Every finding on record at Blue Palms Health and Rehabilitation Center at Fle

Based on observations, interviews and record review, the facility failed to respond to grievances appropriately for two residents (#12 and #13) out of three residents reviewed for grievances.Findings included:1.On 03/17/2026 at 10:15 a.m. an interview was conducted with the SSD (Social Services Director) about grievances. SSD stated that the residents could obtain the grievance forms from the pamphlet holder outside of the social services room. Once completed, they would give SSD the grievance form who would make copies and discuss the grievances in morning meetings. According to the area of concern the SSD would give the grievance to that department to investigate and resolve. This process would take three to five days. If the grievance was not resolved in three days, SSD would follow up. Another way residents could file grievances was during angel rounds where department heads would address resident's concerns.Review of a Resident admission Record dated 03/18/2026 showed Resident #12 was admitted to the facility on [DATE] with diagnoses including but not limited to: unspecified fracture of left patella, muscle wasting and atrophy, disorders of muscle, unspecified abnormalities of gait and mobility, cognitive communication deficit, essential primary hypertension, and unspecified glaucoma.Review of a Brief Interview for Mental Status (BIMS) dated 3/2/26, showed a BIMS score of 15, indicating Resident #12 was cognitively intact.Review of the care plan for Resident #12 showed a focus initiated on 03/08/2026 [Resident #12] needs assist with ADL care related to multiple factors including weakness/decreased mobility s/p recent hospitalization/illness. Intervention included To assist with all ADL tasks and toileting tasks.Review of the care plan for Resident #12 showed a focus initiated on 03/08/2026 [Resident #12] is at risk of falls. The goal showed Resident will ask for assistance with transfer and/or toileting through the review date. The intervention included The resident was to use call light for assistance as needed.Review of the care plan for Resident #12 showed a focus initiated on 03/08/2026 [Resident #12] is at risk for falls related to fracture of left knee, history of falls, incontinenceOn 03/17/2026 at 10:50 a.m. during an observation and grievance review, Resident #12 stated that she was unaware of who filed the grievance on her behalf. Resident #12 said sometimes the wait is long for a Certified Nursing Assistants (CNAs) to respond. As a result, the resident reported occasionally going to the bathroom without assistance.On 03/17/2026 at 11:03 a.m. an interview with Staff C, LPN (Licensed Practical Nurse) who started working at the facility a few weeks ago stated they did not know the facility's grievance process. However, based on their experience, they assumed a form was available somewhere.On 03/17/2026 at 2:49 p.m. an interview was conducted with Resident #12 and a family member about the grievance that was filed by Staff B, Housekeeping Director. The grievance stated on the form was Resident Stated it was hard to get a CNA to help them to the bathroom. The action taken to resolve complaint/grievance was Staff reminded resident that dining room was closed due to RSV [Respiratory Syncytial Virus] outbreak in facility and for the safety of the resident we strongly recommend for all residents to stay in the room. The final resolution stated on the grievance was Resident satisfied and the document was signed off by the SSD (Social Services Director). Resident #12 was confused and stated they had never been to or wanted to go to the dining room. Resident #12 and the family member expressed confusion about where the dining room issue came from. Resident #12 stated no one had come to talk to them about this grievance being resolved so they did not know why the form said, Resident satisfied.On 03/18/2026 at 2:26 p.m. an interview was conducted with Resident #12 about the grievance resolution. The residents stated they had never wanted to go to the dining room. The resident confirmed they were in their own room when they needed the CNA's assistance to go to the bathroom. Resident #12 said they never leave their bed unless they go to therapy. Resident #12 stated they had to go to the bathroom last night on their own again as staff took too long to answer the call light. Resident #12 stated SSD (Social Services Director) never came to discuss the grievance resolution otherwise Resident #12 would have corrected SSD about the dining room portion of the grievance. Resident #12 reiterated they did not know anything about the dining room portion and was confused by this.On 03/17/2026 at 3:25 p.m. a follow up interview was conducted with Resident #12 family member. They stated they have had so many issues, and the facility would always tell them they would file a grievance but nothing would be done after that. The family member said they would find the pajamas of Resident #12 soiled and no one attending the call light to help Resident #12. This grievance was not found in the logs. The family member stated there should have been a grievance filed for February 27th.Review of the Grievance Log showed there were no grievances filed for Resident #12 for 2/27/26 or throughout their stay at the facility other than the grievance about Resident #12 needing a CNA to assist them to the bathroom.On 03/18/2026 at 1:50 p.m. an interview was conducted with Staff B, Housekeeping Director who said they would check in on residents and their concerns during angel rounds. Staff B said Resident #12 complained about waiting a long time for their call light to be answered as they needed assistance from a CNA (Certified Nursing Assistant) to go to the bathroom. Staff B did not know where the dining room part on Resident #12 grievance form came from. Staff B does not speak to any residents about resolutions as Staff B was not responsible for that. Other people who take care of the issue were to do that. On 03/18/2026 at 2:16 p.m. an interview was conducted with DON (Director of Nursing) on the process for department heads handling grievances. DON stated no matter which department head did the angel rounds, the SSD (Social Services Director) would conduct the resolution. DON said SSD was to do the resolution for Resident #12. DON said multiple people did not need to sign the grievance, either the administrator or designee should have signed the grievance.On 03/18/2026 at 2:05 p.m. an interview was conducted with SSD (Social Services Director) about Resident #12 grievance form. SSD stated the resident wanted to go to the lunchroom bathroom however SSD explained to the resident they could not go due to the RSV outbreak. SSD stated there was no concern for Resident #12 memory as they had a 15 BIMS score. SSD stated the resident's family member was always at the facility, so the family member was probably going to the dining. SSD said they only spoke to Resident #12 about the resolution.2.Review of a Resident admission Record dated 03/18/2026 showed Resident #13 was admitted to the facility on [DATE] with diagnoses including but not limited to: polyarthritis, morbid obesity, anxiety, hyperlipidemia, sleep apnea, muscle weakness, muscle wasting and atrophy, need for assistance with personal care, chronic pain syndrome, and hypertension.Review of a Brief Interview for Mental Status (BIMS) dated 2/23/26, showed a BIMS score of 15, indicating Resident #13 was cognitively intact.Review of the care plan for Resident #13 showed a focus initiated on 12/22/2025 Resident is at risk for functional decline in mobility and selfcare. The intervention included Encourage resident to use bell/call light to call for assistance.Review of the care plan for Resident #13 showed a focus initiated on 01/02/2026 [Resident #13] is at risk for complications related to bowel and/or bladder incontinence. The intervention included Provide incontinence there with each incontinence episode as tolerated.On 03/18/2026 at 9:03 a.m. an interview was conducted with Resident #13 about their grievance for getting changed in a timely manner. The grievance form stated, Resident voiced concern on not getting changed in a timely manner. The action taken to resolve the grievance was Staff was educated on answering the call light in a timely manner. The final resolution on the form stated Resident satisfied. This grievance was signed off by SSD. Resident #13 stated they waited two and a half hours to get their brief changed. They would use the call light multiple times however staff would come in to turn it off and say they would be right back. During the night shift from Saturday night to Sunday morning, Resident #13 waited two and a half hours to get their brief changed. Then from Sunday night to Monday morning, they waited an hour and a half to get briefs changed. Resident #13 believed there might have been an issue with night staffing. A few days ago a nurse told Resident #13 they were the only nurse on the floor. While this interview was being conducted, the SSD (Social Services Director) walked into the room and asked if the resident needed anything to which they responded no. After the SSD left the room, Resident #13 stated they had never seen the SSD in their life. Resident #13 stated the SSD did not come in to discuss the grievance resolution with the resident. They didn't know what was done with the follow up, and the resident had not received the form back.On 03/18/2026 at 11:17 a.m. an interview was conducted with the Nursing Home Administrator (NHA) about the expectation for the grievance process. The NHA stated if the family or resident had a concern, they could fill out the form, or the facility would help fill it out. The form would be given to the SSD (Social Services Director) who then logged and copied it. Then it would be sent to the department the concern belonged to. The department head would resolve it and return it to the SSD. Then SSD would talk to the resident or family member(s) to let them know the grievance was resolved. SSD would also ask if the resolution was to their liking. Another way residents could fill out grievances was during angel rounds.On 03/18/2026 at 12:40 p.m. an interview was conducted with the administrator and DON (Director of Nursing) about the appropriate call light response timings. DON stated call lights should be answered at a reasonable time, but at most 10 minutes. The Administrator said the facility was conducting call light audits due to the call light grievances.On 03/18/2026 at 12:04 p.m. an observation was made of an interaction between a resident and the SSD (Social Services Director) in the social services office. The resident told the SSD anytime they used the call light, staff would not do anything because they would come in to turn it off and run out of the room. SSD says this would be discussed in a meeting and training would be provided.On 03/18/2026 at about 12:10 p.m. an interview was conducted with SSD (Social Services Director). SSD stated there was no section for other department heads to sign off on the grievance. SSD stated they always conducted the follow ups. After the department head resolved the grievance with the resident, they would give the grievance form to the SSD who would go back to the resident to make sure they were satisfied. Review of a policy titled Resident and Family Grievances Revised 07/15/2025, showed:It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal.Policy Explanation and Compliance Guidelines:2. The Grievance Officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; Issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations10. Procedure:d. The Grievance Officer Will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form.i. Steps to resolve the agreements may involve forwarding the grievance to the appropriate department manager for follow up e. The Grievance Officer, or designee, Will keep the residents appropriately appraised of progress towards resolution of the grievances. g. In accordance with the residence right to obtain a written decision regarding his or her grievance, the grievance officer will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation the written decision will include at a minimum: i. The date the grievance was received. ii. The steps taken to investigate the grievance.iii. A summary of the pertinent findings or conclusions regarding the residents concern(s)iv. A statement as to whether the grievance was confirmed or not confirmedv. Any corrective action taken or to be taken by the facility as a result of the grievance.vi. The date the written decision was issued

Based on record review and interview, the facility failed to implement their current written policy on resident abuse as it related to annual abuse, neglect, and exploitation training for 2 (Staff B and Staff C) of 6 staff members reviewed. Findings included: During staff record review it was determined that Staff B was hired on 10/2/2001 and last completed abuse training on 9/6/22. It was also determined that Staff C was hired on 10/5/22 and last completed abuse training on 10/5/22, which exceeded the annual training requirement. An interview with the Human Resources Manager on 06/19/2024 at 11:55 a.m. confirmed there was no written evidence that Staff B and C had completed annual abuse training as required. She further confirmed at that time the facility did not have an effective system in place to ensure that annual abuse training was completed as required. The facility abuse policy titled Abuse, Neglect, Exploitation, dated 10/17/22, page 3 of 5, showed under Section II - EMPLOYEE TRAINING - B. Existing staff will receive annual education through planned in -services and as needed. This required component of the policy was not met for 2 of 6 staff members reviewed - B and C. An interview with the Director of Nursing on 6/19/24 at 11:55 a.m. confirmed the facility abuse policy was current and should have been followed as it related to annual staff abuse training.

Based on observation, interview, record review and policy review, the facility failed to ensure adequate supervision and assistive devices to prevent an unwitnessed fall that resulted in serious bodily injury (nondisplaced fracture of second cervical vertebra) as a result of an over inflated air mattress that was not monitored by staff for one dependent resident (#44) out of the sampled two residents. Findings included: On 04/08/24 at 11:15 a.m. Resident #44 was observed in bed with a cervical collar around her neck. During an attempt to interview her, the resident did not speak. On 04/10/24 at 9:12 a.m. Resident #44 was observed in bed with a cervical collar around her neck. Fall mats were observed on both sides of the bed on the floor. A review of the Transfer/Discharge Report showed Resident #44 was admitted on [DATE] and had diagnoses to include nondisplaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing, bipolar disorder, dementia, psychotic disturbance, mood disturbance, anxiety disorder, contracture of the muscle, history of falling, abnormalities of the gait and mobility, contracture of the right hip, left hip, left hand, left knee, and right knee, depression, other fracture of upper and lower end of left fibula, reduced mobility, and unsteadiness on feet. Section C- Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], showed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating severe impairment. Section GG- Functional Abilities and Goals showed Resident #44 was dependent for self-care and mobility. A review of the Order Summary Report with active physician orders as of 04/10/24 revealed the following: Air mattress for prevention (08/09/23), and resident to wear cervical collar at all times, may remove for care and reapply every shift for pain (04/05/24). The Incident by Incident Type log provided by the facility showed the resident had an unwitnessed fall on 03/09/24 at 4:40 a.m. (actual time per progress note 3:50 a.m.) and an unwitnessed fall on 04/04/24 at 11:45 p.m. A review of the progress notes with an effective date range for 03/01/24 to 04/10/24 showed the following: 03/09/24 04:27- Resident found on the floor next to the bed at 03:50. 03/09/24 05:10- Situation- Resident was observed lying on her side on the floor next to the bed. Possible and/or actual contributing factors: Pressure reducing mattress too inflated. Assessment and Appearance: vital signs, ortho blood pressure, pain, and/or injuries: within normal limits. The resident complained of pain but unable to state where. Sent to the emergency room for evaluation and further treatment. 03/9/24 09:25- Resident found on floor face down next to bed at 03:50, resident was responsive when asked about pain. No visible cuts or bruises. Certified Nursing Assistant (CNA) assisted writer with getting resident back in bed, resident was lying on sheet that was on her bed which was used to lift from floor back into lowered bed. No visual injuries, 911 call, family member notified, hospice, and doctor notified. Emergency Medical Technician (EMT) arrived around 04:20. Ambulance service transported to local hospital to be evaluated. 03/13/24 14:14 (2:14 p.m.)- Resident was received at 1:45 pm back from a local hospital by ambulance with a diagnosis of cervical compression fracture due to a fall. Using Percocet for as needed (prn) pain every 6 hours. Resident was received with a collar that should only be removed for care and comfort. Results showed compression fracture in cervical vertebra (c2). 03/15/24 20:16 (8:00 p.m.)- She presented to a local hospital on 03/09/24 for an unwitnessed fall. Per hospital records, computed tomography (CT) of the neck showed acute c2 compression fracture. A neck collar was placed, and she was stable. CT of the cervical spine showed c2 with inferior and anterior osteophyte and vertebral body fracture. Continue cervical collar. The patient was seen today for acute/chronic care management. 03/22/24 13:41(1:41 p.m.)- No gross findings from C1 to C5. Non-diagnostic cervical spine series with non-visualization of the remainder of the inferior cervical spine. Fracture was not excluded. Recommend repeat diagnostic exam to include the inferior cervical spine or CT if unable to obtain appropriate images. 03/22/24 13:56 (1:56 p.m.)- Reviewed cervical spine x-ray. No gross findings from C1 to C5. Non-diagnostic cervical spine series with non-visualization of the remainder of the inferior cervical spine. Fracture was not excluded. Cervical collar in place. 04/05/24 05:43- Resident returned to facility at 05:00 with no new order. 04/05/24 00:01(12:01 a.m.)- Resident found on floor at 11:35 p.m., assessed for injuries, nothing visible observed, and no complaints of pain. 911 called and the resident was sent to a local hospital. 04/05/24 08:30- She was seen for follow up for a fall. She was sent to the hospital and returned with negative findings. Patient was placed on 15-minute checks per facility. Cervical collar in place. She was laying on her side with head of bed elevated. She denied any pain or discomfort. No edema. 04/05/24 09:21- Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months. Level of consciousness / mental status: intermittent confusion. Resident was chairbound / incontinent. Vision status: Poor (with or without glasses). Recent hospitalization history in last 30 days: Yes. Gait / balance: Decreased muscular coordination. Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Fall Risk Score: 14.0. 04/05/24 14:44 (2:44 p.m.)- Resident was reviewed this morning for being found on floor next to bed. The resident was on an air mattress with bolsters to provide spatial awareness. There was no injury noted. She denies pain at this time. She was unable to state what happened. She was sent out to the emergency room with negative findings. Care plan reviewed. Will place resident on 15-minute checks. Will provide mats at bedside bilaterally. Staff to post outside of door on all shifts. Care plan updated. 04/08/24 11:18- The resident was alert, on an air mattress, and good positioning on bed with 15-minute checks Check to prevent falls. The care plan with a Focus area of falls/injury showed Resident #44 was at risk for falls or injury related to history of transient ischemic attack (TIA) and falls initiated on 11/15/21 and revised on10/19/22. Interventions included the following: Assist to wear non-slick footwear that fits, initiated: 11/15/21. Call bell in reach, initiated: 11/15/21. Ensure adequate lighting for all activities, initiated: 11/15/21. Evaluate risk for falls with Fall Assessment Tool, initiated: 11/15/21. Keep areas free of obstructions to reduce the risk of falls or injury, initiated: 11/15/21. Maintain safety precautions as ordered, initiated: 11/15/21. Medication dose adjustment as ordered, initiated: 11/15/21. The resident uses a high back reclining wheelchair with L board for legs when out of bed, initiated: 10/19/22. Physician follow-up prn, initiated: 11/15/21. Staff to post outside room when charting, initiated: 04/05/24. Transferring - Full body lift assist of 2, initiated: 07/15/22. The care plan showed no new interventions after Resident #44 had an unwitnessed fall and sustained a nondisplaced fracture of the second cervical vertebra on 03/9/24. It was not updated until she had another fall on 04/04/24. An additional Focus Area for Resident #44 revealed: (Resident #44) has an ADL self-care performance deficit r/t (related to) CVA and decreased mobility, revised on 10/19/22. The interventions included: Bed Mobility - (Resident #44) requires total assistance from staff for bed mobility and use of bilateral 1/4 rails, Transfer - The resident is totally dependent on (X2) staff with full body lift for transferring. On 04/10/24 at 1:42 p.m. a telephonic interview was conducted with Staff F, Certified Nursing Assistant (CNA). He stated he worked the shift Resident #44 had a fall (3/9/24). It was a regular night and before he left for break, he checked on her and she was asleep. It was a quiet night. When he came from break, Resident #44 was observed on the floor and he went to get the nurse, Staff W, Licensed Practical Nurse (LPN). The resident was talking. Staff W, LPN checked her and they got her back in bed. Staff F, CNA, stated he changed her brief before EMS (Emergency Medical Services) came. She was really contracted. He was still working there (no longer works at the facility) when she returned from the hospital. She had a neck brace and a low bed. He never looked at the mattress. She was really small and didn't notice anything wrong with the mattress at that time. On 04/10/24 at 10:06 a.m. the Regional Nurse Consultant (RNC-1) reported Resident #44's family member presented to the building. He was upset, loud, and stated she was neglected and that caused her to fall. She and Staff E, LPN/Unit Manager met with the family member. They went through her care plan and showed him interventions they had in place. He talked about Resident #44's history with anxiety and was concerned she was having anxiety at night, so they ordered Sertraline. On 04/10/24 at 9:41 a.m. the Director of Nursing (DON) stated Resident #44 does not speak good English. She was very contracted and does not like to lay on her left side. She likes to lay on the right side and only wants to look out the door. The resident likes to look at her roommate because she thinks the roommate was her mother. Staff F, CNA was the assigned aide for the first fall. Staff had just gone in to check on her and shortly after she was on the floor. Staff W, LPN called 911 and they came to pick her up. She was diagnosed with a nondisplaced C2 cervical fracture. Resident #44 had an air mattress and there were no bolsters on the air mattress at the time of the first fall. After looking at the air mattress, it seemed like it was a hospice air mattress and looked like it was over inflated. They think the air mattress caused her to slide off the bed. The initial air mattress came from hospice. She replaced the air mattress with one of their air mattresses. The DON did not know if hospice was checking the air mattress or not. She looked at the air mattress and could not tell what the air mattress was set on. There were no numbers on the dial for her to see. The numbers were faded. For the air mattresses provided by the facility, they have push buttons. She did not know if the staff were checking the air mattresses. No one could tell her when she asked. The DON reported she spoke with staff and told them to make sure they checked the air mattresses but there was no documentation. The DON stated she had hospice come pick up the air mattress while Resident #44 was at the hospital and replaced it with one of their air mattresses. With the mattress she has now, she can see how it was adjusted. She now checks the air mattresses when she sees one in the room. The DON stated they added intervention to keep the bed in the lowest position. She confirmed the interventions were not reflected on the care plan and stated she would expect the care plan to be updated. Staff X, CNA, was the assigned aide for the second fall (4/4/24). Staff X, CNA reported in her statement that she heard talking and when she went in the room Resident #44 was on the floor. She yelled for the nurse. Staff W, LPN came down and she (Staff X) stayed with the resident while he called 911. Any forward motion such as a sneeze or cough, was determined to cause the second fall. Her body alignment was the issue. They do not use side rails, so bolsters were added to the air mattress after the second fall. When staff are not doing care, someone needs to be posted outside of Resident #44's door when charting. This was added to the care plan as an intervention after the second fall. She talked to her Administration about reporting the incident and because they didn't do anything to cause the accident, the first unwitnessed fall which resulted in a nondisplaced fracture of the second cervical vertebra was not reported. When asked why the second fall was reported and there were no injuries, the DON stated because a family member threatened to call the State Agency. She wanted to make sure she was covered so she reported the second fall. On 4/10/24 at 10:16 a message was left for Staff W, LPN. Staff W did not return the call. On 4/10/24 at 10:17 a.m. a message was left for Staff X, Certified Nursing Assistant (CNA), who was assigned to Resident #44 on the night (11:00 p.m. - 7:00 a.m.) of 4/4/24. Staff X did not return the call. On 04/10/24 at 1:08 p.m. the RNC-1 stated they did not have a policy related to checking air mattresses. If there was an issue they would contact Maintenance. Education was requested and was not provided related to checking the air mattress. Review of a policy titled, Fall Prevention Program, implemented on 10/17/22, revealed the following: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 5. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan or care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed . 6. When any resident experiences a fall, the facility will: d. Review the resident's care plan and update as indicated.

Based on observations, interviews with residents and facility staff, and review of the facility's records and policies, the facility failed to provide sufficient staff to provide meal assistance on one floor (second floor) of two floors for six (#32, #15, #30, #3, #18 and #54) of 17 dependent residents, and failed to respond to a call light for Resident #20 for two days (04/09/2024 and 04/10/2024) of a three day survey. Findings included: An observation on 04/09/24 of the lunch meal service revealed the residents in the dining room received their trays starting at 11:34 a.m. Resident #32 was the last one to receive her tray in her room at 12:45 p.m., having waited approximately one hour and twenty minutes. During a facility tour on 04/09/24 at 11:43 a.m. an observation was made of staff distributing trays on the facility's second floor dining room. The residents who eat in their rooms were observed waiting for their trays. An observation was made of Staff R, Certified Nursing Assistant (CNA) on 04/09/24 at 12:25 p.m. passing resident lunch trays on the 200 hall. He stated (Resident #15) was a feeder and he would be feeding him shortly. He walked into the resident's room with the tray, dropped off the tray and walked out. Staff R stated he did not assist him with the meal because (Hospice Staff-1) took over. Staff R stated (Hospice Staff-1) was willing to help feed the resident. On 04/09/24 at 12:38 p.m. an interview was conducted with Hospice Staff #1. She stated she did not know this resident ([#15). She stated she did not know how much he normally ate, she said, I'm here to see him for other things. I decided to assist with his meal because he was waiting. On 04/09/24 at 12:27 p.m. Staff R, CNA dropped off a tray for Resident #48. The resident was waiting to be assisted with meal. After approximately 5 minutes, the resident was observed being assisted by Hospice Staff-2. Staff R stated the Hospice staff was willing to feed the resident. On 04/09/24 at 12:28 p.m. Hospice Staff-1 was observed looking for towels. She was observed walking down the halls looking for linen carts. She asked, Where are the staff? Hospice Staff-1 found the towels and a gown and returned to change Resident #15. During this timeframe, Staff T, Licensed Practical Nurse (LPN) was observed on 04/09/24 from 12:11 p.m. to 12:35 p.m. at the nurses' station on the phone. On 04/09/24 at 12:29 p.m. Staff Q, CNA was observed grabbing a tray from the cart. She stated she was going to feed Resident #30. She stated there were two CNAs and one nurse working in this hall. She stated there were about seven residents that needed to be assisted with meals on her assignment. She stated sometimes it takes them a long time to feed all the residents. She stated she did not know if the food was cold. She stated the residents did not say anything about the food being cold. On 04/09/24 at 12:30 p.m. the Director of Nursing (DON) was observed assisting Resident #18 with a meal while standing. She was heard saying to the resident, It's the blind leading the blind. The DON stated she had come to assist with lunch. On 04/09/24 at 12:36 p.m. an observation was made of two residents' meal trays still waiting to be delivered. Resident #32 was one of the recipients. She was observed sitting in her wheelchair in the middle of her room. Resident #32 was not interviewable. She had not had lunch. An immediate interview was conducted with Staff S, Registered Nurse (RN) on 04/09/24 at 12:37 p.m The nurse confirmed Resident #32 was waiting to be assisted. He pulled the tray out, confirmed the meal ticket and put the tray back in the cart. He stated he had about six residents who needed to be assisted with their meal on his assignment. He stated it was tight during meals. He said, There are not enough hands. On 04/09/24 at 12:39 p.m. an interview was conducted with Staff C, CNA. She confirmed Resident #32 was still waiting to be assisted with her meal. She looked inside the meal cart and saw two trays. She said, Yes, they are still waiting to be assisted. The CNAs on this floor had been assisting other residents in the dining room. They just have to wait. On 04/09/24 at 12:41 p.m. Staff R, CNA stated Resident #32 waited over 45 minutes today. Staff R said, Yes, sometimes they wait an hour. There are too many residents that need assistance. There is no way to get everyone in a timely manner. The CNA stated they needed more help, especially during meal service. On 04/09/24 at12:45 p.m. Staff R, CNA was observed grabbing a chair from the nurses' station and proceeded to Resident #32's room. He was observed assisting her with the meal. An observation on 04/10/24 of the breakfast meal service revealed the residents on the second floor received their trays starting at 7:30 a.m. Resident #54 was the last one to receive his tray in his room at 9:01 a.m. having waited 1.5 hours. On 04/10/24 at 8:23 a.m. Resident #3 was observed receiving meal assistance from Staff U, CNA. The resident's roommate, Resident #30, was observed waiting to receive her breakfast meal. On 04/10/23 at 8:24 a.m. Resident #32 was observed sitting on her bed, awake. The resident was waiting for her breakfast meal. On 04/10/24 at 8:26 a.m. an observation was made of Staff C, CNA grabbing a meal tray and going into room [ROOM NUMBER]. She stated both residents were still waiting to be assisted with their breakfast meal. Staff C set a tray by the door bed. She walked back to the cart and grabbed another tray and set it by the window bed. On 04/10/24 08:43 AM an observation was made of Staff C assisting the resident in the door bed with her meal. Her roommate was observed waiting for her breakfast meal. On 04/10/24 at 8:29 a.m. an observation was made of Staff R, CNA assisting Resident #17 with her meal. Her roommate, Resident #18 was observed waiting for her breakfast meal. On 04/10/24 at 8:31 a.m. an interview was conducted with Staff A, CNA. She stated Resident #51 had been assisted with her breakfast, but they still had a few trays left. On 04/10/24 at 8:37 a.m. Staff R, CNA confirmed there were trays left in the cart. He confirmed he had helped one resident so far. He stated it had been approximately 30 minutes since the trays arrived on the unit. On 04/10/24 at 8:39 a.m., an observation was made of Staff R, CNA grab Resident #18's tray and proceeding to assist her. In an interview Staff R stated there were a few more trays left. On 04/10/24 at 8:40 a.m. an observation was made of Staff U, CNA assisting Resident #32. Across the hall, Resident #3 was observed spooning food to her mouth by herself and dropping a substantial amount on the floor and herself. Staff U had been assisting her earlier, but left her to assist another resident. Staff U stated she left her to finish up while she started assisting Resident #32 who had been waiting. An interview was conducted with Staff R, CNA on 04/10/24 at 8:44 a.m. He stated all the independent residents had eaten breakfast or were just finishing up. Staff R stated the first breakfast trays were delivered about 30 minutes earlier. On 04/10/24 at 8:45 a.m. an interview was conducted with Staff U as she walked out of Resident #32's room. She stated she still had Resident #54 and Resident #15 left. She said, They are waiting. There are four CNAs for the second floor. She stated it takes a long time to assist each resident. She said, if everyone would pitch in, it would help. She stated they assisted in the dining room first and then in the resident rooms. Staff U said, It can be a while. I don't want to give it a timeframe, but it takes very long. On 04/10/24 at 8:57 a.m. an interview was conducted with Staff A, CNA. She said, It takes a long time for the residents to receive their meal because we have four CNAs with 20 feeders. She said, It takes more time for the residents to eat so we need more people. That's a lot. Some need more help than others. On 04/10/24 at 9:01 a.m. an observation was made of Staff R, CNA assisting Resident #54 with his breakfast. On 04/10/24 at 9:25 a.m., an interview was conducted with the Food Service General Manager, (FSGM). He stated breakfast was delivered upstairs at 7:30 a.m. and lunch on 04/09/10 was delivered to the dining room at 11:34 a.m. He stated his expectation was that the resident should receive their meal immediately after it is plated, and no more than 30 minutes after the trays go. He stated he was aware there was a problem. He stated he had conducted an audit and identified the test tray on the cart returned to him at 1:35 p.m. He stated the residents should be served and eating within 30 - 45 minutes of the meal being plated. He stated he had attended a Resident Council meeting and the residents complained of trays taking a long time and food temps not being at par. He stated those complaints had lessened. An interview was conducted with Staff E, Licensed Practical Nurse/Unit Manager (LPN/ Unit Manager) on 04/10/24 at 9:45 a.m. She stated they had 17 assisted diners on the second floor and provided the list. She stated the expectation was for the CNAs and nurses to identify who needed to be assisted with dining and provide them the assistance. She stated the trays should not be left in the room until the resident is ready to receive assistance with the meal. Staff E LPN/UM said, We usually have about five to six CNAs. This morning, we had four CNAs and the unit secretary who is also a CNA should help. She stated it should take 30-45 minutes to have everyone fed from the time the trays come up. She said, There were a lot of assisted diners. She said, I can see how there can be short without the additional help. Staff E stated they looked at this issue in the past and decided certain staff should go upstairs and assist. She stated that a staff member who was supposed to help was out of the office and another one was in a meeting. Staff E said, We did not get them to help this week. The residents should not wait that long for their meal. On 04/10/24 at 9:53 a.m. an interview was conducted with the Food Service Coordinator (FSC). She said, We try to get the trays to the resident as quick as possible. There is a little interruptions. She stated they start with the independent people then the assisted residents. She stated the meal trays should be distributed within 10 minutes of receipt. She confirmed an hour, or more was not acceptable wait time. An interview was conducted with the Staffing Coordinator on 04/10/24 at 1:12 p.m She stated residents' acuity did not determine staffing numbers. She said, No, I go by what they tell me. I have a calculation sheet. I split the staff among the whole day. For the CNAs, the ratio is 1-20 and for the nurses the ratio is 1-40. She stated they were running with the new staffing mandate. She said every once in a while, I don't meet it, but it is never two days back to back. She stated this only happened when they had a late call -in and were unsuccessful trying to cover it. She stated they did not use agency staff. She stated if there were staffing shortages, she would always communicate with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). She said, If staff haven't picked up or I have a lot of open shifts I let them know ahead of time. She stated she was a CNA and she assisted if they were short or if we cannot get someone to come in. The Staffing Coordinator said, During meals other staff take turns assisting on the floor, including department heads. She stated they split up between the first and second floors. She stated there was no schedule. She said, We all jump in and pitch. I was not there yesterday for lunch, and was not here to assist with breakfast. She stated there were two staff members who could have assisted, but they were absent. She stated she had been told as long as they hit the numbers, they were okay. The Staffing Coordinator said, I understand we also need to be aware about the quality of care and meeting the residents' needs. On 04/10/24 at 1:40 p.m. an interview was conducted with the NHA, Regional Clinical nurses (RNC)- 1 and RNC- 2. The NHA stated he was notified as of yesterday there were meal assistance concerns. He said, I became aware as of yesterday. They said it is taking a long time, we have someone that is off, therapy should be assisting. It will be a true practice going forward. He stated on 03/11/24 they did not meet the staffing numbers due to call offs. It was not two days in a row. He said in that case they try and replace as best as they can. Leadership should step in and assist. He stated he had not been notified of concerns with residents waiting to be assisted with toileting. He stated he did not know. The NHA said, That is not our practice. Review of an undated facility document titled, Facility Assessment showed on page 15 of 46, B.2. Acuity - care requirements, [name of facility] staffs above state minimum requirements, with the specific focus on adequate CNA staffing to accommodate this greater need for additional assistance with the number of ADL's including daily care, bed mobility, transfers walk in room, toilet use, eating, dressing, and hygiene/grooming. The population at [name of facility] and the staffing levels provided are deemed sufficient based on resident satisfaction, QA/compliance committee data, resident council feedback, resident interviews and observations, clinical outcomes, and functional improvements. Review of a facility policy titled, Serving a Meal, dated 10/17/22, showed (12.) Remember that some residents take a long time to eat. Provide adequate time for the resident to consume the meal and offer to reheat foods as needed. Review of a facility policy titled, Nursing Services and Sufficient Staff, dated 10/17/22, showed it is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure residents safety and attain or maintain the highest practicable physical mental and psychosocial well-being of each resident. The facility's census, acuity and diagnosis of the resident population will be considered based on the facility assessment. Under policy explanation and compliance guidelines, (1) the facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with the resident care plans. A. Except when waved licensed nurses and B. Other nursing personnel including but not limited to nurse aides. (5) providing care includes but is not limited to assessing evaluating planning and implementing resident care plans and responding to resident's needs. 46234 An observation was made on 4/9/24 at 12:09 p.m. of the call light being activated in Resident #20's room. The call light remained on until Staff Q, CNA went to the room at 12:27 p.m.,18 minutes after it was activated. The call light was turned off and the CNA immediately exited Resident #20's room. A nurse was observed sitting at the nurses' station during this time. An interview was conducted on 4/9/24 at 12:28 p.m. with Resident #20. He said he needed to be changed because he was soiled. He said he is a quick change he just needed assistance. Resident #20 said the CNA came in and turned the call light off and told him staff were doing something with lunch and she would be back. Resident #20 said it always takes a while for call bells to be answered. Resident #20 reactivated his call light. An observation was made on 4/9/24 at 12:31 p.m. of Staff Q, CNA entering Resident #20's room, turning the light off. The resident was asked what the staff member told him. He said the CNA didn't say a word to him, they just turned the light off and walked back out. An observation was made on 4/9/24 at 12:48 p.m. of Staff R, CNA entering Resident #20's room to pick up his lunch tray. The resident was overheard asking the CNA if he was going to change him. The CNA said, Let me check and see which one [CNA] is down here. The CNA left the room and walked away. An observation was made on 4/9/24 at 12:54 p.m. of Resident #20 yelling out hello repeatedly from his bed. At 12:56 p.m. the Activities Director stopped and asked Resident #20 what he needed. He said, I've been waiting a while and he explained he needed to be changed. The Activities Director walked out of the room to find a CNA. An observation was made on 4/9/24 at 1:00 p.m. of Staff R, CNA returning to Resident #24's room and telling the resident, I can't find her so I will go ahead and change you. As Staff R was getting ready, Staff Q, the resident's assigned CAN, came out of a room from helping a resident eat lunch and said she would assist. Review of the Admission Record showed Resident #20 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, contractures, abnormal posture, and need for assistance with personal care. Review of Resident #20's Minimum Data Set (MDS) Section C - Cognitive Patterns, dated 2/27/24, showed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating he was cognitively intact. Section GG, Functional Abilities and Goals, showed he was dependent for toileting hygiene. Section H, Bladder and Bowel, showed the resident was always incontinent of bowel and bladder. An interview was conducted on 4/10/24 at 9:54 a.m. with Staff E, LPN/UM. She said call lights should be answered immediately if staff are able, but at most within two to three minutes. She said during lunch there is one nurse and two CNAs helping residents in the dining room and one nurse and two CNAs helping assisted diners in their room. When asked who was left to answer call lights and assist residents if all available staff are assisting other residents with eating she said, When you put it that way. No one is left to answer call bells. An interview was conducted on 4/10/24 at 3:56 p.m. with the Director of Nursing (DON). She said she expected call lights to be answered in 10 minutes or less. She said any staff member can answer a call light. The DON said she would not expect a CNA to turn off a call light and leave without assisting the resident. She said if a CNA checked on a resident and that resident needed changing, she would expect that CNA to do the work, even if they are not assigned to the resident. The DON said it is not acceptable for a resident to wait 50 minutes to be changed.

Based on observations, interviews, and record reviews, the facility failed to implement an effective infection prevention and control program related to: 1) failing to ensure a contact precautions sign was displayed timely for one resident (#24) diagnosed with Clostridioides difficile (C-Diff), 2) failing to ensure proper usage of personal protective equipment (PPE) by staff and volunteers (I, Q, R, V, and Dog Handler), 3) failing to ensure four staff members (Staff Q, B, C, Director of Nursing) performed hand hygiene, and 4) failing to ensure staff provided hand hygiene for 14 residents (#54, #19, #3, #1, #36, #670, #23, #10, #2, #53, #37, #17, #57, and #33) prior to dining for three days of a three day survey. Findings included: An observation was conducted on 4/8/24 at 10:15 a.m. of Resident #24 in bed with no precaution sign on his door. Throughout the day on 4/8/24 staff were observed entering and exiting the room without donning and doffing PPE. Review of Resident #24's progress notes showed a note from the resident's primary care provider, dated 4/4/24 at 10:38 a.m., revealing the nurse called to notify her Resident #24 had new onset, foul smelling, liquid diarrhea for the past two days. The doctor ordered a stool sample to be collected and tested for C-diff. Review of lab results for Resident #24 showed a positive C-Diff Molecular lab, dated 4/7/24. The lab report showed critical lab results were reported to Staff G, Registered Nurse (RN) on 4/7/24 at 2:30 p.m. Review of the Admission Record showed Resident #24 was admitted on [DATE] with diagnoses to include dementia, cognitive communication deficit, and constipation. Review of Resident #24's Minimum Data Set (MDS) Section C, Cognitive Patterns, dated 1/31/24, showed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Review of the progress notes for Resident #24, dated 4/8/24 at 12:48 p.m. from Staff E, Licensed Practical Nurse (LPN)/Unit Manager (UM), revealed labs were reviewed by the resident's PCP and new orders for Vancomycin 125 mg (milligrams) by mouth every 6 hours for 14 days. Review of orders showed an order for Contact Isolation Precautions and an order for Vancomycin HCL Oral Capsule 125 mg every 6 hours for Clostridioides difficile (C-diff), dated 4/8/24 at 12:51 p.m. Review of the active care plan for Resident #24 showed a plan in place for Contact Precautions for C-Diff, dated 4/8/24. Interventions included staff will follow contact precautions. An observation was made on 4/9/24 at 11:54 a.m. of Staff R, Certified Nursing Assistant (CNA) and Staff Q, CNA entering Resident #24's room to deliver lunch trays. The door had a contact precaution sign as well as a PPE door hanger with supplies. Staff Q, CNA exited the room and did not perform hand hygiene before entering another resident room. An observation was made on 4/9/24 at 11:56 a.m. of Staff Q, CNA entering room [ROOM NUMBER] to deliver a lunch tray, which also had a contact precaution sign and PPE door hanger with supplies. The CNA was observed setting up the resident's lunch tray, arranging the position of the tray table and adjusting the bed with no PPE on. An interview was conducted on 4/9/24 at 12:09 p.m. with Staff R, CNA. He said he did not know Resident #24 was on contact precautions when he delivered the lunch tray. He said he is not assigned to that hall and the nurse didn't tell him. Staff R said he did not notice the sign on the door. He confirmed he did not put on PPE. Staff R said normally for a resident on contact precautions he would set the tray on the table right inside the door, put a gown and gloves on, then enter the room, deliver, and set up the tray. An interview was conducted on 4/9/24 at 2:05 p.m. with Staff Q, CNA. She said she currently had two rooms on contact precautions, Resident #24's room related to C-diff and room [ROOM NUMBER] related to MRSA (Methicillin-Resistant Staphylococcus Aureus). She said for rooms on contact precautions staff should put on a gown and gloves all the time no matter what. Staff Q said for food tray delivery some people say staff should wear PPE all the time and some say staff can carry the tray in, set in down, then walk out without PPE on. An observation was made on 4/10/24 at 11:06 a.m. of Staff V, Registered Nurse (RN). Staff V was in the hallway standing at the medication cart with PPE (gown and gloves) on. She then walked away from the cart and was observed caring for a resident. An interview was conducted on 4/10/24 11:10 a.m. with Staff V, RN. She confirmed she had PPE on in the hall and said she should not have. She said she should have taken the PPE of inside the room at the door. An interview was conducted on 4/9/24 at 4:51 p.m. with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM). She said when critical labs are called to the facility by the lab, the nurse should get the results and call the doctor for orders. She said if they suspect C-diff for a resident, they put them on prophylactic isolation precautions until the lab results come back. Staff E said she was not aware Resident #24 had loose stools and was being tested and if she would have been notified she would have placed him on precautions. She confirmed Resident #24 should have been on precautions Sunday (4/7/24) when the results came back if not sooner. Regarding food trays being delivered to residents on contact precautions Staff E said one CNA should be inside the room with PPE on and another CNA should pass them the tray at the door. The CNA inside the room would set the tray up for the resident and assist if needed, they would then take off the PPE, exit the room and perform hand hygiene. An interview was conducted on 4/9/24 at 5:03 p.m. with the Director of Nursing (DON). She said if a person is on contact precautions for a wound infection and the infection is covered, she would not expect people to put on all of that [PPE] just to pass a tray. She said if the resident is on contact precautions for C-diff she would expect staff to wear PPE anytime they enter the room. The DON said she was not aware that Resident #24 had tested positive for C-Diff on 4/7/24. She was made aware on 4/8/24. The DON said normally if someone is suspected of having C-Diff they are put on contact precautions until it is ruled out. She said she would have expected the resident to have been on precautions while being tested and definitely after the nurse found out the resident was positive for C-Diff. Review of the Contact Precautions sign the facility posted showed: 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 . Review of the policy titled, Management of C. Difficile Infection, implemented 10/17/22, showed the following: Policy: This facility implements facility-wide strategies for the prevention and spread of Clostridioides difficile infections. Policy Explanation and Compliance Guidelines: 4. Licensed nurses may implement preemptive contact precautions when C. difficile infection is suspected, pending results of testing. Once confirmed, contact precautions shall be implemented in accordance with a physician order and facility policy for transmission-based precautions. 5. General principles related to contact precautions for C. difficile: a. All staff are to wear gloves and a gown upon entry into the resident's room and while providing care for the resident with C. difficile. b. Hand hygiene shall be performed by handwashing with soap and water in accordance with facility policy for hand hygiene. c. Maintain on contact precautions for the duration of the illness, but no less than 48 hours after diarrhea has resolved. d. Encourage/assist residents to wash hands frequently. Bathe daily with soap and water. Review of a policy titled, MDRO [Multidrug resistant organism] Infection, implemented 10/17/22. Policy: This facility implements facility-wide strategies for preventing the spread of infections with multidrug-resistant organisms. Policy Explanation and Compliance Guidelines: 3. Infection Control Precautions: a. Staff will use contact precautions in addition to standard precautions when caring for a resident with MDRO infection. b. Signage at entry of the resident's room shall indicate Contact Precautions, and the type of personal protective equipment in required upon entry into the room. 20311 Review of Resident #121's Admission Record revealed she was admitted to the facility on [DATE]. Review of the Resident's 5-day Minimum Data Set (MDS,) dated 3/29/24, revealed a Brief Interview For Mental Status (BIMS) score of 09 (Moderate Cognitive Impairment). Review of Resident #121's physician orders revealed a current order for Doxycycline Hyclate 100 mg every morning and bedtime for MRSA left hip for 28 days, start date 4/8/24, and a physician order for Isolation contact MRSA lt (left) hip wound every shift-4/1/2024. Observations on 4/08/24 at 10:26 a.m. of Resident #121's room revealed an isolation kit hanging on the outside of the door and the room door was open. It was also noted that a sign was posted on the door indicating the room was under Enhanced Barrier Precautions. The sign directed what those who entered the room must do for Enhanced Barrier Precautions. (Photographic Evidence Obtained) Continued observation of Resident #121's room at this time revealed that there were 3 dogs being escorted down the hallway by 3 dog handlers (2 large, 1 small). The group was noted to go in and out of resident rooms on the hallway. During this observation a dog handler with a small dog was noted to enter Resident #121's room without regard to the isolation kit and sign mounted on the door. The dog handler was observed to place the small dog onto Resident #121's lap and Resident #121 hugged, stroked and kissed the dog as the dog licked at the resident. Continued observation on 04/08/24 at 10:27 a.m. revealed the dog handler left Resident #121's room with the dog and entered the room of another resident with the dog, which physically interacted with the second resident. During an interview on 04/08/24 at 10:35 a.m. with Staff G, RN she revealed Resident #121 had a current diagnosis of MRSA in a wound and the resident was on isolation and that visitors should check with the nurse before entering the room. Observations on 4/09/24 at 9:21 a.m. of Resident #121's room revealed Staff I, CNA was noted to walk into the resident room, assisted the resident with organizing her over bed table and nightstand and assist with positioning of resident in the bed. Staff I, CNA was noted to then put on latex gloves then take the resident's meal tray and handed the tray to another staff member. An interview with Staff I at this time revealed that when a resident was on enhanced precautions, and he is performing care that he should be fully gloved up and have on a gown. He reported he should have used a gown and gloves, but that it skipped his mind. During an interview on 4/10/24 at 11:31 a.m. with the Director of Nursing (DON), she reported if a resident is on enhanced precautions and staff is providing close personal care; staff should gown up and be gloved. She reported that all staff are trained on isolation precautions. The DON reported for visitors who need to enter the resident room, the visitor should speak to the nurse before entering the room. Visitors should gown up and use gloves if doing anything hands on with the resident. The DON reported regarding therapy dogs she does not expect the therapy dogs enter the rooms under isolation. She reported therapy dogs would typically go from resident to resident, so it would not be appropriate for the therapy dogs to go into isolation rooms. The DON reported that she can't tell what the process is for this facility related to therapy dogs entering isolation rooms, but all guests should gown up, and speak to the nurse per the sign on the door. She reported the expectation would be that therapy dogs should not go into isolation rooms. She reported in regard to the therapy dog handlers that she does not know how they would know if they should enter an isolated room. She reported that she will need to put something in place. During an interview on 4/10/24 at 11:41 a.m. with the Director of Therapy revealed that therapy dogs come in maybe once a month through Activities, and they do come through the therapy gym. An interview was conducted on 4/10/24 at 11:56 a.m. with the Activities Director. The Activities Director revealed the therapy dogs are a volunteer group from a 3rd party vendor that come in to do visits. She reported the group comes in on a monthly basis and only goes into common areas. She reported, normally the group does not go into resident rooms without facility staff. She reported that she does not expect the group to go into isolation rooms, and the group knows not to go into isolation rooms. 39438 On 4/08/24 at 11:41 a.m. an activity was in progress in the main dining room on the second floor. The residents were observed playing tambourines and one resident had a maraca in her hand. At 11:48 a.m., meal trays for lunch were brought to the main dining room. Four staff members were assisting with passing trays. Staff did not offer or assist Residents #54, #19, #3, #1, #36, #670, #23, #10, #2, #53, #37, #17, #57, and #33 with hand hygiene before the meal. On 4/08/24 at 12:00 p.m. Staff B, CNA was observed seated at a table continuously assisting two residents with their meal at the same time, with the same hand (right), and with no hand hygiene in between. On 4/08/24 at 12:04 p.m., Staff A, CNA whispered something in Staff B's ear. Staff B, CNA, then got up and sanitized her hands using sanitizer from the sanitizing dispenser on the wall in the dining room. She returned to the table and started using a different hand to feed each resident. She then went back to using the same hand (right) to feed each resident with no hand hygiene in between. On 4/09/24 at 11:34 a.m. the meal trays for lunch were brought to the main dining room. The first tray was passed at 11:39 a.m. Staff did not offer or assist Residents #54, #19, #3, #1, #36, #670, #23, #10, #2, #53, #37, #17, #57, and #33 with hand hygiene before the meal. On 4/09/24 at 11:51 a.m. the Director of Nursing (DON) was observed standing assisting Resident #23 with her meal. Her cell phone rang, she pulled the phone from her pocket, stated I don't know who this person is, and placed the cell phone back in her pocket. She did not sanitize her hands before starting back to assist Resident #23 with her meal. On 4/09/24 at 11:59 a.m. the DON rolled her sleeves up, her cell phone rang, she pulled the cell phone from her pocket again, ignored the call, sat down at the table with Resident #54, picked up the utensil, and proceeded to assist Resident #54 with his meal without performing hand hygiene. On 4/09/24 at 12:06 p.m. Staff C, Staffing Coordinator/CNA was observed seated at a table continuously assisting two residents (Resident #37 & #17) with their meal at the same time, with the same hand (right), with no hand hygiene in between. At 12:11 p.m. she was continuously observed assisting the residents with the same hand. She then stated to Resident #17 last bite and then gave her some of the drink from a cup with two handles. Staff C, Staffing Coordinator/CNA, then stated you ate all your food as she wiped Resident #17's mouth. She then started assisting Resident #37 with the same hand with no hand hygiene in between until she finished her meal. On 4/09/24 at 12:07 p.m. Staff D, CNA stated she assists with meals in the dining room two to three days a week. She stated she did not clean the residents' hands prior to lunch. On 4/09/24 at 12:18 p.m. Staff A, CNA stated she assists with meals in the dining room two to three days per week. Activity staff would usually do hand hygiene. When asked who did hygiene today, she stated the CNAs assist with hand hygiene as well. Staff A, CNA then stated she did not clean the residents' hand prior to lunch today because ADL care was provided right before the residents came to the dining room and their hands were clean. On 4/09/24 at 12:23 p.m. Staff C, Staffing Coordinator/CNA stated she was educated to use different hands when assisting two residents with meals at the same time. When asked if she used different hands today, she stated no, and it was because of the way the residents were positioned at the table. On 4/10/24 at 9:29 a.m. Staff E, Licensed Practical Nurse (LPN)/Unit Manager/Infection Preventionist stated the residents do activities and therapy prior to eating lunch. She expects staff to sanitize or wash their hands before eating. She expects hand hygiene after touching anything. Before touching the resident's tray, there should be hand hygiene. Staff should not use the same hand when assisting two residents with their meals at the same time due to cross contamination. Review of the policy titled, Hand Hygiene, implemented on 10/17/22, revealed the following: Policy: 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.

Based on observations, record review and interviews, the facility failed to ensure failed to ensure an order was in place for pressure relieving boots being utilized for one resident (#670) of three residents reviewed for post fall intervention and 2) failed to follow-up on an order for a swallow test for one resident (#43) of a total sample of 46 residents. Findings included: 1. An observation was made on 04/08/24 at 10:08 a.m. of Resident #670 in bed lying down with pressure-relieving boots on both feet. (Photographic Evidence Obtained) The resident stated she cannot get out of the bed because staff are keeping the pressure-relieving boots on her feet. Review of Admission Records showed Resident #670 was admitted on [DATE] with diagnoses including severe protein-calorie malnutrition, muscle wasting and atrophy, edema, and unsteadiness on feet. Review of Resident #670's Skin Observation Tool, dated 02/20/24, showed the resident had bilateral purple boots for pressure relief of heels. Review of Resident #670's care plan showed a plan in place for Skin Integrity, Risk for Alteration Impaired Mobility, dated 03/07/24. Interventions included boots bilateral in bed. Another plan was in place for Skin Impairment: Impaired skin integrity related to wounds present, dated 03/12/24. Interventions included heel boots on qs (a sufficient quantity). Review of Resident #670's Visual/Bedside Kardex Report showed under Resident Care, Staff will float heels with heels up cushion/pillow under calves while in bed. Under the Monitoring/Safety section it documented, Heel protectors while in bed. Review of Resident #670's active physician orders did not show an order in place for pressure-relieving boots. An interview was conducted on 4/10/24 at 1:06 p.m. with Staff V, Registered Nurse (RN). She confirmed she was assigned to care for Resident #670. Staff V said Resident #670 wears pressure-relieving boots to prevent pressure ulcers. She said when she thinks a resident needs the boots, she tells the Unit Manager (UM) and the UM gives her the boots. Staff V said it isn't like medication; you don't need an order for the pressure-relieving boots. She said she thinks Resident #670 had them on anytime she was in bed. An interview was conducted on 04/10/24 at 1:31 p.m. with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM). She stated pressure-relieving boots could be used as an intervention on a care plan and a doctor could give orders for them. When asked how long the boots should stay on a resident the Staff E said, I would say could be based on nurses' judgment. As long as they are getting them out of bed appropriately. Staff E stated they would need to get clarification from the doctor to see how long a resident should have the boots on each day. Staff E stated she recently went through all residents that had pressure-relieving boots to make sure they had orders in place. Staff E reviewed Resident #670's record and confirmed the resident had no orders or specific instructions for use of the pressure-relieving boots. Staff E stated she should have put in an order and asked the doctor to specify instructions. 48823 2. On 04/08/24 at 11:45 a.m. Resident #43 was observed lying in bed with her tube feeding disconnected and hanging on the poll. The feeding was dated 4/7/2024. On 4/9/2024 at 8:30 a.m. Resident #43 was observed lying in bed and appeared to be sleeping. Her tube feeding was connected to the resident and was running at 60 milliliters. On 4/9/2024 at 1:45 p.m. Resident #43 was observed lying in bed with her tube feeding connected at this time. Resident #43 was awake, she stated that she has not been out of bed and that she does not want to get out of bed, she prefers to stay in bed. Review of the Admission Record for Resident #43 revealed an admitted [DATE]. The diagnoses included cerebrovascular disease, aphasia, hemiplegia and hemiparesis of right side, chronic obstructive pulmonary disease, dysphagia, gastrostomy, anxiety disorder, hypertension, and bipolar disorder. Review of the Quarterly Minimum Data Set (MDS) for Resident #43, dated 3/13/2024, revealed: Section A - identification information - reentry date of 1/7/2023 with original entry date of 10/16/2019. Review of the active physician orders, dated 4/10/2024, for Resident #43 revealed: Resident #43 is to have nothing by mouth (NPO), enteral feeding order is Jevity 1.2 to run at 60 milliliters every hour for 20 hours, start at 2:00 PM and run/stop at 10:00 AM. Physical therapy, occupational therapy and speech therapy evaluation and treatment as needed. Schedule resident for swallow test (dated 3/26/2024), occupational therapy to evaluate and treat for sitting abilities (dated 4/5/2024). Review of the progress notes for Resident #43, dated 3/26/2024, revealed Resident #43 to have a swallow test. Review of a progress note for Resident #43, dated 4/4/2024, signed by physician revealed, resident was eating well by mouth before last admission. I am trying to do a new evaluation, discussed today with speech therapy, she will need previous evaluation by occupational therapy, she is always in bed, she needs to position in the chair, resident needs to be out of bed for meals. Review of the active care plan Focus for Resident #43, dated 4/10/2024, revealed: Nutrition Focus for altered nutritional status (date of revision 7/6/2023). Interventions included of offer menu selections, adjust food preference as needed, receive adjusted texture, supplements as ordered (date initiated 12/20/2021), potential for complications related to feeding tube (date of revision 12/5/2022). Review of the census report dated 6/5/2023, 7/2/2023 and 11/2/2023 for Resident #43 showed hospital admissions related to the feeding tube malfunction (6/5/2023), related to cellulitis of feeding tube (7/2/2023), and was for evaluation for complaint of abdominal pain (11/2/2023). Review of a therapy screen, dated 4/2/2024, for Resident #43 revealed a physician order in place for speech evaluation for possible oral diet, plan was discussed with Resident #43 and resident agreed with plan. Review of the medical record therapy screen/occupational interaction note, dated 4/4/2024, for Resident #43 revealed communication was done with the primary care physician that the resident needed occupational therapy for positioning. An interview was conducted with Staff E, Licensed Practical Nurse (LPN), Unit Manager (UM), Infection Control (IC) on 4/9/2024 at 2:08 p.m. Staff E revealed the resident is able to remove her oxygen and refuses to get out of bed. The resident was to have a swallow test completed by speech. She verbalized the resident does not want to take oral foods. Staff E was not sure if it was the texture or not. An interview was conducted with Staff E, LPN/UM/IC, and Staff O, Speech Therapy (ST) and Staff L, Director of Rehabilitation on 04/10/24 at 11:15 a.m. It was revealed the order was for 3/26/2024 (swallow test). ST saw the resident on 4/2/2024 and 4/4/2024. OT saw the resident on 4/5/2024 and full service was to begin on 4/10/2024. During the interview Staff E LPN/UM/ IC revealed the delay in follow-up was related to poor communication during morning meeting. On 4/10/2024 at 10:00 a.m. a request was made to review a policy and procedure for morning clinical meeting. The policy and procedure was not provided by the last day of survey (4/10/24). Review of a policy titled, Referral to Therapy, dated 1/18/2023, revealed: Policy: To ensure clinically appropriate care will be provided a Therapy Request Form may be completed for long term care (LTC) patients. Procedure: 1. The therapy request form is completed and provided to the rehabilitation department. A therapy request form or another similar form/process should be completed for any patient that has change in condition or may need therapy services for prevention, compensatory strategies, or caregiver education. 2. This referral is coordinator with other disciplines and/or nursing referral for therapy possibly warranting a therapy evaluation 3. Upon review, the therapist will make the determination if an evaluation is indicated. 4. Once this form is completed, the results will be shared with the interdisciplinary team members. 5. If a therapy evaluation is indicated the therapy order process will be followed.

Based on observations, interviews and review of facility policy, the facility failed to ensure four resident rooms (212, 216, 217 and 218) were maintained in a clean and sanitary for one of two floors. Findings included: During a tour of Resident room [ROOM NUMBER] on 04/08/24 at 10:16 a.m., an observation was made of the resident's bathroom with dirt and dust on the floor corners. The floors and bathroom walls were stained with brown and dark matter and the toilet was observed with brown stains around the base. A plastic storage bin under the toilet was observed with dust on the surface. The resident in the window bed stated the cleaning could be better. She stated she had seen a cockroach in the bathroom. She stated the toilet was always dirty. She stated they had a nice housekeeping staff member who was no longer there. She stated it had not been the same. An observation of the resident's drinking cup was made with a small insect on the drinking straw. The resident stated she had observed the insects in her room before. During a tour of Resident room [ROOM NUMBER] on 04/08/24 at 10:30 a.m. the toilet was observed with dust, debris, and particles around the floor corners. The floors were observed with stains and the toilet base with brown matter on the surface. The resident in the door bed stated they did not clean very well, the bathroom was always dirty. During an interview on 04/09/24 at 11:10 a.m. with Staff P, Housekeeping, she stated she cleaned all the rooms. She stated if the floors were stained and if she could not get the stains off, she would notify her supervisor. She stated if there were bugs anywhere, she would notify her supervisor. During a tour of Resident room [ROOM NUMBER] on 04/09/24 at 11:17 a.m., two urinals were observed on the resident's head of bed, hooked to the bedside rail. They were observed with urine, stained and with a foul order. The resident in the window bed stated it was always like that. An interview was conducted on 04/10/24 at 9:06 a.m. with Staff M, Housekeeping, Staff P, Housekeeping, and the Housekeeping Manager (Manager). The Manager stated sometimes they have problems with the caulking around the toilet bases in the bathrooms. She said, There is a rust appearance on the toilets' bases, it is hard to come off. Staff P said, I try to use bleach and brush to get it off. Staff M stated it was the first time she saw the small flying insects. The Manager stated no one said anything about the flying insects. She stated she would call maintenance to come and spray. She stated the facility had a pest control contractor who comes on Wednesdays. She stated the problem with the small flying insects was because the showers don't get used often and it could be the drain issue. On 04/10/24 at 10:09 a.m. an interview was conducted with Staff E, Licensed Practical Nurse (LPN)/ Unit Manager. She stated the small flying insects were all around the building. She stated there should not be flying insects on residents' drinking cups, on themselves or in their spaces. She stated the CNAs (Certified Nursing Assistants), and nurses should replace the residents' urinals daily if needed. Staff E observed photographic evidence and said, Insects on resident's plate, that is gross, I can't imagine about the residents who cannot swish the insects off themselves. Staff E stated maintenance knew. She said, We told them. I am not sure what they have done about it. I spoke to him last week Wednesday. Review of a facility policy titled, Daily Resident Room Cleaning Procedure, dated 1/30/23, showed to (b.) clean the bathroom (see bathroom cleaning policy). [This policy was not provided.] (d.) Utilize bathroom cleaner to disinfect the sink, handrails, toilet, and all other surfaces in the bathroom. (I.) Mop the floor if it is not carpeted. 46234 An observation was made on 04/08/24 at 1:47 p.m. of Resident room [ROOM NUMBER]. The wall behind the head of the bed had long scrape marks and baseboards that were cracked with several chunks of wood missing. Review of a facility policy titled, Resident Environment Quality, dated 10/17/22, showed it was the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. (Photographic Evidence Obtained)

Based on observation, record review, interview, and review of the policy and procedure, the facility failed to ensure an unwitnessed fall that resulted in serious bodily injury (nondisplaced fracture of second cervical vertebra) was reported to the appropriate agencies for one resident (#44) out of the sampled two residents. Findings included: On 04/08/24 at 11:15 a.m. Resident #44 was observed in bed with a cervical collar around her neck. During an attempt to interview her, the resident did not speak. On 04/10/24 at 9:12 a.m. Resident #44 was observed in bed with a cervical collar around her neck. Fall mats were observed on both sides of the bed on the floor. A review of the Transfer/Discharge Report showed Resident #44 was admitted on [DATE] and had diagnoses to include nondisplaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing, bipolar disorder, dementia, psychotic disturbance, mood disturbance, anxiety disorder, contracture of the muscle, history of falling, abnormalities of the gait and mobility, contracture of the right hip, left hip, left hand, left knee, and right knee, depression, other fracture of upper and lower end of left fibula, reduced mobility, and unsteadiness on feet. Section C- Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], showed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating severe impairment. Section GG- Functional Abilities and Goals showed Resident #44 was dependent for self-care and mobility. A review of the Order Summary Report with active physician orders as of 04/10/24 revealed the following: Air mattress for prevention (08/09/23), and resident to wear cervical collar at all times, may remove for care and reapply every shift for pain (04/05/24). The Incident by Incident Type log provided by the facility showed the resident had an unwitnessed fall on 03/09/24 at 4:40 a.m. (actual time per progress note 3:50 a.m.) and an unwitnessed fall on 04/04/24 at 11:45 p.m. A review of the progress notes from 03/01/24 to 04/10/24 showed the following: 03/09/24 04:27- Resident found on the floor next to the bed at 03:50. 03/09/24 05:10- Situation- Resident was observed lying on her side on the floor next to the bed. Possible and/or actual contributing factors: Pressure reducing mattress too inflated. Assessment and Appearance: vital signs, ortho blood pressure, pain, and/or injuries: within normal limits. The resident complained of pain but unable to state where. Sent to the emergency room for evaluation and further treatment. 03/9/24 09:25- Resident found on floor face down next to bed at 03:50, resident was responsive when asked about pain. No visible cuts or bruises. Certified Nursing Assistant (CNA) assisted writer with getting resident back in bed, resident was lying on sheet that was on her bed which was used to lift from floor back into lowered bed. No visual injuries, 911 call, family member notified, hospice, and doctor notified. Emergency Medical Technician (EMT) arrived around 04:20. Ambulance service transported to local hospital to be evaluated. 03/13/24 14:14 (2:14 p.m.)- Resident was received at 1:45 pm back from a local hospital by ambulance with a diagnosis of cervical compression fracture due to a fall. Using Percocet for as needed (prn) pain every 6 hours. Resident was received with a collar that should only be removed for care and comfort. Results showed compression fracture in cervical vertebra (c2). 03/15/24 20:16 (8:00 p.m.)- She presented to a local hospital on 03/09/24 for an unwitnessed fall. Per hospital records, computed tomography (CT) of the neck showed acute c2 compression fracture. A neck collar was placed, and she was stable. CT of the cervical spine showed c2 with inferior and anterior osteophyte and vertebral body fracture. Continue cervical collar. The patient was seen today for acute/chronic care management. 03/22/24 13:41(1:41 p.m.)- No gross findings from C1 to C5. Non-diagnostic cervical spine series with non-visualization of the remainder of the inferior cervical spine. Fracture was not excluded. Recommend repeat diagnostic exam to include the inferior cervical spine or CT if unable to obtain appropriate images. 03/22/24 13:56 (1:56 p.m.)- Reviewed cervical spine x-ray. No gross findings from C1 to C5. Non-diagnostic cervical spine series with non-visualization of the remainder of the inferior cervical spine. Fracture was not excluded. Cervical collar in place. 04/05/24 05:43- Resident returned to facility at 05:00 with no new order. 04/05/24 00:01(12:01 a.m.)- Resident found on floor at 11:35 p.m., assessed for injuries, nothing visible observed, and no complaints of pain. 911 called and the resident was sent to a local hospital. 04/05/24 08:30- She was seen for follow up for a fall. She was sent to the hospital and returned with negative findings. Patient was placed on 15-minute checks per facility. Cervical collar in place. She was laying on her side with head of bed elevated. She denied any pain or discomfort. No edema. 04/05/24 09:21- Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months. Level of consciousness / mental status: intermittent confusion. Resident was chairbound / incontinent. Vision status: Poor (with or without glasses). Recent hospitalization history in last 30 days: Yes. Gait / balance: Decreased muscular coordination. Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Fall Risk Score: 14.0. 04/05/24 14:44 (2:44 p.m.)- Resident was reviewed this morning for being found on floor next to bed. The resident was on an air mattress with bolsters to provide spatial awareness. There was no injury noted. She denies pain at this time. She was unable to state what happened. She was sent out to the emergency room with negative findings. Care plan reviewed. Will place resident on 15-minute checks. Will provide mats at bedside bilaterally. Staff to post outside of door on all shifts. Care plan updated. 04/08/24 11:18- The resident was alert, on an air mattress, and good positioning on bed with 15-minute checks Check to prevent falls. The care plan with a Focus area of falls/injury showed Resident #44 was at risk for falls or injury related to history of transient ischemic attack (TIA) and falls initiated on 11/15/21 and revised on10/19/22. Interventions included the following: Assist to wear non-slick footwear that fits, initiated: 11/15/21. Call bell in reach, initiated: 11/15/21. Ensure adequate lighting for all activities, initiated: 11/15/21. Evaluate risk for falls with Fall Assessment Tool, initiated: 11/15/21. Keep areas free of obstructions to reduce the risk of falls or injury, initiated: 11/15/21. Maintain safety precautions as ordered, initiated: 11/15/21. Medication dose adjustment as ordered, initiated: 11/15/21. The resident uses a high back reclining wheelchair with L board for legs when out of bed, initiated: 10/19/22. Physician follow-up prn, initiated: 11/15/21. Staff to post outside room when charting, initiated: 04/05/24. Transferring - Full body lift assist of 2, initiated: 07/15/22. The care plan showed no new interventions after Resident #44 had an unwitnessed fall and sustained a nondisplaced fracture of the second cervical vertebra on 03/9/24. It was not updated until she had another fall on 04/04/24. An additional Focus Area for Resident #44 revealed: (Resident #44) has an ADL self-care performance deficit r/t (related to) CVA and decreased mobility, revised on 10/19/22. The interventions included: Bed Mobility - (Resident #44) requires total assistance from staff for bed mobility and use of bilateral 1/4 rails, Transfer - The resident is totally dependent on (X2) staff with full body lift for transferring. On 04/10/24 at 1:42 p.m. a telephonic interview was conducted with Staff F, Certified Nursing Assistant (CNA). He stated he worked the shift Resident #44 had a fall (3/9/24). It was a regular night and before he left for break, he checked on her and she was asleep. It was a quiet night. When he came from break, Resident #44 was observed on the floor and he went to get the nurse, Staff W, Licensed Practical Nurse (LPN). The resident was talking. Staff W, LPN checked her and they got her back in bed. Staff F, CNA, stated he changed her brief before EMS (Emergency Medical Services) came. She was really contracted. He was still working there (no longer works at the facility) when she returned from the hospital. She had a neck brace and a low bed. He never looked at the mattress. She was really small and didn't notice anything wrong with the mattress at that time. On 04/10/24 at 10:06 a.m. the Regional Nurse Consultant (RNC-1) reported Resident #44's family member presented to the building. He was upset, loud, and stated she was neglected and that caused her to fall. She and Staff E, LPN/Unit Manager met with the family member. They went through her care plan and showed him interventions they had in place. He talked about Resident #44's history with anxiety and was concerned she was having anxiety at night, so they ordered Sertraline. On 04/10/24 at 9:41 a.m. the Director of Nursing (DON) stated Staff F, CNA was the assigned aide for the first fall. Staff had just gone in to check on her and shortly after she was on the floor. Staff W, LPN called 911 and they came to pick her up. She was diagnosed with a nondisplaced C2 cervical fracture. Resident #44 had an air mattress and there were no bolsters on the air mattress at the time of the first fall. After looking at the air mattress, it seemed like it was a hospice air mattress and looked like it was over inflated. They think the air mattress caused her to slide off the bed. The initial air mattress came from hospice. She replaced the air mattress with one of their air mattresses. The DON did not know if hospice was checking the air mattress or not. She looked at the air mattress and could not tell what the air mattress was set on. There were no numbers on the dial for her to see. The numbers were faded. For the air mattresses provided by the facility, they have push buttons. She did not know if the staff were checking the air mattresses. The DON stated she had hospice come pick up the air mattress while Resident #44 was at the hospital and replaced it with one of their air mattresses. Staff X, CNA, was the assigned aide for the second fall (4/4/24). Staff X, CNA reported in her statement that she heard talking and when she went in the room Resident #44 was on the floor. She yelled for the nurse. Staff W, LPN came down and she (Staff X) stayed with the resident while he called 911. Any forward motion such as a sneeze or cough, was determined to cause the second fall. Her body alignment was the issue. They do not use side rails, so bolsters were added to the air mattress after the second fall. When staff are not doing care, someone needs to be posted outside of Resident #44's door when charting. This was added to the care plan as an intervention after the second fall. She talked to her Administration about reporting the incident and because they didn't do anything to cause the accident, the first unwitnessed fall which resulted in a nondisplaced fracture of the second cervical vertebra was not reported. When asked why the second fall was reported and there were no injuries, the DON stated because a family member threatened to call the State Agency. She wanted to make sure she was covered so she reported the second fall. Review of the policy titled, Abuse Prevention and Prohibition, revised on 05/22, revealed the following: 7. Reporting/Response: Report all alleged violations immediately to 1-800-96-ABUSE. In addition, an immediate report must be made to the Survey Agency in Tallahassee. The Elders Justice Act states that the report must not be later than 2 hours after forming the suspicion that resulted in serious bodily injury, or not later than 24 hours if the events that caused the suspicion did not result in serious bodily injury. A one day/five day notification form to be completed and sent to the State Agency in Tallahassee. All necessary corrective actions will be taken depending on the results of the investigation. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences . The facility will also notify the appropriate agencies, based on the nature of the abuse allegation in accordance with State and Federal statute.

Based on observations, interview, and record review the facility failed to develop and implement care plan for two residents (#23 and #670) out of 25 sampled residents. Findings included: 1. An observation was conducted on 4/8/24 at 12:05 p.m. of Resident #23 in the dining room. The resident was asked about her lunch, and she stated she didn't have hearing aids and could not hear. An interview was conducted on 4/8/24 at 2:05 p.m. with Resident #23's family member. He said the resident had hearing aids that had been lost. He was upset Resident #23 was unable to hear him and communicate. Review of the Admission Record showed Resident #23 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, dysphagia, major depressive disorder, chronic kidney disease, and dementia. Review of an Audiology Testing report, dated 7/6/23, showed Resident #23 had severe-profound sloping hearing loss on the left and right side. Recommendations showed the resident could benefit from amplification in both ears. Review of Resident #23's medical record revealed a progress note, dated 3/11/24, from audiology. The note showed audiology spoke with the nurse and, the nurse had the resident's hearing aid bag and case, but she didn't know where the hearing aids were. An interview was conducted on 4/9/24 at 2:11 p.m. with Staff Q, Certified Nursing Assistant (CNA). She said Resident #23 had hearing issues, but her hearing aids did help her when she had them. She said without them the resident could not hear. Review of Resident #23's active care plan did not show a care plan or interventions in place related to hearing impairment. An observation was made on 4/10/24 at 11:18 a.m. of Resident #23 in the dining room. A staff member was trying to communicate with Resident #23. She placed her mouth about 4 inches from the resident's ear and yelled very loudly trying to get the resident to hear her. The staff member repeated this process three times. An interview was conducted on 4/10/24 at 2:24 p.m. with Staff K, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator. Staff K said she was not aware Resident #23 had a hearing impairment or hearing aids. She said nursing staff should have informed her about the resident's impairment and she would have put in a care plan with interventions. Staff K said she would put a care plan in place with interventions to assist the resident in communicating with staff and family. She confirmed the resident should have already had a care plan related to hearing impairment in place. 2. An interview was conducted on 4/8/24 at 10:13 a.m. with Resident #670. The resident stated she had recently had a fall in the facility. Review of the facility's Accident Log showed Resident #670 had a fall on 3/25/24. Review of progress notes for Resident #670 showed a Health Status Note, dated 3/25/24 at 7:23 p.m. showing: At 6.18pm [sic] CNA assigned to resident observed her sitting on the floor in front of her wheelchair by the bedside and notified writer. Write checked on resident denies pain. Resident slide down from the wheelchair ,ROM [Range of motion] done and assisted back to bed, POA [Power of Attorney] and Physician notified no new order extensive assistance with ADL [Activities of Daily Living] provided will cont [continue] to monitor. Review of Admission Record showed Resident #670 was admitted on [DATE] with diagnoses including severe protein-calorie malnutrition, muscle wasting and atrophy, abnormalities of gait and mobility, and unsteadiness on feet. Review of Resident #670's Fall Risk Evaluation, dated 2/20/24, showed the resident had a fall risk score of 13. The evaluation showed, If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented in the care plan. Review of Resident #670's Baseline Care Plan, dated 2/20/24, did not indicate the resident was at risk for falls. Review of Resident #670's Comprehensive Care Plan showed a care plan for risk for falls/injury was not put in place until 3/26/24, the day after the resident had a fall. An interview was conducted on 4/9/24 at 3:39 p.m. with Staff E, LPN/Unit Manager (UM). She said a resident that was a fall risk typically had a care plan initiated with interventions to prevent falls, then it is revised, and new interventions added after they had a fall. Staff E reviewed Resident #670's medical record and said she did not see a care plan in place for being at risk for falls prior to her fall. Staff E said she was going to investigate it and provide an update. A follow-up interview was conducted on 4/9/24 at 3:52 p.m. with Staff E, LPN/UM. Staff E said she reviewed Resident #670's care plans since admission looking to see if there was a discontinued fall risk care plan and, Unfortunately she didn't have one. She confirmed Resident #670 should have had a falls risk care plan with interventions in place to prevent falls. An interview was conducted on 4/9/24 at 5:10 p.m. with the Director of Nursing (DON). She said she was made aware of Resident #670's lack of fall risk care plan prior to her fall on 3/25/24. The DON reviewed the resident's care plans, interventions, and baseline care plan. She confirmed there should have been a fall care plan in place and there was not. Review of a facility policy titled, Comprehensive Care Plans, undated, showed the following: Policy: It is the policy of this facility to develop and implement A comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma informed. . 2. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. . Review of a facility policy titled, Hearing and Vision Services, implemented 10/17/22, showed the following: Policy: It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. Policy Explanation and Compliance Guidelines: 1. The facility will utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing abilities in order to provide person-centered care. This process includes: a. Obtain history from medical records the family and the resident regarding hearing and vision abilities; b. MDS [Minimum Data Set] and care area assessments; c. Ongoing monitoring of sensory problems; d. Care plan development and implantation, and e. Evaluation. 2. Employees should refer any identified need for hearing or vision services/appliances to the social worker/social services designee. Review of a facility policy titled, Fall Prevention Program, implemented 10/17/22, showed the following: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 3. The nurse will indicate on the Care Profile the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 5. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.

Based on observations, record review and interview the facility failed to provide Activities Of Daily Living (ADLs) for two residents (#122 and #123) of five residents sampled for ADL care related to personal hygiene. Findings included: 1. An observation of Resident #122 on 04/08/24 at 10:09 a.m. revealed the resident sitting up in her bed watching television. The resident was observed to have strands of white facial hair on her chin. Interview with Resident #122 at this time revealed she does not like the hair on her chin and that she would like the facial hair to be gone. An observation of Resident #122 on 04/09/24 at 8:54 a.m. revealed the resident sitting in bed. The resident was observed to still have white strands hair on her chin. An interview with the resident at this time revealed she prefers to have her face clear with no facial hair. The resident reported the staff have helped her get washed up, but no one has asked or offered her assistance with the hair on her chin. Review of Resident #122's Admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included muscle wasting and atrophy, unsteadiness on feet, and need for assistance with personal care. Review of the Resident #122's 5-day Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview For Mental Status (BIMS) score of 12 (Moderate Cognitive Impairment). Continued review of the MDS revealed the Resident is dependent with substantial/maximal assist with Shower bath self. Review of the Resident #122's medical record revealed there was no care plan in place to address the resident's need for assistance with ADLs. 2. An observation of Resident #123 on 04/08/24 at 10:09 a.m. revealed the resident sitting up in her bed reading a book. The resident was observed to have strands of white facial hair visible on her chin. An interview with Resident #123 revealed she does not like to have hair on her chin and that she would like the facial hair plucked. An observation on 04/09/24 at 8:57 a.m. of Resident #123 revealed the resident sitting up in her bed reading a book. An interview with the resident at this time revealed the resident does not like hair on her face. She reported that if they gave me a mirror and tweezers I could pluck it myself. Review of Resident #123's Admission Record revealed this resident was admitted to the facility on [DATE] with diagnoses that included muscle wasting, and atrophy, need for assistance with personal care, and unsteadiness on feet. Review of a BIMS Evaluation progress note, dated 4/3/24, revealed Resident #123's BIMS score of a 14 (Cognitively intact). Review of the undated therapy dashboard page revealed this page reflected treatment diagnosis that included Z74.1 (OT) Need for assistance with personal care. Review of the Occupational Therapy Treatment Encounter, dated 4/5/24 and maintained by the therapy vendor, revealed the following: Patient exhibits new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced balance, reduced functional activity tolerance, increased need for assistance from others and pain indicating the need for OT to increase (I) w/ADLs. The document revealed the following in the area of hygiene and grooming Hygiene / Grooming = MI (modified independence). Review of the resident's medical record revealed there was no care plan in place that would be available for staff to access to address the resident's need for assistance with ADL's. An interview was conducted on 04/09/24 at 12:55 p.m. with the Director of Rehabilitation. He reported Resident #123 was being seen by Occupational Therapy (OT) and Physical Therapy (PT) and personal care was being addressed by OT. He reported that he was unsure as to what care is provided on the health side. During an interview on 04/09/24 at 9:21 a.m. Staff J, Registered Nurse (RN) revealed staff should take care of the residents' ADLs. She reported that typically if she goes into the resident rooms and sees anything that needs to be done for the resident that she will let the certified nursing assistant (CNA) know. During an interview on 04/09/24 at 12:47 p.m. with the Director of Nursing (DON) she revealed that her expectation was if the resident is independent with their ADLs staff should ask residents if they need assistance with their ADLs, and if the resident refuses assistance staff are to document and let the nurse know. The DON reported if the resident is dependent on staff for assistance with ADLs staff should anticipate the resident's needs and assist them with their ADL needs. The DON reported if the ADL need is facial hair, staff should address it unless the resident refuses. During an interview on 04/09/24 at 2:17 p.m. with Staff K, MDS Coordinator she revealed a care plan should be in place to address the resident's ADL needs. She reported that usually on admission the admitting nurse will put a baseline care plan in place related to the resident's ADL needs, and then the clinical team will review the orders and diagnosis the day after admission. She reported if anything was needed to be added it is added. She reported she was not sure why Residents' #122 and #123 care plans related to ADLs were missed. Review of the facility policy titled, Activities of Daily Living (ADLs), dated 10/17/2022 revealed the following: Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; Under the section titled, Policy Explanation and Compliance Guidelines: revealed the following: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility policy titled, Promoting/Maintaining Resident Dignity, dated 10/17/2022, revealed the following: 9. Groom and dress residents according to resident preference.

Based on observations, record review and interviews, the facility failed to ensure a change in condition was addressed for one resident (#51) of a total sample of 46 residents. Findings included: Review of the Admission Record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, unspecified, unspecified atrial fibrillation, dysphagia, and need for assistance with personal care. On 04/10/24 at 8:31 a.m. an interview was conducted with Resident #51. She stated she did not feel well and did not know what was wrong with her. She said, I don't feel well. I feel like crawling out of my skin. The resident stated she has been having this feeling for a long time. She stated she notified the staff and her POA (power of attorney). She stated she was not sure what was being done about it. On 04/09/24 at 12:11 p.m., an interview was conducted with Resident #51's POA. She stated she noticed the resident had declined. She used to be in the front side of the building, they moved about 10 residents. She stated the resident has not been herself since then. She stated the residents on the second floor were long-term residents who were very close and use to the staff. She stated they did not move the staff. The POA stated the resident had different CNAs (certified nursing assistants). She said, She (Resident #51) does not do the things she used to do. I have been telling the nurses that I think she has depression; she needs to be seen. The POA stated the resident has had a change which had been going on for at least three weeks, if not more. She restated the resident had not been herself since the move. The POA stated the resident has had no appetite and she reported feeling like her skin was crawling out. During this interview, Resident #51 stated she reported this to the CNA (Staff Q). During an interview on 04/09/24 at 12:15 p.m. with Staff Q, CNA she stated she noticed a change in the resident. She stated the resident had been eating less. She said, Yes, she told me she is not feeling like herself. I think it was last week. I notified the nurse. An interview on 04/09/24 at 12:22 p.m. was conducted with the Food Service Coordinator (FSC). She confirmed she noticed a change in the resident, but she did not know what it was. She stated it had to do with the move. She is more depressed. She is not her jovial self, she is eating less. She stated she would notify the Director of Nursing (DON) if she noted a change. She stated she had not notified anyone prior to this. The FSC stated she had just mentioned it to Staff S, Registered Nurse (RN). An interview on 04/09/24 12:38 p.m. was conducted with Staff S, RN. He stated Resident #51 sometimes ate and sometimes she did not. He stated sometimes she had expressed some concerns related to wounds. He stated he noticed sometimes she slept too much. He stated he monitors the resident. He stated over the weekend the resident had problems with her blood pressure and he notified the doctor. He stated she had not said anything about her skin crawling. He stated the FSC just notified him. An interview on 04/09/24 at 05:07 p.m. was conducted with Staff E, Licensed Practical Nurse (LPN)/ Unit Manager (UM). She stated if a resident had reported a change, they would do a head-to-toe assessment, ask the resident what they were feeling, assess, complete an SBAR (Situation, Background, Assessment, Recommendation), notify doctor and family and follow -up accordingly. She stated she was not aware this resident had a change. A follow-up interview was conducted on 04/10/24 at 10:04 a.m. with Staff E, LPN/UM. She stated she spoke with the resident. She said, She (Resident #51) did tell me that she has not been feeling herself, and she feels her skin is crawling in her neck. She stated it had been going on for a while. She could not identify how long. Staff E stated the Advanced Registered Nurse Practitioner (ARNP) went to see her this morning. Staff E stated the resident had a change in condition on Saturday related to her blood pressure and they started her on IV (Intravenous). She confirmed there was not much follow up until yesterday. Staff E, LPN/UM stated the resident was agreeable for a psych consult which they had scheduled a consult. Staff E stated staff did not do a note for the skin crawling concern. She said, It could be a medication reaction or a psych issue. I would have expected an SBAR or Change in Condition to be documented and to get orders and follow up with the responsible party and make me aware or the DON. I would be upset if I felt like my skin was crawling. Staff E stated staff should have documented her concerns prior to this and contacted the physician for orders. Review of a facility policy titled, Notification of Changes, dated 10/17/22, showed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.

Based on observations, record review and interviews, the facility failed to provide care consistent with professional standards of practice related to oxygen therapy for one resident (#21) of two residents reviewed for oxygen therapy. Findings included: An observation on 04/08/24 at 9:55 a.m. revealed Resident #21 was receiving oxygen via a nasal cannula, the oxygen concentrator was set at two liters per minute. The oxygen tubing was touching the floor and the storage bag was dated 04/01/2024. An observation on 04/08/2024 at 2:00 p.m. revealed Resident #21 in bed and oxygen was in place. An observation on 04/09/2024 at 8:00 a.m. revealed Resident #21 in bed, oral care had been provided and oxygen tubing was removed off the floor, the bag and tubing had been changed and dated 04/08/2024. An observation on 04/10/2024 8:00 a.m. revealed Resident #21 resting in bed receiving oxygen via a nasal cannula at two liters per minute. Review of Admission Record for Resident #21 revealed a date of admission as 9/4/2020. The diagnoses included cerebral infarction, shortness of breath, anxiety, pneumonia, and chronic obstructive pulmonary disease. Review of active physician orders as of 04/10/2024 for Resident #21 revealed no orders for oxygen therapy. Review of Medication Administration Record (MAR) dated 03/01/24 - 03/31/24 for Resident #21 revealed no administration of oxygen therapy. Review of the Treatment Administration Record (TAR) dated 03/01/24 - 03/31/24 for Resident #21 revealed no administration of oxygen therapy. Review of the MAR dated 04/01/24 - 04/09/24 for Resident #21 revealed no administration of oxygen therapy. Review of the TAR dated 04/01/24 - 04/09/24 for Resident #21 revealed no administration of oxygen therapy. Review of the active care plan revealed, date initiated 12/30/2023, revised on 06/2023 and printed on 04/10/2024 for Resident #21 revealed no focus, goal or interventions related to oxygen therapy. During an interview on 04/09/2024 at 2:15 p.m. with, she revealed that Resident #21 prefers to remain in bed and confirmed there was no physician order for the observed oxygen use. During an interview on 04/09/2024 at 4:00 p.m. Staff E, Licensed Practical Nurse (LPN), Unit Manager (UM), Infection Control (IC) verified Resident #21 did not have a physician order for oxygen. Review of the policy titled, Oxygen Administration, dated 10/17/2022, revealed: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and compliance Guidelines: 1. Oxygen is administered under the orders of a physician, except in the case of an emergency. 2. Personnel authorized to initiate oxygen therapy include physicians, registered nurses, licensed practical nurses and respiratory. 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders.

Based on observation, record review and interview the facility failed to appropriately store and secure medications related to one (1st floor) of two units for medication at the bedside and one (200 hall, cart 1) of four medication carts left unlocked. Findings included: 1. Observation of Resident #120's room on 04/08/24 at 10:28 a.m. revealed there was a white cream in a medicine cup in a tissue box on the resident's over bed table which was located to the right side of the resident's bed. The cup was not labeled with the name of the substance and there was no indication for the direction of the use of the substance. Interview with the resident at this time revealed the resident indicated that is icy hot from last night. Also noted in the tissue box was a bottle of eye drops and a container of Icy Hot. There was no direction for use of the eyedrops or the Icy Hot. Resident #120 said, Those are mine that I paid for because my eyes get dry. Continued observation of Resident #120's room revealed a green substance in a disposable 4 oz (ounce) juice cup with a vinyl glove covered over the top of the cup. The cup was on the resident's nightstand located to the left of the resident's bed. Interview with the resident, at this time, revealed she cannot remember what the substance was and that it had been at the bedside since the night before. She was not sure what the green stuff is. (Photographic Evidence Obtained) Review of Resident #120's electronic record revealed there was no physician order for eyedrops, or mentholated topical creams. Additionally, there was no documentation that would indicate the resident had been assessed to independently store and self-administer her medication. An interview on 04/08/24 at 10:32 a.m. with Staff G, Registered Nurse (RN) revealed she had already administered medication to the resident that morning but had not left any topicals at the bedside. Staff G entered Resident #120's room with the state surveyor present and obtained the bottle of eye drops, white cream and green cream. It was noted at this time, the green cream had a mentholated scent and the white cream did not have a mentholated scent. Staff G reported she was not sure what the creams were and discarded them in the garbage. Staff G gave the resident the eyedrops back after the resident indicated they were hers and that she paid for them. An interview on 04/09/24 at 1:53 p.m. with the Director of Nursing (DON) revealed that residents are allowed to keep medications at the bedside if they have an order for the medication, and are assessed to self-administer medication, and are provided with a Medication Administration Record (MAR) at the bedside. An interview with the DON on 04/09/24 at 4:15 p.m. revealed the resident now has an assessment for self-administrating medication and has physician orders for the eyedrops and Icy Hot medication at the bedside. She reported she was not aware of the topicals that were left at bedside in cups, and the green substance was probably from therapy because nursing has no green topicals. An interview on 04/10/24 at 10:48 a.m. with the DON revealed she found out from therapy the substance that was left in the cup was bio-freeze and she was sure that the other substance was barrier cream. The DON reported no one admitted to leaving any substance at the resident's bedside. 46234 2. An observation was made on 4/10/24 at 11:06 a.m. on the 200 unit of an unlocked medication cart. The cart was observed to be unlocked with the keys hanging from the open lock while sitting in a resident hall with no staff members in sight. (Photographic Evidence Obtained.) An interview was conducted on 4/10/24 at 11:10 a.m. with Staff V, RN. She confirmed the unlocked medication cart was assigned to her. She said the medication cart should always be locked when the nurse isn't using it. Staff V said she shouldn't have left the keys in her cart; they should be in her pocket. She said sometimes she gets busy and forgets.

Based on record review and interview, the facility failed to ensure the binding arbitration agreement explicitly informed the resident or their representative of the right to not sign it for three residents (#6, #120, and #122) of three residents sampled. Findings included: 1. Review of the Admission Record for Resident #6 revealed an admitted [DATE]. Resident #6 was noted as her own responsible party. Review of an Admission Minimum Data Set (MDS), dated [DATE], showed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. On 04/10/2024 at 10:45 a.m. an interview was conducted with Resident #6. Resident #6 stated she signed so many forms when she was admitted that she does not remember each one. Upon review of the Arbitration Agreement she signed on 04/05/2024, she stated she remembered signing the Arbitration Agreement. She was not aware the Arbitration Agreement was optional, and she was giving up her right to seek legal action. She stated had she known the Arbitration Agreement was (optional) she wouldn't have signed the Arbitration Agreement. 2. Review of the Admission Record for Resident #120 revealed an admitted [DATE]. Resident #120 was noted as her own responsible party. Review of an MDS, dated [DATE], showed Resident #120 had a BIMS score of 14 out of 15, indicating intact cognition. On 04/10/2024 at 10:50 a.m. an interview was conducted with Resident #120. Resident #120 stated when she was asked to sign forms, she was given a tablet where the signature line was only visible. Upon review of the Arbitration Agreement she signed on 04/05/2024, she stated she remembered signing the Arbitration Agreement. She was not aware the Arbitration Agreement was optional, and she was giving up her right to seek legal action. She stated had she known that the Arbitration Agreement was (optional) she would have signed the Arbitration Agreement. 3. Review of the Admission Record for Resident #122 revealed an admitted [DATE]. Resident #122 was noted as her own responsible party. Review of an MDS for Resident #122, dated 03/28/2024, showed Resident #122 had a BIMS score of 12 out of 15, indicating intact cognition. On 04/10/2024 at 10:55 a.m. an interview was conducted with Resident #122. Resident #122 reviewed a copy of the Arbitration Agreement she signed on 04/05/2024. Resident #122 stated she did not know what the agreement meant. She was not aware the Arbitration Agreement was optional, and she was giving up her right to seek legal action. She stated had she known the Arbitration Agreement was (optional) she wouldn't have signed the Arbitration Agreement. Review of the facility's Arbitration Agreement revealed the agreement did not show an explicit statement the resident or representative did not have to sign the arbitration agreement. The Arbitration Agreement, page 3 of 4 paragraph 4 read: I hereby agree and acknowledge that I have read this Agreement, have understood it, and have been given the opportunity to see legal counsel regarding this agreement. I hereby acknowledge that I agree and wish to be bound by the provisions of the agreement. On 04/10/2024 at 10:15 a.m. an interview was conducted with the Admissions Coordinator. She stated the Arbitration Agreement is verbally explained to the resident as they are admitted to the facility. Residents are verbally told they have the right to have legal counsel review the Arbitration Agreement. She stated the Arbitration Agreement is optional. She reviewed the form and confirmed the form did not inform the resident that signing the Arbitration Agreement was optional.

Based on observations, interviews and review of facility policy, the facility failed to maintain an effective pest control program related to small flying insects observed in three resident rooms (212, 216, and 218) on one of two floors. Findings included: During a tour of Resident room [ROOM NUMBER] on 04/08/24 at 10:16 a.m. an observation was made of small flying insects on the resident's water cup. The resident in the window bed stated the cleaning could be better. She stated she had seen a cockroach in the bathroom. The resident stated she had observed the insects in her room before. On 04/09/24 at 11:10 a.m. an interview was conducted with Staff P, Housekeeping. She stated she cleaned all the rooms. She stated if there were bugs anywhere, she would notify her supervisor. During a tour of Resident room [ROOM NUMBER] on 04/09/24 at 11:17 a.m., two urinals were observed on the resident's head of bed, hooked to the bedside rail. They were observed with urine, stained and with a foul order. An observation was made of small flying insects, approximately 20 of them on the resident's trash can and around surfaces in the room. An observation was made of the small flying insects on the resident's water cup and on his bed. The resident in the window bed stated it was always like that. During a tour of Resident room [ROOM NUMBER] on 04/10/24 at 8:42 a.m. an observation was made of small flying insects on the resident's plate and on their bed. An interview was conducted on 04/10/24 at 9:06 a.m. with Staff M, Housekeeping, Staff P, Housekeeping, and the Housekeeping Manager (Manager). Staff M stated it was the first time she saw the small flying insects. The Manager stated no one had said anything about the flying insects. She stated would call maintenance to come and spray. She stated the facility had a pest control contractor who comes on Wednesdays. She stated the problem with the small flying insects was because the showers don't get used often and it could be the drain issue. On 04/10/24 at 10:09 .m. an interview was conducted with Staff E, Licensed Practical Nurse (LPN)/Unit Manager. She stated the small flying insects were all around the building. She stated there should not be flying insects on residents' drinking cups, on themselves or their spaces. She stated the CNAs (Certified Nursing Assistants), and nurses should replace the residents' urinals daily if needed. Staff E observed the photographic evidence and said, Insects on residents' plate, that is gross. I can't imagine about the residents who cannot swish the insects off themselves. Staff E stated maintenance knew. She said, We told them. I am not sure what they have done about it. I spoke to him last week Wednesday. On 04/10/24 at 3:38 p.m. an interview was conducted with the Director of Facilities. He stated he was made aware of flying insects the previous week. He said, My pest control guys came last week. He said some residents have fruits and flowers which might be causing the flying insects. He stated he could not find any breeding place. He stated if staff observed any pests, they should notify the receptionist to put in a work order. He said, If there is an issue I expect to be notified. Review of the facility's pest log showed no evidence of any insects being reported. The log did not show any work orders or treatments related to pests. 46234 An observation was made on 04/8/24 at 1:47 p.m. in Resident room [ROOM NUMBER] of several small flying insects around the resident's room. A small flying insect was observed landing on a resident's face while she was sleeping. The small flying insects were observed in the same room on 4/9/24. Review of a facility policy titled, Resident Environment Quality, dated 10/17/22, showed it was the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. (10.) Maintain an effective pest control program so the facility is free of pests and rodents. (Photographic Evidence Obtained)

Based on observations, interviews with facility staff, the Medical Director (MD), a resident, a family member, and an Apartment Manager, and review of medical records, policies and procedures, and additional resource documentation, the facility failed to provide adequate supervision and manage risk associated with accident prevention for one (Resident #1) of four facility residents identified as at risk for elopement out of a total sample of 10 residents. On 7/12/2022, Resident #1 ambulated with a 4-wheeled walker, while wearing a wanderguard (electronic monitoring device) on his ankle when he exited the building. The electronically monitored door opened before the wander monitoring device signal was picked up. The door did not secure as it should for a resident with a wander monitoring device but did properly alarm. A staff member silenced the alarm without investigating the cause and notifying others that an alarm had gone off. Resident #1 was a vulnerable adult assessed as having moderately impaired and fluctuating cognition with diagnoses to include muscle weakness, altered mental status, history of recurrent urinary tract infections ([CONDITION(S)] ' s), metabolic [CONDITION(S)], and a foley catheter. Resident #1 was at serious risk of falling, being hit by a car, suffering from heat stroke, or becoming a victim of a serious crime as he traveled approximately 1.1 miles in 93 degree heat along uneven pavement, through the facility parking lot with moving vehicles, curbs, speed humps, parking bumpers, and across roadways/intersections with vehicles traveling and turning at a high rate of speed. The facility is located on a 4 lane heavily traveled roadway with additional lanes for turning and a speed limit of 45 miles per hour. The likelihood of serious physical harm, injury, or death to Resident #1 as a result of the facility ' s failure to provide adequate supervision and manage accident risks to prevent elopement and promote safety resulted in findings of Immediate Jeopardy on 7/12/2022, removed on 7/28/2022 with the scope and severity reduced to a D after verification of implementation of immediacy removal actions. Findings included: On 7/25/22 at 10:00 a.m., an interview with Resident #1 was conducted in his room. Resident #1 was observed to ambulate independently using a four wheeled rolling walker. The resident had a urinary catheter with the urine collection bag contained in a privacy bag that was attached to the lower part of the walker. The resident reported that he has lived in the facility for about 7-8 months and recently left the facility. The resident stated, I was going to come back. I love it here. I live close by, and I am still paying rent. I just wanted some of my merchandise. When asked what type of merchandise he was going to get from his home, he reported that he wanted his electric shaver. Resident #1 stated, I had to stop a policeman to ask for directions. They called the people here, and two nurses picked me up. I wasn ' t scared or afraid because I was going home, to my home, just to pick up some merchandise, and then I was going to come back. The resident reported that the facility gave him an electric shaver after he returned, but it ' s not as good as the one he had at home. I tried to run away before. Now they put a wanderguard on me. This wanderguard rings when I get near a door. They have people get me when it rings and take me back to my room. When I left, I had a wanderguard. The resident reported that the alarm on the exit door did ring but no one came or responded to the ringing alarm. During a telephone interview on 7/26/22 at 9:41 a.m., Resident #1 ' s son revealed he lives in another state, but is very involved with his father ' s care. The son remembered receiving a phone call from the facility ' s nursing home administrator (NHA) on 7/12/22, the day his dad eloped and was found by the police about 3 hours after leaving the facility ' s property. He stated he was very alarmed when he got that call. On that same day at about 12:30 p.m., he also received a call from his dad ' s Apartment Manager, where he lived prior to admission into the facility. The Apartment Manager informed him that his dad was found there, and the police were called. Resident #1 ' s son stated he knows his dad gets confused and really likes to be outside. The son reported that this was not the first time Resident #1 had attempted to leave the building and this also occurred back in May of 2022. In the May instance, the son reported that his father was re-directed before leaving the building and a wanderguard was placed on him at that time. The son stated that the facility contacted him again, last week, requesting to move his dad to an upstairs room. The son stated he agreed with the move but informed the social worker that it was very important for his dad to continue to go outside with staff supervision for walks. A review of Resident #1 ' s admission record revealed the resident ' s prior address before admission to the facility in February of 2022 was a senior living independent apartment complex located approximately 3.6 miles, an estimated 1 hour and 13 minute walk, away from the facility according to Google Maps. In order for the resident to arrive at his previous apartment, he would have needed to travel through the facility ' s campus parking lot and past a manned facility guard shack before reaching East [NAME] Avenue, a highly traveled 4 lane roadway with additional lanes for turning and a speed limit of 45 miles per hour (MPH). The resident would have needed to continue to travel along and across at least two other busy 4 lane roadways with speed limits of 45 miles per hour before reaching his prior apartment. The resident had a urinary catheter and used a four wheeled walker. Resident #1 would have had to travel along uneven pavement, through parking lots with moving vehicles, curbs, speed humps, parking bumpers, and across roadways with vehicles traveling and turning at a high rate of speed. The temperature on 7/12/22, the day Resident #1 eloped from the facility unbeknownst to staff, was a high of 93 degrees and a low of 91 degrees at 12:00 p.m. according to https://www.timeanddate.com/weather/usa/[NAME]/historic?month=7&year=2022. A visit was made to Resident #1 ' s apartment complex on 7/27/22 at approximately 11:15 a.m. Interview with the Apartment Manager on 7/27/22 at 11:30 a.m. revealed Resident #1 had been a tenant for about 8 years. She recalled receiving a call from the police on 7/12/22, the day the resident eloped from the facility. She informed the police that although the resident still had an apartment at the senior independent living complex, he was currently living at the nursing home. The Apartment Manager stated she told the police the name of the Nursing Home and she confirmed that Resident #1 never arrived at the apartment complex. On 7/25/22 at 11:30 a.m., an interview was conducted with the NHA and Director of Nursing (DON). The NHA reported that on 7/12/22 staff saw Resident #1 at approximately 7:30 a.m. for breakfast. The resident was observed again by staff sometime after breakfast between 8:45 a.m. and 9:00 a.m. in his room. At 12:45 p.m., the NHA stated she received a call from a deputy with the local county Sheriff ' s Office informing her Resident #1 was off the facility ' s campus and located at the local bus station. The deputy provided the NHA with the street address to the bus station, which was approximately 1.1 miles away from the facility, an estimated 22-23 minute walk time (Google Maps), which would likely require the resident to pass through the intersection of East [NAME] Avenue and County Road (CR) 581 (also referred to as [NAME] B Downs Blvd) in order to reach the side streets leading to the bus station. According to https://planhillsborough.org/wp-content/uploads/2020/07/VZ-[NAME]-B-Downs-Tech-Memo_REV2020_1230.pdf, the CR 581 corridor has six through lanes with a posted speed limit of 45 miles per hour (MPH). It is a highvolume roadway with an average traffic volume of 52,277 vehicles per day between SR582 (E Fowler Avenue) and CR-582A (E [NAME] Avenue) and 42,851 vehicles per day between CR-582A (E [NAME] Avenue) and E Avenue. Continued interview with the NHA revealed that after the phone call with the deputy, she immediately left the facility with Staff M, a Certified Nursing Assistant (C.N.A.) in a facility car. While traveling to the bus station, the NHA reported that she called her DON to notify her that Resident #1 had eloped from the facility and she was heading to the bus station to pick him up. The DON was working that day but had left the facility briefly for an appointment. The NHA stated when she arrived at the bus station to pick up Resident #1, he was alert and confused with no apparent signs of injury. The resident willingly went with the NHA and Staff M in the vehicle to return to the facility. Once we returned to the facility, the medical director, who was also Resident #1 ' s attending physician, was notified at approximately 1:30 p.m. Nursing completed an assessment of the resident and found no indication of any concerns or injuries. The Executive Director over the facility ' s campus was notified as well as Resident #1 ' s son. The NHA stated she explained to the son that the resident wanted to get some fresh air, and he got turned around. The NHA stated we believe that the resident went out through the double glass automatic doorway known as the breezeway that goes out to a non-enclosed area. The exit door was labeled South on a facility map. The NHA and DON both confirmed that Resident #1 had a wander monitoring device on when he went through the doorway and an alarm did go off; however, Staff N, a Certified Occupational Therapy Assistant (COTA) turned the alarm off without searching for a resident. The NHA stated that during the facility ' s investigation, Staff N, COTA reported that she was not aware that the alarm sounded to signal that a resident with a monitoring device was eloping and thought that the alarm was related to the door being open too long. The NHA stated that on 7/12/22 at 12:15 p.m., Staff A, the assigned CNA could not locate Resident #1 when she went to deliver his lunch meal. Staff A, CNA reported this to Staff G, Resident #1 ' s Registered Nurse (RN) and the Unit Manager, Staff H, License Practical Nurse (LPN). They let the rest of the staff know and started doing the checks to see if he was inside of the building. The DON was not in the facility at that time, and the NHA was not aware that they were looking for the resident when she received the call from the deputy on 7/12/22 at 12:45 p.m. The NHA stated we immediately started an investigation by doing interviews with the floor staff and therapy. We established that Resident #1 ' s usual routine was to go to therapy right after his breakfast. He was not on therapy caseload but received restorative services and enjoyed going to the gym. Resident #1 would ride the exercise bike in the Physical Therapy (PT) gym, drink coffee, and then go out the exit doors in the PT gym, which led to a secured/enclosed outdoor courtyard/patio area. After this, he would return to his room for his lunch. Resident #1 remained in his room on the 1st floor after lunch. His active period was mostly in the morning. On 7/25/22 at 1:48 p.m., the Maintenance Director reported that following the event his team checked all 7 exit doors on 7/12/22 to see if they were all functioning properly and did not identify a concern. On 7/15/22, we called our door contractor just to make sure that we were checking them the right way. The Maintenance Director reported that the door company indicated that all the doors were working as expected; however, they found that the glass sliding automatic door that Resident #1 was believed to exit through was opening before the wanderguard transmitter was picking up, but the door system and antenna were working as expected. The contractor suggested adjustment of the auto door sensor. The Maintenance Director stated all code alert door systems were working and functioning as expected. The Maintenance Director presented door audits labeled door alarms from 5/1/22 through 7/25/22 for each exit. All days had checkmarks with no remarks written in the comments section to include July 12, 2022, or July 15, 2022, the day the door was inspected/serviced by the contractor. Review of the Door Contractor ' s Service Call Job Form revealed an issue date of 7/14/2022. The start date was 7/15/22 with a description of: Customer Described Problem: [Maintenance Director] called in and needs tech to come out to look at the door systems getting potential RFI [Radio Frequency Identification) problem, transmitter at times goes thru the door Suspected Problem: RFI Troubleshooting Steps: none taken just wants tech out . Servicer Notes: On site met with .Assistant Maintenance Dir[[NAME]] and [First Name of NHA] - Director of Nursing. Checked and tested all Code Alert door system. Found sliding glass auto door opening before transmitter was picking up. Door system and antenna working as expected. Suggest adjustment of the auto door motion sensor. Customer requested the [NAME] switches on the receptions desk to be disconnect[ed] so staff can be alrted [sic] sooner. Also will provide quote to add code locks on the receptions desk. All Code alert door system working and functioning as expected. The form was signed by the Assistant Maintenance Director and dated 7/15/22 noting that he had inspected the work performed by the door contractor and acknowledged that the work was completed to his satisfaction. Interview with the NHA and DON on 7/28/22 beginning at 1:00 p.m. revealed that when they were checking the wanderguard exits after the resident returned to the facility on [DATE] they realized that the resident ' s rolling walker triggered movement from the door sensor allowing the door to open. As the resident continued to travel through the open doorway the wanderguard attached to his ankle was detected by the sensor and triggered an audible alarm; however because the door had already opened due to the walker triggering the motion sensor, he was able to exit through the doorway. The door company came out on 7/15/22 and adjusted the sensor so now it has a much shorter/narrower span of detection before allowing the door to open. As an additional safety measure, they have also attached wanderguard devices to the assistive devices like walkers so the sensor will pick up the device and the door will secure as it should have on 7/12/22 and also sound an alarm to notify staff. The NHA also revealed that Staff N, COTA, who turned the alarm off without searching for a resident or notifying other staff of the alarm, had worked at the facility for about a year and was an internal transfer from another related facility. Staff N ' s original employee orientation had occurred at the prior facility and when she transferred to this facility, the Director of Rehabilitation (DOR) at that time oriented her. This DOR was no longer with the company unrelated to this event and they no longer had contact with this prior DOR. Staff N, COTA informed the NHA during her investigation that the orientation she had from the prior DOR did not include information about the door and wanderguard system being connected therefore she did not know to look for anyone or notify staff of the door alarm so a head count could be initiated. The NHA provided a written timeline established as a result of the facility ' s investigation. Review of the Elopement Timeline for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment) with diagnoses of metabolic [CONDITION(S)], essential (primary) hypertension, and cognitive communication deficit. Date of Event: 7/12/22 7:35 a.m. Breakfast served 8:34 a.m. Morning medications administered 8:45 a.m. - 9:00 a.m. Resident sitting on bedside sitting down 9:00 a.m. - 9:10 a.m. Alarm was turned off by staff 9:37 a.m. Resident exited campus 12:15 p.m. CNA reported resident did not return to room for lunch 12:45 p.m. Deputy called to inform facility that resident was outside of campus 12:49 p.m. DON notified 1:15 p.m. - 1:20 p.m. Resident returned to facility by staff 1:30 p.m. Medical Director (MD) notified 1:33 p.m. - Executive Director (ED) notified 2:00 p.m. - Family notified On 7/28/22 at 2:45 p.m., the Medical Director (MD), who was also the attending physician for Resident #1, confirmed that he was informed of Resident #1 ' s elopement the day it happened. The MD stated it surprised me because he has never eloped before. I know he walks around the building, has some dementia, and his thought process can wax and wane but for the most part, he will respond appropriately. I saw him the next day after the elopement and asked him what happened. He said I needed my electric shaver from home and that shaver at home was really good. The MD informed the NHA, and they got him a new shaver. The MD stated he was concerned about this resident getting out of the building. He believed that the resident would know when to cross the street, but he could still get into an accident due to the busy roadways just outside of the facility campus. The MD stated, safety would be a concern. Continued interview with the MD revealed that post incident, the first thing we did was check the wanderguard system and staff recognizing the door alarm and knowing to look for someone. All staff including non-clinical staff were being educated on the elopement risk. The MD stated he did attend an ad-hoc Quality Assurance Performance Improvement (QAPI) meeting the day after the elopement as well. We are working on getting a standardized code process in place. The facility had another QAPI meeting again last week, but they didn ' t cover the elopement during that meeting as thy are still in the monitoring phase for the interventions they put in place. The MD stated Resident #1 has prostatitis, enlarged prostate, a foley catheter and has been in and out of the hospital with infections (most recently in June 2022). We closely monitor the foley and changing it every month. He thinks the resident would be appropriate for a secure ALF (assisted living facility) if one could be located but expressed that the resident required supervision following the events of 7/12/22. On 7/26/22 at 10:30 a.m., the DON reported that sometime in March of 2022 Resident #1 said he wanted to go home. He was close to the doors by the elevator on the first floor. On 3/20/22, the psychiatric Advanced Practice Registered Nurse (APRN) conducted a Mini-Mental Status Exam (MMSE) and the resident scored a 24, indicating no cognitive impairment. The resident refused to have us place a wanderguard on him at that time. Following that, we didn ' t have an issue with him until May 2022 following a hospitalization from [DATE] to 5/14/22 where he pulled out his urinary catheter. When he returned on May 14, 2022, we placed a wanderguard on the resident. The nursing supervisor conducted an elopement evaluation and Resident#1 had expressed that he wanted to leave the facility, this was when the wanderguard was placed. Review of a signed written statement from the NHA dated 7/12/22 at approximately 12:45 p.m. revealed the local County Sheriff ' s Deputy called and spoke to her regarding Resident #1, who was located at (the street address) for the local bus station. The NHA left the facility to pick up resident with Staff M, CNA. Resident #1 was sitting with the deputy at the bus station. No signs and symptoms of distress. Security staff at the bus station reported calling the deputy for assistance. Resident reported to security staff that a female dropped him off at the bus station. Returned resident to facility at approximately 12:56 p.m. Resident reported he got turned around and didn ' t know where he was. Resident stated he wanted to go get some fresh air. MD contacted at 1:30 p.m., notified family son at approximately 2:00 p.m. DON notified at 12:49 p.m. and ED notified at 1:33 p.m. Review of a typed statement with Staff A, CNA ' s signature revealed on 7/12/22 at around 7:30 a.m. Resident #1 was seen in his room and his breakfast tray was delivered. The resident was seen again around 9:00 a.m. - 9:15 a.m. when picking up trays. At an unknown time, Resident #1 was seen walking towards the therapy gym. A second hand written event statement signed by Staff A, CNA dated 7/12/22 at 12:30 (p.m. or a.m. not indicated) revealed she walked into Resident #1 ' s room and noticed that he was not here. She checked the building for the Resident and asked a physical therapist (PT) if she had seen Resident #1. The PT said no. Staff A then called Staff H, LPN/Unit Manager to inform her of missing resident. A search was started for Resident #1. Telephone interview with Staff A, CNA on 7/26/22 at 1:34 p.m. revealed she was currently on leave from the facility unrelated to this incident or any disciplinary action. Staff A confirmed she was Resident #1 ' s assigned aide at the time of the elopement. She stated that her times maybe wrong, but she recalled last seeing Resident #1 in his room after she returned from her lunch break on 7/12/22 at about 12:35 p.m. She stated that he was going to the gym. She further stated that administration had told her that the police contacted the facility at 12:45 p.m. that day, and she must be mistaken in her times. Staff A was insistent that 12:35 p.m. on 7/12/22 was the last time she recalled seeing the resident that day. Staff A reported she was very familiar with Resident #1 and frequently cared for him. She stated his normal routine was to go to the therapy gym every day after breakfast and ride the bike. After that he would walk outside in the enclosed courtyard near the therapy gym, and then return to his room for lunch where he would normally remain for the rest of the day. Staff A stated the resident was alert and oriented, and she would check on him frequently when assigned to his care. Staff A stated the facility standard was to check on residents every 2 hours. Interview with the NHA and DON on 7/28/22 beginning at 1:00 p.m. revealed the CNA ' s don ' t clock out for lunch or have an assigned lunch time so it could not be determined when Staff A, went to lunch or returned from lunch. Review of a typed statement dated 7/12/22 and signed by Staff D, CNA revealed she last saw Resident #1 at 9:00 a.m. sitting on his bed when picking up breakfast tray. Interview with Staff D, CNA on 7/26/22 at approximately 2:35 p.m. revealed she had worked at the facility for about 2 months and had cared for Resident #1 in the past. On 7/12/22 she was not assigned to the resident but was assisting Staff A, the assigned CNA the morning he eloped. She stated she picked up the resident ' s breakfast tray at approximately 9:00 a.m. and observed him dressed in shorts lying in bed. She reported that she did not see him again that morning. Review of a typed statement dated 7/12/22 and signed by Staff G, RN revealed she saw Resident #1 at 8:30 a.m. for medication administration and after that she saw him walking down the hallway towards the therapy room. On 7/25/22 at 1:21 p.m., Staff G, the RN assigned to Resident #1 at the time of the elopement revealed she last saw the resident during her medication pass around 10:00 a.m. - 10:30 a.m. She stated that Resident #1 had received his meds at 8:34 a.m. that morning. Staff G described Resident #1 as alert and oriented. She reported that he had a wanderguard on and she did not know why he had a wanderguard on since he was alert and oriented, but she checked for the wanderguard everyday and recorded this on the Treatment Administration Record (TAR). She reported that the resident could walk around the facility freely and she last saw him walking in the hallway on West wing where his room was located. Staff G stated around lunch time, Staff A, CNA notified her that the resident was not in his room. We went to do the room check together and when he wasn ' t there, we started looking for him. We did the code yellow, which is the elopement code, which can be heard in every single room. We continued looking for him, we checked the entire wing. I didn ' t write a report. When he was returned, I did a full head to toe assessment and found no injuries and no concerns. We started doing 15-minute checks after this which we documented. On 7/23/22, he was moved upstairs because it ' s easier to provide closer supervision to see if he was walking out. A follow up interview was conducted on 7/27/22 at 11:06 a.m. with Staff G. Staff G reported that Resident #1 was mostly alert and oriented, with some confusion. She stated he would get confused closer to the afternoon. Sometimes we would just have to talk to him a little bit. He always knew where he was but would say that he has a house down the road. Review of a hand written statement dated 7/12/22 signed by Staff N, COTA revealed at approximately 9 a.m. she was in the therapy gym and heard the alarm going off. I went out to shut the alarm off and looked around and didn ' t see anyone. On 7/25/22 at 1:55 p.m., a telephone interview was conducted with Staff N, COTA. Staff N reported that she was sitting in the therapy gym when she heard the door alarm. She could not recall exactly how long the alarm was sounding for but stated it was more than one minute. She said she went to the (south) door, turned the alarm off, looked around to see if there was anyone in the area, and didn ' t see anyone. She stated that since this incident, I have received education on door alarms and how to respond to a code yellow, which means elopement. Review of a typed statement dated 7/12/22 at 2:25 p.m. and signed by Staff H, Unit Manager revealed she conducted an interview with Resident #1 in his room after he was returned to the facility on [DATE] from the bus station. She stated the resident said he left the facility shortly after he was done eating his breakfast that morning. He reported that when he left, he went through the guard station and took a right onto [NAME] Avenue. He stated he walked down for a while and then took a left at a major intersection (but could not recall any landmarks). After he took that left, he stated he walked or a while and then realized he got turned around and lost. Resident #1 stated he sat down to rest on the sidewalk when a woman drove up to him and offered him a ride. He accepted the ride from the unknown lady and then got dropped off at the station. Resident #1 reported to the Unit Manager that he was trying to go home. On 7/25/22 at 1:38 p.m., Staff H, LPN/Unit Manger reported that Staff A, CNA came to get me after my wound rounds on 7/12/22. This was around lunch time. I was told that they could not find Resident #1. I ran straight outside because they were already searching inside. I started at the Koi Pond first, then I walked to the guard gate and spoke to the guard. He reported that he had not seen the resident. Where the guard gate was located was the only way in and out. She stated he had to pass the guard gate. A follow-up interview with Staff H, Unit Manager on 7/27/22 at 11:09 a.m. revealed she was somewhat familiar with the resident. She stated the wanderguard was placed on the resident because the resident was expressing that he wanted to go home. His BIMS was fluctuating back in May, but after that he was pretty stable and able to make his needs known. He walks around using his walker and goes near the doors, but never tried to leave. He was very easily re-directed by staff. On 7/25/22 at 11:52 a.m., an interview with Staff O, the Security Guard who worked on 7/12/22 stated, I was busy at the gate with cars coming and going and did not see any residents leave. I was on a bathroom break around 9:00 a.m., maybe that is when he left. We now have a book related to elopement at the gate. We did not have one when the resident left. We used to have a book years ago, but we haven ' t had one since the new company took over. On 7/25/22 at 1:08 p.m., an interview was conducted with Staff P, Security Guard. Staff P stated, I did not see a resident leave. Many people were coming and going. I was relieving the security guard for a bathroom break. Two nurses came by before lunch and asked me if I saw the resident leave. There are new logs at the gate now to identify people who may be confused and want to leave. On 7/26/22 at 11:19 a.m., an Interview was conducted with Staff M, Staffing Coordinator/C.N.A., who accompanied the NHA to pick Resident #1 up on 7/12/22 at approximately 12:40 p.m. from the bus station. She stated the resident was alert and recognized me. He was wearing a shirt, shorts, and tennis shoes. He was with an officer. We escorted the resident back to the car. I was driving the car. The resident said he had gotten lost when he went for a walk. On 7/25/22 at 9:50 a.m., Staff R, RN reported that Resident #1 was moved to the 2nd floor on Saturday (7/23/22) because he had eloped. Staff R described Resident #1 as alert with confusion and had a wanderguard on his left ankle. Staff R stated Resident #1 ambulated with a walker throughout the 2nd floor and the wanderguard will set off an alarm when he gets close to either of the two elevators located on the second floor. Staff R reported Resident #1 continuously asks to leave to go to the first floor because he knows everyone there. However, we cannot let him go alone. He must have a staff member with him due to the elopement risk. Staff R said he was not familiar with the resident prior to the resident moving to the 2nd floor. Restorative nursing was taking the resident outside for walks around the Koi Pond (documentation was provided to demonstrate the resident was offered supervised walks outside). On 7/26/22 at 1:14 p.m., Staff B, Restorative Aide confirmed that she has been working with the resident since 7/4/22 and since he has moved upstairs she continues to take the resident outside for ambulation 3 times a week. Staff B reported that the resident ambulates both inside and outside weather permitting with restorative nursing and has refused only one time, 7/24/22. On 7/27/22 at 11:05 a.m., the Director of Physical Therapy reported that Resident #1 was discharged from PT on 6/27/22. The resident had achieved his highest practical level and was ambulating 300 feet with his walker and no staff assistance. Resident#1 was referred to Restorative therapy on 7/4/22 following his discharge from PT. The Director of Physical Therapy stated he did not notice any signs of confusion with the resident and stated he was very alert. Review of Resident #1 ' s admission record revealed the resident was [AGE] years old, had an initial admitted [DATE], a recent readmission on 6/10/22 following a hospital stay from 6/6/22 to 6/10/22 and diagnoses to include metabolic [CONDITION(S)], muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, urinary tract infection ([CONDITION(S)]), dysphagia, muscle wasting and atrophy, unsteadiness on feet, essential hypertension, other seizures, elevated white blood cell count, obstructive and reflux [CONDITION(S)], acute kidney failure, [CONDITION(S)] without lower urinary tract symptoms, and altered mental status. Upon admission to the facility an Elopement Evaluation was conducted on 2/21/22 with no risk identified. On 3/17/22, an Elopement Evaluation identified that Resident #1 was at risk of elopement due to: a history of/attempting to leave the facility without informing staff, verbal expressions of the desire to go home, packed belongings to go home or stayed near an exit door, had wandering behavior of a pattern/goal directed, and was recently admitted or readmitted in the past 30 days and was not accepting the situation. The clinical suggestions/interventions listed on the evaluation revealed exit alarms should be utilized and staff should be notified of wandering risk. Interview with the DON on 7/26/22 at 10:40 AM revealed no wanderguard was placed on the resident at that time and no documentation was kept to indicate why. The DON did prov [TRUNCATED]

Based on observation, interview, and record review, the facility failed to develop a care plan for one (#1) of four sampled residents reviewed for high risk elopement. Findings included: On 7/25/22 at 10:00 a.m., an interview with Resident #1 was conducted in his room. Resident #1 was observed to ambulate independently using a four wheeled rolling walker. The resident had a urinary catheter with the urine collection bag contained in a privacy bag that was attached to the lower part of the walker. The resident reported that he has lived in the facility for about 7-8 months and recently left the facility. The resident stated, I was going to come back. I love it here. I live close by, and I am still paying rent. I just wanted some of my merchandise. When asked what type of merchandise he was going to get from his home, he reported that he wanted his electric shaver. Resident #1 stated, I had to stop a policeman to ask for directions. They called the people here, and two nurses picked me up. I wasn't scared or afraid because I was going home, to my home, just to pick up some merchandise, and then I was going to come back. The resident reported that the facility gave him an electric shaver after he returned, but it's not as good as the one he had at home. I tried to run away before. Now they put a wanderguard (electronic monitoring device) on me. This wanderguard rings when I get near a door. They have people get me when it rings and take me back to my room. When I left, I had a wanderguard. The resident reported that the alarm on the exit door did ring but no one came or responded to the ringing alarm. Review of Resident #1's admission record revealed the resident had an initial admitted [DATE] and a recent readmission on 6/10/22 following a hospital stay from 6/6/22 to 6/10/22. Upon admission to the facility an Elopement Evaluation was conducted on 2/21/22 with no risk identified. On 3/17/22, an Elopement Evaluation identified that Resident #1 was at risk of elopement due to: a history of/attempting to leave the facility without informing staff, verbal expressions of the desire to go home, packed belongings to go home or stayed near an exit door, had wandering behavior of a pattern/goal directed, and was recently admitted or readmitted in the past 30 days and was not accepting the situation. The clinical suggestions/interventions listed on the evaluation revealed exit alarms should be utilized and staff should be notified of wandering risk. Interview with the Director of Nursing (DON) on 7/26/22 at 10:40 AM revealed no wanderguard was placed on the resident at that time and no documentation was kept to indicate why. The DON did provide evidence that a mini mental status exam on 3/20/22 indicated no cognitive impairment. The DON stated there was no documentation, but the resident refused the wanderguard at that time and because of his cognitive status, the device was not placed. Review of the record revealed no care plan was developed following the Elopement Evaluation in March 2022, which identified Resident #1 at risk. On 5/14/22, another Elopement Evaluation was conducted, again identifying Resident #1 at risk of eloping. The reason for the risk was a history of/or an attempted elopement while at home, wandering, and recent admission or readmission within the past 30 days and was not accepting the situation. No clinical suggestions/interventions were check marked on the evaluation to indicate any interventions were put in place to address the elopement risk and no care plan was developed. However, a review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/10/22, a third Elopement Evaluation was conducted also indicating the resident was an elopement risk. The evaluation indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical suggestions/interventions were once again left unchecked; however, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No care plan was developed related to the elopement risk. The most recent Elopement Evaluation was conducted on 7/12/22 at 2:16 p.m., after the resident had eloped from the facility earlier that day. The resident continued to be at risk of elopement due to a history of/or attempting to leave the facility without informing staff, had verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door, the wandering behavior was a pattern/goal directed, the wandering behavior was likely to affect the safety or well-being of self/others. The clinical suggestions/interventions put in place on this 7/12/22 evaluation were: Apply identification bracelet; Apply personal safety alarm device; Monitor location frequently; Utilize exit alarms; Utilize check-in/check-out log; Document specific behaviors on the behavior log; Review current medication regimen; Notify staff of elopement risk; and Notify staff of wandering risk. A care plan was developed on 7/12/22, the day of the elopement, for risk of wandering/elopement identified. On 7/26/22 at 10:30 a.m., the DON reported that not having a care plan for elopement prior to this event was an oversight. A review of the facility's Policy and Procedure, in place at the time of Resident #1's elopement on 7/12/22, titled Elopement, Risk for or Wandering Resident with a revised date of 11/2016 revealed: Policy: To provide for the safety of residents who are at risk for elopement or wandering. Procedure: 4. When any resident's behavior is witnessed such as attempting to exit the building, trying to exit secured doors, attempting to enter an elevator or continued verbalization of wanting to leave the facility, this behavior must be documented and reported to RN supervisor and passed along and the resident immediately put at risk for elopement. Any resident observed to be aimlessly wandering by staff are also to notify the nurse. If any of these behaviors occur and have not been previously documented or care planned, all interventions used to keep the resident safe must be documented in the nurse's notes and added to the resident's plan of care. The nurse will complete the elopement risk assessment and place resident on wanderguard precautions, if applicable. 5. The nurse and care planning team will identify if the resident is at risk for elopement or if the resident is demonstrating aimless or pointless wandering and develop individualized care plans to ensure the resident's safety. 6. The interventions will be reviewed and updated in relation to the resident's changing needs and on a quarterly basis.

Based on observation, record review, and interviews, the facility failed to ensure the implementation of a baseline care plan which included the physician orders for the resident to be transferred by two staff members one (Resident #3) of nine sampled residents. Findings include: A review of Resident #3's clinical record, the Admission Record, reflected the resident admitted on [DATE]. Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a physician order, dated 06/17/2022, reflected an order, Transfer/Mobility: Mechanical sit to stand x 2. On 06/23/2022 at 10:01 a.m., an observation was conducted of Staff A, Personal Care Attendant (PCA) coming out of Resident #3's room, pushing a sit to stand mechanical lift machine. She was interviewed at this time. She reported that she had provided care to Resident #3, she had used the sit to stand machine for the transfers, out of bed, to the toilet, and to the shower chair. She said Resident #3 could stand, but she was weak. She stated she had just given a shower to the resident, toileted her, and dressed her. She reported no other staff member had assisted her with the latter tasks. Resident #3 was observed sitting in her room. An interview was conducted on 06/23/2022 at 1:55 p.m., with the Staffing Coordinator. She said, because the PCA was not certified, a CNA would work alongside of the PCA. The Staffing Coordinator was asked if a PCA would be allowed to toilet, transfer, and dress a resident alone. She stated that Human Resources (HR) gave the PCA a statement that indicated the parameters of his or her duties. A copy of the parameters was requested, but not provided during the survey. An interview was conducted on 06/23/2022 at 4:11 p.m., with the Director of Nursing (DON). She reported the facility had three types of lifts, two kinds of sit to stand lifts and a (Name brand) lift. She reported Resident #3 was a sit to stand lift, a two person assist, and a PCA should not transfer a resident alone. She said It would put the resident at risk. You need one to steer it and one to maneuver the resident. A review of the facility policy and procedure, Care Plan Summary, revised 11/2017, documented the policy: this facility will provide the resident and /or their representatives with a written summary of the base line care plan that includes: .Any services and treatments to be administered by the facility and personnel acting on behalf of the facility .

Based on resident and facility staff interviews and medical record and facility document review, the facility failed to ensure one (#2) of three sampled residents was free from physical abuse. Findings included: Review of the facility's policy titled Resident Incident Report revealed the policy was to ensure proper follow up was carried out for resident incidents; and evaluations were done to prevent incidents from reoccurring. The policy also provided uniform steps to be followed when a resident incident occurred. Point #7 of the policy indicated nurses' notes in the resident's medical record were to include documentation of all pertinent information. Review of the undated facility policy titled Abuse, Alleged Resident, Neglect or Misappropriation of Resident Property revealed it is the policy to ensure that residents at the facility remain free from abuse, neglect or mistreatment by staff or others. Under the procedure it was documented: 4. Identification a. Through the incident report, staff can report any unusual incidents occurring with residents b. If there is suspected or alleged abuse, staff will notify the Director of Nursing (DON) or his/her designee via phone. An investigation will be initiated immediately, and a report will be electronically submitted within 24 hours . 5. Investigation a. The DON or his/her designee will begin an immediate investigation of the alleged violation . b. When an employee is alleged to have committed abuse, he/she will be suspended pending investigation. 6. Reporting response a. When an incident of abuse, neglect, exploitation, mistreatment, including injuries of unknown source, or misappropriation of property .is alleged or suspected, the facility will immediately, but not later than 2 hours after the allegation is made, 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 notify: i. The resident representative via phone. ii. File a report via the Abuse Hotline iii. The Agency for Health Care Administration (AHCA) by electronic submission. 7. Protection a. Every effort will be made to protect from harm the resident and/or any reporting staff during the investigative process. b. All implicated employees will be immediately suspended pending investigation. 9. Evaluation a. The reporting process will include reporting alleged violations to the State Agency, Nurse Aide Registry, and appropriate licensing authorities if the employee is found to be unfit for service. Definitions: Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. On 4/25/22 at 9:49 A.M., Resident #2 reported that an incident occurred approximately 2-3 weeks ago. The resident stated that a staff member slapped him on the leg while providing care to him. The resident said he didn't have to report the incident because other staff members saw and heard what was being done to him and the staff member no longer works at the facility. Resident #2 stated, He got what he deserved for slapping me and added that there was no injury associated with the slap. On 4/25/2022 at 12:22 P.M., Staff C, Certified Nursing Assistant (CNA) reported that around 4/8/2022 she had been assisting Staff A, CNA in providing care to Resident #2. She reported the resident seemed to be in pain when being moved by Staff A, and the resident swung towards Staff A because he felt that Staff A was being rough with him. Staff A then slapped the resident on the left leg, and the resident began to yell out. The resident yelled out that he was going to report him and Staff A stated, I don't care if I get fired. Staff C stated that she did not report the incident at the time because she was nervous about saying anything. She said that she spoke to Staff B, CNA about the incident, and we both went to report the incident to the Nursing Home Administrator (NHA) on 4/8/2022. On 4/25/2022 a medical record review was conducted for Resident #2 which revealed that the resident was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #2's MDS (Minimum Date Set) assessment dated [DATE] revealed a score of 12 indicating the resident's cognition was moderately impaired. Further review of Resident #2's medical record revealed no skin evaluation or assessment had been made to reflect a follow up of the resident's condition after the allegation of abuse was reported on 04/08/2022. An interview with the NHA on 04/25/22 at 1:06 P.M. regarding the incident revealed that because there was no injury to Resident #2, she did not document anything in the medical record but maintained a separate file in her office. The NHA did indicate that an investigation did occur. The NHA reported that she did report Staff A to the nurse aide registry, but she was unable to provide documented evidence. The NHA stated Resident #2 did not want to press charges according to her interview with the resident on 4/8/22. The NHA reported that the event occurred approximately a week and half prior to it being reported to her by Staff B and C. The report received indicated that Staff A was providing care to Resident #2 along with Staff C. Staff C witnessed Staff A slap the resident on the leg during care and used profanity towards the resident. Staff A was terminated immediately. The required agencies and the resident's representative were notified. The staff who did not immediately report the incident at the time it occurred received education on immediate reporting.

Based on observation and interview with the resident (#1) and the resident's visitor, interviews with facility staff, and review of the resident's medical record and facility documents, it was determined the facility failed to ensure adequate supervision to prevent repeated falls and injuries from the falls for one resident (#1) of three residents, who had been identified as being at risk for falls. Findings included: On 04/25/2022 at 9:55 a.m., Resident #1 was observed in her room, sitting in a recliner, with the footrest extended and her legs stretched out in front of her. She was noted to be wearing tennis shoes. Resident #1 had a visitor sitting next to her, carrying on a conversation. The resident had some difficulty finding words and was not clear in her answer, when asked if she was able to move around the room by herself, or if she needed to ask for assistance. The resident's visitor explained the resident said she knows she should ask but she is stubborn and does what she wants. The visitor added it seemed she didn't want to wait and would get up on her own to get into bed, or to go into the bathroom. Review of the resident's Admission Record revealed she was initially admitted to the facility on [DATE] with diagnoses that included cerebral infarction, muscle wasting and atrophy, and abnormalities of gait and mobility. Review of the Fall Risk Assessment completed for Resident #1 on 03/12/2022, upon her admission, revealed she was identified as being at high risk for falls. The resident was identified as having intermittent confusion, having had one to two falls in the past three months, able to ambulate, incontinent and had a balance problem while standing or walking. A Restorative Screening was conducted on 03/12/2022 an identified the resident as needing some help to ambulate, needing supervision or touching assistance with transfers, and not currently walking, but the goal was to return to independent ambulation. A review of the Resident #1's Minimum Data Set Admission Assessment, dated 03/30/2022, revealed her Brief Interview for Mental Status (BIMS) score was a 5, indicating the resident had severe cognitive impairment. A nurse's note dated 03/12/2022 and written at 2315 (11:15 p.m.) revealed the resident had been found on the floor next to her bed. The note indicated the bed was in the lowest position, the resident had no injury and the resident had reported she had been trying to get out of bed but slid off of the bed. An additional report, provided by the Director of Nursing (DON), documented the resident's fall on 03/12/2022. The report included the nurse's description of the fall: resident was found on floor next to her bed at lowest position. No injury was observed on her body. Resident stated she was not in pain, wanted to get back on her bed. The report included Resident #1's description of her fall: Resident stated she wanted to get out of the bed but could not explain as to why she wanted to get off her bed. She stated she was not in pain or hurt by the incident. The immediate action taken was to retrain the resident on the use of her call light and her room lights were turned on to alert the resident of her surroundings. A nurse's note dated 03/14/2022 indicated the current status: day two from fall, alert with confusion, attempted to get up from bed, aide stayed by her room door. An IDT (interdisciplinary team) meeting was held on 03/14/2022 to discuss the resident's fall on 03/12/2022 with the note indicating the care plan had been updated with new interventions. A review of the resident's care plan revealed a new care plan for Actual Fall (due to) poor balance and poor communication/comprehension had been developed on 03/14/2022. Interventions, dated 03/14/2022, included: for no apparent acute injury, determine and address causative factors of the fall and place 'call don't fall' sign. An observation of Resident #1 in her room on 04/25/2022 at 9:55 a.m. did not reveal a posted sign reminding the resident to call prior to attempting to self-transfer. The resident was transferred to the hospital on 03/14/2022 for reasons unrelated to the fall and returned on 03/23/2022 with the diagnosis of [CONDITION(S)]. A Fall Risk Evaluation was completed on 03/23/2022 with no changes from the Fall Risk Evaluation completed on 03/12/2022 but included the Clinical Suggestion for the resident to wear rubber-soled shoes or nonskid slippers when ambulating. A continued review of Resident #1's nurses' notes revealed on 03/28/2022 an entry read as, day 3 s/p (status post) fall: patient alert with confusion, neuro checks wnl (within normal limits), vs (vital signs) stable, afebrile. Prior notes did not include a fall had occurred on 03/26/2022, however a Fall Risk Evaluation dated 03/26/2022 at 22:07 (10:07 p.m.) was noted. The Evaluation did not describe the details of the fall but contained three changes from the evaluations dated 03/23/2022 and 03/12/2022. The resident on 03/26/2022 was described as chair bound, which required restraints and assist with elimination, rather than ambulatory. The resident was described as having decreased muscular coordination in her gait/balance rather than a balance problem while standing or walking. The resident had 1-2 predisposing diseases present while in the prior evaluations she had no predisposing diseases. There were no clinical suggestions made on this fall evaluation. Review of an additional report describing the resident's fall (03/26/2022) was provided by the DON, on 04/25/2022 at 4:00 p.m., as there was no description in the resident's medical record of the fall on 03/26/2022 until a reference to day 3 s/p fall was written on 03/28/2022. The additional report, dated and timed at 03/26/2022 at 20:10 (8:10 p.m.), indicated the resident was found by the certified nursing assistant in her bathroom on the floor next to her wheelchair. The resident was unable to verbalize what had happened and indicated she wanted to go back to bed. The resident had been checked for injury and a neuro check was made, with no injuries noted. She was assisted back to the low bed with the call light accessible. Review of the resident's care plan revealed a change had been made on 03/28/2022 for the certified nursing assistants to offer to assist the resident back to bed after meals. A nurse's note, dated 04/04/2022, written at 21:11 (9:11 p.m.), documented another resident had found Resident #1 on the floor, face down, next to the bed with a lot of blood on her face and nose. The note detailed, wearing a face mask with plenty of blood on it, small bump noted on forehead. The resident was not able to say how she ended up on the floor. The post fall evaluation, dated 04/04/2022 at 21:11 (9:11 p.m.) revealed the fall had been unwitnessed, but the resident had indicated she had been reaching for something. The evaluation confirmed the resident had an injury from the fall and had been sent to the hospital. Contributing factors to the fall were an unlocked wheelchair. The evaluation indicated the room and bathroom call light were on, but also her personal alarm was sounding when she was found. The evaluation indicated the resident complained about pain at her forehead and nose. The resident returned from the hospital on 04/05/2022 with a small abrasion on her forehead and a small bruise on the bridge of her nose. Interviews were conducted on 04/25/2022 beginning at 12:30 p.m. with Staff C, Certified Nursing Assistant (CNA), Staff F, CNA and Staff D, CNA who worked the 7:00 a.m. to 3:00 p.m. shift on the rehab (rehabilitation) unit. All three CNAs reported the interventions they take with residents known to be at risk for falls were to ensure the resident's bed is in the lowest position, and the floor mats are in place around the bed. Two of the three CNAs reported they would ensure the resident had non-skid socks on. The DON, on 04/25/2022 at 1:30 p.m., reported for residents who can ambulate independently, or attempt to get out of bed without assistance, the floor mats can pose a trip hazard. An interview with the Nursing Home Administrator (NHA) on 04/25/2022 beginning at 3:30 p.m. revealed the facility does not use personal alarms, indicating the evaluation was incorrect by including the personal alarm was sounding. The NHA reported the resident had a fractured nose from this fall. A review of the Xray results, dated 04/04/2022, found in the resident's electronic medical record, revealed she had a comminuted moderately impacted nasal bone fracture. Review of a nurse's note, dated 04/06/2022 at 1310 (1:10 p.m.) revealed the resident was found on the floor in her room, lying on her left side, next to her bed. The note indicated the resident stated she had been trying to get up and her feet slipped out from underneath her. She was observed wearing normal house socks instead of the nonskid socks. The resident was complaining of left wrist pain. The physician was notified and gave a verbal order for a two view Xray of the left wrist. Later that evening, at 2056 (8:56 p.m.) the resident was sent to the hospital with a left wrist fracture. She returned on 04/07/2022 at 4:50 p.m. with a splint on her left wrist. A progress note, dated 04/07/2022, documented an Interdisciplinary Team meeting determined the resident should be offered assistance to return to bed during hours of sleep; ensure proper footwear, and offer one on one activities. Later that day, on 04/07/2022 at 1524 (3:24 p.m.) the resident was moved to a room across from the nursing station for closer observation. A care plan meeting was held on 04/08/2022 with the summary indicating the team would attempt to start the use of a platform walker, as prior to her fall she was walking 100 feet with a four wheeled walker. The plan also indicated there would be a change to the resident's call light to a push button light. The note described the resident as having her left arm in a sling and had two black eyes. A review of the care plan revealed interventions added on 04/07/2022 included: ensure proper footwear, offer assistance to bed during hours of sleep, and offer increased activities. A Fall Risk Evaluation for the fall sustained on 04/06/2022 was reviewed. The resident was described as disoriented times three at all times, having had one to two falls in the past three months, ambulatory but incontinent, with balance problems while standing and walking and jerking or unstable when making turns. No clinical suggestions were included. A Post Fall Evaluation was conducted on 04/06/2022, which described the location of the fall as in the resident's room and the activity at the time of the fall as the resident was attempting to toilet herself. The evaluation included the resident complained of pain in her wrist. The fall detail note was a description of the fall on 04/04/22, not the fall on 04/06/22. Footwear at the time of the fall was described as bare feet, but the nurse's note indicated the resident had on normal socks. A policy was reviewed for a Fall Prevention Mattress, which was described as an alternative to side rails to maintain resident safety when the resident was in bed. On 04/25/2022 at 3:40 p.m., the NHA reported examples of a fall prevention mattress included a scoop mattress or an air loss mattress with bolsters. She reported after looking at Resident #1's mattress that it was neither. She reported the Interdisciplinary Team would discuss the appropriateness of a fall prevention mattress for a resident who fell , and that discussion would be reflected in the IDT meeting notes. Review of the IDT notes located in the Progress Notes in the electronic medical record for Resident #1 did not reveal a discussion about a fall prevention mattress and whether it would be a good intervention for Resident #1. A review of three of the four falls Resident #1 sustained from 03/12/2022 until 04/06/2022 revealed the resident was found next to her bed, with her stating she was trying to get up or to get into her bed. A review of the policy titled Fall Prevention Program read: To reduce the risk of resident falls through evaluation and employment of fall prevention interventions to ensure maximal safety while maintaining the least restrictive environment. The program used an evaluation tool to identify those residents that were at risk for falls, who would then be put on the Fall Risk program. There was no description of the Fall Risk program or what fall prevention interventions would be put into place to reduce the risk of injury from falls.

Based on observations, interviews and record reviews, the facility failed to implement appropriate interventions and to provide adequate supervision to prevent repeated falls for 3 (#2, #4, #5) out of 3 residents reviewed for falls out of a total of 5 residents sampled. Findings included: A review of the facility policy titled Fall Prevention Program (with a revised date of 2/2016 only) Policy: To assure proper follow up is carried out to reduce the amount of resident falls through assessment and staff awareness and implementation of appropriate interventions. 1. A review of the facility incident log on 2/27/2019 for Resident #2 revealed no documentation of witnessed or unwitnessed falls. An interview was conducted on 2/27/2019 at 10:51 a.m., the Nursing Home Administrator (NHA) said, If something is not on the Incident Log, then there was nothing to report. An interview was conducted on 2/27/2019 at 12:01 p.m., the Health Services Director said, We fill out a falls pack and the nurse who witnesses the fall is supposed to document it. If we know about it we document it, report it and it goes on the log. A review of the information sheet for Resident #2 revealed an admission date of [DATE] from an acute care hospital and a discharge date of [DATE]. Pertinent [DIAGNOSES REDACTED]. A review of the 14 day minimum data set ((MDS) dated [DATE] documented in Section C: a brief interview for mental status (BIMS) score of 15/15 which indicates the resident is cognitively intact. A review of section G for activities of daily living the facility documented for bed mobility resident requires extensive assistance of 2+ persons physical assist, Transfers requires extensive assist of 1 person physical assist, for walk in room and to walk in corridor requires extensive assistance of 1 person physical assist along with locomotion on and off of the unit. Resident #2 requires the assistance of 1 person for eating, toilet use requires extensive assistance 1 person physical assist, and personal hygiene resident requires limited assistance of one person physical assist. For moving from a seated to a standing positon the assessment documented Resident #2 was not steady and only able to stabilize with staff assistance, with walking the resident was not steady and only able to stabilize with staff assistance, with turning around the resident is not steady and able to stabilize with staff assistance, with moving on and off the toilet the resident is not steady and requires stabilization with assistance from staff. With surface to surface transfers the resident is not steady and able to stabilize with staff assistance. The assessment documented that Resident #2 had no impairments with upper or lower extremities. Use of a walker and wheel chair listed for assistive devices. The assessment documents the resident is frequently incontinent of bladder and bowel. The assessment documents that on admission there were no pressure ulcers or skin issues. On the MDS dated [DATE] documented as Discharge return not anticipated. On the nursing assessment on admitted d 1/19/2019 documented under Section M for Mobility revealed nothing was checked other than Walker use with that the resident wears glasses, and has minimal difficulty hearing. On 1/19/2019 the Fall Scale documented under Has resident ever fallen before? Yes, injury with fracture Location of injury right shoulder and impaired gait. A review of the care plan for Resident #2 initiated on 2/18/2019 and a revision date of 2/18/2019 documented identified pertinent F[NAME]US areas for: Resident was admitted with a UTI initiated 2/18/19, resident is at risk for a fall or a fall related injury because of (X) marked beside History of falls, prior to admission, in facility. Fall risk factors include (X) marked beside medical factors DM, [MEDICAL CONDITION], UTI, musculoskeletal factors weakness. No (X) beside rolled out of bed, has low bed and mat, all documented on the care plan provided by the director of nurses on 2/28/2019. Goal: Fall related injuries will be decreased initiated on 2/18/19 and revised on 2/18/19 with a target date of 5/07/19. Interventions: Report falls to Doctor and responsible party, (X) by: Instruct resident to sit on the side of the bed for a few minutes when rising from a lying position, incontinence check frequently, toileting plan-take to bathroom before and activities, meals, on rising and at bed time and each round thru out no, educate resident to call for assist prior to ambulating, an (O) is marked by Low bed with mat date applied band and date discontinued blank with a date initiated on 2/18/2019 and revised on 2/18/19, Observe for s/s of side effects from drugs, (dizziness, gait disturbance, weakness, sedation, change in mental status, keep call light within reach, keep area free of clutter, bed in low position, encourage activities, fall screen dates blank, Date initiated on 2/18/19, revised on 2/18/19, (O) marked by Adaptive equipment used related to (blank), (O) Self release Velcro belt in chair Date applied (blank), Date discontinued (blank), (O) lap tray Date applied (blank), Date discontinued (blank), (O) remove lap tray for meals, activities, personal care & repositioning, (X) lock brakes on bed and chair before transferring, (X) appropriate foot wear rubber sole, (X) Referral for screen and or treatment physical therapy (blank), occupational therapy (blank), (X) observe for signs . 1/28/2019 Resident education to call for help, therapy education to use call light and rolling walker. 2/07/2019 therapy screen, 2/10/2019 x-rays, hospital with date initiated 2/18/2019 and revised on 2/18/2019. resident needs assistance with activities of daily living (ADL's), (X) Extensive related to [DIAGNOSES REDACTED], falls, diabetes, hypertension, impaired mobility, weakness, occasional incontinence 2/07/19-5/07/19 date initiated on 2/18/2019 and revised on 2/18/19, Goal: Will have needs met as evidenced by neat and clean appearance thru next review date, initiated on 2/18/2019 and revised on 2/18/19 with a target date of 5/07/19,Will continue to make progress toward skill goals before discharge from skilled care initiated on 2/18/2019 and revised on 2/18/19 with a target date of 5/07/19, will have ADL needs met on a daily basis according to personal preferences initiated on 2/18/2019 and revised on 2/18/19 with a target date of 5/07/19, will maintain highest level of function possible with co-morbidities through next review initiated on 2/18/2019 and revised on 2/18/19 with a target date of 5/07/19. Interventions: Assist resident with toileting needs initiated on 2/18/2019 and revised on 2/18/19, encourage resident to use call bell for assistance with ADL's initiated on 2/18/2019 and revised on 2/18/19 with a target date of 5/07/19, PT/OT/ST evaluation and treat as needed initiated on 2/18/2019 and revised on 2/18/19 with a target date of 5/07/19, use of assistive device with ambulation and locomotion as indicated initiated on 2/18/2019 and revised on 2/18/19 with a target date of 5/07/19. A review of therapy notes revealed: PT/OT Screen dated 1/31/2019 not filled out- documented at the bottom by evaluation: on case load, PT evaluation and P[NAME] dated S[NAME] 1/20/2019- certification period 1/20/2019-2/18/19. History of falling onset date 1/18/2019. Therapeutic exercises, neuromuscular re-education, gait training, manual therapy techniques, PT evaluation: moderate complexity. Speech therapy evaluation done on 1/24/19 Diet regular Current liquid consistency thin, speech services not warranted. An interview was conducted on 2/28/2019 at 3:37 p.m., with the Director of Therapy Services who said, We do have a Fall Committee and we meet after a resident fall is reported. For Resident #2 the fall on 1/28/2019 at that time she was on current therapy case load. The new interventions we implemented were Patient education to use call light for assistance, Therapy screen, Ensure and encourage patient to use rolling walker with ambulation. For Resident #2 for the fall on 2/07/19 our new intervention was to offer her a snack. For the fall on 2/10/2019 our intervention after that fall was to send her to the hospital for a full evaluation and frequent checks by staff. An interview was conducted on 2/28/19 at 9:30 a.m., the Director of Nurses (DON) reviewed the care plan that had been provided for Resident #2 and confirmed the care plan had documented it was initiated on 2/18/2019, Yes, that was after the patient had already gone to the hospital. The corporate nurse present said, The initial care plan was initiated on 1/21/2019 A review of the Interim care plan documented, Multiple falls at home, impaired mobility and weakness. An interview was conducted on 2/27/19 at 12:17 p.m., the DON came in with the fall documentation for Resident #2's fall on 2/07/19 and 2/10/2019 that was not on the facility incident log. The fall on 2/10/2019 was not reported because the previous DON said we did everything we could. It was her judgement call. I was always taught if in doubt to report it. I am not sure why the fall did not show up on the log. the Nursing Home Administrator said, We did not feel it meet the CMS definition of a reportable event. An interview was conducted on 2/27/2019 at 2:14p.m., the Unit Manager said, Resident #2 was admitted to us after a stay in the hospital for a fall. About 2 weeks after coming to us she became very confused. On 2/7/2019 we received orders to start her on IV (intravenous) fluids. She was already on oral antibiotics. So we did a UA (urinalysis), PO (by Mouth) antibiotics and IV fluids. Her fall, I reviewed it for the next morning when I came in. It happened on the 3-11 shift - as soon as I walked in the 3-11 nurse started talking to me- called the radiologist who said they did not have someone to read the x-ray. Yes, I believe she did have floor mats. I believe it was Staff A, Certified Nurse's Aide (CNA) (provided the incident reports for her to look at) - Yes- it was Staff A, CNA who was working with her on 2/10/2019. Staff A, CNA walked in Resident #2's room and found her on the floor and called for the nurse. The facility had not conducted an internal investigation surrounding the fall on 2/10/2019. On 2/27/2019 at 3:10 p.m., the surveyor requested the facility put together a timeline of the events prior and after the resident fall on 2/10/2019. A review of the documentation provided for the fall on 2/07/2019 with fell 2000 2/07/2019 hand written in the top right corner of the fall check list. The patient was found at 8:00 p.m. Date: 2/07/2019. Before the fall patient was in wheel chair propelling self. Yes, patient was on fall precautions prior to this fall, marked yes to patient was in wheelchair and were the brakes on. What did the resident say that they were trying to do at that time? Get in the car and go home. Yes, was marked beside did the patient have on non-slip foot wear on. Comments: Resident with increased confusion all shift stating she needed to get to her car and go home. Was in bed trying to get up and put in wheelchair. She tried to get up when her wheelchair was unlocked. The nurse found her and put her back in the wheelchair and brought her out into the hallway, assessed her for injuries- no injuries- did not hit her head, no complaints of pain or discomfort. Responsible party notified and the physician was notified. Started neuro checks per protocol. As far as interventions after this fall we tried to educate her again to use her call light and to use her walker. She was alert and oriented on admission. Therapy at the time did educate Resident #2 on call light use, and encouraged her to use her walker. A review of the documentation provided for the fall on 2/10/19 with fell at 7:50 p.m., hand written at the top of the form. The patient was found at 2000, Date: 2/10/2019. Before the fall the patient was in bed. Confusion in PM's. Yes, patient was on fall precautions prior to this fall. What did the resident say that they were trying to do at the time? Go to their car. No, was marked beside did the patient have on non-slip foot wear on. Measurements implemented after fall: Assessment, notified MD, attempted to re-orient. Comments: son aware resident has increased confusion in PM's-STAT orders received for x-ray Left shoulder and bilateral hips. Refused PO pain meds x2. An interview was conducted on 2/28/2019 at 11:13 a.m., with the corporate nurse, Director of Case Management and the DON all reviewed documentation for Resident #2, There was an ER visit but not a hospitalization on [DATE]. Resident #2 had a fall at home with the responsible party. Resident #2 had a follow up orthopedic appointment and the responsible party picked the resident up from the facility and took her to the appointment. After the medical appointment, the responsible party took the resident by her home to visit her dog. While she was there she fell . The responsible party call 911. The resident was sent back to us on 1/29/2019. I don't think the staff knew the responsible party had planned to take her home after her appointment before bringing her back to the facility. Yes there is an order for [REDACTED]. Before the daughter left she and the certified nurse's aide (CNA) got the resident ready for bed, they had toileted her, put her to bed about 6:30 p.m. - around 7:30 p.m., about an hour later, the nurse found the patient on the floor by her bed. Resident#2 said she was going to get her car. Yes, she did complain of left arm and bilateral hip pain. Then they got her back in bed, got her comfortable- the nurse called the MD and a message was left for son. The nurse offered pain meds and she refused. So they had her in the low bed, no Matts at this time. I do not have an order for [REDACTED]. The corporate nurse spoke up and said, The reason they did not send her out when they could not get the x-ray results after 4 hours was because they were looking to try and keep her comfortable. Resident #2 was all ready1:45 confused and there is nothing like leaving at night for a trip to the hospital. That can cause more anxiety and to move her around could have caused her more pain. Plus she refused pain medications when offered. Yes, she was confused after the fall. I think the nurses were just trying to keep her comfortable. A review of the radiology reports revealed Date of Service 2/10/2019 x-ray Forearm AP and LAT, Left- no abnormalities of left forearm are present. Hips bilateral w or w/o Pelvis minimally angulated and minimally displaced intertrochanteric [MEDICAL CONDITION] hip, 2.Minimally displaced [MEDICAL CONDITION] of the right femoral neck. Documented on the x-ray hand written- noted 2/11/19 Results called into MD at 8:40 a.m. A review of the nurses notes for Resident #2 revealed: On 1/19/2019 Fall Scale: Has resident ever fallen before? Yes, injury with fracture Location of injury right shoulder, Impaired gait. On 1/24/2019 received an order for [REDACTED].>On 2/6/19 at 1402 blood glucose (BG) level at 12:00 noon was 43- after eating glucose was 63 and 30 minutes later was 75- MD notified- Son at bedside and made aware. Order given to start Levimir FlexTouch Solution Pen-Injector 10 units SQ 2 x day and to DC [MEDICATION NAME] Mix 70/30 60 units SQ in the morning. Resident left for MD appointment with 2 cans of glucerna given. On .2/6/19 at 14:16 LOA to Dr.'s apt with son via CVT transport. On 2/6/19 at 15:52 BG 91 mg, Insulin held-sup notified OJ given . Resident left unit at 2:30 p.m., with son for orthopedic appointment. Vital signs documented as stable. On 2/6/19 at 23:28 physician orders [MEDICATION NAME] 500 mg to give 1 tab 2 x day for urinary tract infection for 7 days on 2/14/2019 verify culture and sensitivity to see if resistant to antibiotic. On 2/7/19 Son took resident out for otho appointment yesterday-no new orders sent back to facility but per son, physician told him she can either undergo arthroscopy surgery which would require immobility of right arm for 6 to 8 weeks or to continue with therapy to build up strength. A follow-up appointment scheduled for 3/6/19. On 2/7/19 at 15:43 continues to complain of right shoulder pain. X-ray of right shoulder and humorous was negative for acute injury. Limited mobility-MRI was done 2/1/2019 and shows right supraspinatus and infraspinatus tears. On 2/7/19 at 19:34 Alert/confused- up in wheelchair right arm with sling on and resident takes it off-Report from 7-3 nurse that son complained resident calling him and he was at work. Resident looking for her husband to take her home. On 2/7/19 at 22:32 alert to name, confused to time and place, Seen earlier by ARNP. Was in bed at 1945 and then trying to get out of bed. CNA got up and put her in her wheelchair (WC) and resident was self-propelling self in halls. While resident was self -propelling self in halls she tried to stand up and fell . No apparent injuries noted, assisted back to WC per writer and CNA. On 2/10/19 resident daughter visiting all day- yesterday and today- daughter left around 7:30 pm resident fell out of bed onto the floor- no visible injury noted c/o left arm pain and bilateral hip pain-STAT x-ray ordered- son contacted no response- awaiting call back, MD made aware- pain medication given for pain. On 2/10/19 21:15 ARNP for physician notified of fall and orders received for STAT X-ray of left shoulder and bilateral hips- refuses to take any meds for pain. On 2/10/19 at 22:01 Son notified about the fall. He will be in tomorrow morning. On 2/11/2019 at 2:06 Neuro checks were WNL, patient c/o pain in hip area- medicated with [MEDICATION NAME] at 145 a.m.,, spoke to contracted x-ray company an inquired about x-ray results, they stated, We have one radiologist, due to the busy weekend schedule- no one available to read the x-ray results yet. On 2/11/2019 x- ray results received and called to physician with a new order to call 911 EMS dispatched and patient was transported to ER via stretcher, family present at the time of the transfer. Physician Orders: 2/11/19 9:30 am Send the resident to ER for evaluation of FX of right femoral neck and minimal displaced intertrochanteric fracture of left hip s/p fall. A review of the physician telephone orders and Treatment Administration record revealed no orders for bed in low position or for matts at the bedside. An interview was conducted on 2/28/2019 at 11:41 a.m., the responsible party said, I was receiving reports from the facility staff that she was fine- then on 2/10/19 I received a call stating that she had fallen. I was told that portable x-rays were ordered. When I came in the following day I saw her being taken out by stretcher to the hospital. My biggest concern was she laid there all night with broken hips. An interview was conducted on 2/28/2019 at 1:00 p.m., with the DON and the corporate nurse provided documentation of the 2/10/2019 fall as requested. 18:43 Family visited patient in room 19:30 CNA reported patient on the floor next to low bed with mats 19:30 Nurse assessed resident for injury. Patient complaint of pain in left arm and bilateral hips. Nurse and CNA assisted back to bed. [MEDICATION NAME] 50 mg or Tylenol 650 mg offered but patient refused 20:24 Order obtained from MD for left arm and bilateral hip x-ray. Contracted X-ray Company testing was ordered on line at 2024 20:53 Call placed to son to update. No response 21:25 Patient offered pain medications and refused 21:32 Contracted x-ray company arrived on scene 22:13 X-ray completed and verified 22:19 Patient offered immobilizer for comfort-refused. Patient offered pain medication again and refused 22:21 Son returned call and stated he would be in in the morning 2/11/2019 1:45 (AM) patient given [MEDICATION NAME] 50 mg for all over pain 2:06 (AM) called placed by night supervisor to contracted x-ray company for x-ray results and was told there was a delay in transmission of images by the x-ray company (Now at 4 hours since the fall) 2:45 Pain follow up. Pain rated at 4. Tylenol given 5:16 Follow up pain from Tylenol on pain scale =1 8:36 Images received by radiologist from x-ray company 8:43 Images interpreted 8:44 Images reported and emailed to the facility 8:49 Report of images called to facility. MD updated via telephone. ARNP reroute to the facility 9:30 Son arrived at the facility 9:35 Order received to send resident to ER for further evaluation of fracture. Son present at bedside and followed to ER. The DON and the corporate nurse confirmed that the night supervisor did not call the medical director, the administrator, the physician, the DON regarding the delay of a radiologist not reading the x-ray results in a timely manner. The corporate nurse said, I do not know why they would have called any of us. Yes, I guess for additional resources maybe. I do not think it would have changed anything. I know it was almost 12 hours since the fall by the time we got an order to send her to the hospital. But like I said earlier our thinking was we were keeping her comfortable and she was not in a lot of pain. An interview was conducted on 2/28/2019 at 3:45 p.m., said, Yes, I cared for Resident #2. No, I do not remember her having floor matts at the bedside. They were afraid that they would make her fall. No her bed was not in the low position. 2. A review of the facility incident log documented for Resident #4 a witnessed fall on 1/26/19 at 8:20 am, unwitnessed falls on 12/20/18 at 2:38 pm, 1/21/19 at 330 pm. 1/28/19 at 1:50 am, a skin Alteration 12/29/18 7:00 pm and other incident 1/27/194 p.m. A review of the resident information sheet revealed Resident #4 was initially admitted to the facility from an acute care hospital on [DATE] and was re-admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. A review of the MDS Section C: a brief interview for mental status (BIMS) score of 15/15 which indicates the resident is cognitively intact. A review of section G for activities of daily living the facility documented for bed mobility resident requires limited assistance of 1+ persons physical assist, Transfers requires limited assist of 1 person physical assist, for walk in room and to walk in corridor requires supervision and cueing, along with locomotion on and off of the unit. Resident #4 requires the assistance of 1 person for set up only for eating, toilet use requires extensive assistance 1 person physical assist, and personal hygiene resident requires limited assistance of one person physical assist. For moving from a seated to a standing positon the assessment documented Resident #4 was not steady and only able to stabilize with staff assistance, with walking the resident was not steady and only able to stabilize with staff assistance, with turning around the resident is not steady and able to stabilize with staff assistance, with moving on and off the toilet the resident is not steady and requires stabilization with assistance from staff. With surface to surface transfers the resident is not steady and able to stabilize with staff assistance. The assessment documented that Resident #4 had no impairments with upper or lower extremities. Use of a walker and wheel chair listed for assistive devices. A review of the care plan for Resident #4 identified Focus area that resident is at risk for a fall or a fall related injury because of (X) medical factors, musculoskeletal factors balance and gait problem. 12/28/18 to 3/28/19 initiated on 12/28/2018 and revised on 12/28/2018 with a Goal: Fall related injuries will be decreased initiated on 12/28/2018 and revised on 12/28/2018 with a Target Date of 3/28/19. Interventions: Report falls to Doctor and responsible party. (X) Instruct resident to sit on the side of the bed for a few minutes when rising from a lying position, incontinence check frequently, toileting plan-take to bathroom before and activities, meals, on rising and at bed time and each round thru out noc, educate resident to call for assist prior to ambulating, an (O) is marked by Low bed with mat date applied bland and date discontinued blank with a date initiated on 12/28/2018 and revised on 1/22/19, Observe for s/s of side effects from drugs, (dizziness, gall disturbance, weakness, sedation, change in mental status, keep call light within reach, keep area free of clutter, bed in low position, encourage activities, fall screen dates blank, Date initiated on 2/18/19, revised on 2/18/19, (O) marked by Adaptive equipment used related to (blank), (O) Self release Velcro belt in chair Date applied (blank), Date discontinued (blank), (O) lap tray Date applied (blank), Date discontinued (blank), (O) remove lap tray for meals, activities, personal care & repositioning, (X) lock brakes on bed and chair before transferring, (X) appropriate foot wear rubber sole, (X) Referral for screen and or treatment physical therapy (blank), occupational therapy (blank), (X) observe for signs . 12/20/2018 bed in low position, fall screen, neuro checks. 1/21/2019 Prompt voiding. To ER for eval, visual cues sign to call for asset, neuro checks Report any changes in Bowel and Bladder to nurse. Low urine output, Foul smelling urine or bowel, Pain, frequency, urgency, Diarrhea, constipation, monitor labs as ordered and report to physician. Check resident frequently for incontinent episodes, offer toileting before and after meals, activities, and naps and on each round during night if awake. Provide incontinence/peri care after each incontinent episode. 1/26/2019 Therapy screen refer to physician for med review, possible [MEDICATION NAME] at hs, 1/28/19 Refer to physician for med adjustment for sleep, 2/05/19 Neuro checks and therapy screen, 2/15/19 Med review, Visual cue, tape on walker, encourage to use walker with date initiated 12/28/18 and revised on 2/18/19. An interview was conducted on 2/28/19 at 1:51 p.m., with MDS, DON and the corporate nurse and reviewed the falls for Resident #4: On 1/26/19 at 8:20 a.m., a witnessed fall- a nurse was standing outside of the resident's room at the medication cart and witnessed the resident slide out of her wheelchair onto the floor. The resident said, I wanted to go to bed. The Resident was assessed for injury- ROM done, no injuries, marks or bruises noted- resident assisted back to bed. Physician and at 8:35 a.m. The family was notified. Our interventions were for a therapy screen. The Director of Nurses said, The resident is very active at night particularly. No, I do not see therapy evaluation in the record for that day. I think she was on therapy case load from 11/22/18-11/30/18 and then they picked her up again for 12/04/2018 to 12/23/18. I believe she was in an open therapy certification on 2/12/2019, but I think they are done now. A review of the unwitnessed falls on 12/20/18 at 2:38 p.m., she was found by the LPN who heard a patient yelling from a room and found Resident #4 lying on the floor in front of the bath room door. The patient stated she was coming out of the bathroom slipped and fell on the floor. Her ROM was assessed for all extremities without difficulty, denied pain or discomfort at time. The resident was assisted back to her wheelchair. Neuro checks were imitated, they are done on all unwitnessed falls. Because a lot of her falls are around meal time we implemented a prompt voiding schedule on 12/20/18. So it's essential voiding every 2 hours- ask them. A review of the medical record revealed no documentation of prompt voiding under Tasks for CNA's. There was no documentation in the record to confirm that prompt voiding had been implemented. On 2/5/2019 neuro checks were implemented and therapy screen was requested. We also asked for the Physician's consideration to add [MEDICATION NAME] we did start it on her but that was not added until on 2/7/19. On 1/21/19 at 3:30 p.m., found by the same LPN who works the day shift down there- she heard a patient screaming for help and she found the patient lying on her back, with a skin tear noted to left arm, and 2 open areas on her forehead, the resident complained of back pain. The nurse applied pressure to the open areas on her forehead. Resident #4 said she was trying to go to the bath room and fell . Resident #4 was sent to the ER for evaluation. X-rays of her chest. Pelvis, left elbow- CT scan of her head and spine were all negative. Resident #4 returned to the facility on the same day. Interventions: We put a visual cue on her wall that says, Call don't fall put in her room. We continued with the prompt voiding and the neuro checks. No she was not screened by therapy after this fall. Part of the process is that therapy is involved with the interventions we will be implementing. On 1/28/2019 at 1:50 a.m., the nurse was notified by CNA that the resident was on the floor in her room. The resident was found siting on the floor with her back towards the head of the bed and feet facing the foot of the bed. The Resident's bed was in a moderate to low position. It was noted the call light and bed control were on patient's bed. The resident denied injury and stated she slipped off of the bed. The nurse assessed her for injuries, there were, no visible injuries noted no redness or bruising. There were no interventions for this fall. We had previously referred to the physician for a possible medication adjustment, [MEDICATION NAME] for sleep. On 2/6/2019 2:10 a.m., Resident #4 was found by the LPN who is our night nurse. said she heard a patient calling for help and found Resident #4 sitting on the floor- her feet pointing towards the foot of the bed, back to the head of the bed. The resident said she was trying to go to the bathroom and slipped off of the bed. Our interventions for that fall were on 2/05/2019 initiated neuro checks and therapy screen on 2/7/2019. Therapy did not recommend an evaluation at that time. The resident's bed was placed in lowest position order dated 2/6/19. On 2/7/19 the physician ordered the residents [MEDICATION NAME] increased from 3mg to 5mg. On 2/15/19 at 5:05 a.m., the resident was found by the nurse on who observed the resident lying on the floor next to her wheelchair. There were no apparent injuries noted at the time. Resident#4 stated that she needed to go to the bathroom and was trying to go by herself and that she knew she was not to go by herself. No, there is nothing documented about her foot wear. Resident #4 is confused with impaired memory- There were recent changes in medication. The interventions for that fall was to place the bed in the lowest position every shift and initiated neuro checks. A therapy evaluation was not done by therapy. She went back on therapy case load on 2/12/2019. We did put a bright colored tape on the handles of her walker to make it easier for her to fin. I believe that was on the care plan. A review of the physician orders revealed an order dated 2/06/2019 to discontinue matt at bedside. An observation was conducted on 2/27/2019 at 3:20 p.m., the resident had a matt at bedside. The resident was in bed, awake and watching television. ¼ side rails were up, bed was in low position, and call bell was within reach. The bedside table was not within reach, lips were parched, and resident said she was thirsty observed the cup at bedside dated 2/27/19 ¼ full. An observation was conducted on 2/28/19 at 2:45 p.m., with the DON. Resident #4 was in bed eyes closed, eye glasses on, bed in low position, 1/4 side rails were in the up position, call light was within reach. Observed walker with bright green neon tape on hand rest. Did not see visual sign up in resident's room. The bedside table with a glass of water was not within the resident's reach. The resident's bed is positioned with the foot of the bed turned towards the door. The head of the bed was adjacent to the head of the