. NA #7 further stated the charge nurse told her that Resident #10 was a high fall risk, but she did not know of any other intervention to prevent falls in place. During an interview on 06/14/2023 at 12:21 PM, NA #4 stated the charge nurse verbally notified the nursing assistants at shift change about resident care requirements and let them know if there were any changes. NA #4 further stated there was a report sheet for the nurses that had resident care information on it, but she had never seen it because she was not a nurse. NA #4 said the charge nurse told her Resident #10 was a high fall risk, had multiple falls while in the facility, and used two side rails to prevent falls out of bed. NA #4 said if Resident #10 tried to get out of bed unassisted, staff would put Resident #10 in their wheelchair and place them at the nurses' station for increased observation if she was not sleeping in bed. During an interview on 06/14/2023 at 12:40 PM, Licensed Practical Nurse (LPN) #2 stated the charge nurse used a report sheet that was updated throughout the day with any changes in resident status, and the charge nurse verbally reported the care each resident required to the nursing assistants. She said there was nothing in writing for care staff to refer to. LPN #2 stated Resident #10 was a high fall risk due to attempts at transferring without assistance. She said Resident #10 had frequent falls so staff kept them near the nurses' station, and LPN #2 did not think Resident #10 had any falls from bed. During an interview on 06/14/2023 at 12:55 PM, the ADON stated the charge nurse gave verbal report to the aides and nursing assistants about the care each resident required. The ADON stated she did not know if Resident #10 was a high fall risk. She said Resident #10 had multiple falls at the facility. She said she did not know when the last fall was and did not know what fall interventions were in place for Resident #10. During an interview on 06/14/2023 at 1:30 PM, the DON stated she was working on a form for the nursing assistants to reference for guidance about resident care. The DON indicated the form would include things like activities of daily living (ADLs) and care planned interventions to prevent falls. The DON said that currently, resident care needs were verbally relayed between staff members, and the facility did not have that information documented for staff to reference. The DON stated Resident #10 was a high fall risk and continuously tried to stand up out of their wheelchair, so they kept Resident #10 in a common area for increased supervision. The DON stated the DON, ADON, and the charge nurse determined fall interventions and interventions were reassessed every three to six months. The DON stated falls were documented under the Risk Management section in the resident's EMR. A request for all risk management forms and documentation following each fall for Resident #10 was requested but only one dated 04/18/2023 was provided. A review of the risk assessment form provided by the DON, dated 04/18/2023, indicated Resident #10 attempted to get out of their wheelchair unassisted and hit their head on the table. The form indicated the resident sustained a contusion and bruising to the face and forehead. The form did not address interventions put into place to prevent another fall. During an interview on 06/15/2023 at 12:13 PM, the Physical Therapy Assistant (PTA) stated the interdisciplinary team (IDT) discussed Resident #10's frequent falls in their weekly meeting. She thought Resident #10's fall risk interventions included non-skid socks, placing Resident #10 at the nurses' station, and changing the wheelchair cushion so Resident #10 had a harder time standing up out of the wheelchair. The PTA indicated all interventions should be documented in the EMR, and each intervention should be part of the comprehensive care plan. 2. Review of Resident #96's Admission Record revealed the facility admitted the resident on 04/22/2023 with diagnoses including acute respiratory failure, adjustment disorder with mixed anxiety and depressed mood, macular degeneration, and age-related osteoporosis. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #96 had a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS indicated that Resident #96 required limited assistance from one staff with bed mobility and transfers and used a wheelchair for mobility. According to the MDS, the resident had no falls in the two to six months prior to admission and no falls since admission to the facility. The MDS indicated the resident did not use bed (side) rails as a physical restraint. A review of Resident #96's electronic medical record (EMR) on 06/13/2023 revealed no evidence a completed comprehensive care plan was initiated for the resident. Review of Resident #96's Initial Plan of Care, dated 04/22/2023, indicated the resident was blind, used glasses, and required assistance with mobility, turning, and transfers. The Initial Plan of Care did not indicate the resident was at risk for falls or used side rails and the plan of care did not include interventions directing staff on preventing falls for Resident #96. A review of Resident #96's EMR from 04/22/2022 through 06/16/2023 revealed no evidence the resident was assessed for the use of side rails. A review of Resident #96's Progress Notes from 05/09/2023 through 06/09/2023 revealed: - On 05/09/2023 at 3:51 AM - siderails x 2 [two side rails] for positioning - On 05/11/2023 at 8:27 AM - siderails x 2 for positioning - On 05/13/2023 at 7:45 AM - siderails x 2 for positioning - On 05/13/2023 at 7:06 PM - siderails x 2 for positioning - On 05/16/2023 at 7:10 AM - siderails x 2 for positioning - On 06/04/2023 at 4:51 AM - Resident #96 was awake the entire shift propelling themselves in their wheelchair in the hallway verbalizing the desire to leave. Staff attempted to guide Resident #96 to their room and into bed, but the resident repeatedly refused. - On 06/06/2023 at 4:10 AM - siderails for positioning - On 06/09/2023 at 3:29 AM - At 2:57 AM, Resident #96 fell asleep in their wheelchair and fell forward out of their wheelchair suffering a large hematoma to the right side of their forehead. Resident #96 was transported to the emergency room with no further injuries noted. A review of the clinical record for Resident #96 from 06/09/2023 through 06/16/2023 revealed no evidence the facility attempted to determine what may have caused or contributed to Resident #96's fall and develop a care plan with interventions to reduce the likelihood of another fall following the fall on 06/09/2023. During an interview on 06/12/2023 at 10:15 AM, Resident #96 stated they fell forward out of their wheelchair after falling asleep in the chair a few days prior. Resident #96 stated they did not know why staff put those barriers up on each side of the bed when they were in the bed. The resident stated that was why she fell asleep in her wheelchair. Resident #96 said she did not like getting into bed because of the barriers in place keeping them in the bed. Resident #96 made these statements while pointing toward the side rails on their bed. Observation on 06/13/2023 at 7:15 AM, revealed Resident #96 was in a low bed with two side rails in the raised position. During an interview on 06/13/2023 at 2:08 PM, Resident #96 stated they felt confined and stranded and had a fear of not being able to get out of the bed because of those stoppers staff put in place on their bed. Resident #96 made these statements while pointing at the side rails on their bed. During an interview on 06/13/2023 at 4:45 PM, the Assistant Director of Nursing (ADON) stated all documentation related to resident falls was in the progress notes. There was no incident report form or other fall details included elsewhere in the resident's EMR. During an interview on 06/14/2023 at 8:55 AM, Certified Medicine Technician (CMT) #19 stated Resident #96 was partially blind and a fall risk. CMT #19 said she did not know if Resident #96 had any fall risk interventions in place. She said the nurses were responsible for any implemented fall risk interventions. During an interview on 06/14/2023 at 9:19 AM, Nursing Assistant (NA) #8 stated she received verbal report at shift change and checked in with the charge nurse for any updates on residents needs for care. NA #8 stated she did not know if Resident #96 was a high fall risk, and some residents who were high fall risks used both side rails in bed. NA #8 stated she knew two side rails in place constituted a restraint. During an interview on 06/14/2023 at 11:55 AM, the Restorative Aide (RA) said the facility was in the process of revising their patient care forms. The patient care forms included care information and instructions for resident care that the charge nurse provided to the aides and nursing assistants. The RA further stated there was nothing in writing for staff to refer to that included instructions for specific resident care. The RA stated Resident #96 was not a fall risk, and the RA was not aware of any falls since admission. The RA stated Resident #96 had two side rails up in bed for safety. The RA did not know if Resident #96 tried to get out of bed, but she was not told anything different other than both side rails should be in the raised position when Resident #96 was in bed. During an interview on 06/14/2023 at 12:12 PM, NA #7 stated the charge nurse verbally notified the nursing assistants at shift change about the care residents required and if there were any changes in care. NA #7 indicated she thought there was a book at the nurses' station that outlined resident care requirements, but she did not know the location of the book. NA #7 stated she thought Resident #96 was a high fall risk, and she did not know of any implemented fall preventions to prevent further falls. She said Resident #96 used two side rails when in bed because they tried to get out of bed on their own. During an interview on 06/14/2023 at 12:40 PM, Licensed Practical Nurse (LPN) #2 stated the charge nurse used a report sheet that was updated throughout the day with any changes in resident status, and the charge nurse verbally reported the care each resident required to the nursing assistants. She said there was nothing in writing for care staff to refer to. LPN #2 stated Resident #96 recently had a fall out of their wheelchair. The next morning, she received report from the night nurse that Resident #96 refused to go to bed that night, and she had not received reports of the resident refusing to go to bed before. During an interview on 06/14/2023 at 12:55 PM, the ADON stated the charge nurse gave verbal report to the aides and nursing assistants about the care each resident required. The ADON stated Resident #96 was a newer resident who was now a high fall risk since they had a fall. The ADON did not know of any newly implemented fall risk interventions to prevent further falls and did not know if Resident #96 used side rails when in bed. During an interview on 06/14/2023 at 1:30 PM, the Director of Nursing (DON) stated she was working on a form for the nursing assistants to reference for guidance about resident care. The DON indicated the form would include things like activities of daily living (ADLs) and care planned interventions to prevent falls. The DON said that currently, resident care needs were verbally relayed between staff members, and the facility did not have that information documented for staff to reference. The DON stated Resident #96 was a high fall risk due to a recent fall out of their wheelchair after falling asleep. The DON stated the only time staff used two side rails for a resident was if they were a high fall risk or at risk of rolling out of bed because otherwise, two side rails were considered a restraint. 40141 3. Review of Resident #8's Admission Record indicated the facility admitted the resident on 04/26/2023 with diagnoses that included chronic obstructive pulmonary disease, type 2 diabetes mellitus, and cerebral infarction. The admission Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The resident required extensive assistance from staff with bed mobility and transfer and was totally dependent on staff for toilet use; walking and locomotion did not occur during the review period. The resident had no limitations in range of motion and used a wheelchair for mobility. The MDS indicated the resident had no falls since admission or prior to admission. A review of Resident #8's medical record revealed there was no comprehensive care plan for Resident #8. A review of Resident #8's clinical record revealed the resident was not assessed for fall risk upon admission. A review of the Initial Plan of Care, dated 04/26/2023, revealed Resident #8 required assistance of one staff for mobility, turning, and transfers. The Initial Plan of Care did not indicate the resident was at risk for falls or include interventions to prevent falls. A review of nursing Progress Notes, dated 05/29/2023 at 1:35 AM, revealed Resident #8 was found on the floor in the resident's room. The resident said they were returning to bed from the bathroom. The note indicated there was no visible injury, but the resident was unable to straighten the left leg, and ice was applied to the left hip. The resident complained of pain, and pain medications were administered. The note indicated Resident #8 was transferred to the hospital for evaluation. A review of the risk management form presented by the Director of Nursing (DON), dated 05/29/2023 at 1:08 AM, revealed the resident was found in the resident's room on their left side. The form indicated no injuries were observed at the time of the incident. A note indicated the resident could not extend the left leg after the fall and range of motion was not within normal limits. The Injuries Report Post Incident section indicated no injuries were observed after the incident. The form also indicated a pain level of 0. The form did not match the incident that was documented in the progress note on 05/29/2023 at 1:35 AM which indicated the resident complained with pain and was treated with medication after the fall. The form also did not indicate a root cause analysis was completed for the fall or interventions to prevent further falls were implemented. A review of nursing Progress Notes, dated 05/30/2023, indicated Resident #8's family member called the facility to report a computed tomography (CT) scan was completed at the hospital and revealed the resident had a crack in the head of the femur. A review of the clinical record for Resident #8 revealed no evidence the facility attempted to determine what may have caused or contributed to the resident's fall and develop a care plan with interventions to reduce the likelihood of another fall following Resident #8's falls. During an interview on 06/14/2023 at 8:52 AM, Nursing Assistant (NA) #4 said they were not aware of any fall interventions for Resident #8. During an interview on 06/14/2023 at 9:09 AM, the Restorative Aide (RA) indicated she was informed in verbal report that fall interventions for Resident #8 was that the resident was a two-person transfer since the fall. During an interview on 06/14/2023 at 9:21 AM, NA #7 stated she was verbally told Resident #8 had a fall and the intervention for the resident was to bring them to the TV room or desk to keep them from being in their room at the end of the hall. During an interview on 06/14/2023 at 12:32 PM, NA #8 stated she did not know the fall interventions for Resident #8. She said she would have to ask the nurse. During an interview on 06/14/2023 at 12:40 PM, Licensed Practical Nurse (LPN) #2 stated they completed a fall risk assessment to know if someone was a fall risk and then verbally told the aides. LPN #2 indicated fall risk interventions were verbally passed on to staff. LPN #2 indicated Resident #8 did not have fall interventions because the fall was an isolated incident. During an interview on 06/14/2023 at 12:56 PM, the Assistant Director of Nursing (ADON) indicated she guessed Resident #8 was a fall risk since he had a fall. She indicated fall interventions implemented since the fall on 05/29/2023 included a two-person transfer and working with therapy. She said the resident would tell the CNAs he did not need two people to transfer. 4. Review of Resident #145's Admission Record indicated the facility admitted the resident on 05/24/2023 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, Alzheimer's disease, and hypertension. Review of the National Institute of Diabetes and Digestive and Kidney Diseases website showed: - Diabetic neuropathy is nerve damage that can occur in people with diabetes. - Nerve damage symptoms can range from pain and numbness in feet to problems with the functions of internal organs, such as your heart and bladder. Review of Resident #145's electronic medical record (EMR) revealed the resident's required admission Minimum Data Set (MDS) assessment had not been completed. Review of Resident #145's EMR revealed there was no comprehensive care plan for the resident. A review of the Initial Plan of Care, dated 05/24/2023, revealed Resident #145 required assistance of one staff for mobility, turning, and transfers. The Initial Care Plan did not indicate the resident was at risk for falls or include interventions to prevent falls. A review of the clinical record for Resident #145 revealed no evidence a fall risk assessment was completed for the resident. A review of a nursing Progress Notes, dated 05/29/2023 at 3:05 AM, revealed Resident #145 was found on the floor, in the hallway. The resident had blood on the inside and outside of the nose and mouth. The resident denied pain but was sent to the hospital. A Progress Note, dated 05/29/2023 at 2:46 PM, indicated Resident #145 returned to the facility with a diagnosis of closed fracture of the nasal bone. A review of nursing Progress Notes, dated 06/03/2023 at 10:45 PM, revealed Resident #145 was on the floor beside the bed and told staff they were trying to reach something and slid out of the bed. The note indi[TRUNCATED]

Based on observations, interviews, record review, the facility failed to assess and/or reassess residents for the safe use of side rails, review the risks and benefits of side rails with the resident and/or the resident's responsible party (RP), obtain informed consent, and attempt appropriate alternatives prior to installing and using side rails on resident beds for 2 (Resident #96 and Resident #10) of 7 residents reviewed for side rail use. Resident #96 stated the side rails were barriers, made her feel confined and stranded, and she had a fear of not being able to get out of bed because of them- causing her to not want to get into her bed to sleep at night. As a result she fell asleep in her chair, fell forward and obtained a large hematoma on the right side of her forehead. Resident #10 had severe impaired cognition, a history of falls, and a history of getting out of bed via the foot of the bed with the side rails up. Facility staff reported putting up both side rails and raising the foot of the bed in an effort to prevent the resident from getting out of bed, increasing the risk of falls. The facility also failed to properly assess the safety of side rail use in conjunction with a low air loss mattress for 5 (Residents #20, #17, #5, #18, and #8) of 5 residents reviewed who used a low air loss mattress and had bilateral side rails. Failure to ensure bed rails and mattresses were compatible increases the risk of residents becoming entrapped in the side rails. The facility census was 42. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care). The IJ began on 04/10/2023. The Administrator and Assistant Administrator (AA) were notified of the IJ and provided with the IJ template on 06/15/2023 at 3:44 PM. With additional information, an updated IJ template was provided to the Administrator on 06/20/2023 at 8:59 AM. A Removal Plan was requested. The IJ was determined to be removed on 06/23/2023 after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of E. Findings included: A review of the facility's undated Policy on Restraint Usage, that was included in the Admission Agreement, indicated, Physical restraints are considered to be any practice or device that the resident cannot remove easily, which restricts the resident's freedom of movement or access to his or her body. Further review of the policy indicated, Restraints will be used in non-life threatening situations only: (1) when an assessment of the resident determines a restraint is required to treat a medical symptom and is the least restrictive therapeutic intervention; (2) with a physician's order; (3) after the use of the restraint has been explained to the resident and any involved family member or legally- authorized representative; (4) when the benefits of the restraint outweigh the identified risks; and (5) if the resident or legally-authorized representative does not refuse the restraint. A review of the facility's policy titled, Proper Use of Side Rails, revised in October 2010, revealed, Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) The policy indicated, 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's a. bed mobility; and b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet. 4. The use of side rails as an assistive device will be addressed in the resident care plan. Regarding consent, the policy indicated, 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Further review of the policy revealed the following: 11. If side rail use is associated with symptoms of distress, such as screaming or agitation, the resident's needs and use of side rails will be reassessed. 12. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). 1. Review of Resident #96's Admission Record revealed the facility admitted the resident on 04/22/2023 with diagnoses including acute respiratory failure, adjustment disorder with mixed anxiety and depressed mood, macular degeneration, and age-related osteoporosis. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #96 had a Brief Interview of Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. The MDS indicated that Resident #96 required limited assistance from one staff with bed mobility and transfers and used a wheelchair for mobility. According to the MDS, the resident had no falls in the two to six months prior to admission and no falls since admission to the facility. The MDS indicated the resident did not use bed (side) rails as a physical restraint. Review of Resident #96's Initial Plan of Care, dated 04/22/2023, indicated the resident was blind, used glasses, and required assistance with mobility, turning, and transfers. The Initial Plan of Care did not indicate the resident was at risk for falls or used side rails. Review of Resident #96's electronic medical record (EMR) on 06/13/2023 revealed there was no comprehensive care plan for the resident. Review of Resident #96's progress notes revealed side rails were used on the following dates and times from 05/09/2023 to 06/06/2023: - On 05/09/2023 at 3:51 AM - siderails x 2 [two side rails] for positioning - On 05/11/2023 at 8:27 AM - siderails x 2 for positioning - On 05/13/2023 at 7:45 AM - siderails x 2 for positioning - On 05/13/2023 at 7:06 PM - siderails x 2 for positioning - On 05/16/2023 at 7:10 AM - siderails x 2 for positioning - On 06/06/2023 at 4:10 AM - siderails for positioning Review of a health status progress note, dated 06/04/2023 at 4:51 AM and written by nursing staff, indicated Resident #96 was awake the entire shift propelling themselves in their wheelchair in the hallway verbalizing the desire to leave. The note indicated staff attempted to guide Resident #96 to their room and into bed, but the resident repeatedly refused. Review of a health status progress note, dated 06/09/2023 at 3:29 AM and written by nursing staff, indicated that at 2:57 AM, Resident #96 fell asleep in their wheelchair and fell forward suffering a large hematoma to the right side of their forehead. Resident #96 was transported to the emergency room with no further injuries noted. A health status progress note indicated the resident returned to the facility on [DATE] at 11:30 AM. Review of Resident #96's EMR indicated no side rail assessment had been completed to determine if side rails were a safe approach for the resident. Further review of Resident #96's medical record revealed there was no informed consent, or physician's order for side rail use. During an interview on 06/12/2023 at 10:15 AM, Resident #96 stated they fell forward out of their wheelchair after falling asleep a few days prior. Resident #96 stated they did not know why staff put those barriers up on each side of the bed when they were in the bed and said that was why they fell asleep in their wheelchair that night. Resident #96 stated they did not like getting into bed because of the barriers in place keeping them in the bed. Resident #96 made these statements while pointing toward the side rails on their bed. During an observation on 06/13/2023 at 7:15 AM, Resident #96 was in a low bed with two side rails in the raised position. The side rails were on both sides of the bed and extended approximately 3/4 the length of the bed. It was determined on 06/14/2023 that the side rails were 42.5 inches long. During an interview on 06/13/2023 at 2:08 PM, Resident #96 stated they felt confined and stranded, and had a fear of not being able to get out of bed because of those stoppers staff put in place on their bed. Resident #96 made these statements while pointing at the side rails on their bed. During this interview, Resident #96's family member signaled to the surveyor that Resident #96 was mostly blind. During an interview on 06/14/2023 at 9:19 AM, Nursing Assistant (NA) #8 stated she did not know if Resident #96 was at high risk for falls. NA #8 said some residents who were at high fall risk used two side rails when in bed. NA #8 then stated she knew two side rails in the raised position constituted a (physical) restraint. During an interview on 06/14/2023 at 11:55 AM, the Restorative Aide (RA) stated Resident #96 was not at risk for falls and she was not aware of any falls the resident had since admission. The RA stated Resident #96 had two side rails up (raised) when in bed for safety. The RA did not know if Resident #96 attempted to get out of bed independently. During an interview on 06/14/2023 at 12:12 PM, NA #7 stated that when she came into work after Resident #96's fall and saw the resident's face, she asked the charge nurse what happened. NA #7 stated she thought Resident #96 was at high risk for falls. NA #7 said Resident #96 used two side rails when in bed because the resident tried to get out of bed on their own. During an interview on 06/14/2023 at 12:32 PM, NA #8 stated the charge nurse informed the nursing assistants if a resident used one or two side rails. She stated she did not know if Resident #96 used one or two side rails when in bed. During an interview on 06/14/2023 at 12:40 PM, Licensed Practical Nurse (LPN) #2 stated Resident #96 recently had a fall out of their wheelchair. She said the next morning (06/09/2023), she received report from the night nurse who stated that Resident #96 refused to go to bed that night, and LPN #2 had not received reports about the resident refusing to go to bed before. LPN #2 stated Resident #96 used one side rail for turning and repositioning. She said staff only placed two side rails in the raised position if a resident requested the side rails be raised or if a resident had a low air loss mattress. LPN #2 stated there was no other reason a resident would have two side rails in the raised position when in bed. LPN #2 further stated licensed nurses completed side rail assessments and passed information from the assessments on to the nursing assistants. During an interview on 06/14/2023 at 12:55 PM, the Assistant Director of Nursing (ADON) stated side rail use was assessed upon admission, and staff only used two side rails in the raised position based on a resident's request. The ADON stated one side rail was typically used to aid residents with sitting up in bed or transfers. She said side rail use was determined in collaboration with nursing and the physician. The ADON then stated she did not know if Resident #96 used side rails when in bed. During an interview on 06/14/2023 at 1:30 PM, the Director of Nursing (DON) stated she thought Resident #96 used one side rail in bed for call light and bed adjustment control placement so Resident #96 knew where the devices were located. The DON stated the only time staff used two side rails for a resident was if the resident was at high risk for falls or at risk of rolling out of bed, because otherwise two side rails were considered a physical restraint. During an interview on 06/15/2023 at 12:30 PM, the DON stated Resident #96 was new to the facility, and she was not sure if things fell through the cracks for the resident. The DON stated the necessity for side rail use was probably determined from assessments completed upon admission that indicated a resident's fall risk. The DON further stated she expected side rail assessments to be completed prior to resident use, and side rail use should be included in a resident's care plan. During an interview on 06/17/2023 at 3:25 PM, Resident #96 stated the previous night was their first night in the facility without those stoppers on their bed and they had the best night of sleep since admission. Resident #96 pointed to the bed which had the side rails removed/secured in the low position as they made this statement and then requested to please continue to keep it that way. The resident's side rails were removed on 06/16/2023 following surveyor inquiry. 2. A review of Resident #10's Admission Record indicated the facility admitted Resident #10 on 11/12/2018 with diagnoses including osteoarthritis, paranoid schizophrenia, bipolar disorder, Parkinson's disease, and dementia. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severely impaired cognition. The MDS indicated Resident #10 was independent with bed mobility, transfers, and walking. According to the MDS, Resident #10 had no falls since admission or the prior assessment. The MDS indicated the resident did not use bed (side) rails as a physical restraint. Review of Resident #10's comprehensive care plan revealed focus areas, with initiation dates of 09/20/2022 and 11/21/2022, showed the resident at risk for falls. Resident #10's comprehensive care plan did not indicate the resident used side rails when in bed. Review of Resident #10's Bed Rail Assessment, dated 12/10/2022, indicated Resident #10 did not express a desire to have side rails or an assist bar for safety and/or comfort and had a history of falls. The Bed Rail Assessment indicated Side Rails/Assist Bar are not indicated at this time. This was the resident's most recent side rail assessment. There was no informed consent, or physician's order for side rail use in the electronic medical record (EMR). Review of a health status progress note, dated 04/10/2023 at 8:18 AM and written by nursing staff, revealed Resident #10 was found kneeling at the bedside and appeared to have gotten out of bed (OOB) w/o [without assistance] due to both side rails being up. A review of Resident #10's progress notes dated from 09/01/2022 to 06/15/2023 indicated repeated use of two side rails when in bed for positioning. For example, the following progress notes written from 05/13/2023 to 06/15/2023 referred to side rail use: - On 05/12/2023 at 9:13 AM - siderails x 2 [two side rails] for positioning - On 05/16/2023 at 7:16 AM - siderails x 2 for positioning - On 05/18/2023 at 5:28 AM - siderails x 2 for positioning - On 05/20/2023 at 4:19 AM - siderails x 2 for positioning - On 05/20/2023 at 7:54 AM - siderails x 2 for positioning - On 05/22/2023 at 6:41 AM - siderails x 2 for positioning - On 05/23/2023 at 7:35 AM - siderails x 2 for positioning - On 05/25/2023 at 9:16 AM - siderails x 2 for positioning - On 06/04/2023 at 5:14 AM - siderails x 2 for positioning - On 06/06/2023 at 8:59 AM - siderails x 2 for positioning - On 06/08/2023 at 7:53 AM - siderails x 2 for positioning - On 06/15/2023 at 5:16 AM - siderails x 2 for positioning During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds, including Resident #10's, were equipped with bilateral side rails that measured 42.5 inches long as measured by Licensed Practical Nurse (LPN) #2 at 4:40 PM. During an interview on 06/14/2023 at 11:55 AM, the Restorative Aide (RA) stated Resident #10 used two side rails when in bed to prevent falls because Resident #10 occasionally scooted to the foot of the bed and tried to get out that way. During an interview on 06/14/2023 at 12:12 PM, Nursing Assistant (NA) #7 stated Resident #10 used two side rails when in bed because Resident #10 liked to get up on their own. NA #7 stated Resident #10 often scooted to the foot of the bed, so staff raised the foot of the bed to prevent Resident #10 from getting out of bed. During an interview on 06/14/2023 at 12:21 PM, NA #4 stated Resident #10 used two side rails when in bed to prevent them from getting out of bed because they were at high risk for falls. During an interview on 06/14/2023 at 12:32 PM, NA #8 thought Resident #10 used one side rail when in bed and did not know if Resident #10 was at high risk for falls. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated licensed nurses completed side rail assessments then passed that information on to the nursing assistants. LPN #2 stated two side rails were only used if a resident requested them or if they had a low air loss mattress; there was no other reason a resident would have two side rails in the raised position when in bed. LPN #2 then stated she did not know if Resident #10 used side rails when in bed, had not received reports that Resident #10 tried to get out of bed, and was not aware of any falls the resident had from bed. During an interview on 06/14/2023 at 12:55 PM, the Assistant Director of Nursing (ADON) stated the appropriateness of side rail use was assessed upon a resident's admission. She said residents typically only used one side rail for positioning or to aid with transfers and two side rails were only used when a resident requested them. The ADON did not know if Resident #10 used side rails when in bed. The ADON further stated she did not know if a physician's order was required for side rail use. During an interview on 06/14/2023 at 1:30 PM, the Director of Nursing (DON) stated side rail use was reassessed every three to six months, and the facility used side rails to prevent residents from rolling out of bed. During an interview on 06/15/2023 at 12:23 PM, the ADON stated side rail use should be included in a resident's care plan and thought the Minimum Data Set (MDS) Coordinator updated and completed the comprehensive care plans. During an interview on 06/15/2023 at 12:30 PM, the DON stated Resident #10 was new to the facility, and she was not sure if things fell through the cracks for the resident. The DON stated the necessity for side rail use was probably determined from assessments completed upon admission that indicated a resident's fall risk. The DON further stated she expected side rail assessments to be completed prior to resident use, and side rail use should be included in a resident's care plan. 3. Review of Resident #17's Admission Record revealed the facility admitted the resident on 03/06/2023 with diagnoses including atherosclerotic heart disease, hypothyroidism, hyperlipidemia, dementia, and congestive heart failure. Review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #17 had a Brief Interview for Mental Status Score (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was totally dependent upon staff for bed mobility and transfers. According to the MDS, Resident #17 had no falls in the six months prior to admission or since admission. The MDS indicated the resident did not use bed (side) rails as a physical restraint. Per the MDS, the resident was receiving hospice care. During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds were equipped with bilateral side rails that measured 42.5 inches long as measured by Licensed Practical Nurse (LPN) #2 at 4:40 PM. Low air loss mattresses were in use on five of the beds with bilateral side rails. Resident #17's bed was one of the beds with a low air loss mattress and bilateral side rails. Review of Resident #17's Initial Plan of Care, dated 03/07/2023, revealed the resident was dependent upon staff for activities of daily living. The Initial Care Plan did not indicate the resident used side rails when in bed. Review of Resident #17's medical record on 06/12/2023 revealed there was no comprehensive care plan for the resident. A review of Resident #17's Order Summary Report, that included active physician's orders as of 06/15/2023, revealed no order for the use of side rails. Review of a health status progress note, dated 06/15/2023 and written following inquiry by the surveyors, indicated an order was received from the medical doctor for Side rails up x 2 with Alternating Low Air Loss Mattress while in bed. The note indicated the resident's responsible party (RP) was aware and voiced no concerns. A review of Resident #17's admission Bed Rail Assessment, dated 06/15/2023 and written following inquiry by the surveyors, indicated the resident had no history of falls. According to the Bed Rail Assessment, use of side rails was indicated for use as bilateral enablers to promote independence. The assessment was completed by the Assistant Director of Nursing (ADON) (a Licensed Practical Nurse), who signed in the RN [registered nurse] signature and Date box. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated staff used two side rails in the up (raised) position only if a resident requested the side rails be raised or if the resident had a low air loss mattress. During an interview on 06/18/2023 at 9:15 AM, LPN #2 stated there was nothing in writing for staff to refer to regarding the use of a low air loss mattress in conjunction with side rails. No evaluation was conducted of the 'fit' of the low air loss mattress to the bed frame, i.e. gaps between the side rails and mattress when the bed was unoccupied or occupied. 4. Review of Resident #8's Admission Record indicated the facility admitted the resident on 04/26/2023 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and cerebral infarction. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance from staff with bed mobility and transfers and was totally dependent upon staff for toilet use. The MDS indicated the resident used a wheelchair for mobility. According to the MDS, Resident #8 had no falls in the six months prior to admission or since admission. The MDS indicated the resident did not use bed (side) rails as a physical restraint. During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds were equipped with bilateral side rails that measured 42.5 inches long as measured by Licensed Practical Nurse (LPN) #2 at 4:40 PM. Low air loss mattresses were in use on five of the beds with bilateral side rails. Resident #8's bed was one of the beds with a low air loss mattress and bilateral side rails. Review of the Initial Plan of Care, dated 04/26/2023, revealed Resident #8 required assistance of one staff for mobility, turning, and transfers. The Initial Plan of Care did not indicate the resident used side rails. Review of Resident #8's medical record revealed there was no comprehensive care plan for the resident. Further review of Resident #8's medical record revealed there was no side rail assessment, informed consent, or physician's order for side rail use. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated staff used two side rails in the raised position only if a resident requested the side rails be raised or if the resident had a low air loss mattress. During an interview on 06/18/2023 at 9:15 AM, LPN #2 stated there was nothing in writing for staff to refer to regarding the use of a low air loss mattress in conjunction with side rails. No evaluation was conducted of the 'fit' of the low air loss mattress to the bed frame, i.e. gaps between the side rails and mattress when the bed was unoccupied or occupied. 5. Review of Resident #20's Admission Record revealed the facility admitted the resident on 08/14/2015 with diagnoses including protein-calorie malnutrition, vascular dementia, depression, and hemiplegia. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #20 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making based on the Staff Assessment for Mental Status (SAMS). The MDS indicated the resident was totally dependent upon staff for bed mobility and transfers. According to the MDS, the resident had a functional limitation in range of motion in one upper extremity and both lower extremities. The MDS indicated the resident did not use bed (side) rails as a physical restraint. During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds were equipped with bilateral side rails that measured 42.5 inches long as measured by Licensed Practical Nurse (LPN) #2 at 4:40 PM. Low air loss mattresses were in use on five of the beds with bilateral side rails. Resident #20's bed was one of the beds with a low air loss mattress and bilateral side rails. Review of Resident #20's care plan revealed a focus area, with an initiation date of 11/03/2022, that indicated the resident had a potential for pressure ulcer development. An intervention was added on 06/15/2023 that directed staff as follows: SR [side rails] up x 2 [two side rails] per mattress manufacturer's recommendations. This intervention was added following surveyor inquiry about side rail use. Review of Resident #20's Bed Rail Assessment, dated 06/15/2023 and written following inquiry by the surveyors, indicated the resident had a history of falls. According to the Bed Rail Assessment, Side Rails/Assist bar are indicated and serve as an enabler to promote independence. The assessment was completed by LPN #2, who signed under the heading RN [registered nurse] Signature and Date. Review of Resident #20's Order Summary Report revealed a physician's order, dated 06/15/2023 (following inquiry by the surveyors), for Side rails up x 2 with Alternating Low Air Loss Mattress while in bed. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated staff used two side rails in the raised position only if a resident requested the side rails be raised or if the resident had a low air loss mattress. During an observation on 06/18/2023 at 8:30 AM, Resident #20 was in bed lying on a low air loss mattress with bilateral side rails in the raised position. During an interview on 06/18/2023 at 9:15 AM, LPN #2 stated there was nothing in writing for staff to refer to regarding the use of a low air loss mattresses in conjunction with side rails. No evaluation was conducted of the 'fit' of the low air loss mattress to the bed frame, i.e. gaps between the side rails and mattress when the bed was unoccupied or occupied. 6. Review of Resident #5's Admission Record revealed the facility admitted the resident on 08/10/2022 and readmitted the resident on 12/17/2022 with diagnoses that included metabolic encephalopathy, functional quadriplegia, depression, and anxiety. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required extensive assistance from staff with bed mobility and transfers. According to the MDS, Resident #5 had functional limitations in range of motion in the bilateral upper and lower extremities. The MDS indicated the resident did not use bed (side) rails as a physical restraint. During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds were equipped with bilateral side rails that measured 42.5 inches long as measured by LPN #2 at 4:40 PM. Low air loss mattresses were in use on five of the beds with bilateral side rails. Resident #5's bed was one of the beds with a low air loss mattress and bilateral side rails. Review of Resident #5's care plan revealed a focus area, with an initiation date of 10/06/2022, that indicated the resident had an activities of daily living (ADL) self-care performance deficit related to quadriplegia. The care plan also included a focus area, with an initiation date of 09/20/2022, that indicated the resident had the potential for impaired skin integrity. On 06/15/2023, following inquiry by the surveyors, the following intervention was added to this focus area: SR [side rails] x 2 [two side rails] per therapeutic mattress manufacture [manufacturer's] recommendations. Review of Resident #5's Bed Rail Assessment, dated 06/15/2023 and completed following inquiry by the surveyors, indicated the resident did not have a history of falls. The Bed Rail Assessment revealed side rails were indicated for use as bilateral enablers to promote independence. The assessment was completed by LPN #2, who signed under the heading RN [registered nurse] signature and date. Review of Resident #5's Order Summary Report revealed a physician's order dated 06/15/2023 (following inquiry by the surveyors) for Side rails up x 2 with Alternating Low Air Loss Mattress while in bed. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated staff used two side rails in the raised position only if the resident requested it or if they had a low air loss mattress. During an interview on 06/18/2023 at 9:15 AM, LPN #2 stated there was nothing in writing for staff to refer to regarding the use of a low air loss mattress in conjunction with side rails. No evaluation was conducted of the 'fit' of the low air loss mattress to the bed frame, i.e. gaps between the side rails and mattress when the bed was unoccupied or occupied. 7. Review of Resident #18's Admission Record revealed the facility admitted the resident on 11/03/2019 with diagnoses including dementia, osteoporosis, right and left femur fractures, and Alzheimer's disease. Review of a quarterly Minimum [NAME] Set (MDS), dated [DATE], revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. According to the MDS, the resident required extensive assistance with bed mobility and transfers. The MDS indicated the resident did not use a bed (side) rail as a physical restraint. During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds were equipped with bilateral side rails that measured 42.5 inches long as measured by Licensed Practical Nurse (LPN) #2 at 4:40 PM. Low air loss mattresses were in use on five of the beds with bilateral side rails. Resident #18's bed was one of the beds with a low air loss mattress and bilateral side rails. Review of Resident #18's care plan revealed a focus area, with an initiation date of 09/21/2022, that indicated the resident had a potential for impaired skin integrity. On 06/15/2023, following inquiry by the surveyors, the following intervention was added to this focus area: SR [side rails] x 2 [two side rails] per therapeutic mattress manufacture [manufacturer's] recommendations. A review of Resident #18's Bed Rail Assessment, dated 06/15/2023 and completed following inquiry by the surveyors, indicated the resident had a history of falls. The Bed Rail Assessment revealed side rails were indicated for use as bilateral enablers to promote independence. The assessment was completed by LPN #2, who signed under the heading RN [registered nurse] signature and date. Review of Resident #18's Order Summary Report revealed a physician's order, dated 06/15/2023 (following inquiry by the surveyors), for Side rails up x 2 with Alternating Low Air Loss Mattress while in bed. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated staff used two side rails in th[TRUNCATED]

Based on interviews, record review, and facility policy review, the facility failed to identify significant weight loss and implement nutritional interventions for one (Resident #17) of two residents reviewed for weight loss. Specifically, Resident #17 lost 11.4 pounds (8.06%) in seven days and 21.0 pounds (14.85%) in 28 days and had no nutritional interventions implemented. The facility census was 42. Findings included: Review of a facility policy, titled, Nutrition and Hydration to Maintain Skin Integrity, dated 2001 and revised in October 2010, revealed, The purpose of this procedure is to provide guidelines for the assessment of resident nutritional needs, to aid in the development of an individualized care plan for nutritional interventions, and to help support the integrity of the skin through nutrition and hydration. The policy indicated, The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The policy indicated steps in the procedure included, 4. Implement nutritional support and interventions according to the plan of care. Review of Resident #17's Admission Record revealed the facility admitted the resident on 03/06/2023 with diagnoses that included atherosclerotic heart disease, dementia, and congestive heart failure. The resident was receiving hospice care and services. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance of one person with eating. According to the MDS, Resident #17 had a weight loss of 5% (percent) or more in the last month or 10% or more in the last six months, and was not on a physician-prescribed weight loss regimen. Review of Resident #17's Initial Plan of Care, dated 03/07/2023, revealed the resident required total assistance with eating. The initial plan of care did not indicate the resident was at risk of weight loss. Review of Resident #17's medical record on 06/12/2023 revealed no comprehensive care plan with interventions to address any decline in appetite, food preferences, or nutrition/hydration. Review of Resident #17's Order Summary Report revealed a physician's order dated 03/11/2023 for a mechanical soft diet. A review of Resident #17's weights that were documented in the electronic medical record (EMR) indicated the resident weighed: - 03/13/2023 141.4 pounds - 03/20/2023 130.0 pounds, an 11.4-pound (8.06%) weight loss in seven days - 03/27/2023 128.0 pounds - 04/10/2023 120.4 pounds, a 21.0-pound (14.85%) weight loss in 28 days - 04/17/2023 120.2 pounds Review of Resident #17's initial Comprehensive Nutrition Assessment, completed by the registered dietitian (RD) and dated 03/15/2023, revealed the resident weighed 146.2 pounds, with no weight change noted. The Comprehensive Nutrition Assessment indicated Resident #17 received a mechanical soft diet, independently fed themselves, and consumed 51-75% at meals. The Comprehensive Nutrition Assessment indicated the goal was to promote comfort and quality of life, offer food and drink per resident preference, and maintain weight stability and skin integrity. The assessment indicated the RD planned to monitor and follow up as needed (PRN). A review of Resident #17's nutrition/dietary progress notes, dated 04/17/2023, revealed the resident had a weight loss of 21 pounds, or 14.9%, in the past month. The notes indicated Resident #17's weight was trending down since admission the previous month, the resident was receiving hospice services, and the RD anticipated difficulty maintaining the resident's weight with end-of-life care in place. RD recommendations included offering snacks between meals to supplement intake as able and the RD planned to monitor and follow up PRN. A review of Resident #17's March 2023, April 2023, and June 2023 medication administration record (MAR) revealed no physician orders for nutritional supplements or other nutritional interventions. A review of Resident #17's March 2023, April 2023, and June 2023 treatment administration record (TAR) revealed no physician orders for nutritional supplements or other nutritional interventions. A review of Resident #17's March 2023 and April 2023 meal intake records indicated the resident consumed 50-100% at each meal. Consumption of snacks or supplements was not recorded, and the intake records did not indicate that snacks or supplements were offered. During observations during the survey, the resident ate approximately 50% of meals; staff did not offer snacks or supplements. A review of Resident #17's social services progress notes, dated 04/19/2023, revealed a care plan meeting was held, and Resident #17's family member voiced concerns that at times Resident #17 was not hungry when the resident was served their meal. The family member suggested that the resident might benefit from being offered food after meals. Review of Resident #17's hospice notes, dated 05/03/2023, revealed the resident had a diagnosis of anorexia as of 03/06/2023. The notes indicated that facility staff reported to hospice staff that Resident #17 consumed about 25% of one to two meals per day. The notes indicated that Resident #17 had decreased intake, and weight loss was significant and ongoing. A review of Resident #17's nutrition/dietary progress notes dated 05/26/2023 revealed the resident weighed 122.4 pounds and was down 23.8 pounds (16.3%) in the past quarter. The notes indicated the resident had no skin issues per nursing assessment. The notes indicated the resident's weights were more stable in the last month and there were no recommended changes due to stable weight. A review of Resident #17's health status progress notes, dated 06/06/2023, indicated the hospice aide and nurse identified new, facility-acquired pressure ulcers on the resident's bilateral heels; an unstageable pressure injury on the left heel and a Stage 3 pressure ulcer on the right heel. The hospice nurse notified the physician and family and obtained wound treatment orders. A review of Resident #17's medical record indicated there was no documentation that the physician was notified of the resident's weight loss. During an interview on 06/17/2023 at 12:11 PM, Licensed Practical Nurse (LPN) #2 stated Resident #17 consistently ate about 50% at meals, and there were no nutritional supplements or snacks offered to the resident. LPN #2 stated Resident #17 had two facility-acquired pressure ulcers, one on each heel, and indicated the pressure ulcers might be a little bigger in size than when staff first identified them. During an interview on 06/18/2023 at 10:44 AM, the Hospice Nurse stated she took over Resident #17's care about six weeks prior the survey and had no knowledge of Resident #17's weight loss in March 2023. The Hospice Nurse stated she was occasionally at the facility during meals, and Resident #17 consistently ate about 50%. The Hospice Nurse stated there were no nutritional interventions in place to prevent further weight loss. During an interview on 06/20/2023 at 9:52 AM, the Dietary Manager (DM) stated he knew nursing obtained resident weights, but he was not a part of that process. The DM said if nursing notified him of a resident's weight loss, they discussed possible nutritional interventions they could implement. The DM said Resident #17 did not eat much at meals, but he was not aware of the resident's weight loss. The DM further stated he did not know who the RD was, and his only interaction with her was when she came to the facility to do the kitchen sanitation audit. During an interview on 06/21/2023 at 10:05 AM, the RD stated she had provided dietary consultation at the facility since September 2022 and was in the facility for five to seven hours, one day per month. The RD stated she screened new admissions, looked at the weight records for any gains or losses, completed wound referrals, conducted quarterly and annual assessments, and made nutritional recommendations when needed. The RD further stated she touched base with facility staff to see if there were any concerns that needed to be addressed and compared weekly weights for trends. When asked about Resident #17's weight loss in March 2023, the RD replied that she would check the interventions that were put in place and get back to the surveyor. During a follow-up interview on 06/21/2023 at 10:28 AM, the RD stated Resident #17 had significant weight loss between March 2023 and April 2023, and she was not aware of the resident's weekly weight loss during that time. The RD said that no facility staff member notified her of Resident #17's significant weight losses from week-to-week in March 2023. The RD said she completed an admission note on 03/15/2023, and the significant weight loss occurred after that visit. The RD indicated that in her note on 04/17/2023, she identified the weight loss and recommended that staff offer snacks, but she was not sure if the facility implemented any further nutritional interventions for Resident #17 to prevent further weight loss. During an interview on 06/21/2023 at 2:07 PM, the Assistant Director of Nursing (ADON) stated she was responsible for entering resident weights obtained by the Restorative Aide (RA) into the medical record, and if she noticed a weight difference, she notified the RD. The ADON stated she did not remember if she notified the RD about Resident #17's significant weight loss in March 2023. The ADON said the RD also monitored the weights, so if there were any concerns, the RD would see them. During an interview on 06/21/2023 at 2:11 PM, the RA stated she obtained resident weights and compared the weight she obtained to the previous weight. The RA said she then notified the nurse if there was a big difference. The RA stated she could not remember if she notified the nurse in relation to Resident #17's significant weight loss in March 2023, but indicated she should have notified the nurse and reweighed the resident to ensure weight accuracy. During an interview on 06/21/2023 at 2:13 PM, the Physician stated facility staff were supposed to notify him of any significant weight loss. The Physician said Resident #17 recently came into the facility, and he had not been notified and was not aware of Resident #17 experiencing significant weight loss since admission. When informed of Resident #17's weekly weights from March 2023 to April 2023, the Physician stated he would have ordered some sort of supplementation, and for a weight change that significant in a such a short period, he would have also ordered additional tests to rule out the presence of cancer. During an interview on 06/24/2023 at 12:32 PM, the ADON stated the RD looked at resident weights monthly, and she did not know the RD's process for weight monitoring. The ADON said if a resident had significant weight loss, nursing was expected to consult the physician and follow their orders. During an interview on 06/24/2023 at 1:37 PM, the Administrator stated she expected staff to follow the facility's policy for weight monitoring and significant weight changes.