Every finding on record at Birch Hill Health Services

Based on interview and record review, the facility did not ensure the security and privacy of medical information for 1 resident (R) (R7) of 3 sampled residents. R7's care plan was posted in R1's room. Family Member (FM)-C observed the care plan and informed staff. Findings include: The facility's Resident Rights document indicates: .Privacy: Residents have the right .to confidentiality concerning their personal and medical information . The facility's Health Insurance Portability and Accountability Act (HIPAA) document indicates: .HIPAA-Prohibited Activities: .Leaving resident information accessible to people who have no right to see it . On 7/1/26 at 10:26 AM and 7/2/26 at 10:54 AM, Surveyor interviewed FM-C who stated R7's care plan was posted inside the door of R1's closet. FM-C did not recall the date they observed the care plan but verified they saw R7's name and care plan content. FM-C stated R1's care plan had been posted, but then went missing and R7's care plan was posted instead. FM-C informed Director of Nursing (DON)-B when they left the facility that day. When FM-C returned the next day, R1's care plan was posted and R7's care plan was removed. On 7/1/26 at 4:03 PM, Surveyor interviewed DON-B who verified FM-C told them another resident's care plan was posted in R1's room. When DON-B went to look at the care plan, it had been removed and replaced with R1's care plan. DON-B stated R1 changed rooms in the same hallway a couple times and indicated staff knew how to care for R1. DON-B verified a care plan should be in the right room for the right resident.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R3) of 3 sampled residents. R3 was on contact precautions. Multiple staff provided care for R3 without donning the appropriate personal protective equipment (PPE). Findings include: The facility's Transmission Based (Isolation) Precautions policy, revised 3/2026, indicates: .9. Initiation of Transmission-Based Precautions (TBP) (isolation precautions): a. Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on TBP/isolation empirically while awaiting confirmation. b. The physicians of the resident requiring TBP will be notified of the need for TBP and any other pertinent clinical information .c. The TBP will be the least restrictive possible for the resident under the circumstances. Duration will depend on the infectious agent or organism involved. d. Signage that includes instructions for use of specific personal protective equipment (PPE) will be placed in a conspicuous location outside the resident's room, wing, or facility-wide. Additionally, either the Centers for Disease Control and Prevention (CDC) category of TBP (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. d. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on TBP .10. Contact Precautions: a. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. b. Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g.,VRE, C. difficile, noroviruses .). c. Residents experiencing .fecal incontinence or diarrhea .should be placed on contact precautions even before a specific organism has been identified . R3 was readmitted to the facility on [DATE] and had diagnoses including congestive heart failure and anxiety. A Minimum Data Set (MDS) assessment, dated 4/7/26, stated R3 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. R3's Certified Nursing Assistant (CNA) task completion record indicated R3 had ongoing diarrhea with loose, watery stools on 14 of 18 days since 6/14/26. There was missing documentation for two days. The facility's June and July 2026 infection control line lists included the following information: Directions: When a staff member or resident has any of the listed symptoms put them on this list .Any resident being added to this list should be placed on droplet and contact precautions immediately . Surveyor noted R3 was added to the list on 6/14/26 for diarrhea. The list did not contain a last symptom or wellness date as the symptoms were ongoing. On 7/1/26 at 8:41 AM, Surveyor observed a contact precautions sign near R3's door that indicated: STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Surveyor also observed a cart next to R3's room that contained PPE. On 7/1/26 at 8:44 AM, Surveyor observed CNA-D enter R3's room without donning a gown or completing hand hygiene. Surveyor was in the hallway near the door and could hear CNA-D speak with R3 about cares that would be provided. At 8:45 AM, Surveyor observed CNA-D near the exit of R3's room wearing gloves but not a gown. Surveyor interviewed CNA-D who stated they had checked on R3 who was on the toilet. CNA-D indicated they were aware of R3's contact precautions due to ongoing diarrhea and should have donned a gown prior to entering the room, however, CNA-D thought R3 only needed water. CNA-D verified they should have donned a gown to provide water since staff should apply PPE prior to any entry of R3's room. On 7/1/26 at 8:52 AM, Surveyor observed CNA-E deliver beverages to R3's room without wearing a gown or gloves. CNA-E then exited the room and did not complete hand hygiene. CNA-E continued down the hall to other residents' rooms to deliver beverages On 7/1/26 at 8:52 AM, Surveyor observed Director of Nursing (DON)-B remove a tray from a food cart and deliver it to R3's room (as CNA-E was exiting). DON-B did not don a gown or gloves or complete hand hygiene prior to entering the room. On 7/1/26 at 8:53 AM, Surveyor interviewed DON-B who indicated they did not don a gown or gloves prior to entering R3's room because they did not touch R3. When asked if R3 was on contact precautions, DON-B indicated R3 should not be on contact precautions and removed the contact precautions sign. DON-B indicated R3 should only be on enhanced barrier precautions (EBP) for a catheter. When Surveyor informed DON-B that staff indicated R3 had active diarrhea, DON-B stated R3 did not have diarrhea. During the interview, Surveyor observed CNA-D exit R3's room. When DON-B asked CNA-D if R3 had diarrhea, CNA-D said yes. DON-B then put the contact precautions sign on top of a PPE cart and exited the area while stating they needed to determine why the physician had not done anything about R3's diarrhea. On 7/1/26 at 9:32 AM, Surveyor interviewed CNA-E who stated they were told they did not need to wear PPE to enter a resident's room to deliver drinks and that PPE was only needed for cares. CNA-E verified they did not check the sign outside R3's room prior to entry to the determine precautions in place for R3. CNA-E indicated if they had read the sign they would have donned PPE and completed hand hygiene prior to entering the room. On 7/1/26 at 12:50 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-F who stated the process for putting a resident on contact precautions includes the following steps: An order is created and entered in the resident's Medication Administration Record (MAR), the physician is notified, and a sign and PPE cart are placed outside the resident's room. ADON-F indicated staff should also enter a progress note that indicates when precautions were started and when the physician was notified, and should update the resident's the care plan. ADON-F stated residents are not removed from contact precautions until they are symptom-free for 48 hours or 72 hours for respiratory precautions. ADON-F stated all staff have regular TBP training. On 7/1/26, Surveyor reviewed R3's care plan which contained an intervention (initiated 7/1/26 by DON-B) for contact precautions related to diarrhea due to laxative use. R3's Kardex (an abbreviated care plan used by nursing staff) also indicated they were on contact precautions. An order entered on 7/1/26 by DON-B indicated R3 started contact precautions on 7/1/26 at 2:00 PM due to diarrhea. R3's progress notes did not indicate contact precautions were initiated on 7/1/26 or that R3's physician was contacted regarding the precautions. On 7/1/26 at 3:38 PM, Surveyor interviewed DON-B who indicated residents should be symptom-free for 48 hours before they are removed from precautions for diarrhea. DON-B verified R3 was not symptom-free for 48 hours during any period between 6/14/26 and 7/1/26. DON-B indicated they entered a contact precautions order and updated R3's care plan and Kardex on 7/1/26; however, precautions should have been in place since 6/14/26 and R3's orders, care plan, and Kardex should have been updated on 6/14/26. DON-B indicated they should have created an E-interact note regarding R3's change in condition and entered a progress note that indicated R3 was placed on contact precautions and the physician was notified. DON-B indicated they should not have included wording on R3's care plan that they had diarrhea due to laxative use since it was not confirmed by the physician. DON-B indicated staff should check signage before entering a resident's room to ensure appropriate the PPE is used. DON-B indicated they should not have removed the sign from R3's room and it was re-posted. DON-B stated all staff have been trained on TBP and staff who entered R3's room should have worn the appropriate PPE.

Based on staff interview and record review, the facility did not thoroughly investigate an allegation of sexual abuse for 2 residents (R) (R42 and R8) of 2 sampled residents.Staff witnessed R42 kiss R8 in the hallway on 1/24/26 then follow R8 into R8's room. Licensed Practical Nurse (LPN)-F entered R8's room and observed R42 unzipping R42's pants in front of R8 who was lying on the bed with a book and appeared confused. The allegation of sexual abuse was not thoroughly investigated.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.From 2/9/26 to 2/11/26, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, cognitive communication deficit, and depression. R42's Minimum Data Set (MDS) assessment, dated 1/14/26, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R42 had moderately impaired cognition.From 2/9/26 to 2/11/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, and anxiety. R8's MDS assessment, dated 12/16/25, had a BIMS score of 6 out of 15 which indicated R8 had severly impaired cognition.R42's medical record contained a progress note, dated 1/24/26 and written by LPN-F, that indicated R42 and (R8) were observed consensually kissing in the hallway by an unnamed housekeeping staff. The staff watched R42 and R8 enter R8's room and then left to inform LPN-F. LPN-F verified with the housekeeping staff that the kiss was consensual then went to R8's room. LPN-F observed R8 lying on R8's bed holding a book and R42 standing in front of R8 and unzipping R42's pants. LPN-F indicated R8 appeared confused. LPN-F told R42 that R42's actions were inappropriate, and asked R42 to zip R42's pants and leave the room. LPN-F stated R8 thanked LPN-F for asking R42 to leave. LPN-F notified R42's activated Power of Attorney for Healthare (POAHC) who wondered if R42's sexual behavior was due to a medication that was discontinued a year ago. R42's POAHC indicated when the medication was discontinued, there was a warning that sexual behavior could reappear or worsen. R42's POAHC indicated R42 had increased incidents of that nature with various females since the medication was discontinued. LPN-F answered all questions and faxed the provider regarding the previously discontinued medication per R42's POAHC's request. R42's POAHC found the situation distressing since it was recurrent. The progress note indicated Director of Nursing (DON)-B was aware of the incident.On 2/10/26 at 11:05 AM, Surveyor interviewed LPN-F who indicated a housekeeper saw R8 and R42 kissing on 1/24/26 and told LPN-F that it was consensual because neither pulled back from the kiss. When the housekeeper saw R8 and R42 enter R8's room, the housekeeper informed LPN-F. LPN-F went to R8's room and observed R42 start to unzip R42's pants while R8 was lying on the bed and holding a book. LPN-F stated R42 appeared confused. LPN-F stopped R42 from unzipping R42's pants. R42 pulled up the zipper, left the room, and appeared frustrated. LPN-F informed R42 that R42 could not kiss residents or unzip R42's pants. R42 appeared to understand. LPN-F indicated situations can be consensual then become non-consensual depending on a resident's cognitive status. Following the incident, LPN-F notified DON-B and R42 and R8's POAHCs. LPN-F stated R8's POAHC was understanding of the incident; however, R42's POAHC was concerned the incident was related to a medication that was discontinued a year ago. LPN-F indicated the facility did not have a formal assessment for determining consensual sexual behavior. LPN-F notified R42's physician on the day of the incident but was not sure the result of the update.On 2/10/26 at 11:17 AM, Surveyor interviewed DON-B who was not present when the incident occurred but thought LPN-F had ensured the safety of R8 and R42 and updated R8 and R42's POAHC. DON-B indicated R42's physician was notified and would review R42's medication and plan of care during a scheduled meeting on 2/17/26. The physician also wanted psychiatry involved. DON-B indicated the facility does not have a formal assessment to determine consensual sexual behavior and stated LPN-F stopped the situation before it became non-consensual. DON-B indicated staff know to watch residents for distress and indicated if a resident is distressed, the behavior is considered non-consensual. DON-B indicated abuse did not occur.On 2/11/26 at 12:23 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware of the incident and was away from the facility when the incident occurred. DON-B was present during the interview indicated staff were not certain that R42 unzipped R42's pants. When Surveyor indicated a thorough investigation would have helped the facility determine if R42 unzipped R42's pants and if other residents or staff had similar concerns, NHA-A nodded in agreement.

Based on staff interview and record review, the facility did not ensure appropriate weight monitoring was provided for 2 residents (R) (R9 and R29) of 4 sampled residents.R9's provider and Power of Attorney for Healthcare (POAHC) were not notified of weight loss or gain greater than 3 pounds (lbs) from 11/4/25 to 1/30/26. In addition, R9 was not re-weighed for weight loss or gain greater than 3 lbs. R9's daily weights were not documented as ordered and were not obtained with a consistent device.R29's provider and Guardian were not notified regarding weight loss or gain greater than 3 lbs from 9/1/25 to 2/1/26. In addition, R29 was not re-weighed for weight loss or gain greater than 3 lbs.Findings include:The facility's Weight Monitoring policy, revised 12/21/22, indicates: The Interdisciplinary Team (IDT) will strive to prevent, monitor, and intervene for undesirable weight changes for residents .Weight Monitoring .5. Team members will follow a consistent approach to weighing and use an appropriately calibrated and functioning scale (e.g., wheelchair scale or bed scale). Since weight varies throughout the day, a consistent process and technique (e.g., weighing the resident wearing a similar type of clothing, at approximately the same time of day, using the same scale, either consistently wearing or not wearing orthotics or prostheses, and verifying scale accuracy) can help make weight comparisons more reliable. 6. Any weight change of 5 pounds or more since the last weight assessment will be taken for confirmation .8. The threshold for significant weight change will be based on the following criteria where percentage of body weight change = (usual weight-actual weight)/(usual weight) x 100: a. 1 month - 5% weight change is significant; greater than 5% is severe. b. 3 months - 7.5% weight change is significant; greater than 7.5% is severe. c. 6 months - 10% weight change is significant; greater than 10% is severe. 9. If the weight change is desirable, it will be documented by the Registered Dietitian (RDN)/designee and no change in the care plan will be necessary. 10. Nursing staff will notify the individual or responsible party, physician and RDN/designee of any individual with an unintended significant weight change .Interventions: .2. The undesired weight change will be discussed with the resident and/or responsible party.1. From 2/9/26 to 2/11/26, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including unspecified severe protein calorie malnutrition, dysphagia, hypothyroidism, type 2 diabetes, metabolic encephalopathy, myxedema coma, and sequelae of cerebral infarction. R9's Minimum Data Set (MDS) assessment, dated 1/20/26, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R9 had severly impaired cognition. R9 had an activated POAHC.A care plan, initiated 10/29/25, indicated R9 was at risk for nutritional status change related to self-care deficit, type 2 diabetes, chronic obstructive pulmonary disease, obesity, and metabolic encephalopathy. The care plan contained goals that R9's skin would show signs/symptoms of healing and R9 would maintain weight as evidenced by no significant weight changes (>/= 5% in 30 days, >/= 7.5% in 90 days, or >/= 10% in 180 days). The care plan contained interventions (dated 10/29/25) to provide diet as ordered (CCHO diet, L2/mechanical-alterterd texture, regular/thin consistency), record weight per facility protocol/Medical Doctor (MD) orders, and review weights and notify Registered Dietitian (RD), MD, and responsible party of significant weight change.R9's medical record indicated R9 was being monitored by cardiology and had been on a heart monitor.R9's medical record contained the following orders:~ Magic cup at bedtime once daily for supplement (dated 10/30/25)~ Med Plus 2.0 120 milliliters (ml) three times daily for supplement between meals and after dinner (dated 11/26/25)~ Consistent carbohydrate (CCHO) diet mechanical-altered texture with regular/thin consistency (dated 12/26/25)~ Mirtazapine 7.5 milligrams (mg) give 1 tablet by mouth once daily for depression and appetite stimulation (dated 11/20/25)~ Daily weights and vital signs once daily (dated 10/29/25)On 2/11/26, Surveyor reviewed the facility's standing orders with Director of Nursing (DON)-B. Standing orders signed by the provider on 6/23/25 indicated: Weight: If diagnosis of heart failure, notify provider if there is a 3 pound gain in 1 day or 5 pound gain in 7 days.Surveyor reviewed R9's weights and noted the following:~ On 1/31/26 at 12:10 PM, R9 weighed 173.8 lbs (wheelchair scale) ~ On 1/30/26 at 9:01 AM, R9 weighed 174.4 lbs (wheelchair scale) (There was no re-weigh. R9's weight up 3 lbs.) ~ On 1/29/26 at 12:06 PM, R9 weighed 171.4 lbs (wheelchair scale) ~ On 1/21/26 at 1:30 PM, R9 weighed 176.6 lbs (wheelchair scale) ~ On 1/20/26 at 10:14 AM, R9 weighed 177.0 lbs (wheelchair scale) (There was no re-weigh. R9's weight was down 9.6 lbs.) ~ On 1/19/26 at 1:10 PM, R9 weighed 186.6 lbs (wheelchair scale) ~ On 1/18/26 at 8:44 AM, R9 weighed 187.8 lbs (wheelchair scale) (There was no re-weigh. R9's weight up 6.4 lbs.)~ On 1/17/26 at 10:25 AM, R9 weighed 181.4 lbs (wheelchair scale) (There was no re-weigh. R9's weight was up 5.8 lbs.)~ On 1/16/26 at 1:10 PM, R9 weighed 175.6 lbs (wheelchair scale) (There was no re-weigh. R9's weight was down 6 lbs.) ~ On 1/14/26 at 1:38 PM, R9 weighed 181.6 lbs (wheelchair scale) ~ On 1/13/26 at 10:48 AM, R9 weighed 179.9 lbs (wheelchair scale) ~ On 1/12/26 at 9:31 AM, R9 weighed 179.4 lbs (wheelchair scale) (There was no re-weigh. R9's weight was up 11.6 lbs.) ~ On 1/11/26, there was no weight recorded for R9.~ On 1/10/26 at 1:43 PM, R9 weighed 167.8 lbs (wheelchair scale) ~ On 1/9/26, there was no weight recorded for R9.~ On 1/8/26 at 11:33 AM, R9 weighed 167.6 lbs (wheelchair scale) (There was no re-weigh. R9's weight was down 8 lbs.) ~ On 1/7/26 at 8:52 AM, R9 weighed 175.6 lbs (wheelchair scale) (There was no re-weigh. R9's weight was down 5.4 lbs.) ~ On 1/5/26 at 11:27 AM, R9 weighed 181.0 lbs (wheelchair scale) ~ On 1/4/26 at 12:37 PM, R9 weighed 182.6 lbs (wheelchair scale) ~ On 1/3/26 at 8:21 AM, R9 weighed 183.4 lbs (wheelchair scale) (There was no re-weigh. R9's weight up 4.6 lbs.)~ On 1/2/26 at 10:10 AM, R9 weighed 178.8 lbs (wheelchair scale) ~ On 12/28/25 at 12:46 PM, R9 weighed 183.2 lbs (wheelchair scale) ~ On 12/27/25 at 11:11 AM, R9 weighed 182.0 lbs (wheelchair scale) ~ On 12/26/25 and 12/25/25, there was no weight recorded for R9. ~ On 12/24/25 at 11:51 AM, R9 weighed 180.6 lbs (wheelchair scale)~ On 12/17/25 at 8:31 AM, R9 weighed 180.6 lbs (wheelchair scale) ~ On 12/16/25, there was no weight recorded for R9. ~ On 12/15/25 at 1:22 PM, R9 weighed 179.6 lbs (wheelchair scale) ~ On 12/14/25 at 12:51 PM, R9 weighed 178.8 lbs (mechanical lift scale) ~ On 12/13/25 at 10:18 AM, R9 weighed 178.2 lbs (wheelchair scale) ~ On 12/12/25, no weight was recorded for R9.~ On 12/11/25 at 12:31 PM, R9 weighed 178.6 lbs (wheelchair scale)~ On 12/7/25 at 12:24 PM, R9 weighed 181.8 lbs (wheelchair scale) ~ On 12/6/25 at 11:33 AM, R9 weighed 182.3 lbs (wheelchair scale) (There was no re-weigh. R9's weight was up 7.7 lbs.)~ On 12/5/25 and 12/4/25, there was no weight recorded for R9.~ On 12/3/25 at 12:54 PM, R9 weighed 174.6 lbs (wheelchair scale) ~ On 12/2/25 at 11:56 AM, R9 weighed 175.9 lbs (mechanical lift scale) ~ On 11/29/25 at 12:18 PM, R9 weighed 175.5 lbs (wheelchair scale) ~ On 11/28/25 at 11:34 AM, R9 weighed 174.0 lbs (mechanical lift scale) (There was no re-weigh. R9's weight was down 8 lbs.)~ On 11/27/25 at 9:04 AM, R9 weighed 182.0 lbs (wheelchair scale) (There was no re-weigh. R9's weight was up 6.5 lbs.)~ On 11/26/25 at 9:43 AM, R9 weighed 175.5 lbs (mechanical lift scale)~ On 11/19/25 at 10:48 PM, R9 weighed 182.4 lbs (wheelchair scale) ~ On 11/18/25 at 11:28 AM, R9 weighed 184.4 lbs (wheelchair scale) (There was no re-weigh. R9's weight was down 4 lbs.)~ On 11/17/25 at 1:58 PM, R9 weighed 188.4 lbs (wheelchair scale) ~ On 11/16/25 at 12:48 PM, R9 weighed 187.4 lbs (wheelchair scale) ~ On 11/8/25 at 8:48 AM, R9 weighed 189.4 lbs (wheelchair scale) ~ On 11/7/25 at 9:30 AM, R9 weighed 189.5 lbs (wheelchair scale) (There was no re-weigh. R9's weight was down 6.7 lbs.) ~ On 11/6/25 at 10:02 AM, R9 weighed 196.2 lbs (wheelchair scale) ~ On 11/5/25 at 10:14 AM, R9 weighed 198.0 lbs (wheelchair scale) ~ On 11/4/25 at 1:40 PM, R9 weighed 198.8 lbs (mechanical lift scale) (There was no re-weigh. R9's weight was up 4.8 lbs.) ~ On 11/3/25 at 9:48 AM, R9 weighed 194.0 lbs (wheelchair scale) ~ On 11/2/25 at 7:28 AM, R9 weighed 195.5 lbs (mechanical lift scale) ~ On 11/1/25 at 1:41 PM, R9 weighed 196.5 lbs (mechanical lift scale) ~ On 10/30/25 at 10:46 AM, R9 weighed 195.5 lbs (wheelchair scale)~ On 10/29/25 at 11:13 AM, there was a disputed value by the Registered Dietitian (RD)-G. ~ On 10/29/25 at 11:08 AM, R9 weighed 193.5 lbs (wheelchair scale) ~ On 10/28/25 at 11:51 AM, R9 weighed 238.0 lbs (mechanical lift scale) (There was no re-weigh. R9's weight was up 47 lbs.)~ On 10/27/25 at 4:20 PM, R9 weighed 191.0 lbs (mechanical lift scale) A progress note by RD-G, dated 2/9/26, indicated R9 weighed 177.8 lbs. On 1/8/26, R9 weighed 167.8 lbs = 6% weight gain. On 11/4/25, R9 weighed 198.8 lbs = 10.6% weight loss. Significant weight gain x 1 month (6%). Significant weight loss x 3 months (10.6%). R9's weight gain was likely due to good meal and supplement intake. R9's weight loss since admission was likely due to not consuming excessive calories. RD-G recommended R9 continue with diet and supplements as ordered.A progress note by RD-G, dated 1/28/26, indicated R9 weighed 172.6 lbs. On 12/28/25, R9 weighed 183.2 lbs = 5.8% weight loss. On 10/29/25, R9 weighed 193.5 lbs = 10.8% weight loss. Significant weight loss x 1 month (5.8%). R9 took a multivitamin for wound healing, levothyroxine (which may cause weight loss), and mirtazapine (which may increase appetite). R9's weight loss was likely due to levothyroxine treatment with myxedema coma. RD-G recommendaed R9 start vitamin C 500 mg for wound healing.A progress note by RD-G, dated 1/21/26, indicated R9 weighed 177.0 lbs on 1/20/26. On 12/20/25, R9 weighed 179.6 lbs = 1.4% weight loss. A progress note by RD-G, dated 12/17/25, indicated R9 weighed 180.6 lbs. On 11/17/25, R9 weighed 188.4 lbs = 4.1% weight loss. On 11/4/25, R9 weighed 198.8 lbs = 9.2% weight loss. Significant weight loss x 3 months (9.2%). R9's weight loss was likely due to poor meal intake. RD-G recommended R9 continue with diet and supplements as ordered.A progress note by RD-G, dated 11/26/25, indicated R9 weighed 175.5 lbs. On 11/2/25, R9 weighed 195.5 lbs = 10.2% weight loss. Significant weight loss x 1 month (10.2%). R9's weight loss was likely due to poor appetite and poor intake of meals and supplements. R9 refused meals at times. RD-G recommended to increase Med Plus 2.0 120 ml to three times daily.On 2/11/26 at 10:22 AM at Surveyor interviewed RD-G who stated RD-G reviews residents' weights weekly and writes monthly notes. RD-G stated RD-G was not notified of R9's weight loss or gain. RD-G stated R9 received speech therapy who recommends diet types. RD-G recommends supplements and analyzes diet, intake, and weight. RD-G confirmed R9 took mirtazapine to stimulate R9's appetite. RD-G was not sure if the provider was aware of R9's significant weight fluctuations. RD-G stated RD-G notifies nursing staff of RD-G's recommendations and nursing staff obtain orders. On 2/11/26 at 11:45AM, Surveyor interviewed Director of Nursing (DON)-B who indicated a re-weigh is required if there is a difference in weight of 5 lbs since the previous weight. DON-B stated the facility has a standing order to call the provider if the resident has a 3 lb weight change in 1 day or a 7 lb weight change in 1 week for residents with heart failure. DON-B indicated cardiology followed R9 and staff should notify the provider of 3 lb weight changes. DON-B indicated daily weights were ordered due to R9's cardiac history. DON-B indicated nurses should re-weigh R9 if there is a 3 to 5 lb weight change and staff should document the re-weigh. DON-B indicated there should be two weights recorded if a re-weigh is obtained. DON-B indicated nurses enter weights but do not always compare them to the previous weight. DON-B stated nurses should write a progress note for weight loss or gain and update the provider. DON-B verified provider and POA notification was not documented in R9's medical record for weight losses or gains from 11/4/25 through 1/30/26. 2. From 2/9/26 to 2/11/26, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] and had diagnoses including morbid obesity due to excess calories, type 2 diabetes, traumatic subdural hemorrhage with loss of consciousness, unspecified dementia, behavioral disturbance, and anxiety. R29's MDS assessment, dated 11/25/25, had a BIMS score of 7 out of 15 which indicated R29 had severely impaired cognition. R29 had a Guardian.A care plan, dated 8/27/25, indicated R29 was risk for nutritional status change related to dementia, dysphagia, obesity, hypertension and edema, R29 took diuretic medication and had a history of weight changes. The care plan contained a goal that R29 would maintain weight as evidenced by no significant weight changes (>/= 5% in 30 days, >/= 7.5% in 90 days, or >/= 10% in 180 days) and would accept the recommended diet for weight reduction through the next quarter as evidenced by weight loss of 1-2 pounds per week. The care plan contained the following interventions: Provide diet as ordered - CCHO diet, L2/mechanical-altered texture with pureed vegetables, thin consistency. Try to avoid thick bread products, may need to soften more or cut into smaller pieces; Record weight per facility protocol/MD orders; Review weights and notify RD, MD, and responsible party of significant weight change (7/18/22); See tray card for specific food preferences; Snack per R29's preference.R29's medical record contained the following orders:~ Consistent carbohydrate diet, Level 2/mechanical-altered texture, regular/thin consistency (dated 8/7/25) UPDATE (9/3/25): Diet texture - minced and moist. Pureed vegetables. Try to avoid thick bread products. May need to soften more or cut into smaller pieces. General swallow precautions. Small portions.Surveyor reviewed R29's weights and noted the following:~ On 2/1/26 at 9:11 AM, R29 weighed 193.4 lbs (standup scale) (There was no re-weigh. R29's weight was down 5.2 lbs.) ~ On 1/1/26 at 9:44 AM, R29 weighed 198.6 lbs (standup scale) (There was no re-weigh. R29's weight was down 3 lbs.)~ On 12/1/25 at 9:49 AM, R29 weighed 201.6 lbs (standup scale) (There was no re-weigh. R29's weight was down 12 lbs.)~ On 11/5/25 at 11:16 AM, R29 weighed 213.6 lbs (wheelchair scale) ~ On 10/1/25 at 8:01 AM, R29 weighed 211.6 lbs (wheelchair scale) ~ On 9/1/25 at 12:15 PM, R29 weighed 210.4 lbs (wheelchair scale) (There was no re-weigh. R29's weight was down 10.8 lbs.)~ On 8/1/25 at 10:35 PM, R29 weighed 221.2 lbs (wheelchair scale) ~ On 7/1/25 at 12:54 PM, R29 weighed 223.0 lbs (wheelchair scale)A progress note by RD-G, dated 1/7/26, indicated R29 weighed 198.6 lbs. On 12/1/25, R29 weighed 201.6 lbs = 1.5% weight loss. On 10/1/25, R29 weighed 211.6 lbs = 6.1% weight loss. On 7/1/25, R29 weighed 223 lbs = 10.9% weight loss. Significant weight loss x 6 months (10.9%). R29 followed a CCHO diet, level 2/mechanical-altered texture with intakes of 51-100%. R29 accepted snacks at times with 100% intake of those accepted and did not take supplements. No edema was documented x 30 days. The note indicated furosemide can cause weight fluctuations and R29's weight loss was likely due to desired gradual weight loss with morbid obesity. R29's intake was adequate to meet needs. RD-G recommended that R29 continue with diet as ordered and continue to monitor weight/intake.A progress note by RD-G, dated 12/22/25 at 5:56 PM, indicated R29 weighed 201.6 lbs. On 11/5/25, R29 weighed 213.6 lbs = 5.6% weight loss. On 9/1/25, R29 weighed 210.4 lbs = 4.2% weight loss. On 6/1/25, R29 weighed 223.6 lbs = 9.8% weight loss. Significant weight loss x 1 month (5.6%). The note indicated furosemide can cause weight fluctuations and indicated R29's weight loss was likely due to weight fluctuations from diuretic treatment.A progress note by RD-G, dated 11/19/25 at 1:52 PM, indicated R29's average meal intake was 50-100%. On 11/5/25, R29 weighed 213.6 lbs. On 10/1/25, R29 weighed 211.6 lbs = 0.9% weight gain. On 8/1/25, R29 weighed 221.2 lbs = 3.4% weight loss. On 5/1/25, R29 weighed 224 lbs = 4.6% weight loss. R29 had the potential for weight fluctuation related to fluid shifts. R29's weight fluctuations were likely due to diuretic therapy. R29 was on a texture-modified diet with L2/mechanical-altered texture and pureed vegetables. Small portions were added as well as avoid thick bread products/soften or cut into smaller pieces. The note indicated RD-G would monitor and coordinate care with the IDT. R29's care plan was reviewed and updated.A nutrition assessment note by RD-G, dated 8/27/25 at 8:33 AM, indicated R29's average meal intake was 50-100% and R29 ate 2-3 meals per day. On 8/1/25, R29 weighed 221.2 lbs. R29's weight was stable. R29 consumed adequate calories to maintain weight. The note indicated R29 had potential for weight fluctuation related to fluid shifts and diuretic therapy.On 2/11/26 at 11:11 AM, Surveyor interviewed RD-G who stated RD-G received a weight loss triggered/notification on 2/1/26 for R29 whose weight will be discussed at an upcoming quarterly meeting. RD-G confirmed R29 had weight loss over the last year and thought R29 had a weight loss goal due to R29's high BMI. RD-G reviewed R29's intakes with Surveyor and stated RD-G thought R29's weight loss was planned because R29 was obese. RD-G had not discussed R29's weight loss with the provider and verified R29 had lost more weight over the last 3 months. RD-G stated Nursing Home Administrator (NHA)-A or the MDS nurse contact RD-G if they have concerns. RD-G stated RD-G was not notified by staff of weight concerns for R29. RD-G verified R29's January 2026 note indicated R29 had a 10.9% weight loss from 6 months prior. On 2/11/26 at 11:45AM, Surveyor interviewed DON-B who stated a resident should be re-weighed if there is a difference in weight of 5 lbs since the previous weight. DON-B stated the facility has a standing order to call the provider if a resident has a 3 lb weight change in 1 day or a 7 lb weight change in 1 week. DON-B stated nurses should document a re-weigh and indicated there should be two weights documented if a re-weigh occurred. DON-B indicated nurses enter weights but do not always compare them to the previous weight. DON-B stated nurses should write a progress note for weight loss or gain and update the provider. DON-B stated R29's medical record did not indicate the provider and R29's POA were notified of R29's weight loss for 9/1/25 through 2/1/26.

Based on observation, staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R41, R32, and R43) of 3 sampled residents.R41 was on enhanced barrier precautions (EBP) for an indwelling catheter. Certified Nursing Assistant (CNA)-D did not wear a gown while emptying R41's catheter.Registered Nurse (RN)-E did not complete proper hand hygiene during medication pass for R32 and R43.Findings include: The facility's Enhanced Barrier Precautions (EBP) policy, revised 8/8/24, indicates: EBP refer to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high-contact resident care activities. High-contact resident care includes if a resident has a wound or indwelling medical device, without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with an MDRO. The facility's Hand Hygiene policy, dated 11/2/2022, indicates: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .3. Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations .Hand Hygiene Table: Either soap and water or alcohol-based hand rub .before preparing or handling medications. 1. From 2/9/26 to 2/11/26, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including dementia, heart failure, and obstructive uropathy. R41's Minimum Data Set (MDS) assessment, dated 1/28/26, had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated R41 had severely impaired cognition. A care plan, dated 2/9/26, indicated R41 had an indwelling catheter related to obstructive uropathy and was on EBP. Surveyor observed an EBP sign and a personal protective equipment (PPE) cart which contained gowns and gloves outside R41's room. On 2/10/26 at 1:30 PM, Surveyor observed CNA-D enter R41's room, draw the curtain between R41 and R41's roommate, complete hand hygiene, and don gloves. CNA-D retrieved a graduated cylinder, removed R41's catheter bag from a dignity bag, and wiped the drainage spout with an alcohol pad. CNA-D unclamped the drainage spout and emptied urine from the bag into the graduated cylinder. CNA-D then clamped the drainage spout, wiped the spout with an alcohol pad, and put the catheter bag back in the dignity bag. CNA-D emptied the urine into the toilet and rinsed the cylinder. CNA-D then removed gloves and completed hand hygiene. On 2/10/26 at 1:34 PM, Surveyor interviewed CNA-D who, after reading the EBP sign outside R41's door, indicated CNA-D should have worn a gown while emptying R41's catheter. On 2/10/26 at 11:41 AM, Surveyor interviewed Director of Nursing (DON)-B who stated staff should follow precautions signs. 2. On 2/9/26 at 8:20 AM, Surveyor observed RN-E prepare medication for R32. RN-E did not complete hand hygiene before medication preparation or prior to delivering medication to R32. (See interview under example #3.) 3. On 2/9/26 at 8:27 AM, Surveyor observed RN-E prepare medication for R43. RN-E did not complete hand hygiene before medication preparation or prior to delivering medication to R43. On 2/9/26 at 8:32 AM, Surveyor interviewed RN-E who stated hand hygiene should be performed between residents when preparing and providing medication. RN-E verified RN-E did not complete hand hygiene during the observations. On 2/11/26 at 8:04 AM, Surveyor interviewed DON-B who stated staff should complete hand hygiene between residents during medication administration.

Based on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R36) of 3 sampled residents. R36 had a Guardian. The facility did not ensure court-ordered protective placement in the least restrictive environment was obtained after R36's nursing home stay exceeded 60 days. R36 also did not receive an annual review to determine appropriate placement. Findings include: From 2/9/26 to 2/11/26, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, chronic obstructive pulmonary disease (COPD), anxiety, and major depression. R36's Minimum Data Set (MDS) assessment, dated 12/3/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R36 had severely impaired cognition. R36 had a Guardian that was activated on 4/17/20. R36's medical record did not contain protective placement paperwork. On 2/10/26 at 8:15 AM, Surveyor interviewed Director of Memory Care (DMC)-C who indicated the facility did not have protective placement paperwork for R36. On 2/11/26 at 12:21 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility does not have a Guardianship policy and follows Chapter 54 and 55. NHA-A indicated the facility did not obtain protective placement for R36 but will contact Adult Protective Services (APS) to start the process.

Based on staff interview and record review, the facility did not ensure an allegation of sexual abuse was reported to the State Agency (SA) for 2 residents (R) (R42 and R8) of 2 sampled residents.Staff witnessed R42 kiss R8 in the hallway on 1/24/26. R42 then followed R8 into R8's room. Licensed Practical Nurse (LPN)-F entered R8's room and observed R42 unzipping R42's pants in front of R8 who was lying on the bed with a book and appeared confused. The allegation of sexual abuse was not reported to the SA. Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. The facility will report all alleged violations to the Administrator, State Agency .immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.From 2/9/26 to 2/11/26, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, heart failure, dementia, depression, and cognitive communication deficit. R42's Minimum Data Set (MDS) assessment, dated 1/14/26, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R42 had moderately impaired cognition. From 2/9/26 to 2/11/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, and anxiety. R8's MDS assessment, dated 12/16/25, had a BIMS score of 6 out of 15 which indicated R8 had severely impaired cognition.R42's medical record contained a progress note, dated 1/24/26 and written by LPN-F, that indicated R42 and (R8) were observed consensually kissing in the hallway by an unnamed housekeeping staff. The staff watched R42 and R8 enter R8's room then left the area to inform LPN-F. LPN-F verified with the housekeeping staff that the kiss was consensual and went to R8's room. LPN-F observed R8 lying on R8's bed holding a book. R42 was standing in front of R8 and unzipping R42's pants. LPN-F indicated R8 looked confused and LPN-F stopped R42 from unzipping R42's pants. LPN-F stated to R42 that R42's actions were inappropriate and asked R42 to zip R42's pants and leave the room. LPN-F stated R8 thanked LPN-F for asking R42 to leave. LPN-F notified R42's activated Power of Attorney for Healthcare (POAHC) who wondered if R42's sexual behavior was due to a medication that was discontinued a year ago. R42's POAHC indicated when the medication was discontinued, there was a warning that sexual behavior could reappear or worsen. R42's POAHC indicated R42 had increased incidents of this nature with various females since the medication was discontinued. LPN-F answered all questions and faxed the provider about the previously discontinued medication per R42's POAHC's request. R42's POAHC found the situation distressing since it was recurrent. The progress note indicated Director of Nursing (DON)-B was aware of the incident.On 2/10/26 at 11:05 AM, Surveyor interviewed LPN-F who indicated a housekeeper saw R42 and R8 kissing on 1/24/26 and verified to LPN-F that it was consensual because neither pulled back from the kiss. The housekeeper then saw R8 and R42 enter R8's room and informed LPN-F of the incident. LPN-F went to R8's room and observed R42 start to unzip R42's pants while R8 was lying on the bed holding a book and looked confused. LPN-F redirected R42 from unzipping R42's pants. R42 pulled up the zipper, left room, and appeared frustrated. LPN-F informed R42 that R42 could not kiss residents or unzip R42's pants. R42 appeared to understand. LPN-F stated situations can be consensual and then become non-consensual depending on a resident's cognitive status. LPN-F notified DON-B and R42 and R8's POAHCs. LPN-F indicated R8's POAHC was understanding; however, R42's POAHC was concerned the incident was related to a medication that was discontinued a year ago. LPN-F indicated the facility did not have a formal assessment for determining consensual sexual behavior. LPN-F contacted R42's physician on the day of the incident regarding the previously discontinued medication and was not sure the result of the physician update.On 2/10/26 at 11:17 AM, Surveyor interviewed DON-B who indicated R42 had kissed and groped residents in the past and R42's family and physician were aware. DON-B stated DON-B was not present when the incident occurred but thought LPN-F had ensured the safety of R42 and R8 and updated each resident's POAHC. DON-B indicated R42's physician was notified and would review R42's medication and plan of care during a scheduled meeting on 2/17/26. The physician indicated psychiatry should be involved. DON-B indicated the facility does not have a formal assessment to determine consensual sexual behavior and indicated LPN-F stopped the situation before it became non-consensual. DON-B indicated staff know to watch residents for distress and if a resident is distressed, the behavior is considered non-consensual. DON-B indicated the incident was not reportable to the SA because abuse did not occur.On 2/11/26 at 12:23 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware of the incident and was away from the facility when the incident occurred. NHA-A indicated NHA-A contacted the Ombudsman for information about identifying consensual sexual behavior and was planning to implement more staff education.

Based on staff and resident representative interview and record review, the facility did not notify a Guardian of a fall and change in condition for 1 resident (R) (R5) of 5 sampled residents.R5 had a fall with injury on 10/30/25. R5's Guardian was not notified of the fall or change in condition.Findings include:The facility's Fall Prevention and Management Guidelines policy, dated 7/2024, indicates: .7. When any resident experiences a fall, the facility will: .c. Notify the physician and family/responsible party .On 11/10/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including acute metabolic encephalopathy, myxedema coma, hypothyroidism, and urinary tract infection (UTI). R5's Minimum Data Set (MDS) assessment, dated 11/4/25, contained a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R5 had severe cognitive impairment. R5 had a Guardian for healthcare decisions. On 11/10/25 at 12:40 PM, Surveyor observed R5 in a wheelchair in R5's room. R5 had a dark bruise on the right temporal region. Surveyor attempted to interview R5; however, R5 was unable to answer questions. R5's medical record, fall report, and Interdisciplinary Team (IDT) clinical review indicated on 10/30/25 at 4:45 AM, R5 was found on the floor next to R5's bed. R5 was snoring and entangled in the bedding. There was stool on R5's chest and bed. R5 would not speak or open R5's eyes and refused to open R5's mouth for AM medications. Neuro checks were completed as able with no concerns. On 11/10/25 at 12:55 PM, Surveyor interviewed R5's Guardian ((GRD)-C) who was appointed to R5 on 10/27/25 upon R5's admission to the facility. GRD-C visited R5 on 11/3/25 and noticed a bruise on R5's forehead. GRD-C assumed the bruise occurred prior to admission. GRD-C was not informed of R5's fall or injury on 10/30/25. GRD-C indicated GRD-C expects to be notified of any falls or injuries. On 11/10/25 at 4:10 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated Guardian notification depends upon the Guardian's preferences. DON-B verified GRD-C should have been notified of R5's fall and change in condition.

Based on observation, staff interview and record review, the facility did not ensure adequate supervision and assistance to prevent accidents was provided for 1 resident (R) (R5) of 3 sampled residents. R5 sustained a fall with injury on 10/30/25 when R5 fell out of bed and onto the floor. Staff did not complete neurological checks in accordance with the facility's policy. In addition, the Interdisciplinary Team (IDT) identified the need for a bolster mattress. The intervention was not added to R5's care plan.Findings include:The facility's Fall Prevention and Management Guidelines policy, dated 7/2024, indicates: .7. When any resident experiences a fall, the facility will: .2) Neuro checks for any unwitnessed fall or witnessed fall where the resident hits their head: initially, then hourly x 3, continue neuro checks every 4 hours x 6, then continue neuro checks every 8 hours x 6, or as indicated by the physician .8. Review each fall/fall investigation during the next morning meeting/clinical meeting with the Interdisciplinary Team (IDT). Action of the IDT may include: a. Review of investigation and determination of potential root cause of fall .c. Additional revision to the plan of care including any physical adaptation to room, furniture, wheelchair, and/or assistive devices .On 11/10/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including acute metabolic encephalopathy, myxedema coma, hypothyroidism, and urinary tract infection (UTI). R5's Minimum Data Set (MDS) assessment, dated 11/4/25, contained a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R5 had severe cognitive impairment. R5 had a Guardian for healthcare decisions. R5's medical record, fall report, and IDT clinical review indicated R5 was found on the floor next to R5's bed snoring and entangled in bedding on 10/30/25 at 4:45 AM. R5's chest and bed contained stool. Neurological checks were completed at 4:45 AM (as tolerated; R5 would not open R5's eyes or speak with staff); 6:48 AM; 10:21 AM; 11:55 AM; and 9:30 PM. Surveyor noted 5 of 15 neuro checks required to monitor for injury following an unwitnessed fall were completed.On 11/10/25 at 12:40 PM, Surveyor observed a dark bruise on R5's right temporal region incurred during the fall on 10/30/25. R5 was unable to communicate with Surveyor.Surveyor reviewed the IDT results for R5's fall on 10/30/25. The IDT recommended to put a bolster mattress on R5's bed so R5 is aware of the edges of the bed. (R5's care plan did not include an intervention for a bolster mattress.)On 11/10/25 at 4:10 PM, Surveyor interviewed Director of Nursing (DON)-B who verified neuro checks were not completed in accordance with the facility's policy. DON- B also indicated R5's care plan should have been updated in accordance with the IDT's recommendation for a bolster mattress.

Based on staff interview and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 resident (R) (R3) of 1 sampled resident.On 11/7/25, a fracture was discovered in R3's right arm under a cast and above where R3 had a previous fracture repaired on 10/22/25. The facility did not thoroughly investigate the injury of unknown origin.Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: .IV. Identification of Abuse, Neglect, and Exploitation: .B. Possible indicators of abuse include, but are not limited to: .3. Physical injury of a resident of unknown source. V. Investigation of Alleged Abuse, Neglect, and Exploitation: A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. On 11/10/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] from home and had diagnoses including Alzheimer's disease with late onset, dementia-severe with agitation, unspecified fracture of lower end of right humerus, chronic pain, weakness, other osteoporosis with current pathological fracture, and polyosteoarthritis. R3's Significant Change Minimum Data Set (MDS) assessment, dated 11/5/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R3 had severe cognitive impairment. R3 had a Guardian who was R3's spouse.R3's medical record indicated R3 had an X-ray related to right elbow pain and swelling on 10/18/25. The X-ray indicated R3 had an acute transverse supracondylar fracture of the distal right humerus with posterior displacement. On 10/19/25, R3 was transferred to the emergency room (ER) and admitted to the hospital. On 10/22/25, the fracture was surgically repaired. On 10/29/25, R3 returned to the facility with a cast wrapped in an Ace bandage. A progress note, dated 11/3/25, indicated R3 received oxycodone for pain but continued to have pain in the right arm. The physician was notified and gave an order to change oxycodone to every 6 hours as needed.A progress note, dated 11/7/25, indicated R3 was given scheduled and as needed pain medication related to right arm pain but continued to call out in pain and had significant pain with movement. R3's care team stated R3's splint could be adjusted for comfort. The nurse removed the Ace wrap; however, R3 had a hard cast that could not be adjusted. The orthopedist stated to send R3 to the ER for an X-ray. The X-ray indicated R3 had an additional fracture in the right humerus above the repaired site. R3 was scheduled for surgery on 11/11/25 and sent back to the facility pending an appointment on 11/10/25. Surveyor noted the facility did not have an investigation for the additional fracture that was discovered on 11/7/25. R3 could not state how the fracture occurred.On 11/11/25 at 1:19 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A via phone regarding R3's new fracture that was considered an injury of unknown origin which should have been investigated to determine the cause and rule out abuse. NHA-A confirmed the facility did not investigate R3's injury of unknown origin.

Based on staff interview and record review, the facility did not ensure an injury of unknown origin was reported to the State Agency (SA) for 1 resident (R) (R3) of 1 sampled resident. On 11/7/25, a fracture was discovered in R3's right arm under a cast and above where R3 had a previous fracture repaired on 10/22/25. The facility did not report the injury of unknown origin to the SA.Findings include:The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: .IV. Identification of Abuse, Neglect, and Exploitation: .B. Possible indicators of abuse include, but are not limited to: .3. Physical Injury of a resident, of unknown source .VII. Reporting/Response: Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services (APS), and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. On 11/10/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] from home and had diagnoses including Alzheimer's disease with late onset, dementia-severe with agitation, unspecified fracture of lower end of right humerus, chronic pain, weakness, other osteoporosis with current pathological fracture, and polyosteoarthritis. R3's Significant Change Minimum Data Set (MDS) assessment, dated 11/5/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R3 had severe cognitive impairment. R3 had a Guardian who was R3's spouse.R3's medical record indicated R3 had an X-ray related to right elbow pain and swelling on 10/18/25. The X-ray indicated R3 had an acute transverse supracondylar fracture of the distal right humerus with posterior displacement. On 10/19/25, R3 was transferred to the emergency room (ER) and admitted to the hospital. On 10/22/25, the fracture was surgically repaired. On 10/29/25, R3 returned to the facility with a cast wrapped in an Ace bandage. A progress note, dated 11/3/25, indicated R3 received oxycodone for pain but continued to have right arm pain. The physician was notified and gave an order to change oxycodone to every 6 hours as needed.A progress note, dated 11/7/25, indicated R3 was given scheduled and as needed pain medication for right arm pain but continued to call out in pain and had significant pain with movement. R3's care team stated R3's splint could be adjusted for comfort. The nurse removed the Ace wrap; however, R3 had a hard cast that could not be adjusted. The orthopedist stated to send R3 to the ER for an X-ray. The X-ray indicated R3 had an additional fracture in the right humerus above the repaired site. R3 was scheduled for surgery on 11/11/25 and sent back to the facility pending an appointment on 11/10/25. Surveyor noted the injury of unknown origin was not reported to the SA despite the fact R3 did not have a documented fall or other injury to account for the additional fracture.On 11/11/25 at 1:19 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A via phone regarding how the second fracture occurred. Surveyor indicated the fracture was considered an injury of unknown origin that should have been reported to the SA since the fracture could not be linked to an event. NHA-A verified the statement by asking questions regarding the timeliness of the self-report (within 2 hours).

Based on staff interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) in a timely manner or the local police department for 1 resident (R) (R1) of 5 sampled residents. Certified Nursing Assistant (CNA)-E reported to Nursing Home Administrator (NHA)-A that CNA-C barricaded R1 in the nurses' station on 4/15/25. The allegation of abuse was not reported to the SA until 4/23/25. The facility also did not report the allegation of abuse to the local police department. Findings include: The facility's Abuse Prevention Program, dated March 2018, indicates: .Involuntary seclusion refers to the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will or the will of the resident's representative .7. Reporting/Responding: Allegations must be reported to the Administrator/designee immediately. The Administrator/designee will ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported no later than 2 hours after the allegation is made if events that cause the allegation involve abuse or result in serious bodily injury; or not later than 24 hours if events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the SA and other officials/authorities as needed. On 5/20/25, Surveyor reviewed a facility-reported incident (FRI) that was submitted to the SA on 4/23/25. The FRI stated Registered Nurse (RN)-D reported to NHA-A that CNA-C was abusive to residents. On 4/22/25, NHA-A and Director of Nursing (DON)-B suspended CNA-C and initiated an investigation into the allegation of abuse. The facility's final investigation was submitted to the SA on 4/28/25. On 5/20/25, Surveyor reviewed staff statements that were included in the facility's investigation: ~ A statement by CNA-E, dated 4/15/15, indicated CNA-E came in at 2:00 AM on 4/15/25 and found CNA-C completing documentation at the nurses' station while R1 was at the CNA desk with a treatment cart next to R1. When CNA-E asked CNA-C why R1 was positioned like that, CNA-C stated it was because R1 kept going into other residents' rooms. CNA-C then exited the nurses' station and CNA-E took R1 to R1's room for toileting and cares. When CNA-E pulled down R1's pants, CNA-E noted blood and bruising on R1's left lower leg. CNA-E reported the skin concerns to Registered Nurse (RN)-F who assessed R1's leg and provided first aide. RN-F thought the bruising and skin tear were related to a recent fall. CNA-E reported concerns about CNA-C possibly barricading R1 behind the nurses' station desk to RN-D (the AM shift nurse) on 4/15/25 at approximately 10:15 AM. ~ A statement by CNA-C, dated 4/16/25, indicated CNA-C was assigned the the D/E wing but was answering lights on the A wing with residents reporting R1 was going into their rooms. CNA-C brought R1 to the nurses' station and moved the treatment cart behind the CNA desk so R1 would be able to move around the entire area of the nurses' station. While CNA-C was charting, R1 wheeled behind the CNA desk and laid R1's head down on the desk. CNA-C indicated there was enough space for R1 to get between the treatment cart and the CNA desk. CNA-C indicated R1 was in the nurses' station from approximately 12:00 AM until 2:00 AM. CNA-E came in at 2:00 AM and took R1 to the bathroom. CNA-C returned to CNA-C's assigned wing. Surveyor reviewed staff education, dated 4/15/25, related to involuntary seclusion that indicated all residents have the right to freely move about the facility or unit despite behavior and/or diagnoses. Not allowing a resident to move about freely can be a form of abuse. The education included a review of the facility's abuse policy. The education was not signed by CNA-C. On 5/20/25 at 9:41 AM, Surveyor interviewed CNA-E who verified when CNA-E came into work at 2:00 AM, CNA-E observed R1 at the CNA desk in the nurses' station with the treatment cart between R1 and CNA-C. When CNA-E asked why R1 was sitting like that, CNA-C stated it was because R1 kept going into other residents' rooms. CNA-E brought R1 to R1's room and observed blood dripping down R1's left lower leg. CNA-E reported the blood to RN-F at approximately 2:20 AM. RN-F applied a dressing and indicated the wound and bruising were from a previous fall. CNA-E was still concerned and reported the information to RN-D (the AM shift nurse) at approximately 10:15 AM. CNA-E stated R1 would have been unable to wheel R1's self out from behind the CNA desk because CNA-E had to move the treatment cart to wheel R1 out of the nurses' station. On 5/20/25 at 9:56 AM, Surveyor interviewed RN-D who verified R1 fell on [DATE] but had no skin concerns. RN-D felt the bruises were new based on the dark color (versus green or yellow which indicated older bruising). RN-D asked other staff questions to try to figure out the origin of R1's skin tear. CNA-E reported that when CNA-E came in at 2:00 AM, CNA-C had barricaded R1 behind the CNA desk with the treatment cart. RN-D stated DON-B started an investigation into the cause of R1's skin tear on 4/15/25 and it was determined the skin tear/bruising could have resulted from R1 bumping against the treatment cart. RN-D stated DON-B was aware of RN-D and CNA-E's concerns regarding CNA-C on 4/15/25. On 4/22/25, RN-D discovered CNA-C was still working despite the allegations and reported the concerns again to NHA-A and DON-B. On 5/20/25 at 10:55 AM, Surveyor interviewed CNA-C who verified R1 regularly wandered and indicated in the early morning hours of 4/15/25, several residents complained that R1 entered their rooms. CNA-C brought R1 to the nurses' station for 1:1 supervision per R1's care plan. CNA-C indicated R1 could wheel R1's self around the nurses' station and wheeled behind the CNA desk. CNA-C stated when CNA-E came in at 2:00 AM, CNA-C returned to the D/E wing for the rest of the shift. CNA-C verified CNA-C was not suspended from work regarding the allegation until 4/22/25. On 5/20/25 at 12:15 PM, Surveyor interviewed NHA-A and DON-B regarding reporting the allegation of abuse. DON-B stated statements were obtained from RN-F, CNA-C, and CNA-E on 4/15/25 and 4/16/25 while they investigated the skin tear on R1's leg. NHA-A and DON-B confirmed they were aware of the allegation that CNA-C barricaded R1 behind the CNA desk with the treatment cart on 4/15/25. NHA-A and DON-B also verified involuntary seclusion was a form of abuse. NHA-A and DON-B indicated they did not immediately report the allegation of abuse because it did not happen based on re-enactment and staff interviews. NHA-A stated when RN-D reported the same concerns regarding CNA-C on 4/22/25, they suspended CNA-C and initiated a full abuse investigation. NHA-A indicated the allegation was not reported to the local police department because they do not respond to calls like that, especially with residents on the memory care unit.

Based on staff interview and record review, the facility did not thoroughly investigate an allegation of abuse and prevent further potential abuse for 1 resident (R) (R1) of 5 sampled residents. Certified Nursing Assistant (CNA)-E reported to Nursing Home Administrator (NHA)-A that CNA-C barricaded R1 in the nurses' station on 4/15/25. CNA-C was not removed from or supervised during resident care until 4/22/25. Findings include: The facility's Abuse Prevention Program, dated March 2018, indicates: .Involuntary Seclusion refers to the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will or the will of the resident's representative .6. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include: responding immediately to protect the alleged victim, staffing changes to protect the resident(s) from the alleged perpetrator .7. Reporting/Response: .d. Analyzing the occurrence to determine why abuse occurred and what changed may be needed to prevent further occurrences. On 5/20/25, Surveyor reviewed a facility-reported incident (FRI) that was submitted to the State Agency (SA) on 4/23/25. The FRI stated Registered Nurse (RN)-D reported to NHA-A that CNA-C was abusive to residents. On 4/22/25, NHA-A and Director of Nursing (DON)-B suspended CNA-C and initiated an investigation into RN-D's allegations of abuse. The facility's final investigation was submitted to the SA on 4/28/25. On 5/20/25, Surveyor reviewed staff statements that were included in the facility's investigation: ~ A statement by CNA-E, dated 4/15/15, indicated CNA-E came in at 2:00 AM on 4/15/25 and observed CNA-C completing documentation at the nurses' station while R1 was at the CNA desk with a treatment cart next to R1. When CNA-E asked why R1 was positioned like that, CNA-C stated it was because R1 kept going into other residents' rooms. CNA-C exited the nurses' station and CNA-E brought R1 to R1's room for toileting and cares. When CNA-E pulled down R1's pants, CNA-E observed blood and bruising on R1's left lower leg. CNA-E reported the skin concerns to RN-F who assessed R1's leg and provided first aide. RN-F thought the bruising and skin tear were related to a recent fall. CNA-E reported the concern about CNA-C possibly barricading R1 behind the desk in the nurses' station to RN-D (the AM shift nurse) on 4/15/25 at approximately 10:15 AM. ~ A statement by CNA-C, dated 4/16/25, indicated CNA-C was assigned to the D/E wing but answered several lights on the A wing with residents reporting R1 was going into their rooms. CNA-C brought R1 to the nurses' station and moved the treatment cart behind the CNA desk so R1 would be able to move around the entire area of the nurses' station. While CNA-C was charting, R1 wheeled R1's self behind the CNA desk and laid R1's head down on the desk. CNA-C indicated there was enough space for R1 to get between the treatment cart and the CNA desk. CNA-C indicated R1 was in the nurse's station from approximately 12:00 AM until 2:00 AM. CNA-E came in at 2:00 AM and took R1 to the bathroom. CNA-C returned to CNA-C's assigned wing. Surveyor reviewed staff education, dated 4/15/25, related to involuntary seclusion that stated all residents have the right to freely move about the facility or unit despite behavior and/or diagnoses. Not allowing a resident to move about freely can be a form of abuse. The education included a review of the facility's abuse policy. The education was not signed by CNA-C. On 5/20/25 at 9:41 AM, Surveyor interviewed CNA-E who verified when CNA-E came in at 2:00 AM, CNA-E observed R1 at the CNA desk in the nurses' station with a treatment cart between R1 and CNA-C. When CNA-E asked why R1 was sitting like that, CNA-C stated it was because R1 kept going into other residents' rooms. CNA-E brought R1 into R1's room and observed blood dripping down R1's left lower leg. CNA-E reported the concern to RN-F at approximately 2:20 AM. RN-F applied a dressing and indicated the wound and bruising were from a previous fall. CNA-E was still concerned and reported the concern to RN-D (the AM shift nurse) at approximately 10:15 AM. CNA-E stated R1 would have been unable to wheel R1's self out from behind the CNA desk because CNA-E had to move the treatment cart to wheel R1 out of the nurses' station. On 5/20/25 at 9:56 AM, Surveyor interviewed RN-D who indicated CNA-E reported that when CNA-E came in at 2:00 AM, CNA-C had barricaded R1 behind the CNA desk with the treatment cart. RN-D stated DON-B was aware of RN-D and CNA-E's concerns regarding CNA-C on 4/15/25. On 4/22/25, RN-D found out CNA-C was still working despite the allegations and reported the concerns again to NHA-A and DON-B. On 5/20/25 at 10:55 AM, Surveyor interviewed CNA-C who verified CNA-C was not removed from or supervised during resident care until 4/22/25. CNA-C stated DON-B provided education via phone regarding abuse and involuntary seclusion. On 5/20/25, Surveyor reviewed CNA-C's timecard punches from 4/13/25 to 4/28/25 and noted CNA-C worked on 4/16/25, 4/17/25, 4/18/25, 4/20/25, 4/21/25, and 4/22/25. CNA-C returned to work on 4/28/25. On 5/20/25 at 12:15 PM, Surveyor interviewed NHA-A and DON-B regarding the investigation. NHA-A and DON-B indicated they were aware of the allegation of CNA-C barricading R1 behind the CNA desk with the treatment cart on 4/15/25. NHA-A and DON-B verified involuntary seclusion is a form of abuse. NHA-A and DON-B stated they did not immediately suspend CNA-C related to the allegation of abuse because it did not happen based on re-enactment and staff interviews. NHA-A stated when RN-D reported the same concerns regarding CNA-C again on 4/22/25, they suspended CNA-C and initiated a full investigation. DON-B verified CNA-C was suspended from work starting on 4/22/25 pending the results of the investigation and returned to work on 4/28/25.

Based on record review and staff interview, the facility did not revise care plans in accordance with current care needs for 4 residents (R) (R38, R21, R40, and R35) of 14 sampled residents. The facility did not revise R38, R21, and R40's care plans when R38, R21, and R40 started Hospice care. R35 had a restorative program that indicated R35 should be walked to meals. The facility did not revise R35's care plan to indicate staff did not always ambulate R35 to meals but ambulated R35 at other times during the day. Findings include: 1. From 9/23/24 to 9/25/24, Surveyor reviewed R38's medical record. R38 was admitted to the facility on [DATE] and had diagnoses including encephalopathy, depression, and dementia. R38's Minimum Data Set (MDS) assessment, dated 9/11/24, had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated R38 had severe cognitive impairment. R38's medical record contained an order for Hospice evaluation and treatment. On 9/10/24, R38's Hospice paperwork was completed. R38's medical record did not contain a Hospice care plan. 2. From 9/23/24 to 9/25/24, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including adjustment with depressed mood and secondary malignant neoplasm of the brain (brain cancer). R21's MDS assessment, dated 9/6/24, had a BIMS score of 5 out of 15 which indicated R21 had severe cognitive impairment. R21's medical record contained an order, dated 2/13/23, for Hospice evaluation and treatment. R21's medical record did not contain a Hospice care plan. 3. From 9/23/24 to 9/25/24, Surveyor reviewed R40's medical record. R40 was admitted to the facility on [DATE] and had diagnoses including progressive neurological condition, Alzheimer's disease, and dementia. R40's MDS assessment, dated 8/23/24, had a BIMS score of 4 out of 15 which indicated R40 had severe cognitive impairment. R40 started Hospice services on 8/21/24. R40's medical record did not contain a Hospice care plan. On 9/24/24 at 1:56 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed residents who receive Hospice services should have a facility-completed care plan that reflects the needs of the residents. 45943 4. From 9/23/24 to 9/25/24, Surveyor reviewed R35's medical record. R35 was admitted to the facility on [DATE] for therapy and had diagnoses including traumatic brain injury, epilepsy, impulsivity disorder, post-traumatic stress disorder (PTSD), and anxiety. R35's MDS assessment, dated 9/18/24, had a BIMS score of 3 out of 15 which indicated R35 had severe cognitive impairment. R35 had a guardian for healthcare decisions. R35's care plan, revised 4/23/24, indicated R35 required assistance to restore function for mobility related to decreased balance and inability to move independently. The care plan contained a restorative walking program intervention to ambulate R35 with a 4-wheeled walker, gait belt, and the assistance of 1 staff to meals. On 9/24/24 at 11:50 AM, Surveyor observed Nursing Home Administrator (NHA)-A begin to transport R35 to the dining room in a wheelchair with leg rests. Maintenance Director (MD)-H took over and completed the transport. On 9/24/24 at 11:52 AM, Surveyor interviewed NHA-A who indicated NHA-A was not aware R35 should be walked to the dining room for meals. On 9/24/24 at 11:55 AM, Surveyor interviewed MD-H who indicated MD-H was not aware R35 should be walked to the dining room for meals. MD-H indicated MD-H was told R35 should stay in the wheelchair so R35 didn't fall. On 9/24/24 at 1:43 PM, Surveyor interviewed Activities Director (AD)-I who verified AD-I took R35 to the dining room in the morning in a wheelchair. AD-I indicated AD-I was not aware R35 should be walked to the dining room for meals but stated R35 was walked in the hallway at other times. On 9/24/24 at 3:00 PM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-K who indicated Certified Nursing Assistants (CNAs) document on R35's plan of care the number of minutes R35 is walked. Surveyor reviewed the documentation and noted the following: ~ From 7/1/24 to 7/31/24, R35 was walked 3 times per day except on 4 dates when R35 was walked once, 3 dates when R35 refused, and 3 instances that were documented as not applicable. ~ From 8/1/24 to 8/31/24, R35 was walked three times per day except on 3 dates. ~ From 9/1/24 to 9/25/24, R35 was walked three times per day except on 1 date when R35 was not available and 1 date when R35 refused. On 9/25/24 at 10:09 AM, Surveyor interviewed DON-B who verified R35's care plan indicated R35 should be walked to meals. DON-B verified R35 was walked to breakfast that morning and stated DON-B observed R35 walked to supper on 9/24/24. DON-B also observed staff walk R35 at different times of the day other than meals. DON-B indicated DON-B would check with therapy to see if the ambulation order could be changed to include other times than meal time.

Based on observation, staff interview, and record review, the facility did not ensure 1 of 2 refrigerators in the medication storage room that contained vaccines and insulin maintained an appropriate temperature per the facility's policy and instructions on the facility's temperature log. In addition, the facility did not ensure medications for 7 residents (R) (R40, R33, R21, R22, R1, R194, and R3) of 19 residents in 1 of 1 medication cart were dated appropriately when opened. The medication refrigerator log for [DATE] indicated temperatures had been taken only once per day and 8 of the 22 temperatures were out of range. The refrigerator contained vaccines and insulin which required a temperature between ,d+[DATE] degrees F to preserve their integrity. In addition, the facility's policy indicated refrigerator temperatures should be checked twice daily. The medication storage room and medication refrigerator contained expired items and items that were not dated when opened. A medication cart contained open inhalers and eye drops that were not dated when opened. Findings include: The facility's Medication Storage, Storage of Medication policy, dated ,d+[DATE], indicates: .11. Medications requiring refrigeration or temperatures between 36 and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring .A temperature log or tracking mechanism is maintained to verify the temperature has remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily .14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. The facility's Medication Administration, General Guidelines policy, dated ,d+[DATE], indicates: .8. Check expiration date on package/container. No expired medication will be administered to a resident .B. Nurse shall place a date opened sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. C. Certain products or package types such as multi-dose vials and ophthalmic drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. When date open expiration dating is not available from the manufacturer, the following may be considered in determining facility policy: Position statement from American Society of Ophthalmic Registered Nurse and American Society of Cataract and Refractive Surgery state that multi-use eye drops and ointments should be disposed of 28 days after initial use .All other ophthalmic drops are to be considered expired after 60 days from the date opened. The glargine insulin manufacturer [NAME] Lilly insert at 16.2 Storage indicates: Store unused insulin glargine in a refrigerator between 36 F and 46 F (2 C (Celsius) and 8 C). Do not freeze. Discard insulin glargine if it has been frozen. Protect insulin glargine from direct heat and light. The Diabetes Disaster Response Coalition Safe Storage of Insulin pamphlet Pdf., dated 2018, indicates: According to the product labels from all three U.S. insulin manufacturers, it is recommended that insulin be stored in a refrigerator at approximately 36 F to 46 F (this is recommended for unopened insulin). The MSF medical guidelines for povidone-iodine, updated [DATE], indicate: Once the bottle has been opened, solution keeps 30 days. Pfizer labeling for 0.25% acetic acid irrigation, revised [DATE], indicates: The contents of an opened container should be used promptly to minimize the possibility of bacterial growth or pyrogen formation. 3. Discard the unused portion of irrigating solution since it contains no preservative. 3. Discard the unused portion of irrigating solution since it contains no preservative. The National Institutes of Health (NIH) for albuterol nebulizers, dated [DATE], indicates: Store between 2 C to 25 C (36 F to 77 F). Protect from light and excessive heat. Store unit-dose vials in protective foil pouch at all times. Once removed from the foil pouch, use vial(s) within two weeks. Discard the vial if the solution is not colorless. Ipratropium bromide and albuterol nebulizer packaging indicates: Protect from light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within two weeks. Discard if the solution is not colorless. 1. On [DATE] at 8:50 AM, Surveyor noted a medication log posted on the refrigerator in the medication storage room. The log contained one temperature per day. Surveyor also noted 8 of the 22 temperatures on the log were out of range. The log indicated the temperature should be between ,d+[DATE] degrees F. If the temperature was not within range, staff were instructed not to administer medication and alert the Executive Director (ED) or Maintenance Director immediately. Surveyor noted the log contained a range of low temperatures between 24 and 34 degrees on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 8:50 AM, Surveyor noted a sign on the refrigerator that indicated temperatures should be checked twice daily due to vaccines in the refrigerator. On [DATE] at 11:00 AM, Surveyor reviewed the [DATE], [DATE], and [DATE] mediation refrigerator temperature logs. The [DATE] log indicated refrigerator temperatures were out of range on 11 of 30 days. The temperatures ranged from ,d+[DATE] degrees F on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The temperature logs for all 3 months indicated temperatures were checked once per day. 2. On [DATE] at 8:55 AM, Surveyor observed the following items in the medication refrigerator: ~ A multi-use vial of Tubersol (tuberculous testing solution) with no open date. (A PharMerica policy, dated ,d+[DATE] and provided by Nursing Home Administrator (NHA)-A, indicated the vial expired 30 days after opening.) ~ One syringe of Prevnar 20 (pneumococcal vaccine) ~ Five syringes of daptomycin (an antibiotic) with expiration dates of [DATE] ~ A clear container with a can of tomato soup with an expiration date of [DATE] on top of the refrigerator The medication supply closet contained: ~ Three bottles of one daily multivitamins with expiration dates of ,d+[DATE] ~ A 2 pack of Equate multi-purpose solution for soft contact lenses with an expiration date of [DATE] A second refrigerator in the medication storage room labeled for resident food contained the following: ~ A container of Sysco imperial thickened lemon-flavored water opened on [DATE] and expired 7 days after opening ~ A bottle of International Delight zero iced coffee with an expiration date of [DATE] ~ Two chocolate Magic Cups with expiration dates of [DATE] On [DATE] at 9:55 AM, Surveyor confirmed the expired items with Licensed Practical Nurse (LPN)-C. Storage shelves in the medication room contained: ~ Ten DermaPrep liquid barrier skin prep pads with expiration dates of [DATE] ~ Five E-swab collection and transport systems with expiration dates of [DATE] ~ Four povidone-iodine pads with expiration dates of ,d+[DATE] ~ Personal cleaning cloths with expiration dates of [DATE] ~ Nineteen Binax Now COVID-19 tests with expiration dates of [DATE] ~ Two iodoform packing strips with expiration dates of [DATE] and [DATE] ~ XLB transparent film dressing with an expiration date of [DATE] ~ A 300 ml (milliliter) canister with gel for active a.c. therapy system with an expiration date of [DATE] ~ A Bard Touchless Plus unisex pre-lubed urethral catheter kit with an expiration date of [DATE] ~ Two 25 ounce Dover urine leg bags with expiration dates of [DATE] ~ A Vac white foam dressing with an expiration date of [DATE] ~ A Genadyne Y connector for XLR8 Luer with an expiration date of [DATE] ~ A skin staple remover with an expiration date of [DATE] On [DATE] at 11:00 AM, Surveyor verified the expired items with LPN-D. 3. On [DATE] at 12:41 PM, Surveyor observed the medication cart labeled D/E and noted the following: ~ Loteprednol 0.5% ophthalmic gel for R40 with no open date ~ A bottle of Artificial Tears for R33 with an open date of [DATE]. (A PharMerica policy, dated ,d+[DATE] and provided by NHA-A, indicated Artificial Tears should be used used within 60 days after opening) and an albuterol sulfate 90 mcg (microgram) inhaler with no open date. ~ A bottle of Artificial Tears for R21 with an open date of [DATE] ~ An albuterol sulfate 90 mcg inhaler for R22 with no open date ~ An open foil package of albuterol inhalation nebulizers for R22 with no open date ~ A bottle of prednisolone 1% opthalmic suspension for R194 with no open date ~ An open foil Duoneb package for R1 with no open date ~ A bottle of 0.25% acetic acid irrigation for R3 with no open date Following the observation, Surveyor verified the above items with LPN-D. On [DATE] at 1:56 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should date medication when opened. DON-B confirmed medications should be discarded by the expiration date and/or beyond-use date. DON-B also confirmed refrigerator temperatures should be checked twice daily and should be between ,d+[DATE] degrees F. DON-B indicated staff should follow the temperature log instructions; however, DON-B did not have documentation that was completed for the out-of-range temperatures dates.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R194) of 2 residents reviewed for pressure injuries received appropriate care and services to promote healing and/or prevent pressure injuries from developing. During R194's dressing change on 9/24/24, Director of Nursing (DON)-B did not apply iodine as ordered by the physician. Findings include: On 9/24/24, Surveyor reviewed R194's medical record. R194 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, sepsis due to methicillin-resistant Staphylococcus aureus (MRSA), pressure ulcer of foot, and diabetes. R194's Minimum Data Set (MDS) assessment, dated 9/19/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R194 had intact cognition. R194's medical record indicated R194 was responsible for R194's healthcare decisions. R194 had a wound care order, dated 9/19/24, to place iodine and a Xeroform dressing on the stitch area with 4 x 4 gauze and Kerlix and ACE or Coban wrap daily on the left foot. On 9/24/24 at 10:28 AM, Surveyor observed DON-B and Licensed Practical Nurse (LPN)-C perform a dressing change for R194. DON-B applied Xeroform dressing to the stitch area with 4 x 4 gauze, Kerlix, and an ACE wrap. Surveyor noted DON-B did not apply iodine during the dressing change in accordance with the wound care order. On 9/24/24 at 11:55 AM, Surveyor interviewed LPN-C who verified iodine was not applied during the dressing change. LPN-C stated R194 was leaving shortly for an infectious disease appointment and nursing staff would correct the error upon R194's return. On 9/25/24 at 1:35 PM, Surveyor interviewed DON-B who verified DON-B did not apply iodine during R194's dressing change.

Based on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 1 resident (R) (R194) of 5 residents observed during the provision of care. A transmission-based precautions (TBP) sign was not posted outside R194's room to alert staff that R194 was on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). In addition, staff were observed providing care for R194 without gloves or gowns. Findings include: The facility's Infection Prevention and Control Program policy, dated 7/23/24, indicates: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guideline .5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current Centers for Disease Control and Prevention (CDC) guidelines .d. When a resident on transmission-based precautions must leave the resident care unit/area, the nurse shall communicate to all involved departments the nature of the isolation and shall prepare the resident for transport in accordance with current transmission-based precaution guidelines. The CDC guidelines signage documents indicate: Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect surfaces and equipment with a sporicidal agent. On 9/23/24, Surveyor reviewed R194's medical record. R194 was admitted to the facility on [DATE] with diagnoses including Charcot foot wound with infection with MRSA, diabetes, and cancer. R194's Minimum Data Set (MDS) assessment, dated 9/12/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R194 had intact cognition. R194's medical record indicated R194 was responsible for R194's healthcare decisions. On 9/23/24 at 3:05 PM, Surveyor observed a cart outside R194's room. Surveyor did not observe a sign posted outside R194's room to alert staff that R194 was on contact precautions. On 9/23/24 at 3:13 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who verified R194 was on contact and droplet precautions and indicated the sign must have fallen down. On 9/23/24 at 3:15 PM, Surveyor interviewed R194 who indicated staff wore masks and gloves but R194 had not seen staff wear gowns during cares other than dressing changes. On 9/23/24 3:20 PM, Surveyor interviewed Director of Nursing (DON)-B who verified a contact precautions sign was not posted but should be. On 9/24/24 at 7:33 AM, Surveyor observed Physical Therapist Assistant (PTA)-F and Occupational Therapist Assistant (OTA)-G perform dressing and grooming for R194. Surveyor noted PTA-F and OTA-G did not don gowns while working with R194 in R194's room. On 9/24/24 at 7:47 AM, Surveyor observed PTA-F provide therapy for a resident with PTA-F's mask pulled down around PTA-F's neck. On 9/24/24 at 7:53 AM, Surveyor interviewed OTA-G who indicated staff should wear gloves, a gown, and a mask when providing therapy for residents on contact precautions. OTA-G indicated staff are allowed to treat residents on contact precaution in the gym as long as other residents are not present. OTA-G indicated a gown was worn if staff provided physical contact. On 9/24/24 at 7:56 AM, Surveyor observed PTA-F provide therapy for R194 with stretch bands around R194's knees. Surveyor observed PTA-F hold the bands to create tension without wearing gloves or a gown. On 9/24/24 at 8:03 AM, Surveyor interviewed PTA-F who indicated staff should don a gown and gloves for any cares in R194's room. PTA-F indicated holding the bands on R194's legs was not considered physical contact. On 9/25/24 at 1:38 PM, Surveyor interviewed DON-B who verified R194 was on contact precautions due to MRSA in R194's foot wound and drainage from the dressing. DON-B verified therapy staff should wear gowns with R194 to ensure there was no accidental exposure if R194's wound dressing came off during therapy.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R25) of 14 sampled residents was assessed as able to safely and accurately self-administer medication. On 9/23/24, R25 took R25's inhalers to a dialysis appointment to self-administer. R25 did not have a self-administration of medication assessment or a physician order that indicated R25 could safely and accurately self-administer the inhalers. Findings include: The facility's Self-Administration by Resident policy, dated 1/2023, indicates: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. Between 9/23/24 and 9/25/24, Surveyor reviewed R25's medical record. R25 was admitted to the facility for rehab post patellar tendon rupture and bilateral repair on 8/14/24 and had a diagnosis of unspecified asthma. R25's Minimum Data Set (MDS) assessment, dated 8/21/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R25 had intact cognition. R25 attended dialysis 3 times per week. R25's medical record indicated R25 was prescribed the following medications: ~ Advair HFA Inhalation Aerosol (Fluticasone-Salmeterol) 1 puff inhale orally two times a day ~ Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (micrograms/actuation) (Albuterol Sulfate) 2 puffs inhale orally every 4 hours as needed for SOB (shortness of breath) and wheezing A Self-Administration of Medication Assessment, dated 8/14/24, indicated R25 either did not wish to self-administer medication or was unable to make R25's own decision and may not self-administer medication. On 9/23/24 at 1:07 PM, Surveyor observed the medication cart and noted R25's inhalers were missing. Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated R25 took R25's inhalers to dialysis. On 9/25/24 at 11:47 AM, LPN-C provided Surveyor with a physician notification, dated 9/25/24, that indicated R25 wished to self-administer R25's inhalers and keep the inhalers at bedside. R25 currently used albuterol as needed and fluticasone-salmeterol twice daily and was R25's own decision maker. The provider response was to have nursing staff assess for the appropriateness of self administration and indicated it was okay for R25 to self-administer and keep the inhalers at bedside. LPN-C acknowledged R25's self-administration of medication assessment should have been completed prior to 9/25/24.

Based on staff and resident interview, and record review, the facility did not ensure bowel movements were monitored in accordance with the facility's protocol for 1 resident (R) (R3) of 14 sampled residents. R3 had a history of bowel obstruction. From 7/16/24 through 7/20/24, R3 went 5 days without a bowel movement (BM). Staff did not monitor R3's BMs and R3 did not have a bowel elimination care plan. Findings include: The facility did not have a written policy for bowel management; however Director of Nursing (DON)-B indicated the facility had a non-written procedure for bowel management. Between 9/23/24 and 9/25/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including occlusive mesenteric ischemia (a condition that occurs when blood flow to the small intestine is blocked or reduced), history of small bowel obstruction, and other intestinal obstruction unspecified as to partial versus complete obstruction. R3's Minimum Data Set (MDS) assessment, dated 8/17/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R3 had intact cognition. R3 was R3's own decision maker. R3's medical record indicated R3 was hospitalized with bowel obstructions from 8/15/23 to 8/23/23 and 8/6/24 to 8/10/24. R3's medical record did not contain a bowel elimination care plan R3 had the following physician orders: ~ 8 ounces (oz) of Benefiber oral powder (wheat dextrin) once daily for constipation. ~ 30 milliliters (ml) of Milk of Magnesia every 24 hours as needed for constipation. ~ 1 scoop of polyethylene glycol 3350 powder every 24 hours as needed for constipation. ~ 1 tablet of sennosides 8.6 mg (milligrams) as needed for constipation. Take 1 to 4 tablets twice daily (BID). Start with 1 tablet BID and titrate up to 8 tablets per day. ~1 tablet simethicone 80 mg every 6 hours as needed for bloating and gas (starting 8/6/24). ~ 2.5 mg of oxycodone every 4 hours as needed for pain. Between 7/16/24 and 7/20/24, R3 did not have a documented BM. R3 continued to take scheduled Benefiber. Per R3's Medication Administration Record (MAR), R3 was not offered any as needed medication for constipation during the 5 days R3 did not have a BM. R3's medical record indicated the following: ~ On 7/21/24, R3 had 2 BMs (medium and small size, normal formed). ~ On 7/22/24, R3 had 1 BM (small size, normal formed). ~ On 7/23/24, R3 was given Milk of Magnesia at 2:11 PM and 9:18 PM. R3 had 1 BM (medium size, normal formed) and was given oxycodone for pain. ~ On 7/24/24, R3 had 2 BMs (small size, normal formed) and was given oxycodone for pain. ~ On 7/26/24, R3's Benefiber was held due to loose stools. R3 also had 1 BM (medium size, normal formed). ~ On 7/29/24, R3 had 1 BM (medium size, normal formed). ~ On 7/30/24, R3 had 1 BM (medium size, normal formed). ~ On 7/31/24, R3 had 2 BMs (small size, normal formed). ~ On 8/1/24, R3 was given 1 tab of senna at 7:10 AM ~ On 8/2/24, R3 was given 1 tab of senna at 7:10 AM and had 2 BMs (large size, normal formed) at 9:55 PM. ~ On 8/3/24, R3 had 2 BMs (medium and large size, normal formed) and was given oxycodone for pain. ~ On 8/4/24 at 9:24 AM, R3 complained of abdominal pain. The nurse did an assessment and documented bowel sounds were active in all 4 quadrants. R3 was not eating much due to a concern of constipation. The physician gave an order to hold Lasix and potassium and draw labs. R3 had 1 BM (medium size, normal formed). ~ On 8/5/24, R3 had 1 BM (small size, normal formed). A progress note at 10:35 PM indicated R3 felt bloated. Bowel sounds were present in all 4 quadrants. R3 passed gas after auscultation and stated R3 felt better. A request for Gas-X was sent to the physician. R3 was given oxycodone which was effective. ~ On 8/6/24, R3 had 1 BM (small size, normal formed). A progress note at 10:23 AM indicated a Physician's Assistant (PA) faxed an order for simethicone 80 mg. At 9:55 PM, R3 had increased abdominal pain, was given oxycodone that was not effective, and was sent to the emergency room (ER). Surveyor reviewed R3's oxycodone use. Between 7/1/24 and 7/15/24 (prior to going 5 days without a BM), R3 took oxycodone 12 times for pain. Between 7/21/24 and 8/6/24 (after going 5 days without a BM), R3 took oxycodone 5 times for pain (3 of the 5 were between 8/3/24 and 8/6/24). R3's documented pain levels after 7/21/24 were not higher or out of the norm compared to R3's documented pain levels prior to 7/15/24. On 9/25/24 at 12:10 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J who worked regularly with R3. CNA-J indicated before R3 was hospitalized , R3 asked to go to the bathroom and staff assisted R3 though at times R3 tried to go without assistance. CNA-J indicated R3 was more independent now due to therapy, could go to the bathroom by R3's self, and would tell staff if R3 had a BM. CNA-J indicated R3 had always gone to the bathroom regularly but R3 did not feel like it was enough. CNA-J indicated R3 was good about telling staff when R3 went to the bathroom. CNA-J indicated BMs were documented in CNA charting and nursing staff gave CNAs a list of residents on watch for BMs. CNA-J could not recall if R3 was on the list during the 5 days in July that R3 did not have a documented BM. CNA-J indicated CNA-J felt if R3 didn't have a BM for multiple days, R3 would tell staff right away because R3 was concerned about BMs and liked to direct R3's care. On 9/25/24 at 12:17 PM, Surveyor interviewed R3 who indicated R3 kept a close eye on R3's BMs and staff did a good job keeping track as well. R3 indicated R3 had medication to take and asked for it as needed. R3 indicated sometimes R3 refused the medication because R3 didn't want to have diarrhea. R3 stated R3 had back pain for a couple weeks prior to hospitalization but thought it was a muscle pull. R3 indicated the pain was gradual and R3 didn't take anything for it and didn't tell staff. When the pain got worse, R3 was sent to the hospital and diagnosed with a bowel obstruction. R3 felt staff responded appropriately and monitored R3's bowels appropriately. On 9/25/24 at 12:48 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who worked regularly with R3. LPN-D indicated R3 did not express anything out of the ordinary until close to the time R3 was sent to the ER. LPN-D indicated close to that time, R3 reported belly pain but was assessed and had bowel sounds in all 4 quadrants. LPN-D indicated belly pain wasn't unusual for R3 because R3 was anxious and worried. LPN-D indicated when R3 expressed bloating and pain, LPN-D completed an assessment and there were bowel sounds in all 4 quadrants. R3 passed gas after auscultation and felt better. R3's physician was contacted for Gas-X. LPN-D indicated nurses were usually given a sheet by the night (NOC) shift nurse if residents were on watch for a BM or if they hadn't had one in a few days. LPN-D did not recall from if R3 was on one of the sheets in July after R3 did not have a documented BM for 5 days. LPN-D indicated the facility protocol was if no BM for 3 days, give prune juice, then Milk of Magnesia, then if still nothing, NOC shift staff would administer a suppository. On 9/25/24 at 1:17 PM, Surveyor interviewed DON-B who confirmed due to R3's history of bowel obstruction, R3 should have had a bowel elimination care plan. DON-B indicated DON-B could not find a bowel management policy. DON-B indicated staff should offer a resident senna on day 3 if the resident did not have a BM. If the resident didn't have a BM by day 4, staff should offer Milk of Magnesia. On day 5, staff should administer a suppository. DON-B indicated DON-B was unsure what the Medical Director wanted since DON-B had just started the DON role full-time the previous week. DON-B indicated nursing staff should look at the bowel report daily and provide a list of residents who were on watch. When Surveyor informed DON-B that R3's medical record indicated R3 did not have a BM and was not offered PRN medication between 7/16/24 and 7/20/24, DON-B indicated sometimes R3 went to the bathroom but did not tell staff or staff may have provided R3 with PRN medication but didn't document it. DON-B confirmed BMs and medications should be documented in a resident's medical record On 9/25/24 at 1:56 PM, DON-B provided Surveyor with a half sheet of paper with a graph that indicated what staff should do for bowel protocol. The sheet indicated on day 3, the resident should be offered prune juice. On day 4, the resident should be offered Milk of Magnesia. On day 5, the resident should be offered a suppository. If there were no results by day 5, staff should contact the physician.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R5) of 7 sampled residents was monitored for adverse reactions to antipsychotic medication. R5 was prescribed Seroquel (an antipsychotic medication) for dementia with behaviors. The facility did not complete a baseline Abnormal Involuntary Movement Scale (AIMS) assessment for R5 prior to the start of the medication. Findings include: The National Institute for Health, www.ncbi.nlm.nih.gov Tardive Dyskinesia, updated 4/24/23, indicates: Numerous rating scales determine the presence and severity of tardive dyskinesia. The most widely used instrument is the AIMS. It is recommended to administer the AIMS at baseline before initiating antipsychotic medications, with a follow-up screening performed no longer than three months later. Upon evaluation of the patient, it can be noted that tardive dyskinesia is present at rest and somewhat diminished when there is any form of volitional movement. For example, tongue dyskinesias reduce when the patient is asked to protrude their tongue. The facility's Psychotropic Medications policy, with a review date of 10/24/22, indicates: .8. Residents who receive an antipsychotic medication will have an AIMS test performed on admission, or at least every 6 months, when the antipsychotic medication is changed, and as needed (PRN). Between 9/23/24 and 9/25/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbance. R5's Minimum Data Set (MDS) assessment, dated 8/14/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R5 had moderate cognitive impairment. R5 had an activated Power of Attorney for Healthcare (POAHC). R5's medical record indicated R5 was prescribed 25 milligrams (mg) of Seroquel once daily for dementia with behaviors on 9/18/24. R5's medical record did not contain an AIMS assessment. On 9/25/24 at 1:17 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R5 was scheduled to have an AIMS assessment completed on 9/26/24. When Surveyor requested the facility's policy, DON-B indicated the facility's policy did not indicate if a baseline AIMS assessment should be completed. DON-B acknowledged a baseline AIMS assessment prior to the start of antipsychotic medication provided a comparison for symptoms in subsequent AIMS assessments.

Based on record review and staff interview, the facility did not ensure each resident received care consistent with professional standards of practice to prevent PIs (pressure injuries) from developing, promote healing and/or prevent infections of the PIs for 1 Resident (R) (R1) of 2 sampled residents reviewed for PIs. R1 developed a stage 2 PI to the crease of the buttock and a stage 2 to the right buttock on 1/30/19. The facility failed to have an RN (Registered Nurse) assess the PI until another PI developed on 2/3/19 to the left buttock. A temporary plan of care or plan of care was not initiated for the development of actual PIs on 1/30/19. Orders from the physician were not received back after the facility faxed a request for a dressing to the PI, and the facility did not follow up with the physician for orders related to the PIs. The facility failed to appropriately assess, care plan, and follow up with the physician regarding R1's PIs resulting in actual harm to the resident. Findings include: 1. On 2/26/19, the Surveyor reviewed R1's closed electronic medical record. The medical record indicated R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The electronic medical record included a 14 day scheduled MDS (Minimum Data Set)assessment dated [DATE], that documented R1 scored 4 out of 15 on the cognitive screen (the higher the score, the more cognizant; significant cognitive impairment in this case), required extensive assistance for bed mobility and transfer, did not ambulate, was at risk for the development of pressure injury, had two stage 2 PIs, and had a pressure reducing device for bed and chair. R1's skin observation tool, dated 1/31/19, documented the reason for the assessment was a weekly observation of skin. The skin observation tool indicated R1 had no skin impairments that had previously been identified and there were not any pressure injuries that were currently not being addressed/monitored. R1's Braden skin risk score assessment (scale for predicting pressure injury risk), dated 1/31/19, documented R1 was at risk for the development of pressure injuries with a score of 18. R1's mobility was slightly limited with R1 making frequent, though slight, changes in body or extremity position independently, R1 was chairfast with the ability to walk severely limited or nonexistent, and R1's usual food intake pattern was adequate. R1 did not have a plan of care or temporary plan of care related to having a potential for skin integrity from admission and did not have a plan of care or temporary plan of care related to having actual skin impairment after developing two stage 2 PIs on 1/30/19. R1's current plan of care, dated 2/4/19, indicated R1 had a potential for impairment to skin integrity related to weakness and mobility impairment. R1 had potential/actual impairment to skin integrity. Interventions with an approach start date of 2/4/19 included: ~ administer meds/vitamins as ordered ~ follow facility protocols for treatment of [REDACTED].>~ keep skin clean and dry. ~ meds/labs/treatments as ordered ~ pressure reduction bed ~ pressure reduction chair On 1/24/19 at 11:25 AM, a skin observation tool was completed for R1 on admission. There were not any skin impairments identified on the skin observation tool. On 1/24/19 at 5:56 PM, the progress notes indicated R1 was admitted to the facility today at 11:05 AM with no skin significance observed. On 1/30/19 at 3:19 AM, the progress note written by LPN (Licensed Practical Nurse)-A indicated R1 had an open slit noted to coccyx area measuring 7.5 cm (centimeters) x 0.5 cm and a small open area to the right mid buttock measuring 1.0 cm x 0.5 cm. Slit area to coccyx moist. [MEDICATION NAME] applied. Physician updated. On 1/30/19 at 6:09 AM, a fax was sent to the physician office. The fax indicated R1 had an open slit to coccyx measuring 7.5 cm x 0.5 cm along with small open area to mid right buttock measuring 1 cm x 0.5 cm. (MONTH) we have orders for [MEDICATION NAME] and change every three days and as needed? The fax was not received back at the facility and the facility did not contact the physician again regarding the development of PIs until 2/3/19 when another PI developed. On 2/3/19 at 9:30 AM, the progress note written by LPN-B indicated R1 had a pressure injury acquired in house incident on 2/3/19 at 8:00 AM. Incident details indicated initially two areas were found on 1/30/19 by night shift. Dressing had been applied. A new third open area measuring 1 cm x 0.5 cm was found this morning on left inner buttock while doing cares. R1 now has a total of three open areas on inner buttocks/coccyx. Areas measure 7.5 cm x 0.5 cm to coccyx with small slough in center. Smaller area on right inner buttock measuring 1.0 cm x 0.5 cm. Despite treatment and dressing in place, wounds continue to worsen due to refusal of R1 to be repositioned with dislocated shoulder and incontinence. No signs of infection. No exudate. Cleaned with saline and [MEDICATION NAME] applied for protection. R1 described area as sore and was given Tylenol and repositioned for comfort. Immediate care plan interventions included air mattress applied to bed and strict repositioning schedule applied. New orders to be in place after physician comes to look at wound today. On 2/3/19 at 10:50 AM, the progress note written by LPN-B indicated R1 had three open areas on inner buttocks/coccyx. Areas measured 7.5 cm x 0.5 cm along coccyx and had white slough in center. Smaller area on inner right buttock measured 1.0 cm x 0.5 cm. Newest PI found this morning was on inner left buttock and measured 1.0 cm x 0.5 cm. Treatment in place however continues to get worse due to refusal of resident to be repositioned with dislocated shoulder. New air mattress applied this morning. Educated R1 on need to stay off of buttocks as it will continue to get worse. R1 was cooperating and is laying on left side propped with pillows to keep R1 off of coccyx at this time. On 2/3/19 at 6:36 PM, the progress note written by LPN-C indicated R1 was seen by the physician tonight. Orders received included Vitamin C 500 mg (milligrams) daily, Prostat protein supplement 30 ml (milliliters) twice daily, alternating air mattress, Venelex ointment twice daily to three PIs topically, position change for R1 every two hours keeping pressure off the buttocks, and [MEDICATION NAME] gel applied to back/shoulders/knees three times daily for pain. A PUSH ( Pressure Ulcer Scale for Healing) Tool (used to measure the status of pressure wounds over time) completed by DON (Director of Nursing)-D dated 2/3/19 at 10:30 AM, indicated R1 had a facility acquired stage 2 PI to the right buttock measuring 1.5 cm x 1.5 cm x 0.2 cm that developed on 1/30/19. Area is on the right buttock near the crease. Staff apply ointment per order of the physician which keeps it fairly moist. There is slough coverage, 95% and 10% pink tissue surrounding. Worsening. A PUSH Tool completed by DON-D dated 2/7/19 at 10:32 AM, indicated R1 had a facility acquired stage 2 PI to the left buttock near crease measuring 3.5 cm x 2.0 cm x 0.1 cm that developed on 2/3/19. Wound to left buttock appears moist due to staff applying ointment. The area is covered with slough to about 70% with surrounding tissue remaining red. Worsening. A PUSH Tool completed by DON-D dated 2/7/19 at 10:39 AM, indicated R1 had a facility acquired stage 2 PI to the crease of buttock measuring 4.5 cm x 1.5 cm X 1.0 cm that developed on 1/30/19. This wound is in the crease of R1's buttock. It is covered with a moist slough 60% with 40% red tissue. Area is moist due to the prescribed ointment application. Worsening. On 2/8/19 at 10:47 AM, the progress note written by DON-D indicated a fax was sent to the physician asking the physician for a statement regarding R1's PIs being unavoidable due to R1's inability to change positions and refusals to let staff reposition R1 at times. On 2/8/19 at 2:27 PM, a telephone conversation with the physician office indicated the facility called the office requesting a referral to a wound clinic for unspecified PI stage. On 2/11/19 at 11:17 AM, the progress note written by DON-D indicated a note was received from the physician regarding R1's wounds. The note documented, due to chronic right sided extremity weakness due to polio, (R1) is unable to independently adequately reposition (self) from off (R1's) buttocks. (R1) is also extremely weak from (R1's) multiple chronic medical problems. This has resulted in coccygeal pressure sores. Additionally, (R1) also refuses to let staff reposition (R1) at times. On 2/13/19, R1's physician progress notes [REDACTED]. R1 has very foul, necrotic like odor and deep longitudinally oriented PI over the coccyx extending toward rectum and appears quite deep, the physician did not probe it. Less deep bilateral PIs over the ischial tuberosities. R1 was admitted to the hospital for IV (intravenous) antibiotics and irrigation and debridement of extensive pressure ulcer of the coccyx. Culture will be obtained. Alternating pressure bed. Once treatment of [REDACTED]. Impression: PI of coccyx, unspecified PI stage. On 2/26/19, the facility provided the Surveyor with the TAR (Treatment Administration Record) from 1/1/19 through 1/31/19. No site of administration data found for TAR. There were not any orders for treatment to PIs for R1 in (MONTH) 2019 even though the facility had requested a treatment on 1/30/19 for R1's PIs. On 2/26/19, the Surveyor reviewed R1's discharge summary from the hospital. Date of admission was 2/13/19 and date of discharge was 2/19/19. The principal discharge [DIAGNOSES REDACTED]. R1 was started on IV antibiotics for the decubitus ulcer and wound cultures were performed. Informal consult with wound nurse was made. The wound nurse suggested normal saline irrigation of the wound daily. Then apply Santyl and gauze to the central ulcer and cover with [MEDICATION NAME]. Duoderms cut to size were suggested for the superficial lateral buttock ulcerations. These dressing changes were performed daily and R1's wound showed much improvement. The wound culture grew back small amounts of normal skin and GI (gastrointestinal) flora. Was changed to an oral antibiotic. At the time of discharge, the wound size was decreasing. R1 was kept off buttocks and position changes were performed every two hours. A 5 cm x 7 cm decubitus ulcer was noted in the buttock crease superior to the anus. White devitalized tissue in the wound base with two 1 cm x 1 cm areas of eschar in the wound. No granulation tissue was noted. One superficial 1 to 2 cm ulceration is located lateral to the large decubitus wound on the left buttock. A few smaller superficial ulcers are lateral to the large decubitus ulcer on the right buttock. On 2/26/19 at 1:45 PM, the Surveyor interviewed DON-D regarding R1's PIs. DON-D verified DON-D was not WCC (wound care certified) and the facility did not have a WCC nurse. DON-D stated the facility uses the wound clinic when a resident develops a wound. DON-D then stated, We don't have as much documentation as we should on PIs for (R1). On 2/26/19 at 2:43 PM, the Surveyor interviewed DON-D regarding R1's PIs. DON-D verified R1 had a slit on the coccyx to start. The slit got worse which was why DON-D put the PI at a stage 2 on 2/3/19 when assessed. A&D was ointment from a standing order was used to start on R1's PI while waiting for the physician to respond from the fax dated 1/30/19. DON-D confirmed the facility follows the NPUAP (National Pressure Ulcer Advisory Panel) guidelines for the prevention and treatment of [REDACTED]. On 2/26/19 at 3:40 PM, the Surveyor interviewed RNC (Regional Nurse Consultant)-E regarding the TAR from (MONTH) 2019 not having any treatment documented for R1's PIs which developed on 1/30/19. RNC-E confirmed there was not a treatment ordered in (MONTH) 2019 for R1's PIs because the order that was sent to the physician requesting a [MEDICATION NAME] dressing on 1/30/19 was never returned to the facility from the physician and no one at the facility attempted to call the physician when an order was not received for the treatment of [REDACTED]. On 2/26/19 at approximately 4:00 PM at the exit conference, DON-D indicated the initial assessments completed on R1's PIs were in DON-D's head (as DON-D was pointing at her head), not written on paper. On 2/27/19, the facility sent further information regarding R1's PIs to the Surveyor. The information sent included documentation on a notebook regarding R1's PIs. A notebook entry indicated R1 had a slit on butt on 1/30/19. On 1/31/19, the notebook documentation indicated R1 had a slit on coccyx measuring 7.5 x 0.5 and right mid butt 1 x 0.5. The notebook did not indicate staging of the PIs nor other pertinent information related to PIs, and was not signed by DON-D or an RN (Registered Nurse). On 3/5/19 at 2:35 PM, the Surveyor interviewed CRN (Clinic RN)-F regarding R1's PIs. CRN-F verified the clinic had received a fax from the facility on 1/30/19 regarding R1's PIs. Another physician was on call for R1's physician. The other physician signed the fax on 1/30/19 and CRN-F faxed the signed request back to the facility at 9:51 AM. It was not known the facility did not receive the fax back on 1/30/19 as the facility did not call back regarding R1's PIs until 2/3/19. On 2/3/19 the facility advised the clinic that R1 now had three PIs that showed up last week. The facility was asking how to care for the PIs. A physician on call for R1's physician went to the facility and spoke with the nurse. While at the facility, the physician ordered Vitamin C, a protein supplement, to reposition R1 every 2 hours, alternating air mattress, and Venelex ointment to be applied twice daily. On 2/8/19, the facility requested a referral to the wound clinic as R1 was refusing to reposition due to pain.

Based on observations, staff and resident interviews and record review, the facility did not ensure 1 resident (R1) of 6 sampled residents received adequate supervision to prevent accidents. R1 had a long and recent history of multiple falls. R1's revised care plan interventions that were put into place after each fall were not consistently implemented. On [DATE], R1 sustained a fall with a resultant fractured left hip. Care plan interventions to include cueing the resident to lay down after the evening meal, toileting the resident after the evening meal, and keeping the resident within sight after the evening meal and until the resident went to bed were not completed. Surgical intervention could not be performed as the result of R1's advanced age and comorbities. R1 returned to the facility on bed rest with a Foley catheter in place to limit the need for repositioning, was placed on narcotic medications to control pain, and was placed on end of life comfort care only. R1 expired on [DATE]. Additionally, the facility did not conduct a through investigation into R1's fall that occurred on [DATE], to determine the root cause of the fall in order to implement appropriate interventions to prevent like falls. Facility failure to adequately supervise and consistently implement fall prevention care plan interventions for R1 created a finding of immediate jeopardy on [DATE]. The facility was notified of the immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. This is evidenced by: R1 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. At the time of survey, the resident's age was 98. R1's current fall CAA (Care Area Assessment) which triggered as a result of R1's annual MDS (Minimum Data Set) assessment dated [DATE], documented at risk for falls due to past history of falls, decreased balance and requires staff assist with toileting. Resident is aware of need for assist with toileting, will attempt self transfers at times. Chair and bed alarm in place. R1's most current MDS assessment dated [DATE], documented the facility had assessed the resident to score 5 of 15 on the cognition screen (the higher the score, the more cognizant); required extensive assistance from staff to complete all activities of daily living; was not steady, only able to stabilize with staff assist when moving from a seating to standing position, when moving on and off toilet, and during surface to surface transfers; was 56 inches tall and weighed 112 pounds; and had sustained 2 falls with no injury and 1 fall with injury (except major). Review of R1's medical record included the following documentation: ~ [DATE] at 00:06 Had an unwitnessed fall resulting in a head injury. Has some bruising at hairline across forehead. Alarm sounded. Appears pulled self out of wheel chair by using the assist rail. Sent to the emergency room with no new orders. Immediate care plan intervention: Assist resident with cares and to bed prior to 10:00 p.m. or earlier if resident requests. ~ [DATE] at 19:16 Resident found sitting up on buttocks with back resting on the wheel chair and feet under the bed with knees slightly bed. Stated fell trying to get self into bed. Was trying to self transfer into bed after supper. No injury. Immediate care plan intervention: Assist resident to bed after meals as resident allows. ~ [DATE] at 14:00 Resident found on floor tangled up in wheel chair with the foot pedal between legs and lying on the other foot pedal under the left side of torso. Stated, I just fell . Resident unable to explain in detail. Found at the end of A-wing. Bruising noted to left hand on [DATE]. Verbal permission to move to a room right near nursing station when room becomes available due to on going confusion for closer monitoring. Be sure call light within reach and encourage resident to use it for assistance as needed. Immediate care plan intervention: Remove pedals from wheel chair when self propelling. ~ [DATE] at 21:05 Resident found sitting on the floor in the front lobby between wheel chair and couch. Legs out in front in sitting position. No injuries noted. Has increased confusion during the evening hours. Immediate care plan intervention: Keep within site of staff after evening meal until goes to bed. R1's current plan of care relating to falls, initiated on [DATE], indicated the resident has a history of falls, and has had actual falls. Care plan interventions included: ~ non skid socks and/or shoes if needs to get out of bed (implemented [DATE]) ~ therapy evaluation and treat as ordered (implemented [DATE]) ~ toilet at 7:00 a.m., before and after meals, before bed and every 2 hours at night (implemented [DATE]) ~ continue interventions under at risk plan (implemented [DATE]) ~ bed alarm (implemented [DATE]) ~ body pillow while in bed (implemented [DATE]) ~ chair alarm (implemented [DATE]) ~ keep within sight of staff after evening meal until goes to bed (implemented [DATE]) R1's care card, utilized by direct care staff included all the above mentioned fall interventions. Additional documentation in R1's medical record include the following: ~ Unwitnessed incident on [DATE] at 7:45 p.m. Writer alerted at 19:45 (7:45 p.m.) by another client that resident (1) was on the floor at end of A wing lounge. Resident was found with head to the right side of couch, next to the garbage can. Resident was laying on right side. Right shoulder and arm were beneath (the resident). Right leg was folded underneath the resident, with left leg extended. Resident was found with skin tear to left forearm/elbow. Resident's right shoe and glasses were off, next to head. Resident complained of pain to left hip. Sent to hospital via squad. Immediate plan of care intervention: Every 30 minute checks. ~ [DATE] at 8:00 p.m., resident was assessed post fall to have an oxygen saturation level of 91% on room air, was afebrile, and had normal ranges of respiratory rate, heart rate, and blood pressure. R1's emergency room documentation dated [DATE] indicated, skin tear of elbow without complications, left. Has a fracture of the left hip. This will require resident to be bed bound. May use Tylenol with Hydrocodone ,[DATE] (a narcotic pain reliever) 1 to 2 tablets every 6 hours as needed for pain. A Foley catheter has been placed to limit the need for moving the patient. Discussed the finding with the patient's POA (Power of Attorney). Resident also has a skin tear to the left elbow which has been cleaned and dressed per the nursing staff. Continue with usual local wound care as needed. The resident was transported back to the facility on [DATE] at 10:44 p.m., and was to be placed on end of life comfort care measures. R1's medical record included nursing documentation indicating the resident required 10 doses of the ordered PRN (as needed) narcotic pain medication from [DATE] through [DATE], after R1 was readmitted post left hip fracture. On [DATE] at 6:20 a.m., the resident expired. On [DATE], NHA (Nursing Home Administrator)-B initiated an investigation into the fall sustained by R1 on [DATE]. Documentation included an interviews with R5, who initially discovered R1 on the floor, LPN (Licensed Practical Nurse)-D, who was the first nurse to assess R1 after the fall, CNA (Certified Nursing Assistant)-E, who was assigned to care for R1 on the evening of the fall, and additional facility staff working the evening of [DATE] who had knowledge of R1's fall. All of the documented statements did not address and/or include evidence whether or not R1's chair alarm had been sounding or if the chair alarm had been placed on the resident's chair prior to the fall. The investigation did not indicate whether other fall care plan interventions which had been implemented previously for R1 had been followed. The investigation did not include the following documentation: ~ evidence whether or not staff had tested the chair alarm ~ whether or not the chair alarm had been on the chair ~ whether or not R1 had been toileted after the evening meal ~ whether or not staff had offered R1 to lay down after the evening meal ~ why R1 was at the very furthest point from the nursing station in the A wing day room, out of staff view and unsupervised at the time of the fall. On [DATE], NHA-B summarized the fall incident and root cause of R1's fall as follows: At approximately 7:45 p.m. on [DATE], resident (1) was found on the A wing day room lying on the floor by resident (5). Upon discovery, resident was assessed by nurse and was found to be complaining of hip pain. Due to the complaints of hip pain, resident was transferred to the emergency room . Resident was unable to state what was attempting to do at time of fall. Witness statements were obtained and chart review was completed. (R1) had been observed at 7:30 p.m. by (CNA-E) as she was coming out of a room after providing cares. As (CNA-E) was coming out, stated she saw (R1) self propelling down the hall toward her. (CNA-E) stated that she (CNA-E) was headed to the B wing to assist with a resident. At approximately 7:45 p.m. is when the resident was observed lying on the floor just minutes after being observed by CNA. The wing that (R1) was heading down was the wing that she had been recently moved from. (R1's)room was recently moved from (a room far from nursing station on A wing to a room very near the nursing station on A wing) to be closer to the nurse's station. (R1's) care plan had been reviewed which indicated a chair alarm. At the time resident was found, the alarm was in place but staff do not recall it was sounding. When alarm tested by writer, it was found to be in working order. Considering it was in good repair post fall test, we can only conclude that the alarm may have failed to sound on that particular occasion which was unforeseeable. Accordingly, not withstanding the fact that it appeared to be in good working order post fall, we nonetheless replaced it to be safe. We identified one like resident with an alarm which was tested and found to be in good working order. On [DATE], resident returned to the center. The hospital did not recommend surgical intervention for resident due to comorbidities, age, and frailty. The family was in agreement. The resident's order included bed rest and pain management. On [DATE], resident expired. Upon conclusion of investigation, it can reasonably be concluded that resident had been propelling down the hall on which had recently resided possibly looking for old room. Resident had been receiving therapy services for strength improving therefore, feeling more confident with self transfer. Resident unable to state what was attempting to do at the time of fall so it is indeterminate as to the cause. It was also determined that caregiver misconduct did not occur. The root cause analysis of resident 1's fall with resultant hip fracture on the evening of [DATE] was not conducted in a thorough manner. The summary included R1's care plan had been reviewed, without addressing the following care plan interventions: ~ whether or not the resident's chair alarm functioned or if the alarm had been placed on the chair immediately post fall, as the alarm was not checked by staff until the day after the fall and staff interviews did not indicate staff were questioned regarding the alarms status. ~ toileting immediately after the evening meal ~ if staff had offered to lay the resident down after the evening meal ~ the reason R1 had not been consistently observed by staff after the evening meal until was in bed for the night had been implemented. The facility implemented staff education in the form of a memo that required staff to read and sign off on that indicated, All resident's care plans must be reviewed prior to performing care. When performing cares, the care plan should be followed completely. If there are any questions as to the information included in a care plan or how to perform a task on the care plan, staff must ask their nurse on duty or contact the Director of Nursing for clarification. At the time of this investigation survey, no additional actions had been taken by the facility to ensure staff where consistently following resident care plan interventions. When Surveyor reviewed the above information, the root cause of resident 1's fall, which was stated to be a non functioning chair alarm, did not correspond to the facility's plan to prevent like falls, rather it focused on following resident care plan interventions but was not specific to fall care plan interventions for residents. On [DATE] at 7:20 a.m., Surveyor interviewed LPN-A regarding R1. LPN-A stated, (R1) went to the emergency room after a fall with a fractured hip. Due to age, it was decided not to repair the hip because the resident would not survive the surgery. The resident came back to the facility and passed away within days of the fall. The resident was to go on Hospice services the day after dying. The resident had a history of [REDACTED]. On [DATE] at 8:30 a.m., Surveyor interviewed NHA-B regarding R1. NHA-B stated, (R1) was recently moved from a room at the end of A wing to a room closer to the nurses station. (R1) was found at the very end of the A wing hall in the day room. The resident had been up in the wheel chair and was last seen at 7:30 p.m. (on [DATE]) and was found on the floor at about 7:45 p.m. No one heard the alarm. I know it was working the day of the fall because I heard it go off while the resident was squirming in the chair when I went to see (resident's) family member. That was about 3:30 p.m. or 4:00 p.m. I tested the alarm the next day ([DATE]) at 8:15 a.m. and the chair had already been moved out of the A wing day room. The chair alarm had not gone off when the resident fell . Staff stated they looked at the alarm at the time of the fall and it was plugged in correctly but not one sat in it and tested it. Another resident found (R1) on the floor. (R1) came back from the emergency room the same night ([DATE]) with a [DIAGNOSES REDACTED]. The first staff member, (LPN-D) to see the resident on the floor stated the alarm was not sounding. I did not ask questions of the staff about the alarm status until after our consultant reviewed staff statements after the fact. (CNA-E) was taking care of (R1) that evening ([DATE]) and she stated the resident's alarm had not sounded at the time of the fall. I went back and asked staff including (LPN-G) after I had completed the initial interviews, I am not sure of the date when I did that, and I did not add that to the investigation that was sent to the state. Originally I did educate (CNA-E) verbally on [DATE]. We are still working on the education for the rest of the staff. Some have not worked since the investigation. The education was to make sure staff were following resident plans of care, not on checking alarms to ensure they were functioning and how often alarms should be checked. On [DATE] at 8:55 a.m., Surveyor interviewed R5, who was assessed to be alert and oriented in all three spheres. R5 stated, I usually watch television in the day room at the end of the A wing hall. I was going down there and I saw an empty wheel chair just at the opening of the day room. There was no alarm ringing. I turned the corner to the right into the day room and saw (R1) on the floor with (resident's) head about 5 feet from the wheel chair and legs about a foot from the wheel chair. One shoe was off and was laying on one side on the floor. I went looking for staff and had to go down the hall quite a ways and called to the nurse (LPN-D) and told her that (R1) was laying on the floor. (LPN-D) told me she would be down there in a minute so I walked back to be with (R1). I know what (R1's) alarm sounds like because she would often lean forward in the wheel chair and would set off the alarm. At that time, R5 and Surveyor walked down to the A wing day room. R5 described where R1's wheel chair had been located ([DATE]) and where R1 had been found on the floor. It was noted by the surveyor that the A wing day room was the furthest point on the A wing from the nurses station. The day room is shaped like a T off the end of A wing. R5 indicated R1 had been lying on the floor in an area where the resident could not be visualized from anyone coming down the A wing hall way or by anyone seated in the the nurses station. On [DATE] at 9:00 a.m., Surveyor reviewed R1's documented alarm check record which indicated on [DATE], the alarm was documented as checked at 12:47 a.m. and last at 10:33 a.m. On [DATE] at 9:15 a.m., Surveyor interviewed LPN-D via the telephone regarding R1. LPN-D stated, (R1's) alarm was not alarming. We didn't test it right after the fall (on [DATE]). I don't recall if the alarm was actually on the chair or not at the time of the fall. I know the alarm was working when the resident was working with therapy earlier in the shift because I heard it. I called the DON (Director of Nursing) when the fall occurred ([DATE]). The administrator did not ask me about the alarm. I was called the next day ([DATE]) at home, and I wasn't asked about the alarm then, nor was I asked when I came into work the evening of [DATE] when I saw the Administrator. R1 was to be toileted right after supper, which is around 6:00 p.m. to 6:30 p.m., was to be put into pajamas and asked if wanted to go to bed after supper, and staff were supposed to keep (R1) in sight at all times in the evening until was laid down for the night. The education I got after the fall was to follow resident care plan interventions and to check alarm functioning more frequently. On [DATE] at 9:10 a.m., NHA-B approached Surveyor and stated, (R1) was recently moved from a room at the end of the A wing to a room on A wing closest to the nurse's station. The resident's plan of care included a toileting program. (CNA-E) stated to me that she did not toilet (R1) immediately after supper (on [DATE]), that she could recall and that was not charted either. (R1's) plan of care also included the resident was to be assisted to bed after the evening meal if allowed, for safety. (CNA-E) did not even attempt this (on the evening of [DATE]). R1 was to be kept within eye sight of staff after the evening meal until the resident went to bed. This was not done. CC (Corporate Consultant)-C reviews everything on a self report before we submit it. (R1) was a frequent faller. I was directed by corporate not to state anything about not following (R1's) fall plan of care and the self report should be generic. I don't think they were trying to hide anything. I did ask staff about the alarm and was told not to put those statements in writing. (R1) was last seen (on [DATE]) at 7:30 p.m. and found on the floor about 7:45 p.m. I believe all staff stated the alarm had not been sounding, but I don't know if I specifically asked staff if the alarm was on the chair and if it was sounding or not, so I didn't put that in the statements. I stated in my conclusion that the alarm was in place but not sounding because I thought I asked at least one staff member and they told me yes, but I don't recall who that was. (CNA-E) got called to another resident's room and didn't redirect (R1) to a supervised area. I didn't put that in (CNA-E's) statement. That's why I did following resident plan of care intervention education for (CNA-E). Per corporate, I did start that same education for the rest of the staff. I put a note up for all staff to read and sign. On [DATE] at 10:00 a.m., Surveyor interviewed DON-F regarding R1. DON-F verified to the surveyor that on the evening of [DATE], LPN-D called and spoke with her regarding the fall sustained by resident 1. DON-F stated, I usually ask if the resident is in pain, ask about the plan of care, and asked if the alarm was in the chair. (LPN-D) told me the alarm was on the chair, but not working. (LPN-D) told me the alarm had been working prior to 4:00 p.m. that day ([DATE]). I didn't know about the resident not being toileted, but I knew the resident was not within eye sight of staff and I told them the resident had to be within line of sight. I told staff to change the chair alarm, but didn't direct them to test it. On [DATE] at 10:10 a.m., Surveyor interviewed LPN-G via the telephone regarding R1. LPN-G stated, (The evening of [DATE]), (R1's) alarm was not sounding. I'm not sure if the alarm was on the chair or not. I wasn't that resident's nurse that evening, so (LPN-D) talked with the DON, not me. On [DATE] at 11:30 a.m., Surveyor interviewed CNA-E via the telephone regarding R1. CNA-E stated, (On the evening of [DATE]), (R1's) alarm did not sound. The alarm was on the chair. I checked the alarm at 4:30 p.m. or 4:45 p.m., and it was activated. I didn't toilet (R1) or ask if (R1) wanted to lay down after supper. I was on another wing (B wing) when (R1) fell . I did not make sure (R1) was placed in an area within eye sight of another staff member. The NHA did mention about the alarm. I told her it was on the chair. I wasn't asked if it alarmed. I got education about following the plan of care of toileting, asking residents to lay down after supper and making sure the resident was in eye sight of staff after supper. (R1) was doing fine prior to the last fall. I hadn't seen any recent great physical or mental decline. I worked with (R1) a lot. On [DATE] at 3:30 p.m., Surveyor interviewed MD (Medical Doctor)-H regarding R1. MD-H was R1's primary care provider. MD-H stated, After (R1's) fracture, it was decided the resident was not a surgical candidate. The resident was sent back to the nursing home for comfort care. End of life care was put into place after the fracture. The resident was [AGE] years old, had declines, and was frail. Due to dementia and age, surgery was not an option. The outcome would have been different if the resident had been younger, say 80, and could have had surgery. If that were the case, the resident would probably have made it through. According to an article at verywell.com entitled How Dangerous is a Broken Hip when you are Older, published in May of 2016 by Sharon Basaraba and reviewed by a board-certified physician: Falls have the dubious honor of being the top cause of injury and injury-related deaths in people older than 65. Mortality rate after a broken hip: A few different research studies have investigated the mortality rate after a hip fracture. For example, a 2011 paper published in the Journal of the American Medical Association (Internal Medicine) investigated a total of 5,580 older women over a period of almost [AGE] years. The women were recruited from four regions in the United States between ,[DATE], for the Study of Osteoporotic Fractures (SOF). The mortality rate was double among the women who'd suffered a broken hip in the first year after injury. In other words, during the 12-month period after breaking their hip, those women had twice the risk of death, when compared with women of a similar age without a hip fracture. More than half the deaths occurred within the first three months after a break. Previous studies, such as a meta-analysis published in 2010 in the Annals of Internal Medicine, have shown an even higher rate of short-term mortality after a hip fracture. In this review of studies published between 1957 and 2009 (involving a total of 578,436 women and 154,276 men over the age of 50), researchers from Belgium and the United States found the risk of death in both men and women in the three months after a hip fracture to be between five and eight times higher. The facility's failure to adequately supervise and consistently implement fall prevention care plan interventions for R1 created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], by which time it had completed the following: ~ [DATE]- R1's care plan was updated with re-admission. ~ [DATE]- additional measures were taken which included: * All alarms where audited to verify they were in correct operating order. * Validated that all residents with alarms had a task in Pointclickcare to test every shift. * TARs (treatment administration record) updated to have alarm audited by nurses every shift. * TARs updated to change battery every three months. * NHA completed verbal education with CNA regarding following the plan of care and following care plan interventions. * Validated standard protocol of highlighting changes to careplans which are placed at the nurses ' station for all staff to review before working their shift was in place. ~ [DATE], mandatory all-nursing staff training was provided regarding following care plans. ~ [DATE], all custom care plan interventions were reviewed and modified as necessary. ~ [DATE], * Initiated new fall risk assessments on all residents and updating care plans accordingly. * Additional training regarding policies and procedures provided. * Audits have been developed and will be completed per designated audit schedule. These audits include: Fall intervention audit tool, alarm tracking, and comprehensive care plan which include the bowel and bladder program. Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the center ' s QAPI (Quality assurance performance improvement) Committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits will be determined at that time. If issue are identified, re-education will be done. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as needed.