Every finding on record at Broadway by the Sea

Based on interview and record review the facility failed to provide the necessary care and services for one of 11 sampled residents (Resident 2) by failing to:1. Ensure Resident 2 was monitored and reassessed for a fever with temperature of 100.1.2. Ensure Acetaminophen (medication used for fever) 325mg (mg-metric unit of measurement) tablets oral were administered as ordered.These failures placed Resident 2 at risk for increased fever, dehydration and the potential to lead to infection and a decline in medical status. Findings:During a review of Resident 2's admission Record, the admission record indicated the Resident was admitted to the facility on [DATE] with the diagnoses including lack of coordination (impairment in muscle movement, balance, and motor control), dysphagia oropharyngeal phase, (a swallowing disorder caused by difficulty transferring food from the mouth to the esophagus), urinary retention ( is the inability to fully empty the bladder).During a review of Resident 2's Minimum Data Set ([MDS] - a resident assessment tool), dated 01/31/2026, the MDS indicated, Resident 2's cognitive (ability to think and reason) skills for daily decision making was moderately impaired. The MDS indicated Resident 2 required setup or clean- up assistance (helper sets up, resident completes activity) from staff with eating, oral hygiene, and personal hygiene.During a review of Resident 2's vital sign record dated 02/04/2026 at 23:40 pm, the vital sign record indicated Resident 2 had a fever of 100.1 degrees Fahrenheit (F) recorded.During a review of Resident 2 Order Summary report dated 01/27/2026, the Order Summary report indicated Resident 2 had an order for Acetaminophen 325 mg two tablets by mouth every six hours as needed for fever greater than 100 degrees. There was no documentation for temperature monitoring or reassessment.During an interview and record review on 02/05/2026 at 2:40 p.m. with License Vocational Nurse (LVN) 2, LVN 2 stated Resident 2's temperature was elevated from the previous shift. LVN 2 stated it is the responsibility of the Licensed Nurse to monitor any change of condition and elevated temperatures of residents to see if the temperature went down and to give medication as ordered. LVN 2 stated she took Resident 2's temperature and did not have time to document the temperature. LVN 2 stated she will monitor the temperature for residents that has change of condition.During an interview on 02/05/2026 at 3: 36 p.m., with the Director of Nursing (DON), the DON stated the licensed staff on duty failed to give the Acetaminophen medication for the fever. The DON stated licensed staff should assess, give medication as ordered and continue monitoring for fever.During a review of the facility Policy and Procedure (P&P) dated 04/2025. titled, Change of condition/Quality of Care, the P&P indicated, the nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. The P&P indicated the resident will then be placed on the 24-Hour Report and Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions

Based on interview and record review, the facility failed to provide pharmaceutical services for two of two sampled residents (Resident 1 and Resident 2) by failing to administer 9 a.m. medications one hour before or after the scheduled time.This deficient practice placed Resident 1 and Resident 2 at risk for increased adverse drug reactions, increased symptoms and mismanagement of the medication regimen.Findings:1. During a review of Resident 1's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 1 was original admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included Type 2 diabetes with circulatory complications (involve damage to large and small blood vessels caused by chronic high blood sugar, inflammation, and atherosclerosis), hypertension (high blood pressure), dysphagia (difficulty swallowing).During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/24/2025, the MDS indicated, Resident 1's cognitive (ability to think and reason) skills for daily decision making were severely impaired. The MDS indicated Resident needed substantial/maximal assistance - (Helper does more than half the effort) with eating, oral hygiene, and personal hygiene.During a review of Resident 1's Order Summary Report dated 02/2026, the Order Summary Report indicated Resident 1 had orders to receive the following medications:1. Aspirin (decreases inflammation and inhibits blood clotting 81milligrams (mg - unit of measurement) one time a day.2. Ferrous Gluconate (medication to prevent iron-deficiency) 324 mg one time a day.3. Furosemide (medication to reduce excess fluid from the body 20 mg (one time day.4. Metoprolol (medication used to treat high blood pressure) 50 mg one time a day.5. Multivitamin (medication to provide essential vitamins and minerals) one time a day.6. Tamiflu (medication to antiviral medication used to treat and prevent influenza A and B) 75 mg two times a day for influenza until 02/09/2026.7.Spironolactone 25 mg (medication to remove excess fluid) 0.5 one time a day.8. Sacubitril-Valsartan (medication to reduce the risk of heart failure) 24-26 mg two times a day.During a review of Resident 1's Medication Audit Report dated 02/05/2026, the audit report indicated all medication was administered to Resident 1 as follows:1. On 02/02/2026-Aspirin 81mg was scheduled to be administered at 9 a.m. but was administered to Resident 1 at 11:27 a.m. (over 1 hour 27 minutes after the scheduled dose).2. On 02/02/2026-Ferrous Gluconate 324 mg was scheduled to be administered at 9 a.m. but was administered to Resident 1 at 11:27 a.m. (over 1 hour 27 minutes after the scheduled dose).3. On 02/02/2026-Furosemide 20 mg was scheduled to be administered at 9 a.m. but was administered to Resident 1 at 11:27 a.m. (over 1 hour 27 minutes after the scheduled dose).4. On 02/02/2026-Multivitamin one tablet was scheduled to be administered at 9 a.m. but was administered to Resident 1 at 11:27 a.m. (over 1 hour 27 minutes after the scheduled dose).5. On 02/02/2026-Tamiflu 75 mg was scheduled to be administered at 9 a.m. but was administered to Resident 1 at 11:27 a.m. (over 1 hour 27 minutes after the scheduled dose).6. On 02/02/2026-Spironolactone 25 mg was scheduled to be administered at 9 a.m. but was administered to Resident 1 at 11:27 a.m. (over 1 hour 27 minutes after the scheduled dose).7. On 02/02/2026-Metoprolol 50 mg was scheduled to be administered at 9 a.m. but was administered to Resident 1 at 11:27 a.m. (over 1 hour 27 minutes after the scheduled dose).8. On 02/02/2026-Sacubitril-Valsartan Oral Tablet 24-26 mg was scheduled to be administered at 9 a.m. but was administered to Resident 1 at 11:27 a.m. (over 1 hour 27 minutes after the scheduled dose). 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included lack of coordination (impairment in muscle movement), dysphagia oropharyngeal phase, (a swallowing disorder caused by difficulty transferring food from the mouth to the esophagus, often resulting from neurological issues), urinary retention (the inability to fully empty the bladder).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive (ability to think and reason) skills for daily decision making was moderately impaired. The MDS indicated Resident 2 required setup or clean- up assistance (helper sets up, resident completes activity) from staff with eating, oral hygiene, and personal hygiene.During a review of Resident 2's Order Summary dated 02/2026, the Order Summary Report indicated, Resident 2 was to receive the following medications:1.Tamiflu 30 mg two times a day for influenza.During a review of Resident 2's Medication Audit Report 2/5/2026, the audit report indicated Resident 2 was administered the following medications:1. On 02/02/2026 - Tamiflu 30 mg was scheduled to be administered at 9 a.m. but was administered to Resident 2 at 11:37 a.m. (over 1 hour 37 minutes after the scheduled dose).During an interview on 02/05/2026 at 2:04 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated medication should be given one hour before and hour after. LVN 1 stated she had multiple things to do, that is why she was behind with the medication administration pass. LVN 1 stated she will call for assistance next when she is behind with passing medications because this would interfere with medication administration time.During an interview on 02/05/2026 at 2:40 p.m. with LVN 2, LVN2 stated Resident 2 medication was not given on time because the pharmacy delayed delivering the medication for Resident 2. LVN 2 stated, she knew it was her duty to follow up with the pharmacy if the medication was not delivered on time.During an interview on 02/05/2026 at 3: 36 p.m., with the Director of Nursing (DON), the DON stated scheduled medications should be given 1 hour before and 1 hour after the scheduled time. The DON stated it was important to administer medications as scheduled to ensure effectiveness and minimize the side-effects. The DON stated staff should ask for help when they are behind but will give an in-service again to make sure staff call for assistance.During a review of the facility's dated 01/2017. policy and procedure (P&P) titled, Medication Administration -General Guidelines, the P&P indicated, Medications are administered in a safe and timely manner, as prescribed. The P&P also indicated medications are administered within (60 minutes) of scheduled time, unless otherwise specified by prescriber.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) physician and power of attorney ([POA] decision maker) was notified of refusals of Ciclopirox cream (antifungal cream) treatment to both feet BID for tinea pedis (fungal infection) on 1/8/2026, 1/10/2026, 1/11/2026 and 1/12/2026.This failure resulted in Resident 1 not receiving treatment and care for four days and had the potential to cause infection, inflammation and hospitalization.Findings:During a review of Resident 1's admission Record dated 1/21/2026, the admission record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including diabetes mellitus (a condition in which the body fails to process glucose (sugar)), and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility).During a review of Resident 1's History and Physical (H&P) dated 12/17/2026, the H&P indicated Resident 1 was alert and oriented.During a review of Resident 1's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 11/7/2026, the MDS indicated Resident 1 had moderate cognitive impairment (a decline in cognitive functions like memory, language, thinking). The MDS indicated Resident 1 needed substantial/ maximal assist (helper does more than half the work) with activities of daily living ([ADL] such as toileting, dressing and bathing). The MDS indicated Resident 1 had an infection on both feet.During a review of Resident 1's physician order dated 11/6/2025, the physician order indicated to administer Ciclopirox cream to both feet once a day for Tinea Pedis.During a review of Resident 1's Progress Note dated 1/8/2026 at 9:56 a.m., the progress note indicated Resident 1 had refused treatment on both of her feet.During a review of Resident 1's Progress Note dated 1/10/2026 at 10:24 a.m., the progress noted indicated Resident 1 had refused treatment on both of her feet.During a review of Resident 1's Progress Note dated 1/11/2026 at 11:40 a.m., the progress noted indicated Resident 1 had refused treatment on both of her feet.During a review of Resident 1's Progress Note dated 1/12/2026 at 1:08 p.m., the progress noted indicated Resident 1 had refused treatment on both of her feet.During a review of Resident 1's Treatment Administration Record (TAR) dated 1/21/2026, the TAR indicated Resident 1 had refused her feet fungal treatments of ciclopirox cream to both feet on 1/10/26, 1/11/2026, and 1/12/2026.During a phone interview on 1/21/2026 at 11:04 am with Treatment Nurse (TXN) 2, TXN 2 stated he should have notified the physician and the POA after Resident 1's third fungal treatment refusal to both of her feet on the following days: 1/8/26, 1/10/26, 1/11/2026 and 1/12/2026.During a concurrent interview and record review on 1/21/2026 at 3:00 pm with the Director of Nurses (DON), Resident 1's Tx refusal documentation and GACH ER summary visit report were reviewed. The DON stated TXN 2 should have done a COC when Resident 1 refused her feet fungal treatment for the third time, so the nurses could have let the physician know and possibly see about a new plan of care. The DON stated that TXN 2 should have notified Resident 1's POA that Resident 1 refused treatment on her feet so the POA could have talked to Resident 1 about her refusing care.During a review of the facility's policy and procedure (P&P) titled Change of Condition dated 4/2025, the P&P indicated it is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. The P&P indicated if at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. The P&P indicated nurse shall use his/ her clinical judgment and contact the physician. The P&P indicated the resident/ resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause foodborne illness (food poisoning) for 74 out of 84 total residents in the facility by failing to:1. Ensure a bag of mixed vegetables in the refrigerator were properly stored and labeled with an open date.2. Ensure a box of waffles were stored and sealed properly in the freezer.3. Ensure a bag of sweet potato fries were stored properly in the freezer labeled with an open date.These deficient practices had the potential to result in pathogen (germ) exposure and placed residents at risk for developing foodborne illnesses with symptoms including nausea, vomiting and diarrhea. Findings:During a concurrent observation and interview on 1/5/2026 at 8:28 a.m., the initial kitchen tour was conducted with the Dietary Supervisor (DS). There were observations of the facility refrigerator that contained a bag of mixed vegetables in the refrigerator that was not properly stored and did not have a label with an open date. There was an observation in the freezer of a bag of sweet potato fries and a box of waffles that were not stored properly, and the sweet potato fries did not have an open date. The DS stated his cook (CK 1) used the mixed vegetables for an omelet (unknown date) and forgot to label and date the leftovers. The DS stated they serve a vulnerable population, and they could be negatively affected by unsafe food handling.During an interview on 1/5/2026 at 11:06 a.m., with the Registered Dietician (RD), the RD stated all food stored in the kitchen needed to have a delivery date, date opened, and/ or a use by date (the last day recommended for consuming a food product while it's still at its best quality) so that spoiled food or food of poor quality was not served to the residents. The RD stated all food items needed to be properly sealed and covered so the food was not open to air because oxidation (a chemical reaction that occurs when food is exposed to oxygen, causing it to break down and lose its nutritional value) occurs and the food spoils faster. The RD stated it was the dietary staff responsibility to ensure food was labeled, dated, and stored properly.During a review of the facility's policy and procedure (P&P) titled Food Receiving, labeling, and Storage dated 11/2022, the P&P indicated all foods stored in the refrigerator or freezer were to be covered, labeled, and dated ( use by date).

Based on interview and record review, the facility failed to ensure residents' medical records were up to date as per the facility's policy and procedure (P&P) regarding advance directives ([AD], a legal document of a resident's wishes regarding medical treatment) for four of five sampled residents (Resident 2, Resident 8, Resident 11, and Resident 86).These deficient practices violated the residents' rights to be fully informed of the option to formulate an AD and had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff.Findings: A. During a review of Resident 2's admission record, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and last re-admission was on 11/4/2025 with diagnoses including sepsis (a life-threatening blood infection), End Stage Renal Disease (ESRD-irreversible kidney failure), and dependence on dialysis (mechanical removal of toxins from the blood due to the body's inability to do so). During a review of Resident 2's History and Physical (H&P), dated 11/4/2025, the H&P indicated, Resident 2 had the capacity (ability) to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 2 required maximal assistance (Helper does more than half the effort) from one staff for shower/bath, transfer, toilet hygiene, moderate assistance (Helper does less than half the effort) from one staff for bed mobility, dressing, and setup or clean up assistance (Helper sets up or cleans up) from one staff for eating, and oral hygiene. During a concurrent interview and record review on 1/7/2026, 10:14 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 2's Physician Orders for Life-Sustaining Treatment ([POLST]- a set of medical orders that communicate a patient's wishes for end-of-life interventions), dated 11/4/2025 was reviewed. The POLST section D (Information and Signature) indicated, the Advance Directive (AD- a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) availability and discussed AD with the resident or legal decision maker sections were left blank. RNS 1 stated, all sections of the POLST should be completed including section D regarding AD. RNS 1 stated, it was important to complete the AD section to honor the resident's wishes because the resident would be treated as Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive including invasive procedures) against his/her wishes if it was not completed. During a concurrent interview and record review on 1/7/2026, at 3:02 p.m., with the Social Service Director (SSD), Resident 2's Social Services Assessment (SSA), dated 11/17/2025 was reviewed. The SSA indicated, the SSD verbally educated Resident 2 about the right to formulate an AD, Resident 2 was not interested at this time. The SSD stated, she did not have any written evidence that she provided the written education regarding the right to formulate an AD. The SSD stated, she thought she provided verbal education, but she should have provided written information as well. The SSD stated, it was her responsibility to ensure documenting the availability of an AD and the discussion (with Resident 2) regarding an AD with Resident 2 or their decision maker on POLST to honor the resident's wishes regarding care and treatment. B. During a review of Resident 8's admission record, the admission record indicated Resident 8 was admitted to the facility on [DATE] with osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of right ankle and foot, unstageable pressure ulcer (a full-thickness wound where the base is hidden by dead tissue, making its true depth and severity impossible to determine until the covering is removed) on sacral area (the triangular bone [sacrum] at the base of the spine, located between the lower back [lumbar vertebrae] and the tailbone [coccyx], connecting the spine to the pelvis), and surgical removal of fingers and left toes. During a review of Resident 8's History and Physical (H&P), dated 8/1/2025, the H&P indicated, Resident 8 had the capacity (ability) to understand and make decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bath, dressing, toileting hygiene, transfer, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating. During a concurrent interview and record review on 1/7/2026, at 10:35 a.m., with RNS 1, Resident 8's POLST, dated 8/1/2025 was reviewed. The POLST section D (Information and Signature) indicated, no AD and there was no documentation regarding discussion with Resident 8 or Resident 8's decision maker for AD. RNS 1 stated, she could not tell if the right to formulate an AD was discussed with Resident 8 based on POLST because it was not documented. During a concurrent interview and record review on 1/7/2026, at 3:18 p.m., with the SSD, Resident 8's Social Service Summary (SSS), dated on 11/11/2025 was reviewed. The SSS indicated, the SSD verbally educated Resident 8 on the right to formulate an AD, but Resident 8 was not interested. The SSD stated, she could not provide any evidence that she provided education to Resident 8 on the right to formulate an AD. The SSD stated, she should have made sure that written information was given to Resident 8. The SSD stated, she should have ensured that POLST section D regarding the discussion with the resident or decision maker was documented. During an interview on 1/8/2026, 3:22 p.m., with the Director of Nursing (DON), the DON stated, AD and POLST should be available for all residents regardless. The DON stated, SSD and staff should have ensured the completion of POLST and provided written information regarding AD. The DON stated, AD and POLST were important to honor residents' wishes and the guideline for how to treat residents in emergency situation. C. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dysphagia (difficulty swallowing), hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 was rarely or never understood, and required supervision (helper provides verbal cues and/or touch assistance) with self-care abilities such as personal and oral hygiene, dressing and was maximal assistance (helper does more than half the effort) with mobility such as sit to stand and transfers. During a review of Resident 11's H&P dated 3/10/2025, the H&P indicated Resident 11 was not alert and oriented to person, place, or time. The H&P indicated Resident 11 was forgetful, an inaccurate historian and unable to make medical decisions. During a review of Social Services assessment dated [DATE], the Social Services Assessment indicated Resident 11 and/or Resident 11's representatives had been informed in a manner easily understood of their right to formulate advanced directives. The Social Services Assessment indicated Resident 11 was not a good candidate for formulating an advance directive. The Social Services Assessment did not indicate if Resident 11's representatives had been informed of the right to formulate an advance directive. D. During a review of Resident 86 's admission Record, the admission Record indicated Resident 86 was admitted to the facility on [DATE], readmitted on [DATE] with diagnoses of anemia (a condition where the body does not have enough healthy red blood cells), benign neoplasm of parotid gland (a noncancerous growth, appearing as a slow-growing, painless lump in front of the ear), and diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86 had severe cognitive (thought process) impairment for daily decision making, and was maximal assistant with self-care abilities such as toileting hygiene, bathing, and personal hygiene and was moderate assistance with mobility such as sit to stand and transfers. During a review of Resident 86's Social Services Assessment, dated 11/17/2025, the Social Services Assessment indicated Resident 86 and/or Resident 86's representatives had been informed in a manner easily understood of their right to formulate advance directives. The Social Services Assessment indicated Resident 86 was alert and oriented times two (a person is aware of their person (knows their name) and their place (knows where they are), but may not know the time (date/day/season) or situation (why they are there). The Social Services Assessment indicated Resident 86 had a family member involved in care. The Social Services Assessment indicated Resident 86 had periods of confusion; and Resident 86 was not a good candidate to formulate an advance directive at this time. There was no indication on the Social Services Assessment whether Resident 86's representatives had been informed of the right to formulate an advance directive. During a concurrent interview and record review on 1/7/2026 at 3:01 p.m., with the SSD, Resident 11 and Resident 86's Social Service Assessments dated 11/17/2025 were reviewed. The SSD stated Resident 11 did not have an AD. The SSD stated Resident 11 was confused during admission and was not able to formulate an AD. The SSD stated Resident 11 was not a good candidate for formulating an AD. The SSD stated the assessment was not clear whether Resident 11's representative was informed of the right to formulate an AD. The SSD stated for Resident 86, the resident could not formulate an AD. The SSD stated Resident 86 could make decisions, but was not able to formulate an AD due to being confused at times. The SSD stated the Social Service Assessment was not clear whether Resident 86's representative was informed of the right to formulate an AD. During an interview on 1/8/26 at 3:30 p.m. with the Director of Nursing (DON), the DON stated an AD was a document of the residents' wishes, and the care they would want if they become incapacitated. The DON stated if residents were not provided education to formulate AD, the residents and/or resident representatives are not able to able to formulate an AD on what the wishes are for the residents and their care in the facility. During a review of the facility's policy and procedure (P&P), titled Advance Directive and Associated Documentation, revised in 04/2025, indicated it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. The facility recognizes and respects the residents' right to choose their treatment and make decisions about care to be received at the end of their life .1. prior to, upon, or immediately after admission, a facility staff member shall: a. provide the resident/family or responsible agent written information, in a manner easily understood by the resident or resident representative, regarding the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives. b. document in the resident health record that, at the time of admission, the resident and/or resident representative have been provided with written information regarding advance directives. c. inquire whether they have completed an Advance Directive. 2. If the resident is incapacitated at the time of admission and is unable to receive information or indicate whether they have executed an advance directive, the facility may give advance directive information to the resident's representative in accordance with existing State law.

Based on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a resident assessment tool) for three of four sampled residents (Resident 11, Resident 33, and Resident 86). The facility failed to indicate: Resident 11 had a gastrotomy/feeding tube ([G-Tube], a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems). Resident 33 was receiving Restorative Nursing Assistant services ([RNA] services helps residents regain and maintain physical function, mobility, and independence through specialized exercises, transfers, and positioning). Resident 86 was receiving RNA services.This deficient practice had the potential to result in inaccurate assessment and services for the residents due to inaccurate MDS assessments and care screening tool practices.Findings:a. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dysphagia (difficulty swallowing), hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities).During a review of Resident 11's Order Summary Report dated 10/18/2025, the Order Summary Report indicated enteral (nutrition administered through the stomach or intestines) feed order two times a day Glucerna 1.5 (a calorically dense formula to help minimize blood sugar) at 66 mL/hr (milliliter per hour, a unit of measurement of flow rate used primarily in healthcare for fluid administration) to provide 480 mL/720 kcal (kilocalories, the same unit of energy, measures the energy your body gets from food and uses for activities to provide energy) two times a day, turn on at 8:00 p.m. and off at 4:00 a.m. or until complete. During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 was rarely or never understood and the brief interview for mental status was not done for daily decision making, and required supervision (helper provides verbal cues and/or touch assistance) with self-care abilities such as personal and oral hygiene, dressing and was maximal assistance (helper does more than half the effort) with mobility such as sit to stand and transfers. The MDS indicated Resident 11 did not have a feeding tube such as a nasogastric (a soft, flexible tube inserted through the nose, down the esophagus, and into the stomach for short-term medical purposes, such as delivering nutrition) or abdominal tube (G-Tube) for nutritional approaches while a resident in the facility.b. During a review of Resident 33 's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses of spinal stenosis (the narrowing of spaces within your spine, putting pressure on the spinal cord and nerves, often causing pain, numbness, cramping, or weakness in the back, legs, or arms), chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, affecting the arm, leg, or face).During a review of Resident 33's Order Summary Report dated 10/10/2025, the Order Summary Report indicated RNA program for both lower extremities (legs) [active assisted range of motion ([AAROM] a technique where an individual use their own muscles to move a limb with help from a therapist to improve strength and flexibility) using a cycle (a bike that assists individuals who struggle to participate in therapeutic exercise due to strength, coordination or neurological challenges) every day two times a week or as tolerated.During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33 had intact cognitive (thought process) skills for daily decision making, and was maximal assistant with self-care abilities such as oral hygiene, bathing, and putting on shoes and was moderate assistance (helper does less than half the effort) with mobility such as sit to stand and transfers. The MDS indicated Resident 33 did not participate in RNA program. c. During a review During a review of Resident 86 's admission Record, the admission Record indicated Resident 86 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of anemia (a condition where the body does not have enough healthy red blood cells), benign neoplasm of parotid gland (a noncancerous growth, appearing as a slow-growing, painless lump in front of the ear), and diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 86's Order Summary Report dated 10/18/2025, the Order Summary Report indicated RNA program AAROM of bilateral upper extremities ([BUE's], both arms) and BLEs with a cycle three times a week or as tolerated.During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86 had severe cognitive impairment for daily decision making, and was maximal assistant with self-care abilities such as toileting hygiene, bathing, and personal hygiene and was moderate assistance with mobility such as sit to stand and transfers. The MDS indicated Resident 86 did not participate in RNA program.During a concurrent interview and record review on 1/7/2026 at 3:53 p.m. with the MDS Coordinator (MDSC), the Order Summary Reports, and MDS dated [DATE], 11/28/2025, and 12/5/2025 were reviewed. The MDSC stated for Resident 33 and Resident 86, they would look at orders, and if the orders were still active, then look at RNA progress notes to see if the residents were still getting RNA services. The MDSC stated the Resident 33 and Resident 86 were getting RNA services. The MDSC stated if it was not documented that residents received the 15 minutes session, then the RNA services were not done. The MDSC stated if residents do not get RNA services, the residents can decline functionally (lose ability to do activities of daily living). The importance of residents receiving RNA services as ordered was to maintain their function and to not decline in their ROM, and ambulation. The MDSC stated for Resident 11, the MDS assessment was miscoded. The MDSC stated all MDS coding should be accurate, for their plan of care, what the residents have and the care the facility was providing to the residents.During an interview on 1/8/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated the MDS assessment was an assessment of the resident, what the resident has and what type of care was being provided to residents before transmitted to Centers for Medicare and Medicaid Services ([CMS], provides health coverage through Medicare, Medicaid, and the Children's Health Insurance Program). The DON stated the importance of accurate MDS coding was the overall accuracy of what the resident has, the status of the resident and to get credit for the care the facility was providing to the resident and if it was miscoded, the facility was not treating the residents according to what they have.During a review of the facility's policy and procedure (P/P), titled Resident Assessment and Associated Processes, revised 4/2025, indicated it is the policy of this facility that residents will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessments of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified.each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment, as well as the date the data was obtained.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of three sampled residents (Resident 71 and Resident 49) related to: A. Failing to monitor and document Resident 71's intake and output for suprapubic catheter (a thin tube inserted through a small opening in the lower abdomen directly into the bladder to drain urine) daily accurately.B. Failed to monitor and document Resident 49's intake and output for urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) every shift and every 24 hours. This failure had the potential to result in Resident 71 and 49's needs not being met, affecting the residents' well-being, including significant changes in urine output being missed, and poor patient outcomes.Findings: A. During a review of Resident 71's admission record, the admission record indicated Resident 71 was initially admitted to the facility on [DATE] and last re-admission was on [DATE] with sepsis (a life-threatening blood infection), acute (sudden onset) pyelonephritis (a sudden, serious bacterial infection and inflammation of the kidney), and chronic kidney disease (the kidneys have become damaged over time). During a review of Resident 71's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 71 had fluctuating (irregularly varied) capacity to understand and make decisions. During a review of Resident 71's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 71 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bath, dressing, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, toilet hygiene, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating and oral hygiene. During a concurrent interview and record review on [DATE], at 10:14 a.m., with Registered Nurse Supervisor (RNS)1, Resident 71's Order Summary Report (OSR), dated [DATE] was reviewed. The OSR indicated, Resident 71 had a suprapubic catheter to closed drainage system (a sterile medical system that collects fluids from a surgical site or wound through a drainage tube) for obstructive uropathy (a urinary tract disorder due to structural or functional obstruction of urinary flow) ordered on [DATE]. The OSR indicated, calculate total 24 hours intake and output on every night shift, ordered on [DATE]. RNS 1 stated, Resident 71 was transferred to a General Acute Care Hospital (GACH) due to leakage of the suprapubic catheter on [DATE]. RNS 1 stated, Resident 71's Primary Care Physician (PCP) emphasized the importance of monitoring and documenting intake and output accurately to prevent complications such as blockage and leakage for the suprapubic catheter. During a concurrent interview and record review on [DATE], at 10:20 a.m., with RNS 1, Resident 71'a Medication Administration Record (MAR), dated from 10/2025 to [DATE] was reviewed. The MAR indicated, calculate total 24 hours intake and output on every night shift as follows: a. there was no documentation regarding intake and output amount in milliliter (ml) on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. b. total output was documented as frequency instead of measurement on [DATE] (twice: x2), [DATE] (x2), [DATE] (x2), [DATE] (x2), [DATE] (x2), [DATE] (once: x1), [DATE] (x2), [DATE] (x2), [DATE] (x2), and [DATE] (x1). c. total output was documented total output as zero ml or N/A (not applicable) on [DATE] (0ml) and [DATE] (N/A). RNS 1 stated, Resident 71's intake and output were not monitored and documented accurately. RNS 1 stated, output from the suprapubic catheter should be documented in measurable units ml instead of documenting the frequency such as once or twice. RNS 1 stated, if the total 24 hour output was zero, that would indicate something was wrong and it should be documented as a Change in Condition (CIC) Evaluation (a significant alteration in an individual's physical status) and the PCP should be notified. RNS 1 stated, there was no CIC Evaluation that was done on [DATE]. During a concurrent interview and record review on [DATE], at 3:33 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 71's Care Plan Report (CPR), revised [DATE] was reviewed. The CPR Focus indicated, Resident 71 had a suprapubic catheter. The CPR Goal indicated Resident 71 would remain free from catheter related trauma through [DATE]. The CPR Interventions included, calculate total 24 hours intake and output on every night shift. The MDSC stated, all care plan interventions should be implemented to provide proper care. The MDSC stated, inaccurate monitoring and documenting of intake and output would lead to inaccurate resident assessment. The MDSC stated, this would delay the treatment and care of complications such as blockage and leakage of suprapubic catheter. During an interview on [DATE], 3:08 p.m., with the Director of Nursing (DON), the DON stated, the resident's care plan is that specific resident's plan of care, and it should be implemented as it stated. The DON stated, care plan interventions should be implemented and reevaluated. The DON stated care plan interventions were from IDT meeting and should be implemented to prevent recurrent events or problems. B. During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including benign prostatic hyperplasia ([BPH], a common, non-cancerous growth of the prostate gland that squeezes the urethra, causing urinary issues like weak stream, and incomplete bladder emptying), urinary tract infection ([UTI]- an infection in the bladder/urinary tract), and dementia (a progressive state of decline in mental abilities). During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49 had intact cognitive (thought process) functioning for daily decision making and was moderate assistance (helper does less than half the effort) with self-care abilities such as eating, oral hygiene, personal hygiene and upper body dressing and required supervision (helper provides verbal cues as resident completes activity) for sit to stand and transfers. During a review of Resident 49's Order Summary Report, the Order Summary Report indicated to calculate total 24 hours intake and output on PM shift, every night shift ordered on [DATE] and to monitor intake and output every shift for use of foley catheter ordered on [DATE]. During a review of Resident 49's untitled care plan, revised on [DATE], the untitled care plan focus indicated resident had an indwelling catheter for BPH obstructive uropathy (any blockage in the urinary tract that causes urine to back up) at risk for infections and related complications with goals of will show no signs or symptoms of urinary infection through review date and interventions to calculate total 24 hours intake and output on the PM shift every night. The untitled care plan dated [DATE] indicated a focus of at risk for UTI due to sediment and foul odor urine noted in foley catheter with goals of will have no signs or symptoms of complications until next review date and interventions to monitor intake and output. During a review of Resident 49's MAR for [DATE], [DATE] and [DATE], the MAR indicated calculate total 24 hours intake and output on PM shift every night shift, there was missing documentation on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The MAR indicated monitor intake and output every shift for use of foley catheter, there was missing documentation on [DATE] nocturnal shift (a work schedule that covers overnight hours, typically from 11 p.m. to 7 a.m.), [DATE] p.m. shift (a work schedule that occurs starting around 3 p.m. and ending around 11 p.m.),[DATE] nocturnal shift, [DATE] nocturnal shift, [DATE] nocturnal shift, [DATE] nocturnal shift, [DATE] nocturnal shift, [DATE] day shift (typically covers the standard working hours from 7 a.m. to 3 p.m.), [DATE] day shift, [DATE] p.m. shift, [DATE] nocturnal shift, and [DATE] nocturnal shift. During a concurrent observation and interview on [DATE] at 10:43 a.m., with Resident 49 in his room, Resident 49 was lying in bed watching television. Resident 49 stated he had a urinary catheter inserted because he could not urinate like before. Resident 49 stated he was having trouble urinating and kept getting UTIs. During a concurrent interview and record review on [DATE] at 4:06 p.m., with the MDSC, the untitled care plan dated [DATE], and the MAR for [DATE], [DATE] and [DATE] were reviewed. The MDSC stated the importance of monitoring resident's intake and output was to make sure the resident's kidney function was functioning properly. The MDSC stated if the resident has a condition where their kidney function was affected, it was important to accurately document the intake and output to make sure the resident was not in fluid overload, and the kidneys were functioning properly. The MDSC stated that for the missing documentation of output from the foley catheter, indicated the monitoring was not done. During an interview on [DATE] at 3:30 p.m., with the Director of Nursing (DON), the DON stated a care plan was a plan of care for residents that included interventions that staff should implement. The DON stated care plans are person centered and if the care plan indicated to document intake and output, the interventions must be followed. The DON stated if the intake and output are not accurately documented, the resident could be retaining urine the staff does not know about, and the kidney function could be compromised. During a review of the facility's policy and procedures (P&P) titled Comprehensive Person Centered Care Planning revised [DATE], indicated, it is the policy of this facility that the interdisciplinary team ([IDT], a collaborative group of various professionals such as nurses, doctors, therapists, social workers, dietitians, etc. working together with the patient and family to create a comprehensive, person-centered care plan) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure the care plans for two out of twelve sampled residents (Resident 5 and Resident 6) were revised to reflect their current plan of care by failing to ensure:a. The care plan for Resident 5 was updated to reflect his current nutritional needsb. The care plan for Resident 6 was updated to reflect his current urinary continence status This deficient practice had the potential for Resident 5 and Resident 6 to not receive person centered care. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses of dementia (severe memory, thinking, and reasoning decline that interferes with daily life, caused by diseases damaging brain cells) and encephalopathy (a broad term for any widespread brain disease or dysfunction, altering brain function due to infections injury). During a review of Resident 5's Care Plan Report titled, Resident requires tube feeding the Care Plan Report indicated Resident 5 had an active care plan that was initiated on 8/21/2025 for tube feeding related to history of dysphagia (problems swallowing) and weight loss. The interventions for Resident 5 included receiving Glucerna (a type of nutritional formula) 1.5 via gastrostomy tube (a tube inserted directly into the stomach for nutrition) at 75 milliliters (ml, a unit of measurement) an hour for 20 hours a day to provide 1550 ml of formula and 2250 kilocalories (kcal, a unit of measurement of energy). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 10/8/2025, the MDS indicated Resident 5 had severe cognitive impairment (a significant loss in memory, thinking, and decision-making abilities, making independent living difficult or impossible). During an interview on 1/7/2025 at 9:26 a.m., licensed vocational nurse (LVN) 1 stated Resident 5's diet was upgraded, and he no longer received nutrition via the gastrostomy tube, he ate by mouth. During an interview and concurrent record review on 1/8/2025 at 1:18 p.m., with the Director of Nursing (DON), Resident 5's current physician's orders were reviewed. The DON stated she reviewed Resident 5's current physician's orders and Resident 5 had been eating by mouth since 11/20/2025 and no longer had a physician's order for tube feeding (stop date 12/5/2025). The DON stated it was important to have accurate care plans that have been revised to reflect residents 5's status so the healthcare team could be on the same page. The DON stated Resident 5's current care plan reflected Resident 5 was continuing to receive tube feeding for nutrition and that was not correct. The DON stated Resident 5's care plan should have been revised and care plans are revised when there are any changes to the plan of care. During a review of the facility's policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning dated 4/2025, the P&P indicated the resident's comprehensive plan of care would be reviewed and/or revised after both comprehensive and quarterly reviews. b. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (damage or disease that affects brain function), chronic kidney disease, and benign prostatic hyperplasia (BPH - an enlargement of the prostate gland causing difficult urination and incomplete bladder emptying). During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6's cognition (ability to learn, reason, remember, understand, and make decisions) was intact, required supervision when eating and for oral hygiene, required moderate assistance (helper does less than half the effort) for upper body dressing, required maximal assistance (helper does more than half the effort) for toileting hygiene and bathing, and was dependent for lower body dressing. During a concurrent observation and interview on 1/5/2026 at 10:58 a.m., with Resident 6, Resident 6 stated he used to have a urinary catheter (a flexible tube that drains urine from your bladder into a bag outside the body), but now uses a urinal when urinating. No catheter bag was observed with Resident 6. During a concurrent interview and record review on 1/7/2026 at 11:25 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 6's medical record was reviewed. RNS 1 stated Resident 6's urinary catheter was discontinued on 11/20/2025. RNS 1 stated Resident 6's care plan for titled, Has risk for urinary retention related to BPH, initiated on 12/1/2025 indicated interventions to educate family and/or resident on catheter care and importance of catheter care, provide catheter care if urinary catheter is present, and urinary catheterization as indicated and maintain patency (no blockage) of catheter. RNS 1 stated the care plan is incorrect and should have been revised when the urinary catheter was removed. During an interview on 1/8/2026 at 2:01 p.m., the DON, the DON stated it was important to revise care plans so there is a continuity of care and to ensure that we are giving the right care to the resident. The DON stated care plans should be revised when there is a change of condition, changes with care or medication, and quarterly. During a review of the facility's policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning dated 4/2025, the P&P indicated the resident's comprehensive plan of care would be reviewed and/or revised after both comprehensive and quarterly reviews.

Based on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 3 and Resident 2) who received hemodialysis (HD-process of removing waste products and excess fluid from the body) treatment received care in accordance with standards of practice, as evidenced by:A. Failing to ensure Resident 2 received Hemodialysis twice a week as orderedB. Failing to ensure resident 3 who received hemodialysis had an emergency kit at resident's bedside.These failures had the potential to result in Resident 2 suffering from complications such as fluid overload (too much fluid builds up in the body, causing swelling), electrolyte imbalance (the body has too much or too little of essential minerals), and dangerous buildup of toxins/waste and Resident 3 receiving delayed intervention during accidental bleeding. Findings: During a review of Resident 2's admission record, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and last re-admission was on 11/4/2025 with sepsis (a life-threatening blood infection), End Stage Renal Disease (ESRD-irreversible kidney failure), and dependence on dialysis. During a review of Resident 2's History and Physical (H&P), dated 11/4/2025, the H&P indicated, Resident 2 had the capacity (ability) to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 2 required maximal assistance (Helper does more than half the effort) from one staff for shower/bath, transfer, toilet hygiene, moderate assistance (Helper does less than half the effort) from one staff for bed mobility, dressing, and setup or clean up assistance (Helper sets up or cleans up) from one staff for eating, oral hygiene. During an interview on 1/5/2026, at 11:28 a.m., with Resident 2 in his room, Resident 2 stated, he was scheduled to go to Hemodialysis (HD) twice a week (Monday and Friday). Resident 2 stated, he missed his HD appointment on 1/2/2026 (Friday) because no one came to pick him up for HD appointment. Resident 2 stated, he was concerned that he might miss another appointment and suffering from complications such as confusion and heart issues due to toxin accumulation. Resident 2 stated, no one arranged the makeup session for his missed HD session. During a concurrent interview and record review on 1/7/2026, at 10:14 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 2's Order Summary Report (OSR), dated 1/7/2026 was reviewed. The OSR indicated, Hemodialysis on Monday and Friday with pick up time at 1:15 p.m. was ordered 11/4/2025. RNS 1 stated, Resident 3 had an order to receive HD twice a week. RNS 1 stated, she was not sure the reason why Resident 3 missed HD on 1/2/2026 and there was no documentation. RNS 1 stated, Resident 3 should have received his makeup HD session, but there was no makeup HD session scheduled. RNS 1 stated, the staff should have notified the doctor for further recommendation if the resident missed HD to prevent the complications. During a concurrent interview and record review on 1/7/2026, at 10:18 a.m., with RNS 1, Resident 2's Dialysis Care Documentation/Communication (DCDC) Log, dated from 12/29/2025 to 1/5/2026 was reviewed. The DCDC Log indicated, there was no documentation on 1/2/2026. RNS 1 stated, DCDC documented before and after HD session. RNS 1 stated, resident's weight, vital signs (measurements of the body's essential functions, typically including body temperature, pulse rate, respiratory rate, and blood pressure), HD access site assessment, assessment of potential complications, location of HD received, any new order from HD center were documented on DCDC. RNS 1 stated, there was no documentation between 12/29/2025 and 1/5/2026. RNS 1 stated, Resident 2 did not receive HD on 1/2/2026 and no makeup session scheduled. During an interview on 1/7/2026, at 11:50 a.m., with the Case Manager (CM), the CM stated, she thought that Resident 2 refused to go HD on 1/2/2026, but there was no documentation regarding this. The CM stated, nursing staff should have documented and notified the doctor for recommendation. The CM stated, she did not hear anything from the nursing staff and she did not arrange makeup HD session. During an interview on 1/7/2026, 3:02 p.m., with the Social Service Director (SSD), the SSD stated, she was not notified regarding Resident 2's missing HD session. The SSD stated, if the HD appointment was missing, the staff should have followed up and notified her, the CM and she could arrange the makeup HD session. The SSD stated, HD was important to prevent complications such as irregular heart rhythm due to high potassium (too much potassium in the blood, causing symptoms from fatigue to dangerous heart problems, and is managed with diet, meds, or dialysis) and fluid overload. During an interview on 1/8/2026, at 3:22 p.m., with the Director of Nursing (DON), the DON stated, missing HD session could cause serious health problems such as shortness of breath (the feeling of not getting enough air, often described as chest tightness, struggling to breathe, or feeling like you're suffocating), confusion, and arrhythmia (irregular heartbeats). The DON stated, the staff should have followed through with HD appointments and notified the doctor when the resident missed HD session. During a review of the facility's Policy and Procedure (P&P) titled, Dialysis, Transportation Arrangements for, revised 4/2025, the P&P indicated, Policy: It is the policy of this facility to assist residents in arranging transportation to and from an off-site dialysis facility. Procedure: 1. If a resident requires dialysis appointments as part of his/her care and treatment plan at an off-site certified dialysis facility, the facility should coordinate with resident or resident representative in establishing transportation arrangements . 3. Requests for transportation should be made as far in advance as possible. During a review of the facility's Policy and Procedure (P&P) titled, Transportation to Diagnostic/Dialysis Appointment, revised 5/2019, the P&P indicated, Policy: It is the policy of this facility to assist residents in arranging transportation to/from diagnostic/dialysis appointments when necessary. Procedure: 3. Should it become necessary for the facility to provide transportation, the social service designee will be responsible for arranging the transportation. During a review of the facility's Policy and Procedure (P&P) titled, Dialysis (Renal), Pre-and Post-Care, revised 4/2025, the P&P indicated, Policy: It is the policy of this facility to participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Collaboration and Communication of Care: 1. The care of the resident receiving dialysis services will reflect ongoing communication, coordination and collaboration between the nursing home and dialysis staff. 2. Staff will immediately contact and communicate with the attending physician/practitioner, resident/resident representative, and designated dialysis staff regarding any significant changes in the resident's status. Documentation: 1. Documentation related to pre- and post-dialysis care will be placed in the clinical record and include .c. Communication between facility and dialysis staff or medical provider. During a review of the facility's Policy and Procedure (P&P) titled, Ancillary Services, revised 12/2023, the P&P indicated, Policy: It is the policy of this facility that Social Services staff will coordinate ancillary services to promote residents' optimal well-being. Procedures: 1. Social Services will maintain a system to monitor ancillary services. During a review of Resident 3's admission Record (Face sheet), the admission Record indicated the facility admitted Resident 3 on September 7, 2025 with diagnoses that included end stage renal disease (ESRD, when kidneys are no longer able to work as they should to meet the needs of the body) dependence on hemodialysis (a treatment that cleans a person's blood when kidney is not working), type 2 diabetes mellitus (adult onset diabetes - a chronic condition that affects the way the body processes blood sugar), During a review of the Physician's Orders, dated 11/1/2025, Resident 3 required hemodialysis every Tuesday, Thursday and Saturday at 8:20 a.m. During a review of the Minimum Data Set (MDS - assessment and care-screening tool), dated 9/23/2025, the MDS indicated Resident 3's cognition was intact, was independent in making decisions regarding daily tasks. The MDS indicated Resident 3, required extensive assistance on staff for transfer, dressing, toilet use, personal hygiene, and bathing. During an interview on 1/7/2026 at 10:21 a.m., with Resident 3, the resident stated he had not seen an emergency dialysis kit (supplies to manage sudden bleeding from the dialysis access site) in his bedside drawer. During an observation and interview on 1/7/2026 at 11:07 a.m., with Licensed Vocational Nurse (LVN) 8, LVN 8 looked in Resident 3's bedside table, drawers and closet and stated she could not find an emergency kit to use in case of emergency bleeding for Resident 3. During an observation and interview on 1/7/2026 at 11:21 a.m., with Assistant Director of Nurses (ADON), the ADON stated they did not know where Resident 3's emergency kit was. During an interview and record review on 1/8/2026 at 2:01 p.m., with the Director of Nursing (DON), the DON stated Resident 3, should have an emergency kit at resident's bedside. During a review of the facility's policy and procedure (P&P) titled Dialysis Pre-Post Care dated 4/2025, the P&P indicated, any problems with resident's access site such as excessive bleeding should be addressed immediately.

Based on interview and record review, the facility failed to educate and offer the COVID-19 (a highly contagious infection ) vaccination (medication to reduce risk for infection) for the 2025-2026 respiratory infection season (October 2025 - March 2026) for one of five sampled residents (Resident 7) and all staff. These failures had the potential to result in spreading the COVID-19 virus. Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with acute exacerbation and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 11/28/2025, the MDS indicated Resident 7 had severed cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, oral hygiene, and lower body dressing , and required supervision for toileting hygiene, personal hygiene, bathing, and lower body dressing. The MDS indicated Resident 7's COVID-19 vaccination is not up to date. During a concurrent interview and record review on 1/8/2026 at 11:28 a.m., with the Infection Prevention nurse (IPN), Resident 7's medical record was reviewed. The IPN stated there was no documentation that Resident 7 was offered the COVID-19 vaccination for the 2025-2026 respiratory infection season and educated on the risks and benefits of receiving the vaccination. During a concurrent interview and record review on 1/8/2026 at 11:37 a.m., with the IPN, the Covid Vaccination log for staff was reviewed. The IPN stated the respiratory season is from October 1st to March 31st. The IPN stated it was the facility's responsibility to offer the vaccinations to all residents and staff. The IPN stated there was no documentation that staff were offered the COVID-19 vaccination for the 2025-2026 respiratory infection season and educated on the risks and benefits of receiving the vaccination. The IPN stated it was important to offer the vaccinations and educate all residents and staff on the risks and benefits of taking the vaccinations to mitigate the spread of the COVID-19 infection. The IPN stated the facility follows the California Department Public Health (CDPH - - Health Care- Associated Infections Program Recommendations dated August 2025. The CDPH recommendations, dated August 2025, indicated the Center for Medicare and Medicaid Services (CMS) requires Skilled Nursing Facilities (SNFs) to educated and offer COVID-19, influenza (contagious respiratory infection), and pneumococcal (illness caused by an infectious organism) vaccines to residents, and to educate and offer COVID-19 vaccines to health care providers. During an interview on 1/8/2026 at 2:01 p.m., with the Director of Nursing (DON), the DON stated the facility educates and offers the COVID-19 vaccination to all residents and staff. The vaccination consent form is proof that residents and staff were educated and offered the vaccination. During a review of the facility's policy and procedure (P&P), titled Immunizations, COVID-19, May 2021, the P&P indicated to minimize the risk of resident acquiring, transmitting, or experiencing complications from COVID-19 by assuring that each resident: is informed about the benefits and risks of immunizations.has the opportunity to receive, unless medically contraindicated or refused or already immunized, the COVID-19 vaccine.if declined, the facility is to document the reason why resident did not receive the COVID-19 immunization in the electronic medical record.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents, Resident 31, received their meal tray at the same time as their roommates This deficient practice has the potential to compromise residents' dignityFindings: During a review of the admission Record indicated Resident 31 was admitted to the facility on [DATE] with the diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), osteomyelitis of left ankle and foot (inflammation of bone, due to infection) and non-pressure ulcer (a small open wound found on the skin) of left heel and midfoot.During a review of Resident 31's Minimum Data Set (MDS- a resident assessment tool) dated 12/20/2025, the MDS indicated the resident had the ability to make self understood and the ability to understand others. The MDS further indicated Resident 31 was independent with eating, oral hygiene (the ability to use items to clean teeth), and Resident 31 required extensive assistance on staff for transfer, dressing, toilet use, personal hygiene, and bathing.During a review of Resident's 31's physician order on 12/27/2025, the attending physician's order indicated, consistent carbohydrates, ([CCHO] bread, rice, fruit and milk]), no added salt, 80 grams regular protein diet (eating a normal amount of protein each day to help the body stay strong and healthy).During a lunch observation on 1/7/2026, at 12:58 p.m., in Resident 31's room, Resident 31 did not receive his lunch tray at the scheduled meal service time, while Resident ,3 and Resident 23, received and completed lunch.During an interview on 1/7/2026, at 1:07 p.m., with Resident 31, Resident 31 stated, his meal tray was frequently delivered later than his roommate's and stated this has been an ongoing issue affecting timely receipt of meal.During a concurrent observation and interview on 1/7/2026 at 1:02 p.m., with Certified Nursing Assistant 2 (CNA 2), in Resident 31's room, observed the Registered Nurse Supervisor 1 (RNS 1) wearing gloves, mask and gown and giving lunch tray to Resident 31. CNA 2 stated that she forgot to serve the lunch tray to Resident 3.During an interview on 1/7/2026, at 3:27 p.m., with Registered Nurse Supervisor 1 (RNS 1), stated that daily meal tray service served at set times; breakfast at 7:15 a.m., lunch at 12:12 p.m., dinner at 5:15 p.m., and failure to deliver trays as scheduled may negatively impact the resident's nutrition and dignity.During an interview on 1/7/2026, at 4:06 p.m., with Dietary Supervisor (DS), stated that the warm food cart is delivered by kitchen staff to each nurses 'station 10 minutes prior to scheduled tray pass by nursing staff. failure to deliver trays as scheduled can affect resident's dignity.During a concurrent interview and record review on 1/8/2026 at 2:30 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Resident Rights, dated 3/2023 was reviewed. The facility's policy and procedure (P&P) titled, Resident Rights indicated,.7. To ensure all residents are informed of their rights. The DON stated, that Certified Nurse Assistants (CNAs) should uphold the dignity of residents by ensuring food trays are served warm to all residents same time with their roommates.

Based on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of five sampled residents (Resident 60).This failure had the potential to delay staff response and prevent Resident 60 from receiving necessary care and services. Findings:During a review of Resident 60's admission record, the admission record indicated Resident 60 was initially admitted to the facility on [DATE] and the last re-admission was on [DATE] with cataracts (a clouding of the lens of the eye), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) with left side hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and left side hemiparesis (the weakness of one entire side of the body).During a review of Resident 60's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 60 had the fluctuating capacity to understand and make decisions.During a review of Resident 60's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 60 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bath, transfer, sit to stand, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, dressing, toilet hygiene, and setup or clean-up assistance (Helper sets up or cleans up) from one staff for eating and oral hygiene.During a concurrent observation and interview on [DATE], at 2:26 p.m., with Resident 60 in his room, Resident 60's call light was under the pillow. Resident 60 stated, he could not find the call light. Resident 60 stated, he could not move his left side due to a previous CVA, and he could not reach the call light if was not placed on his right side. Resident 60 stated, he felt helpless when he could not find his call light because he had to wait until the staff came by to get what he needed.During an interview on [DATE], at 2:30 p.m., with the Assistant Director of Nursing (ADON) in Resident 60's room, the ADON stated, she could see the call light was placed under the pillow which Resident 60 would not be able to reach it. The ADON stated, the call light should be placed within reach of Resident 60 and it should be placed on Resident 60's right side due his left sided weakness so he is able to use it. The ADON stated, if the call light was not within reach, Resident 60 would not be able to call for help and possibly have a fall trying to get out of bed to get help, because he was a high risk of fall.During an interview on [DATE] at 2:52 p.m., with the Director of Nursing (DON), the DON stated call lights should always be accessible and within the resident's reach. The DON stated that if the call light was not within the resident's reach, the resident would be unable to call for assistance to get his or her needs met. The DON stated, the residents who were at high risk of falling should be able to reach the call light to prevent fall related injuries.During a review of Resident 60's Care Plan Report (CPR), revised on [DATE], the CPR Focus indicated, Resident 60 had risk for falls related to CVA with left side weakness, cataract and balance problems. The CPR Interventions indicated, be sure the call light is within reach and encourage to use it to call for assistance as needed.During a review of the facility's Policy and Procedure (P&P) titled, Call Light/Bell revised 5/2023, the P&P indicated, POLICY: It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures . Place the call device within resident's reach before leaving room.

Based on interview and record review, the facility failed to notify the physician when Resident 9 refused medications for one of three sampled residents (Resident 9). This failure had the potential to result in delayed care to address the effects of Resident 9's refusal of medication. Findings: During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (stroke - loss of blood flow to a part of the brain), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), anemia (a condition where the body does not have enough healthy red blood cells), and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2025, the MDS indicated Resident 9 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating and oral hygiene, required moderate assistance (helper does less than half the effort), and required maximal assistance (helper does more than half the effort) for toileting hygiene and bathing. During a concurrent interview and record review on 1/7/2026 at 11:44 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 9's medical record was reviewed. RNS 1 stated Resident 9 had an order to receive epoetin alpha (medication to treat anemia) injection solution 10000 unit/milliliter (mL - unit of measurement) inject one syringe in the evening every Tuesday due to resident's history of anemia. RNS 1 stated Resident 9 was diagnosed with anemia. Resident 9's Medical Administration Record for January 2026 indicated Resident 9 did not receive the epoetin alpha injection as scheduled on 12/23/2025. RNS 1 stated there was no documentation indicating the physician was notified of the missed dose. RNS 1 stated Resident 9's change of condition (COC) dated 12/29/2025 at 2:21 p.m., indicated Resident 9's hemoglobin (red blood cell) level on 12/29/2025 at 3:38 p.m., was critically low at 6.1 grams/deciliter (g/dL - unit of measurement) (reference range 12.0-15.5 g/dl). RNS 1 stated on 12/29/2025 at 11:33 p.m., Resident 9's hemoglobin level was critically low at 5.8 g/dL. RNS 1 stated the facility should have notified the physician of the missed dose of epoetin alpha injection solution 10000 unit/ml, because the missed dose of epoetin alpha could have caused her hemoglobin to drop. During an interview on 1/8/2026 at 2:01 p.m., with the Director of Nursing (DON), the DON stated it was important to notify the physician when Resident 9 refused the epoetin alpha injection so the physician can decide if Resident 9's medications or plan of care should be updated. The DON stated it was important to inform the physician when an epoetin alpha medication is missed for a resident with a diagnosis of anemia because there is a risk the hemoglobin would get low and may require additional care such as a blood transfusion. During a review of the facility's policy and procedure (P&P), titled Change in Condition, dated 4/2025, the P&P indicated if, at any time, it is recognized by an one of the team members that the condition or care needs of the resident have changed, the licensed nurse or nurse supervisor should be made aware.the nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions.there will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation.

Based on interview and record review, the facility failed to implement its abuse reporting and prevention policy by failing to report an injury of unknown origin to to the California Department of Public Health (CDPH - state licensing and certification agency) and other officials which includes the Long-Term Care Ombudsman, Law Enforcement, and Licensing Agency for Based on interview and record review, for one of one sampled residents (Resident 9). Theis deficient practice resulted in CDPH being unaware of the injury of unknown origin and possible abuse allegation to conduct a timely investigation. This deficient practice had the potential for information to be lost and/or forgotten. Findings: During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (stroke - loss of blood flow to a part of the brain), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), anemia (a condition where the body does not have enough healthy red blood cells), and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2025, the MDS indicated Resident 9 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating and oral hygiene, required moderate assistance (helper does less than half the effort), and required maximal assistance (helper does more than half the effort) for toileting hygiene and bathing.During a review of Resident 9's Physician Order Summary dated 1/8/2026, the Order Summary indicated: an order Resident 9 may transfer to the general acute care hospital (GACH) due to fracture on the right leg on 12/29/2025.During a concurrent interview and record review on 1/7/2026 at 11:44 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 9's medical record was reviewed. Resident 9's change of condition (COC) dated 12/29/2025 at 2:21 p.m., indicated Resident 9 experienced swelling to the right lower thigh, and the physician ordered an x-ray (a diagnostic procedure that shows image of bones and organs) . Resident 9's nursing process note dated 12/29/2025 at 10:44 p.m., indicated the x-ray results showed a fracture of the distal femur (lower thigh bone). RNS 1 stated there was no indication that Resident 9 experienced a fall to cause the fracture. RNS 1 stated the cause of Resident 9's fracture should have been reported and investigated because it was not normal to have a bone fracture. During a concurrent interview and record review on 1/8/2026 at 2:12 p.m., with the Director of Nursing (DON), Resident 9's medical record was reviewed. The DON stated it is the facility policy to report injuries of unknown origin within 24 hours if they did not know how or why the resident got an injury. The DON stated there was no report made for Resident 9's injury of unknown origin, there should have been. During a concurrent interview and record review on 1/8/2025 at 3:11 p.m. with the Administrator (ADM), the policy and procedure (P&P) titled Abuse: Prevention of and Prohibition Against, dated 12/2023, was reviewed. The ADM stated unusual occurrences should be reported to CPDH within 24 hours. The P&P indicated an injury of unknown source is used to classify an injury when all of the following are met:The source of the injury was not observed by any person; andThe source of the injury could not be explained by the resident; andThe injury is suspicious because of the extent of the injury of the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time or the incidence of injuries over time.The P&P indicated possible indicators of abuse include but are not limited to: bruises, skin tears and injuries of unknow source.The P&P indicated allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate state or federal agencies in the applicable timeframes, as per this policy an applicable regulations. During a review of the facility's policy and procedure (P&P), titled Unusual Occurrence Reporting, dated 4/2023, the P&P indicated unusual occurrences shall be reported by the facility within twenty-four hours either by telephone (and confirmed in writing) or facsimile to the local health officer and the Department.

Based on interview and record review, the facility failed to follow it's policy and procedure (P&P) titled, Fall Management System, for one out of two sampled residents (Resident 27) by not investigating an allegation of a fall incident. This deficient practice had the potential for an actual fall for Resident 27 to not be discovered and probable causal factors to not be identified.Findings:During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of hemiplegia (cannot move or weak on one side of the body) of the right side and abnormalities of gait and mobility.During a review of Resident 27's Transfer Out Progress Note dated 11/3/2025, the Transfer Out Progress Note indicated Resident 27 was alert and orientated and able to make her needs known and Resident 27 was complaining of pain on the right-hand radiating (pain that travels from one body part to another) up to her right shoulder. The Transfer Out Progress Note indicated Resident 27 was transferred out to the General Acute Care Hospital (GACH) on 11/3/2025 for evaluation of the right-hand pain.During a review of Resident 27's GACH- Emergency Department Encounter (paperwork was received by the facility from the GACH) dated 11/3/2025, the Emergency Department Encounter indicated Resident 27 came in with a chief complaint of right arm and hand pain status post (after) a fall 7 days prior. The Emergency Department Encounter indicated Resident 27 fell backwards and fell onto hand with her right palm up.During a review of Resident 27's Minimum Data Set (MDS, a resident assessment tool) dated 12/14/2025, the MDS indicated Resident 27 was cognitively intact (has sufficient judgment, planning, organization, self-control, and persistence needed to manage the normal demands of the resident's environment). The MDS indicated Resident 27 had not had any falls since readmission or since the prior assessment.During an observation and concurrent interview on 1/6/2026 at 8:27 a.m., Resident 27 stated she fell around the end of October 2025 at the facility and hurt her right hand. Resident 27's right hand was observed to be wrapped in an ace bandage (a stretchy, elastic cloth wrap used to provide firm, adjustable compression for injuries like sprains and strains, helping to reduce swelling, support joints, and improve blood flow for better healing).During an interview and concurrent record review on 1/8/2026 at 12:59 p.m., with the Director of Nursing (DON), Resident 27's GACH-Emergency Department Encounter dated 11/3/2025 was reviewed. The DON stated Resident 27 had not fallen at the facility since admission. The DON stated she reviewed the GACH- Emergency Department Encounter dated 11/3/2025 and saw Resident 27 reported a fall to the GACH but she was not aware of the incident until now. The DON stated the registered nurse (RN) supervisor re-admitting the resident back (unknown RN) to the facility post GACH transfer should have reviewed the GACH records and reported the fall to herself (the DON) so she could have investigated the reported allegation of a fall. The DON stated if a resident stated they fell, but it was not witnessed, facility staff should investigate it as an actual fall. The DON stated it was important to investigate allegations of fall because the facility needs to assess if any fall precautions needed to be implemented for the resident and so they can complete an investigation as to what happened with the fall and what caused it or if it happened to prevent repeat falls.During a review of the facility's policy and procedure (P&P) titled Fall Management System dated 4/2025, the P&P indicated a review of all fall incidents would include an investigation to determine probable causal factors.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 16) was seen in a timely manner by a Registered Dietician (RD) after an order for a RD consult was placed due to poor oral (PO) intake.This deficient practice had the potential to lead to unintentional weight loss for Resident 16 due to unaddressed poor oral intake. Findings:During a review of Resident 16's admission Record (face sheet), the admission Record indicated Resident 16 was admitted to the facility 12/3/2025 with diagnoses of encephalopathy (a broad term for any widespread brain disease or dysfunction, altering brain function due to infections, toxins, trauma, metabolic issues, or lack of oxygen) and infective endocarditis (a serious infection of the heart's inner lining (endocardium) or valves, usually caused by bacteria entering the bloodstream, though fungi or other germs can also be responsible). The admission Record did not list dementia as one of Resident 16's current diagnoses.During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 16 had moderate cognitive impairment (signifies more pronounced memory and thinking issues than normal aging). The MDS indicated Resident 16 had not had any weight loss but was on a mechanically altered (change in texture of food or liquids) therapeutic diet (e.g., low salt, low cholesterol).During a review of Resident 16's Documentation Survey Report- Amount Eaten for the month of 12/2025, the Document Survey Report indicated between 12/4/2025 to 12/31/2025, Resident 16 ate 0-25% of her meal on 12 occasions, 26-50% of her meal on 17 occasions, refused meals 13 times, and the amount of food eaten was not documented for 16 occasions. During a review of Resident 16's Nutrition Evaluation and RDN (RD) Review dated 12/4/2025, the Nutrition Evaluation and RDN Review indicated Resident 16 had poor PO intake, PO intake would continue to be monitored, and nursing staff was to notify the RD of any significant changes.During a review of Resident 16's Progress Notes- SBAR (situation, background, assessment, and recommendation) Summary for Providers dated 12/8/2025, the SBAR Summary for Providers indicated Resident 16 had a change in condition (COC) due to poor PO intake with decreased appetite and fluid intake. Resident 16 was noted to only eat small portions of meals despite encouragement and assistance with feeding.During a review of Resident 16's Order Summary Report active as of 1/9/2026, the Order Summary Report indicated the physician placed an order 12/8/2025 for an RD consult.During a review of Resident 16's Documentation Survey Report- Amount Eaten for the month of 1/2026, the Document Survey Report indicated between 1/1/2026 to 1/8/2026, Resident 16 ate 0-25% of her meal on 8 occasions, 26-50% of her meal on 6 occasions, refused meals 1 time, and the amount of food eaten was not documented for 1 occasion.During an observation on 1/6/2026 at 12:36 p.m. Resident 16 was sitting in the dining room being fed her lunch and she only consumed 50% of her meal.During an interview and concurrent record review on 1/8/2026 at 12:35 p.m., RD 1 stated the last time Resident 16 was seen by a RD was on 12/4/2025 and there were no current RD progress notes after that encounter. RD 1 stated he reviewed Resident 16's Amount Eaten for the past 14 days and Resident 16 continued having poor PO intake with most days being under 50%. RD 1 stated he was not aware of the RD consult order placed on 12/8/2025 and Resident 16 should have been seen the first Thursday after the order was placed (12/11/2025) but it was not done because nursing staff did not inform RD 1 or RD 2 of the consultation. RD 1 stated nursing staff needed to inform the RDs if PO intake continued to be low. RD 1 stated it was important that the RD saw the resident in a timely manner after a new consult order was placed to address any concerns the medical team had and if the resident was not seen in a timely manner for poor PO intake it could lead to possible weight loss and malnutrition (a serious condition from deficiencies, excesses, or imbalances in nutrient intake).During an interview and concurrent record review on 1/8/2026 at 1:26 p.m., the Director of Nursing (DON) stated she reviewed Resident 16's active Physician's Orders (Order Summary Report) and noted an order for RD consult was placed on 12/8/2025. The DON stated she reviewed Resident 16's RD Consultation Notes/ Assessments and Resident 16 was not seen by the RD after the RD consult order was placed on 12/8/2025 (last time seen by RD was 12/4/2025). The DON stated it was important that the nursing team communicated new RD consult orders to the RDs so the RDs could follow up as soon as possible and current issues could be relayed to them so they could complete their assessment and incorporate new interventions if needed.During a review of the facility's policy and procedure (P&P) titled Nutrition Status Management reviewed 4/2025, the P&P indicated if there was a significant change in the resident's condition related to weight or nutrition, the RD would make recommendations to offer additional nutrition to those residents. The P&P indicated the RD would monitor and evaluate the resident's response or lack of response to the interventions.

Based on observation, interview, and record review, the facility failed to ensure effective pain management for one of three sampled residents (Resident 8), as evidenced by failing to assess and document Resident 8's pain level and the effectiveness of the pain medication before and after giving the pain medication.This failure had the potential to result in Resident 8 not being able to get quality sleep, decreased energy and decreased participation in activities and therapy sessions due to unrelieved pain.Findings:During a review of Resident 8's admission record, the admission record indicated Resident 8 was admitted to the facility on [DATE] with osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of right ankle and foot, unstageable pressure ulcer (a full-thickness wound [caused by unrelieved pressure] where the base is hidden by dead tissue, making its true depth and severity impossible to determine until the covering is removed) on sacral area (the triangular bone [sacrum] at the base of the spine, located between the lower back [lumbar vertebrae] and the tailbone [coccyx], connecting the spine to the pelvis), and surgical removal of fingers and left toes.During a review of Resident 8's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 8 had the capacity (ability) to understand and make decisions.During a review of Resident 8's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 8 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bath, dressing, toileting hygiene, transfer, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating.During a concurrent observation and interview on [DATE], at 11:30 a.m. with Resident 8 in his room, Resident 8 had wound dressing on the left foot and amputated (the surgical removal of a limb or other body part) fingers. Resident 8 stated, he was getting treatment for infected left foot and he lost few fingers due to diabetic (a condition wherein the body is not able to process sugar, which can lead to poor wound healing) ulcers (an open sore, usually on the foot, that develops in people with diabetes due to nerve damage and poor circulation). Resident 8 stated, his pain level was 6 or 7 out of 10 in numeric pain scale (a pain screening tool, commonly used to assess pain severity at that moment in time using a 0-10 scale, with zero meaning no pain and 10 meaning the worst pain imaginable) because of the infection in his left foot. Resident 8 stated, he had constant pain and his pain level has never been zero even after taking pain medication. Resident 8 stated, he could not sleep well and did not want to participate in activities and therapy because his pain was not relieved.During a concurrent interview and record review on [DATE], 10:14 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 8's Actie Order Summary Report (OSR), dated [DATE] was reviewed. The OSR indicated, a physicians order dated [DATE] to monitor pain level using the following scale: 0=no pain, 1-3 =mild pain, 4-6 =moderate pain, and 7-10 severe pain every shift. The OSR indicated, a physicians order dated [DATE] to give Acetaminophen (Tylenol-a medication for relieving mild pain and fever) 325 milligram (mg) two tablets by mouth every four hours as needed for mild pain (pain level of 1-3) . The OSR indicated, a physicians order dated give Hydrocodone-Acetaminophen (Norco-a medication to relieve pain) 7.5-325 mg 1 tablet by mouth every four hours as needed for moderate to severe pain (pain level of 4-10) was ordered on [DATE]. RNS 1 stated, the staff should assess and document level of pain before and after providing the pain medication in Medication Administration Record to evaluate the effectiveness of medication. During a concurrent interview and record review on [DATE], at 10:35 a.m., with RNS 1, Resident 8's Medication Administration Record (MAR), dated from [DATE] to [DATE] was reviewed. The MAR indicated, monitor pain level using the following scale, 0=no pain, 1-3 =mild pain, 4-6 =moderate pain, and 7-10 severe pain every shift as follows:a. pain level of 0 was documented every shift.b. there was no pain level documented on [DATE] (PM shift :3-11 shift).The MAR indicated, give Tylenol 325 mg two tablets by mouth for mild pain (1-3) every four hours as needed, and it was not given.The MAR indicated, give Norco 7.5-325 mg one tablet by mouth for moderate (4-6) and severe pain (7-10) every four hours as follows:a. There was no documentation of pain level before and after giving the pain medication on MAR.b. Norco was given on [DATE] at 12:30 p.m.c. Norco was given daily except [DATE], [DATE], [DATE], [DATE], and [DATE]RNS 1 stated, the staff should have documented actual pain level before and after giving Norco in MAR per policy. RNS 1 stated, she believed that Resident 8 was having pain frequently and his pain level probably not being zero as documented due to his medical condition.During a concurrent interview and record review on [DATE], at 3:33 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 8's Minimum Data Set (MDS), dated [DATE] was reviewed. The MDS section J (Health Condition) indicated, Resident 8 received as needed pain medication and had occasionally experienced pain. The MDS section J indicated, Resident 8 occasionally pain made it hard to sleep at night and limited his participation. The MDS section J indicated, Resident 8 occasionally pain limited day to day activities and his numeric rating scale of pain was 8 out of 10. The MDSC stated, Resident 8 had severe pain that affected his sleep and limiting daily activities based on MDS assessments. The MDSC stated, if the pain was not managed effectively, it would affect resident's quality of life negatively because the resident's activity of daily life (ADL) would decline and quality of sleep at night would decline as well.During a concurrent interview and record review on [DATE], 3:15 p.m., with the Director of Nursing (DON), Resident 8's Progress Notes (PN) dated from [DATE] to [DATE] was reviewed. The PN indicated, there were no documentation of the pain level after giving Norco on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The DON stated, the pain level should be assessed and documented before and after administration of pain medication to evaluate effectiveness of medication on MAR. The DON stated, there was documentation of the pain level before giving Norco in PN, but re-assessment of the pain level after administration was not documented consistently. The DON stated, she was not sure why some of the pain level assessments were documented on PN and it should be documented in MAR. The DON stated, if the pain is not relieved effectively, the staff should notify the doctor. DON stated accurate pain assessment is a critical element to managing pain effectively. DON stated controlling pain is important to improve or maintain resident's quality or life, daily activity, sleeping, and healing process.During a review of Resident 8's Care Plan Report (CPR), revised [DATE], the CPR Focus indicated, pain related to surgical incision, wound, and infection. The CPR Goal indicated, Resident 8 will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through [DATE]. The CPR Interventions indicated, follow pain scale to medicate as ordered, monitor/document pain characteristic (quality, severity, location, onset, and duration), and pain assessment every shift.During a review of the facility's Policy and Procedure (P&P) titled, Pain Recognition and Management, revised 4/2025, the P&P indicated, Policy : It is the policy of this to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the residents' goals and preferences. Procedure: 3. Pain will be identified and documented in the electronic health record (EHR) a. Using a scale of 1-10 is most common. b. Medication(s) received, refused and response to medication will be documented on the Electronic Medication Administration Record (e-MAR). c. If the pain management program is not effective, the licensed nurse will contact the resident's physician . 5. Monitoring: a. Monitor pain status every shift using either the numerical pain rating (1-10). b. Monitor for effectiveness of interventions and/or adverse consequences. c. Consult physician for additional interventions if pain is not relieved by current orders.

Based on observation, interview and record review, the facility failed to document medication administration for one of three sampled residents (Resident 6). This failure had the potential to result in Resident 6 receiving duplicate doses of acetaminophen (medication used to reduce pain or fever) which places residents at risk for liver problems due to taking too much acetaminophen. Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (damage or disease that affects brain function) and kidney disease. During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 11/4/2025, the MDS indicated Resident 6's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 6 required supervision when eating and for oral hygiene, required moderate assistance (helper does less than half the effort) for upper body dressing, required maximal assistance (helper does more than half the effort) for toileting hygiene and bathing, and was dependent for lower body dressing. During a review of Resident 6's Physician Order Summary dated 1/8/2025, the Order Summary indicated an order for Acetaminophen Oral Tablet 325 milligrams (MG- a unit of measurement of weight), give two tablets by mouth every four hours as needed for generalized pain, not to exceed (nte) 3 grams (G- a unit of measurement)/24 hours of any acetaminophen sources, starting 1/8/2026. During a concurrent observation and interview on 1/7/2026 at 9:08 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed administering two tablets of acetaminophen to Resident 6. LVN 2 stated he administered two tablets of acetaminophen for Resident 6's complaint of pain. During a concurrent interview and record review on 1/7/2025 at 12:29 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 6's Medication Administration Record (MAR) for January 2026 was reviewed. RNS 1 stated there was no documentation indicating Resident 6 received acetaminophen on 1/7/2025. RNS 1 stated It was important to document any medication administration as soon as it is administered to decrease the risk of medication overdose. During an interview on 1/8/2026 at 2:01 p.m., with the Director of Nursing (DON), the DON stated it was important to document medication administration when the medication is administered. The DON stated if an acetaminophen administration was not documented, there was a risk that Resident 6 could receive an additional dose of acetaminophen. The DON stated if a resident is given duplicate doses of acetaminophen, it can place a resident at risk of liver problems. According to the Food and Drug Administration ([FDA] federal agency responsible for protecting public health by regulating the safety, effectiveness, and labeling of foods, drugs etc.) taking too much acetaminophen, also known as an acetaminophen overdose, is unsafe and can lead to liver failure and death. (https://www.fda.gov/drugs/information-drug-class/acetaminophen) During a review of the facility's policy and procedure (P&P), titled Medication Administration - General Guidelines, dated January 2017, the P&P indicated the individual who administers the medication dose records the administration on the resident's MAR after the medication pass is completed. At the end of each medication pass, the person administering the medications reviews the MAAR to ensure necessary doses were administered and documented.

Based on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 16)'s diagnoses list was updated to reflect her dementia (severe memory, thinking, and reasoning decline that interferes with daily life, caused by diseases damaging brain cells) diagnosis.As a result of this deficient practice, Resident 16 was receiving medications for a dementia diagnosis that was not listed as one of her current problems.Findings:During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses of encephalopathy (a broad term for any widespread brain disease or dysfunction, altering brain function due to infections, toxins, trauma, metabolic issues, or lack of oxygen) and infective endocarditis (a serious infection of the heart's inner lining (endocardium) or valves, usually caused by disease causing organisms). The admission Record did not list dementia as one of Resident 16's current diagnoses.During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 16 had moderate cognitive impairment (signifies more pronounced memory and thinking issues than normal aging). The MDS indicated Resident 16 had dementia although it was not listed as her current diagnosis.During an interview and concurrent record review on 1/8/2026 at 3:21 p.m., with the Director of Nursing (DON), Resident 16's current and active physicians orders as of 1/8/2026 (Order Summary Report) were reviewed. The DON stated Resident 16 was receiving Memantine 5milligrams twice daily for dementia. The DON stated she reviewed Resident 16's current diagnoses list as of 1/8/2026 and dementia was not listed on the current diagnoses list. The DON stated it was important to have an updated diagnoses list to reflect all current diagnoses to ensure the residents were receiving the proper treatments and medications to address the current list of diagnoses. The DON stated the potential outcome of receiving medication for a disease that was not listed on the diagnosis list was that the resident could be receiving improper treatment.During an email exchange on 1/13/2025, the administrator (ADM) confirmed the facility did not have a policy and procedure (P&P) for accuracy of documentation.

Based on observation, interview and record review, the facility failed to implement infection control measures by failing to ensure Restorative Nurse Aide (RNA -provides specialized care to help patients recover and keep their functional abilities) 1 wore Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) properly for one of three sampled residents (Resident 71) who was on Enhanced Barrier Precaution (EBP-an infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with multidrug-resistant organisms or increased risk factors like wounds/devices, expanding beyond Standard Precautions to prevent MDRO spread where direct contact is likely).This failure had the potential to result in compromised infection control measures and the spread of infection among residents, staff, and visitors.Findings:During a review of Resident 71's admission record, the admission record indicated Resident 71 was initially admitted to the facility on [DATE] and last re-admission was on [DATE] with sepsis (a life-threatening blood infection), acute (sudden onset) pyelonephritis (a serious bacterial infection and inflammation of the kidney), and chronic kidney disease (the kidneys have become damaged over time).During a review of Resident 71's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 71 had fluctuating (irregularly varying) capacity to understand and make decisions.During a review of Resident 71's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 71 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bath, getting dressed, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, toilet hygiene, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for eating and oral hygiene.During a concurrent observation and interview on [DATE], at 10:19 a.m., with RNA 1, there was an EBP sign on the wall above Resident 71's bed. RNA 1 was performing Active Assisted Range of Motion (AAROM-a type of exercise where a person moves a joint as much as they can, but receives help from a therapist, equipment (like a strap or stick), gravity, or their other limb to achieve a greater range of motion) on Resident 71's right leg. RNA 1 was wearing a face mask and gloves. RNA 1 was not wearing a gown. RNA 1 was holding Resident 71's right leg up and his nursing uniform was touching the bed linen. RNA 1 stated, he did not know that Resident 71 was on EBP because of a suprapubic catheter (a thin tube inserted through a small opening in the lower abdomen directly into the bladder to drain urine). RNA 1 stated, he should have worn the gown because AAROM required high contact with Resident 71, and high contact with out a gown could to spread infection.During an interview on [DATE], at 10:35 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated, the staff should wear a mask, a gown, and gloves before performing high contact activities such as bathing, hygiene care, changing, transferring, and providing AAROM to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) when they were caring for the residents who were on EBP.During an interview on [DATE], at 2:58 p.m., with the Director of Nursing (DON), the DON stated, PPE should be worn correctly according to different types of isolation. The DON stated, Resident 71 met the criteria for EBP due to a suprapubic catheter which was an invasive line. The DON stated EBP required wearing a mask, gown, and gloves before performing high contact resident care that required touching the residents. The DON stated, the staff must wear proper PPE to protect themselves and the vulnerable residents in the facility.During a review of Resident 71's Order Summary Report (OSR), dated [DATE], the OSR indicated, EBP and PPE required for high contact care activities due to an indwelling medical device/suprapubic catheter ordered on [DATE]. The OSR indicated, RNA to perform AAROM of bilateral lower extremities in all available directions three times a week, ordered [DATE].During a review of Resident 71's Care Plan Report (CPR), revised [DATE], the CPR Focus indicated, Resident 71 had suprapubic catheter. The CPR Interventions indicated, use Enhanced Barrier Precaution.During a review of the facility's Policy and Procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, revised 3/2024, the P&P indicated, Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable disease and conditions. Procedure: 3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gowns and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs).

Based on interview and record review, the facility failed to ensure the resident, who was assessed at risk for falls with poor safety awareness, did not fall and sustained injury for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1's untitled care plan, dated 7/5/2024, identifying the resident as fall risk, had specific interventions used and carried out to prevent the resident from falls and injuries. 2. Ensure untitled care plan, dated 7/5/2024, identifying Resident 1 as fall risk, was reviewed and revised after the resident's fall on 8/20/2024, to have specific interventions to safeguard the residents from future falls and injuries. 3. Ensure staff has taken precautions (unspecified) to prevent Resident 1 falls as indicated in untitled care plan dated 7/8/2024, for the anticoagulant (blood thinner) therapy. 4. Ensure staff followed the facility's policy and procedure (P/P) titled Fall Management System dated 12/2023, which indicated residents with high risk factors identified on the fall risk evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. These deficient practices resulted in Resident 1's unwitnessed fall on 10/24/2024 and sustaining injuries leading to resident's transfer to the General Acute Care Hospital (GACH) d admission to the Intensive Care Unit ([ICU] critical care unit in the hospital that takes care of patients who are critically ill) where Resident 1 was diagnosed with an 8.0 millimeters ([mm] a unit of measure of length) subdural (one of the tissue layers of the brain) hematoma (a collection of blood after a head injury) and an acute hyperextension (forceful extension of a joint beyond its normal limits) fracture [a break] in the spine that involves a triangular fragment of bone) of the C6 (bone located at the base of the neck) vertebral body (bone in the neck). While at the GACH Resident 1 was intubated (a tube inserted into a person's mouth or nose, then into their windpipe to help deliver oxygen to the body) following with tracheostomy (a surgical opening through the neck into the windpipe to allow air to fill the lungs), and on 11/12/2024 had a [NAME] (a small, rotating cutting tool used by surgeons and dentists to remove or reshape bone) hole evacuation (a surgical procedure that involves drilling small holes in the skull to drain blood or excess fluid) for the treatment of the subdural hematoma. On 12/9/2024 Resident 1 undergone cervical (the neck) bone to thoracic (chest) bone fusion (the process of combining two or more things into one) and decompression (to release pressure) . surgery. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation ([A-Fib], irregular heartbeat), repeated falls, dementia (a progressive state of decline in mental abilities), and traumatic subdural hemorrhage (secondary to a fall pre-admission). During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool) dated 10/25/2024, the MDS indicated Resident 1 was moderately independent (some difficulty in new situations) in daily decision making and required partial/moderate assistance (helper does less than half the effort) in completing activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician Order dated 7/5/2024, the Physician Order indicated to administer Apixaban (medication to thin the blood and prevent clots) 5.0 milligrams ([mg] a unit of measurement of mass) one tablet by mouth two times a day for A-Fib. During a review of Resident 1's Fall Risk Evaluation dated 7/5/2024, the Fall Risk Evaluation indicated Resident 1 scored a ten indicating Resident 1 was a medium risk for falls. During a review of Resident 1's untitled care plan dated 7/5/2024, the care plan indicated Resident 1 was a high risk for falls related to recurrent falls and getting up unassisted despite encouragement not to do so. The care plan indicated the interventions included reviewing information on past falls, determining causes of the falls, and removing any potential causes if possible. During a review of Resident 1's untitled care plan dated 7/8/2024, the care plan indicated Resident 1 was on anticoagulant therapy related to A-Fib and was at risk for bruising (skin discoloration from damaged, leaking blood vessels underneath the skin), bleeding, and related complications. The care plan's interventions included resident/family/caregiver teaching to include avoiding activities that could result in injury and to take precautions to avoid falls. During a review of Resident 1's Change in Condition (COC) dated 8/20/2024 and timed at 10:17 a.m., the COC indicated Resident 1 had fallen out of his wheelchair when he was trying to get to his bed, the resident stood up and slid from the wheelchair. During a review of Resident 1's Fall Risk evaluation dated 8/20/2024, the Fall Risk Evaluation indicated Resident 1 was a high risk for falls. During a review of Resident 1's Fall Committee Interdisciplinary Team ([IDT] a group of health care professionals from different disciplines who work together to provide care) note dated 8/21/2024, the Fall Committee IDT note indicated the root cause of Resident 1's fall on 8/20/2024 was due to Resident 1was initiating self-transfer and not asking for assistance. During a review of Resident 1's Physical Therapy ([PT] treatment to improve how the body performs physical movements) Discharge Summary dated 8/29/2024, the PT Discharge Summary indicated Resident 1 required supervision or touching assistance (helper makes light contact to guide or stabilize the person) during transfers and ambulation (walking). The PT Discharge Summary indicated Resident 1 required ongoing cueing (to give instructions) due to poor safety awareness. During a review of Resident 1's Fall Committee IDT note dated 9/18/2024 (28 days from the fall on 8/20/2024), the Fall Committee IDT note indicated a recommendation to remove Resident 1 from the Fall Committee on this date (9/18/2024). The note indicated there were no incidence of Resident 1's fall or injury, and interventions (unspecified) were effective at this time. During a review of Resident 1's COC dated 10/24/2024 and timed at 11:30 p.m., the COC indicated Resident 1 had experienced a fall which resulted in swelling on the left side of his forehead and upper left eyelid. During a review of Resident 1's Physician Order dated 10/24/2024, the Physician Order indicated to transfer Resident 1 to the GACH for further evaluation and treatment. During a review of the Paramedic (emergency medical response team) Report Sheet dated 10/24/2024, the Paramedic Report Sheet indicated Resident 1 sustained an unwitnessed ground level fall (a fall that happens when someone is standing, and their feet touch the ground before they fall) and Resident 1 had a one inch laceration (a wound that is produced by the tearing of soft body tissue) to the left side of his forehead. During a review of Resident 1's Fall Committee IDT note dated 10/25/2024 and timed at 9:34 a.m., the Fall Committee IDT noted indicated after hearing an unfamiliar sound coming from Resident 1's room, Resident 1 was found by the Licensed Vocational Nurse 2 (LVN 2) lying on the floor by the bedside table near the bed. The Fall Committee IDT note indicated Resident 1 reported to LVN 2 that he heard his daughter calling him and he was going to meet her when he stood up from the bed. The Fall Committee IDT note indicated on 10/24/2024 Resident 1 was transferred to the GACH for further evaluation due to Resident 1 being on anticoagulant medication. The Fall Committee IDT note indicated the IDT team concluded Resident 1 tried to get out of bed unassisted, lost his balance and fell on the floor. During a review of Resident 1's Emergency Department (ED) Physician Notes dated 10/25/2024 and timed at 10:25 a.m., the ED Physician Note indicated Resident 1 was found to have an acute (sudden onset) subdural hematoma, and was admitted to ICU, where he was administered Kcentra medication (reverses the effects of a blood thinning medication in adult with acute major bleeding) for urgent reverse of Apixaban effect. During a review of Resident 1's Computerized Tomography Scan ([CT]- a type of imaging that uses radiography (a procedure that uses beams of light to create an image of a body part) techniques to created detailed images of the body) of the Spine (bones and other tissues that reach from the base of the skull to the tailbone) dated 10/25/2024, the CT Scan of the Spine indicated Resident 1 had acute hyperextension fracture of the C6 vertebral body. During a review of Resident 1's CT scan of the head dated 10/25/2024, the CT scan of the head indicated an 8.0 mm acute subdural hematoma. During a review of Resident 1's Operative Report dated 12/9/2024, the Operative Report indicated Resident 1 had Cervical bone to Thoracic bone fusion and decompression During a review of Resident 1's GACH's Discharge Summary dated 12/23/2024, the Discharge Summary indicated Resident 1 had a [NAME] hole evacuation on 11/12/2024 for treatment of the subdural hematoma. During an interview on 2/11/2025 at 2:00 a.m., with Certified Nursing Assistant (CNA) 1, the CNA 1 stated for residents who were high risk for falls and were attempting to get out of bed unassisted, she would check on them every two hours, sit close to their room, and keep an eye on them. During an interview on 2/11/2025 at 2:03 a.m., with LVN 1, the LVN 1 stated a resident ( in general), who were high risk for falls, required frequent monitoring every two hours. LVN 1 stated for residents, who were getting out of bed unassisted, she would assign a 1:1 sitter (a person provides constant supervision) because the resident needs constant redirection and monitoring. During an interview on 2/11/2025 at 12:52 p.m., with the Physical Therapist (PT 1), the PT 1 stated Resident 1 required contact guard (lightly touching the resident to help with balance or stability) during ambulation due to Resident 1's poor safety awareness. During an interview on 2/11/2025 at 1:42 p.m., with Registered Nurse 1 (RN 1), the RN 1 stated Resident 1 was a high risk for falls. RN 1 stated residents, who had dementia and were high fall risk, required reminders to use the call light (to call for assistance), rounding (checking on the resident) and monitoring at least every two hours to ensure their safe. During an interview on 2/11/2025 at 2:07 p.m., with the Director of Nursing (DON), the DON stated when a resident (in general) is admitted to the facility, upon admission a fall risk assessment is completed and if needed, a care plan related to falls is created. The DON stated when a resident (general) sustains a fall, a rehabilitation screen is completed, the root cause of the fall is investigated and discussed with the IDT team, and the resident's care plan will be updated. The DON stated for Resident 1, frequent monitoring and visual checks every two hours should have been added to the care plan and implemented. The DON stated that if Resident 1 was frequently monitored, it could have decreased his chances of falling. The DON stated Resident 1 would have benefited from having a 1:1 sitter assigned to him. According to the National Institute of Health's ([NIH] the primary agency of the United States government responsible for conducting and supporting medical research) article titled Anticoagulant use in older persons at risk for falls: therapeutic dilemmas, dated 7/1/2023 the article indicated anticoagulants may increase the risk of intracranial hemorrhage, internal bleeding, prolonged bleeding due to falls. The article indicated assessing and modifying risk factors for falls and bleeding can make anticoagulant therapy safer. https://pmc.ncbi.nlm.nih.gov During a review of the facility's policy and procedure (P/P) titled Fall Management System dated 12/2023, the P/P indicated residents with risk factors identified on the fall risk evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The P/P indicated the care plan interventions will be developed to prevent falls by addressing risk factors and will consider the particular elements of the evaluation that put the resident at risk. The P/P indicated after a resident sustains a fall, the resident's care plan will be updated.

Based on interview and record review, the facility failed to ensure a resident, who was assessed at a moderate risk for developing a skin injury and had intact skin upon admission, did not develop a Stage III (full thickness tissue loss - underlying fat tissue may be visible, but bone, tendon, or muscle is not exposed) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the sacro-coccyx area (tailbone) measuring nine centimeters [(cm) unit of measurement] in length, nine cm in width and 0.1 cm in depth for one of two sampled residents (Resident 40). The facility failed to: 1. Implement Resident 40's (untitled) care plan intervention to turn and reposition the resident every two hours, to prevent the resident from developing a pressure injury by relieving the pressure from the sacro-coccyx area. 2. Implement the facility's policy and procedure (P&P) titled, Skin and Wound Monitoring and Management revised 12/2023, that indicated in order to prevent the development of skin breakdown/pressure injuries to reposition the resident. These deficient practices resulted in Resident 40 developing a facility-acquired, preventable, Stage III pressure injury on the sacro-coccyx area measuring nine cm in length, nine cm in width and 0.1 cm in depth. The wound had scant serosanguinous (contains or relates to both blood and the liquid part of blood - serum) exudate (fluid that leaks out of blood vessels into nearby tissues) with 20 percent (%) slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds) and 80 % epithelial (appears pink or pearly white, and wrinkles when touched, occurs in the final stage of healing) tissue. Findings: During a review of Resident 40's Admission Record, the Admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of greater trochanter of right femur (hard area on the outside of the hip), age related osteoporosis (a disease that causes bones to become weak and more likely to break) with pathological (caused by disease) fracture, type 2 diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), abnormal posture, need for assistance of personal care, difficulty of walking, and lack of coordination. During a review of Resident 40's Minimum Data Set ([MDS], a resident assessment tool), dated 7/12/2024, the MDS indicated Resident 40's cognitive skills (ability to think and reason) for daily decision-making were moderately impaired. The MDS indicated Resident 40 required partial assistance (helper does less than half the effort helper lifts support or holds trunk or limbs but provides less than half the effort) with toileting hygiene and rolling left and right (ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated Resident 40 was at risk for developing pressure injuries. The MDS indicated Resident 40 did not have pressure ulcers or any unhealed pressure injuries. The MDS indicated Resident 40's skin was intact and did not have any ulcers, wounds, and skin problems. During a review of Resident 40's Braden Scale (a scoring tool used to predict residents' risk of developing a pressure injury, total scores range from 6 - 23. A lower score indicating a higher risk of developing a pressure injury) assessment, dated 7/11/2024, the Braden Scale assessment indicated Resident 40's score was 14 indicating Resident 40 was at moderate risk for developing a pressure injury. The Braden Scale indicated Resident 40's skin was often moist, the resident was chairfast (capable of maintaining a sitting position but lacking the capacity of bearing own weight), had very limited mobility, was unable to make frequent or significant positional changes independently and required moderate to maximum assistance when moving. During an interview on 11/5/2024 at 10:16 a.m., with Resident 40, Resident 40 stated he had a wound on his buttocks area because the facility staff left him sleeping on one side for too long. Resident 40 stated that facility staff did not reposition him to take the pressure off his buttocks area. During an interview and record review on 11/6/2024 at 3:13 p.m., with Registered Nurse (RN 1), Resident 40's Licensed Nurses Skin Evaluation - PRN (as needed)/weekly, dated 9/29/2024 was reviewed the Licensed Nurses Skin Evaluation indicated Resident 40's skin had no redness, bleeding, or open skin areas noted upon assessment. RN 1 confirmed Resident 40's skin was intact on 9/29/2024. During an interview and record review on 11/6/2024 at 3:18 p.m., with RN 1, of Resident 40's Licensed Nurses Skin Pressure Ulcer Weekly documentation, dated 10/8/2024, the Licensed Nurse Skin Pressure Ulcer Weekly documentation indicated Resident 40 had a suspected deep tissue injury ([SDTI ]- Non blanching [skin that doesn't fade when pressure is applied to it indicating bleeding under the skin] purple or maroon skin discoloration) pressure injury in the sacro-coccyx area which was not present on admission (1/5/2023), on the MDS dated [DATE], and on the Licensed Nurses Skin Evaluation date 9/29/2024. During an interview and record review on 11/6/2024 at 3:25 p.m., with RN 1, of Resident 40's Licensed Nurse Skin Pressure Ulcer Weekly documentation dated 10/8/2024, the Licensed Nurse Skin Pressure Ulcer Weekly documentation indicated the STDI measured 9.5 cm by 9.5 cm with no depth, no exudate, and with attached wound edges. RN 1 stated Resident 40 had an STDI on 10/8/2024, nine days after Resident 40's skin was assessed and was intact. During an interview and record review on 11/6/2024 at 3:28 p.m., with RN 1, Resident 40's Order Summary report as of 11/7/2024, was reviewed and the summary report indicated the following: a. A physician's order dated10/14/2024, for a nutritional supplement (Nutrition powder to promote wound healing) one time a day for supplement (wound healing) for 30 days one packet with six ounces of fluids. b. A physician's order dated 10/9/2024, for a low air loss mattress (mattress designed to prevent and treat pressure wounds) c. A physician's order dated 10/8/2024, Wound consult until wound resolves. d. A physician's order dated 10/8/2024, for Ascorbic acid (Vitamin C supplement) 500 milligrams by mouth one time a day. e. A physician's order dated 10/12/2024, for Medi honey wound/burn dressing external gel (wound dressing to promote healing) apply to Sacro-coccyx topically as needed for stage III pressure injury. Clean with Normal saline (salt and water solution), pat dry, apply Medi honey, apply skin prep to peri wound then cover with dry dressing. f. A physician's order dated 10/8/2024, Pro-Stat Oral liquid (supplement liquid protein for wound healing) give 30 milliliters in the evening. During a continued interview and record review on 11/6/2024 at 3:28 p.m., with RN 1, Resident 40's Order Summary report as of 11/7/20241 RN 1 stated the orders indicated were interventions initiated because of Resident 40's newly developed and identified pressure ulcer. During an interview and record review on 11/6/2024 at 3:40 p.m., with RN 1, Resident 40's untitled care plan initiated on 4/26/2023, and revised on 7/2/2024, was reviewed. This care plan indicated Resident 40 was at risk for impaired skin integrity. The care plan goal indicated Resident 40 would have intact skin, free of redness, blisters (a fluid-filled sac in the outer layer of skin that may be caused by rubbing, or pressure), or discoloration through review, dated on 10/8/2024. During an interview and record review on 11/6/2024 at 3:43 p.m., with RN 1, Resident 40's untitled care plan initiated on 4/26/2023, and revised on 7/2/2024, was reviewed, the care plan interventions included Resident 40 would be encouraged to turn and reposition with assistance as necessary. RN 1 stated the care plan was not updated with new interventions on 10/8/2024 when Resident 40's STDI was identified. RN 1 stated the care plan intervention did not indicate turning and repositioning routinely every 2 hours. RN 1 stated the care plan should be updated and implemented to prevent further pressure injury development. During an interview on 11/7/2024 at 12:14 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 40 developed a preventable, facility acquired pressure ulcer because Resident 40 had impaired mobility and was probably not repositioned every two hours. During an interview and record review on 11/7/2024 at 1:47 p.m., with LVN 1 Resident 40's Documentation Survey Report for September and October 2024, the Turned and Repositioned Task documentation was reviewed. The Turned and Repositioned Task documentation indicated Resident 40 was not turned and repositioned on each shift. LVN 1 stated there was no documented evidence Resident 40 was turned and repositioned every two hours on every shift for the month of September and October. During an interview and record review on 11/8/2024 at 12:30 p.m., with the Director of Nursing (DON), Resident 40's Surgical Consult Note, dated 10/10/2024, was reviewed. The Surgical Consult Note indicated Resident 40 had a wound located in the sacro-coccyx area measuring 9.0 cm in length and 9.0 cm in width and 0.1 cm in depth. The wound had scant serosanguinous exudate with 20 %slough and 80 % epithelial tissue and the wound edge was macerated (skin looks soggy there may be a white ring around the wound that are too moist or have exposure to too much drainage). During an interview and record review on 11/8/2024 at 12:36 p.m., with the DON, Resident 40's Surgical Consult Note, dated 10/10/2024, was reviewed. The DON stated repositioning the resident was important to prevent pressure injuries on residents' (in general) skin. The DON stated a resident should not develop a Stage III pressure ulcer while in the facility, but it also depends on the resident's comorbidities (medical diagnoses). The DON stated if the turning and repositioning every two hours was not documented then it was not done. The DON stated care plans should be updated. During a review of Pressure Injury Prevention Points Portable Document Format (PDF) published by the National Pressure Injury Prevention Advisory Panel, copyright 2020, the PDF indicated the following pressure injury prevention points: 1. Consider bedfast and chairfast individuals to be at risk for development of pressure injury. 2. Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. 3. Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. 4. Continue to reposition an individual when placed on any support surface. 5. Reposition weak or immobile individuals in chairs hourly (www.npiap.com) During a review of the facility's P&P titled, Skin and Wound Monitoring and Management revised 12/2023, the P&P indicated: 1. A resident having pressure injury received necessary treatment and services to promote healing, prevent infection, and prevent new avoidable pressure injuries from developing. 2. ln order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: a. Stabilize, reduce, or remove any existing any underlying risks. b. Monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition. c. Reposition the resident.

Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 8) did not receive unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior and used to treat mental health disorders). The facility failed to: 1. Ensure Resident 8 w, not prescribed and administered Ativan (a prescription medicine often used to treat people living with anxiety [extreme worry]) 1 milligrams ([mg] a unit of weight measurement), every four hours as needed (PRN) for agitation (feelings of irritability, mental distress, or severe restlessness) and shortness of breath (SOB) for 14 day, without documented indication for use. 2. Ensure Resident 8 was not administered Ativan 1 mg every four hours for six days along with other psychotropic medications (Seroquel and Risperdal), causing Resident 8 to be over sedated. 3. Ensure Resident 8 was not prescribed and administered two antipsychotic (medication used to treat certain mental/mood disorders such as schizophrenia [a mental disorder characterized by abnormal thought processes and deregulated emotions], and bipolar disorder [a mental illness characterized by periods of elevated mood and periods of depression], medications simultaneously, Seroquel 50 mg for dementia (a progressive loss of memory) with psychotic (a person affected with psychosis [a severe mental disorder that causes a person to lose touch with reality and have disrupted thoughts and perceptions] features, manifested by visual hallucinations (false perceptions of things that seem real but are not) of seeing non-existent dead people, ordered on 6/14/2024 and Risperidone 1 mg for a mood disorder manifested by agitation, ordered on 6/20/2024. 4. Ensure Resident 8 was not prescribed antipsychotic medications Seroquel and Risperidone, that were not indicated for use for residents who displayed behaviors related to diagnoses of vascular dementia (a chronic condition that affects memory, thinking and behavior, caused by conditions that damage blood vessels and disrupts blood flow and oxygen supply to the brain) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). 5. Ensure Resident 8 was not prescribed Ativan 1 mg every four hours as needed for agitation, and Risperdal 1 mg two times daily for a mood disorder manifested by agitation as chemical restraints, as evidenced by interview that Resident 8 often tried to get out of bed unassisted, was at risk of falling and that was why she was given Ativan. 6. Ensure Resident 8 did not receive multiple psychotropic medications (Seroquel, Risperdal and Ativan) simultaneously causing the resident to fall four times from 6/15/2024 thru 7/13/2024. 7. Ensure the licensed nurses notified Resident 8's attending physician when Resident 8 had a change of condition (COC) and Risperdal was held due to drowsiness. 8. Ensure Resident 8's medication regimen, including monitoring and assessment of side effects/adverse reactions to psychotropic medications administered to Resident 8, was coordinated with the facility's nursing/medical staff and the Hospice team caring for Resident 8. 9. Ensure Resident 8's Responsible Party 1 (RP 1) was provided an informed consent by the Prescriber of Ativan, when Ativan was increased from 0.5 mg PRN for agitation, to 1 mg every four hours for agitation, and not by the Hospice case manager or the facility nurses. On 7/22/2024 at 6 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM), Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD) due to the facility administering unnecessary anti-psychotic medications to Resident 1, causing her to be over sedated. On 7/24/2024, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 7/24/2024 at 1:31 p.m., in the presence of the facility's ADM and DON. The facility's IJPR included the following immediate actions: 1. The Interdisciplinary ([IDT] a group of professionals from different disciplines who work together to achieve a common goal using their different perspectives and expertise) and the hospice agency reviewed Resident 8's medication regimen and care on 7/23/2024 at 10:00 a.m. 2. The DON and ADON in-serviced all licensed nursing staff on 7/22/2024 and 7/23/2024. Any licensed nursing staff currently on leave will receive an in-service prior to the start of their next shift. The in-services included the following: a. Recognition and documentation of Resident 8's COC. b. Implement interventions that call for non-pharmacological interventions versus the use of psychotropic medications that are not indicated for use with residents with dementia-related behaviors. c. Recognizing, monitoring, documenting, and reporting any COC's associated with adverse effects of medication administration. d. Recognizing when psychotropic medications are not indicated for use. e. Recognizing possible duplicate medication therapy and to follow up with nursing administration and/or the resident's physician for clarification. f. Who is responsible for the consent of psychotropic medications. Corrective Actions: 1. The IDT (consisting of the DON, Social Services Director (SSD), Director of Rehabilitation ([DOR] a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather by drugs or surgery, who plans, administers, and directs operation of the rehabilitation programs), Dietary Supervisor, Hospice Medical Director, Hospice DON, and Resident 8's family member (FM 1), reviewed Resident 8's medication regimen and care on 7/23/2024 and the residents medications were adjusted. The Seroquel was discontinued on 7/19/2024. The Ativan was changed to 1 mg two times daily PRN. Resident 8 will be seen and evaluated by the psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) on 7/24/2024. 2. The DON and ADM consulted with the Hospice physician on 7/23/2024 and 7/24/2024. Per the physician, in his clinical opinion (and as documented in his clinical note in the resident's chart), Risperdal is justified for the resident at the current dosage, and he has declined to discontinue or lower the dosage of Risperdal. Physician has documented his rationale in the resident's chart. Identification of other Residents: The DON, ADON, and RN Supervisor (RNS) reviewed residents with antipsychotic medications on 7/23/2024. Eleven additional residents with antipsychotic medications were reviewed and none of the residents were identified to have antipsychotic medications prescribed for Dementia or Alzheimer's Disease. Actions Taken to Prevent Reoccurrence: RN Clinical Resource in-serviced the DON and the ADM on 7/22/2024 regarding: a. Recognition and documentation of Resident 8's COC. b. Implement interventions that call for non-pharmacological interventions versus the use of psychotropic medications that are not indicated for use with residents with dementia-related behaviors. c. Recognizing, monitoring, documenting, and reporting any COC's associated with adverse effects of medication administration. d. Recognizing when psychotropic medications are not indicated for use. e. Recognizing possible duplicate medication therapy and to follow up with nursing administration and/or the resident's physician for clarification. f. Who is responsible for the consent of psychotropic medications. The DON and ADON conducted in-services with all licensed nursing staff on 7/22/2024 and 7/23/2024. Any licensed nursing staff currently on leave will receive an equivalent in-service prior to the start of their next shift. The in-services included the following: a. Recognition and documentation of Resident 8's COC. b. Implement interventions that call for non-pharmacological interventions versus the use of psychotropic medications that are not indicated for use with residents with dementia-related behaviors. c. Recognizing, monitoring, documenting, and reporting any COC's associated with adverse effects of medication administration. d. Recognizing when psychotropic medications are not indicated for use. e. Recognizing possible duplicate medication therapy and to follow up with nursing administration and/or the resident's physician for clarification. f. Who is responsible for the consent of psychotropic medications. The DON or designee will review residents with new orders for antipsychotic medications daily (Monday through Friday) to verify the orders are indicated for the residents' diagnoses and behaviors. Monitoring to Ensure Ongoing Compliance: a. The Medical Records Director (MRD) or designee will conduct a review of new orders daily (Monday through Friday) to ensure the informed consent has been obtained from a physician, orders are present for behavior monitoring, side effect monitoring, nonpharmacological interventions if appropriate, and the resident has a care plan in place. Any concerns will be relayed to the DON for follow up daily (Monday-Friday). The MRD was in serviced by the DON on 7/24/2024 regarding this process. b. The DON will report the progress of the monitoring to the Quality Assurance and Performance Improvement ([QAPI] a management approach whose goal is to create, implement, and maintain a program that focuses on systems of care, outcomes of care quality of life, and resident and staff satisfaction) Committee monthly for 6 months or until substantial compliance has been achieved. Completion Date: 7/24/2024 Findings: During a review of Resident 8's Admission Record (Face sheet), the Face Sheet indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, vascular dementia with severe agitation, palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), anxiety, mood disorder, and a history of falls. During a review of Resident 8's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/21/2024, the MDS indicated Resident 8's cognitive skills for daily decision making were severely impaired and Resident 8 required a one-person substantial/maximal physical assist to complete her activities of daily living ([ADL]) such as dressing, bathing, hygiene, toileting, bed mobility [turning and repositioning] and transferring from chair/bed to chair. During a review of Resident 8's Physician's Order Summary Report (the Physician's Order Summary Report indicated Resident 8 was prescribed the following medications: 1. On 6/14/2024 - Seroquel 50 mg at bedtime for dementia with psychotic features manifested by visual hallucinations of seeing nonexistent dead people. 2. On 6/20/2024 - Risperdal 1 mg twice a day for a mood disorder, manifested by agitation. 3. On 6/14/2024 - Ativan 0.5 mg every four hours as needed (PRN) for agitation and shortness of breath (SOB) for 14 days. 4. On 7/11/2024 - Ativan 1 mg every four hours for agitation and SOB for 14 days. During a review of Resident 8's untitled Care Plan, dated 6/18/2024, the Care Plan (CP) indicated Resident 8 was on an anti-anxiety medication (Ativan). The Care Plan's goals indicated Resident 8 would be free from adverse reactions related to anti-anxiety medications and would have decreased episodes of anxiety. The Care Plan's intervention indicated to administer the anti-anxiety medication, monitor Resident 8 for side effects including drowsiness, lack of energy, clumsiness, dizziness, confusion/disorientation, monitor and record occurrence of target behaviors of agitation and SOB every shift, and provide Resident 8 with non-pharmacological interventions such as redirection, repositioning, offer snacks, assess pain, provide back rubs, provide a quiet environment to express feelings. During a review of Resident 8's untitled Care Plans dated 6/18/2024, the Care Plans indicated Resident 8 was taking anti-psychotic medications ([Risperidone, Seroquel]. The Care Plan's goals indicated Resident 8 would not have any reactions related to the anti-psychotic medication. The Care Plan's interventions indicated to monitor and document Resident 8's episodes of behavior, identify and document Resident 8's adverse reactions/side effects to the anti-psychotic medications, including drowsiness and provide and document non-pharmacological interventions such as redirection, repositioning, offer snacks, assess pain, provide back rubs and a quiet environment. During a review of Resident 8's Medication Administration Record (MAR) dated 6/2024 and 7/2024, the MAR indicated the following: 1. From 6/14/2024 thru 6/30/2024, 7/1/2024 thru 7/11/2024 and 7/17/2024, Resident 8 was administered Seroquel 50 mg at 9 p.m. The MAR from 6/14/2024 thru 7/17/2024 indicated Resident 8's dementia related psychotic features manifested by hallucinations of seeing non-existent dead people, were documented as zero occurrences, and drowsiness and hypotension documented as N (none) on each shift. (7 a.m. to 3 p.m., 3 p.m. to 11 p.m. and 11 a.m. to 7 a.m. shifts). 2. From 6/21/2024 through 6/30/2024, and from 7/1/2024 through 7/17/2024, Resident 8 was administered Risperidone 1 mg twice a day. The MAR dated from 6/21/2024 through 7/17/2024 indicated Resident 8's agitation related to a mood disorder manifested by agitation was documented as zero episodes and side effects related to the anti-psychotic medication including drowsiness and hypotension were documented as N (none) on each shift. 3. On 6/17/2024 at 4:19 p.m., 6/18/2024 at 8:26 p.m., 6/23/2024 at 2:37 a.m., 6/23/2024 at 9:30 a.m., 7/10/2024 at 5:59 p.m., and 7/11/2024 at 4:06 p.m., Ativan 0.5 mg was administered to Resident 8 every four hours for anxiety manifested by agitation and SOB. The MAR dated from 6/17/2024 through 7/17/2024 indicated zero documented occurrences of Resident 8's episodes of anxiety manifested by agitation and SOB and the side effects related to the anti-anxiety medication, including sedation, drowsiness, ataxia (clumsy movements), dizziness, falls and hypotension were documented as N (none) on each shift. 4. The MAR indicated, per Resident 8's Physician's Order, Resident 8 received Ativan 1 mg every four hours as follows: a. On 7/12/2024 at 12 a.m., 4 a.m., 8 a.m., and 8 p.m. b. On 7/13/2024 at 12 a.m., 4 p.m., and 8 p.m. c. On 7/14/2024 at 12 a.m., 4 a.m., 8 a.m., 12 p.m., 4 p.m., and 8 p.m. d. On 7/15/2024 at 12 a.m., 4 a.m., 8 a.m., 12 p.m., 4 p.m., and 8 p.m. e. On 7/16/2024 at 12 a.m., j4 a.m., 8 a.m., 12 p.m., and 8 p.m. d. On 7/17/2024 at 12 a.m., 4 a.m., and 8 a.m. During a review of Resident 8's Clinical Record, the Clinical Record indicated Resident 8 had four fall incidents from 6/15/2024 through 7/13/2024 during the period that Resident 8 was administered Seroquel, Risperdal, and Ativan as follows: 1. During a review of Resident 8's COC form dated 6/15/2024 and timed at 7:20 a.m., the COC form indicated Resident 8 had an unwitnessed fall and was found on the floor inside her room, face down with her head facing the door. During a review of Resident 8's Nursing Home to Hospital Transfer form dated 6/15/2024 and timed at 7:53 a.m., the Nursing Home to Hospital Transfer form indicated Resident 8 was transferred to a General Acute Care Hospital (GACH) on 6/15/2024 at 7:20 a.m. During a review of Resident 8's COC form dated 6/15/2024 and timed at 3:39 p.m., the COC form indicated Resident 8 was readmitted to the facility with a diagnosis of adult concussion (a mild traumatic brain injury that affects the brain function caused by an impact to the head or body). 2. During a review of Resident 8's COC form dated 6/16/2024 and timed at 8:17 a.m., the COC form indicated Resident 8 had a witnessed fall incident where she lowered herself down on the floor by the doorway of her room, was confused, unable to understand instructions, and unable to walk unassisted. 3. During a review of Resident 8's COC form dated 6/20/2024 and timed at 12:33 a.m., the COC form indicated Resident 8 had an unwitnessed fall, where she was found sitting on a floor mat beside her bed. 4. During a review of Resident 8's COC form dated 7/13/2023 and timed at 1:20 a.m., the COC form indicated Resident 8 had an unwitnessed fall and was found lying on the floor between her and her roommate's bed. The COC form indicated Resident 8 sustained a lump on the right area of the back of her head, complained of pain rated 9 to10 (on an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) to the back of her head and her right and left iliac (upper portion of the hip), and was more confused and sleepier than usual. During a review of Resident 8's Nursing Home to Hospital Transfer Form dated 7/13/2024 at 3:53 a.m., the Nursing Home to Hospital Transfer Form indicated Resident 8 was transferred to a GACH for evaluation and treatment due to a hematoma (an area of blood that collects blood outside of the blood vessels often caused by an injury or trauma) on the right upper area of the back of her head. During a review of Resident 8's COC form dated 7/18/2024 and timed at 6 p.m., the COC form indicated Resident 8 was drowsy with a blood pressure of 80/50 millimeters of mercury ([mmHg] blood pressure unit of measurement. The reference range for adult blood pressure 120/80 mmHg]), a decreased level of consciousness ([LOC] a person's awareness and understanding of what is happening in their surroundings), was sleepy and lethargic (a state of fatigue and low energy). During a telephone interview on 7/18/2024 at 4:30 p.m., RP 1 stated the hospice nurse informed him of Resident 8's increased agitation during the previous week (date unknown) and (RP 1) gave his consent to increase Resident 8's Ativan to 1 mg every four hours PRN for agitation. RP 1 stated he visited Resident 8 on 7/17/2024 at 2 p.m., and Resident 8 would not wake up, was snoring and had bouts of congestion and coughing. RP 1 stated Resident 8 attempted to wake up and say something to him (RP 1), but immediately went back to sleep. RP 1 stated he asked LVN 1 if there had been any changes in Resident 8's condition or medication and LVN 1 told him there were no changes. RP 1 stated he was worried that Resident 8 was overmedicated. During an observation 7/18/2024 at 6:12 p.m., with Certified Nursing Assistant (CNA 5), Resident 8 was observed in bed asleep with her mouth wide open, snoring and breathing slow and deep. Resident 8 was did not respond to repeated verbal and tactile (touching) stimuli (anything that causes a reaction or response) when CNA 5 called her name, asked her to open her eyes held and squeezed both of Resident 8's hands. During an interview on 7/18/2024 at 6:16 p.m., CNA 5 stated Resident 8 had been tired and was sleeping a lot since last week (date unknown) and it was hard for Resident 8 to open her eyes and stay awake in order to eat and drink. CNA 5 stated Resident 8 had never been drowsy like this before and despite being forgetful and/agitated at times, Resident 8 had always been able to follow directions and attend activities. CNA 5 stated RP 1 visited Resident 8 on 7/17/2024 at approximately 2 p.m., and he (RP 1) was concerned about Resident 8's drowsiness. CNA 5 stated RP 1 spoke to the charge nurse (LVN 1) about his concerns. During an interview on 7/18/2024 at 6:02 p.m., LVN 4 stated earlier that day (7/18/2024) during her rounds she observed Resident 8 was lethargic and decided not to give the resident Risperidone because she (LVN 4) was concerned that Resident 8 would not be able to swallow the medicine properly. During an interview on 7/19/2024 at 8:30 am., LVN 1 stated he called the Hospice Nurse (HN 1) to verify Resident 8's consent and the order for Ativan 1 mg, however, he did not document it in Resident 8's chart. LVN 1 stated he did not call Resident 8's physician nor did he create a COC when Resident 8 was observed drowsy and lethargic on 7/17/2024 because he was waiting on the HN 1 to initiate a COC. During a telephone interview on 7/19/2024 at 12:01 p.m., HN 1 stated she visited Resident 8 on 7/17/2024 at 9:30 a.m. and observed that Resident 8 was drowsy and unable to wake up despite shaking her up. HN 1 stated she was not informed that Resident 8 had a COC. HN 1 stated she was the one who informed RP 1 that Resident 8's Ativan dosage and administration time was being changed, and she did not know who was responsible to inform RP 1 to obtain an informed consent for new and/or changes to the psychotropic medications. During an interview on 7/19/2024 at 1:36 p.m., RNS 2 stated the licensed nursing staff should monitor the behavior of Residents who take psychotropic medications and the side effects/adverse reactions related to those medications. RNS 2 stated the Hospice Physician should contact the residents and/or their RP to inform them when psychotropic medications were prescribed and/or there are changes to the prescription. During a telephone interview on 7/19/2024 at 4:56 p.m., Resident 8's Hospice Physician stated he prescribed Ativan 1 mg every four hours to Resident 8 because of increased agitation; however, the facility staff must be diligent and monitor Resident 8's response to the medication and call him for any untoward changes in Resident 8's condition. The Hospice Physician stated Resident 8's agitation should be relieved to make her comfortable but not to the point of lethargy. During a telephone interview on 7/22/2024 at 12:58 p.m., LVN 8 stated she gave Resident 8 Ativan 1 mg as ordered (dates unknown), and stated she (LVN 8) was not sure what to assess Resident 8 for prior to administering the Ativan. During a telephone interview on 7/22/2024 at 2:05 p.m., LVN 7 stated he gave Resident 8 Ativan 1 mg as ordered (dates unknown), and did not assess Resident 8 for any side effects or adverse reactions. LVN 7 stated Resident 8 often tried to get out of bed unassisted and was at risk of falling and that was why she was given Ativan. During a telephone interview on 7/22/2024 at 2:52 p.m., LVN 6 stated Resident 8 was on several psychotropic medications and the hospice nurse would usually obtain the consent for the medications from the resident and/or the RP. LVN 6 stated it was the duty of each licensed nurse to verify the order with the physician and to ensure the medication's dose and or/frequency was not over the limit to prevent complications. During an interview on 7/22/2024 at 3:16 p.m., the Assistant Director of Nursing (ADON) stated Resident 8's Hospice Physician should obtain the consents for psychotropic medication from the residents and/or their RP before prescribing the medication and the licensed nurses should verify the order with the physician to ensure the consent was obtained from the resident and/or their RP before psychotropic medication is administered. During an interview and record review on 7/22/2024 at 4:43 p.m., the DON stated the consent for a psychotropic medication should be obtained by the physician prior to administering the medication. The DON stated monitoring should be conducted and documented to ensure accurate information was collected to determine if a gradual dose reduction ([GDR] tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose can be discontinued) of the Resident 8's psychotropic medications were appropriate and if Resident 8 had any side effects and/or adverse reactions associated with the medications. The DON stated the licensed nurses should inform the physician immediately if there is a COC so there is no delay in evaluation and treatment of the resident. The DON stated the care provided by the facility and the Hospice agency must be collaborative to ensure there is no delay in the delivery of care and services. During a review of the facility's Policy and Procedure (P/P) titled, Psychotropic Medications revised 12/2023, the P/P indicated it is the policy of the facility to: a. Ensure that residents are not given any psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. b. Ensure such medications should not be administered for the purpose of discipline or convenience and will be considered only after nonpharmacological interventions have been attempted and failed. c. Ensure efforts will be made by the licensed nurses to verify informed consents from the resident and their responsible party and must be documented in the resident's clinical record before carrying out the physician's orders. d. Ensure the licensed nurses shall review the classification of the drug, the appropriateness of the diagnosis and its indication, behavior monitored and related adverse side effects prior to verification of the admission and such behavior monitoring and/monitoring of adverse side effects shall be documented in the resident records/or physician orders. e. Ensure upon the change of condition or initiation of a new order for psychoactive medications, the facility will obtain consent prior to initiation of the new medication. During a review of the facility's (P/P) titled, Care and Treatment Psychotropic Drug Use revised 8/2017, the P/P indicated the psychotropic medication was prescribed to treat a specific diagnose condition, as documented in the chart: a. Should not be in excessive dose. b. Monitoring for adverse consequences and effectiveness of medications are in place and documented. c. Informed consent was obtained prior to medication use. During a review of the facility's P/P titled, Significant Change of Condition, Response revised 12/2023, the P/P indicated residents of the facility must receive quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing including during a change of condition. The P/P indicated the licensed nurses must perform and document an assessment of the resident and identify the need for additional interventions, considering implementation of existing orders or nursing interventions or through the resident's provider using the SBAR (Situation Background Assessment Recommendation) to obtain new orders or interventions and the licensed nurse shall use his/her clinical judgement to contact the physician based on the urgency of the situation and the resident's representative will be notified on the change of condition and any changes in the resident's medical or nursing care.

Based on observation, interview and record review, the facility failed to ensure the residents, who were assessed as a high risk for falls, had preventative measures implemented to prevent them from falls and injuries for three out of eight sampled residents (Residents 1, 3, and 4). The facility failed to: 1. Implement interventions including landing mats and bed alarm for Resident 1 as care planned Resident 1 had a history of falls on 10/24/2023 and 11/20/2024 and was assessed as a high fall risk. 2. Ensure Licensed Vocational Nurse (LVN 1) had knowledge of Resident 1's high risk for fall, how to access Resident 1' Care Plans, to implement interventions to safeguard Resident 1 from falls and injuries, and knowledge of facility's protocol for falls. 3. Implement bed in the lowest position for Resident 3, who had a history of seizures (brief episodes of involuntary movement which may include a part of the body or the entire body) as care planned. Resident 3 was assessed as a high fall risk. 4. Implement Resident 4's bed in the lowest position. Resident 4 was assessed as a high fall risk. 5. Ensure the facility has a protocol in place for facility staff to identify high fall risk residents and implement resident specific fall prevention measures for the residents who are identified as a high fall risk. 6. Ensure the licensed nurses (LNs) followed the facility's policy and procedure (P&P) titled, Fall Management System, by implementing individualized care plan interventions for residents who were identified as a high fall risk. 7. Ensure the licensed nurses discussed the residents who were at risk for falls at the daily huddle meetings and upon shift report and were responsible for relaying the information to the care team. 8. Ensure the licensed nurses were implementing resident centered Care Plan with interventions based on the resident's fall risk assessment. These failures resulted in: A. Resident 1 falling from the bed to the floor on 3/4/2024, vomiting (an act of throwing up the contents of the stomach through the mouth) and having an altered level of consciousness (a change in a person's state of awareness [ability to relate to self and the environment] and arousal [alertness]) on 3/5/2024. Resident 1 was transferred to a general acute care hospital (GACH) on 3/5/2024 and subsequently admitted to the Intensive Care Unit ([ICU] an area in the hospital which handles severe, potentially life-threatening cases) with diagnoses including with head trauma (any injury to the scalp, skull, or brain caused by injury), abrasion (a superficial rub or wearing off of the skin) to the right forehead, intracranial (within the skull) hemorrhage (bleeding) with thick subdural hematoma ([SDH] a collection of blood between the covering of the brain and the surface of the brain which develops after an injury to the head) over the right cerebral hemisphere (the part of the brain that controls muscle functions and also controls speech, thought, emotions, reading, writing, and learning) secondary to fall. Resident 1 required immediate endotracheal ([ET] placed within the trachea [windpipe]) intubation (a medical procedure in which a tube is placed into the windpipe through the mouth or nose to assist breathing), emergent right temporal (area of the brain located behind the ears) parietal (area of the brain at the top rear of the head) craniotomy (a medical procedure in which a piece of bone from the skull is removed to access the brain for surgical repair) and subdural hematoma evacuation (a surgical procedure which is done to remove a pooling of blood in the brain) with subdural drainage placement due to a high probability of clinically significant, life-threatening deterioration. While in ICU Resident 1 later required a tracheostomy (a surgically created hole in the windpipe which provides an alternative airway for breathing) due to a total dependence on ventilator (a machine used to help a person breathe when they can no longer breathe on their own) for breathing and gastrostomy tube ([GT] a tube which is inserted through the wall of the abdomen directly into the stomach which is used to give medications, fluid, and liquid food to a patient) for nutrition and medication administration. B. Residents 3's and Resident 4's care plans for fall with interventions to prevent falls and injuries were not being resident-centered and not implemented thus placing these residents at risk for injury resulting from a fall. On 3/19/2024 at 2:13 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) related to the lack of a system in place to indicate what specific fall prevention measures nursing staff must utilize and implement for the residents who are identified as a high fall risk was called in the presence of the Administrator (ADM) and Assistant Director of Nursing (ADON). On 3/20/2024 at 3:53 p.m., the facility submitted an acceptable IJ removal plan ([IJRP] an intervention to immediately correct the deficient practices). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 3/20/2024 at 4:25 p.m., in the presence of the ADM, ADON and Registered Nurse Clinical Resource (RNCR) 1. The IJRP included the following: 1. Resident 1 was transferred to the hospital on 3/12/2024 and has not returned to the facility. 2. Resident 3 was re-evaluated by a licensed nurse on 3/19/2024 and identified to be at high risk for falls. On 3/20/2024, the IDT started reviewing and updating the care plan interventions based on Resident 3's individual risk factors. 3. Resident 4 was re-evaluated by a licensed nurse on 3/19/2024 and identified to be at high risk for falls. On 3/20/2024, the IDT started reviewing and updating care plan interventions based on Resident 4's individual risk factors. 4. On 3/19/2024, the facility IDT implemented a Falling Star Program to communicate high fall risk residents to the facility staff. 5. The Director of Staff Development (DSD), ADON, and RNCR 1 initiated licensed nurses in-services (staff education sessions) regarding the evaluation of residents' fall risk upon admission, readmission, with every fall and as needed. 6. The DSD, ADON, and RNCR 1 initiated all Certified Nursing Assistants (CNAs) in-services regarding the Falling Star Program. 7. The DSD, ADON, and RNCR 1 initiated in-services with all facility staff regarding the updated Fall Management Policy, the Falling Star Program for high risk for fall residents, and the Special Needs List. 8. On 3/19/2024 and 3/20/2024, the ADON, the Minimum Data Set ([MDS] a standardized assessment and care planning tool) Nurse ([MDSN] long-term nurses specializing in assessing the needs of long-term care residents), the Unit Manager (UM), RNCR 1, and the Infection Prevention Nurse (IP) re-evaluated all residents (84 total) for their fall risk and documented this in the Licensed Nurse-Fall Risk Evaluation. These were reviewed by RNCR 1. 32 residents were identified to be at high risk for falls and were added to the Falling Star Program. Their fall risk interventions were added to the Special Needs List for staff reference and this list will be updated daily, Monday through Friday, by the DSD. The Special Needs List will include residents' individual fall interventions and will be available in the nursing stations for reference. 9. On 3/19/2024, the DSD, ADON, RNCR 1 and Therapy Program Manager reviewed and updated the Special Needs List to include all current residents, their fall risk, and fall interventions. This list will be updated daily Monday through Friday by the DSD. The Special Needs List will include residents' individual fall interventions and will be available in the nursing stations for reference. 10. Person centered CPs developed interventions were added to the CPs specific to resident's identified as high fall risk. 11. The Fall Committee (including ADON, Director of Rehabilitation [DOR], DSD, Maintenance Director, Social Services, Activities, and CNA Designee) will review all high-risk residents in the Falling Star Program weekly to ensure their interventions are resident-centered and appropriate. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including epilepsy (a disorder of the brain characterized by repeat seizures, lack of coordination (not able to move different parts of the body together with intention), need for assistance with personal care, unspecified dementia (the impaired ability to remember, think, or make decisions which interfere with doing everyday activities), and hemiplegia (total or partial loss of the ability to move one side of the body) affecting the left nondominant (part of the body which is not used as much) side. During a review of Resident 1's History and Physical (H&P), dated 1/16/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognitive (a person's ability to think, learn, remember, use judgement, and make decisions skills for daily living) skills for daily decision making were severely impaired. The MDS indicated Resident 1 was totally dependent on staff for eating, personal hygiene, toileting, bathing, upper and lower body dressing and rolling left to right in bed. During a review of Resident 1's Fall Risk Evaluation, dated 6/17/2023, the Fall Risk Evaluation indicated Resident 1 was assessed as a high fall risk. During a review of Resident 1's untitled Care Plan, initiated on 6/17/2023, the Care Plan indicated Resident 1 was identified to be at risk for falls related to left sided weakness, unsteady gait (manner of walking) /balance, generalized muscle weakness, and hypertension (high blood pressure). The Care Plan goal indicated Resident 1 would be free of falls through review date of 3/8/2024. The Care Plan interventions for Resident 1 included to have landing mats (high-impact foam pads which are placed adjacent to the bed on the floor to help reduce the impact of falls and help prevent injury from potential falls) at bedside. During a review of Resident 1's Fall Risk Evaluation dated 10/24/2023 and timed at 9:52 p.m., the Fall Risk Evaluation indicated Resident 1 was assessed as a high fall risk after sustaining a fall from the bed to the floor on 10/24/2023. During a review of Resident 1's Fall Risk Evaluation dated 11/20/2023, the Fall Risk Evaluation indicated Resident 1 was assessed as a high fall risk after sustaining a second fall from the bed to the floor on 11/20/2023. During a review of Resident 1's untitled Care Plan dated 11/22/2023, the Care Plan indicated Resident 1 utilizes bed and wheelchair alarm to alert staff and resident when he gets up unassisted. The Care Plan goal indicated Resident 1 will remain free of complications related to alarm use through review date of 3/8/2024. The Care Plan interventions included to apply a sensor pad (a weight sensitive alarm device) as ordered. During a review of Resident 1's quarterly Fall Risk Evaluation dated 12/14/2023, the Fall Risk Evaluation indicated Resident 1 was assessed as a high fall risk. During a review of Resident 1's Readmission Note dated 1/19/2024 and timed at 10:30 p.m., the Readmission Note indicated Resident 1 was readmitted from a GACH where he had been transferred to on 1/17/2024 due to syncope (fainting or passing out) during hemodialysis (a mechanical procedure to remove waste products and excess fluid from the blood when the kidneys [a pair of organs which remove waste and extra water from the blood and keep chemicals balanced in the body] stop working). During a review of Resident 1's readmission Fall Risk Evaluation dated 1/13/2024, the Fall Risk Evaluation indicated Resident 1 was assessed as a high fall risk. During a review of Resident 1's Change of Condition ([COC] a document indicating a deterioration or improvement in a resident's physical or behavioral health which may require a modification in the resident's treatment) dated 3/4/2024 and timed at 8:09 p.m., the COC indicated Resident 1 had an unwitnessed fall from the bed to the floor. The COC indicated Resident 1 sustained redness to the right side of his forehead. The COC indicated to initiate neurological check (identifying and assessing the functions of the vital portions of the central nervous system [transmits signals between the brain and the rest of the body which controls the ability to move, breathe, think, and see] functioning) for 72 hours. During a review of Resident 1's COC dated 3/5/2024 and timed at 2:34 a.m., the COC indicated Resident 1 was vomiting and had ALOC. The COC indicated Resident 1 was awake and alert but unable to maintain eye contact or verbalize his needs. During a review of Resident 1's Incident Report (a documentation tool used by emergency medical responders ([EMRs] provide immediate lifesaving care to critical patients who are not in the hospital) to record patient data when arriving on the scene) dated 3/5/2024, the Incident Report indicated Emergency Medical Services ([EMS] a system which provides emergency medical care) were called to the SNF. The Incident Report indicated Resident 1's level of consciousness (being awake and aware of surroundings) was an 11 based on the Glasgow Coma Scale ([GCS] clinical scale used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients which is scored between 3 and 15, with 3 being the worst and 15 the best). The Incident Report indicated Resident 1 was found with an abrasion to the right temple area. On 3/5/2024 Resident 1 was subsequently transported to a GACH due to ALOC and traumatic injury (physical injuries of sudden onset and severity which require immediate medical attention) During a review of Resident 1's GACH Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the GACH on 3/5/2024 under trauma services (a hospital equipped and staffed to provide care for patients suffering from major traumatic injuries such as falls, motor vehicle collisions, or gunshot wounds). During a review of Resident 1's GACH Trauma/Resuscitation Flowsheet dated 3/5/2024 and timed at 3:31 a.m., the Trauma/Resuscitation Flowsheet indicated Resident 1 had an abrasion and a hematoma to the right forehead. During a review of Resident 1's Physician's Emergency Documentation dated 3/5/2024 and timed at 3:42 a.m., the Physician's Emergency Documentation indicated Resident 1 was brought in by EMS from SNF after an unwitnessed fall with evidence of head trauma and activated as a trauma alert. The Physician's Emergency Documentation indicated Resident 1 normally had a GCS of 13 and presented to the GACH with a GCS of 11. The Physician's Emergency Documentation indicated Resident 1 presented in critical condition, with concern for acute decompensation (failure of an organ) and possible cardiopulmonary arrest (sudden, unexpected loss of heart function, breathing and consciousness). During a review of Resident 1's Computed Tomography ([CT] a procedure which uses a computer linked to an x-ray an imaging study which takes pictures of bones and soft tissue] machine to make a series of detailed pictures of areas inside the body) scan dated 3/5/2024 and timed at 4:04 a.m., the CT scan indicated Resident 1 had a 1.7 centimeter ([cm] a measure unit of length) thick acute subdural hematoma over the right cerebral hemisphere and a 1.1 cm midline shift (when the natural centerline of the brain is pushed to the to the right or left following traumatic brain injury associated with a hematoma) from right to left. During a review of Resident 1's GACH Neurosurgery Operative and Procedural Report dated 3/5/2024 and timed at 8 a.m., the Neurosurgery Operative and Procedural Report indicated Resident 1 underwent a right sided frontotemporal (the areas behind the forehead and behind the ears) craniotomy for evacuation of acute subdural hematoma and resection (surgery to remove tissue or part or all of an organ) of membranes (layer which protect the brain), and externalized drain placement (tube which drains excess fluid or blood from the brain and stops the fluid building up). The Neurosurgery Operative and Procedural Report indicated Resident 1 was then transferred to the ICU post-operatively. During a review of Resident 1's GACH Operative and Procedure Report dated 3/13/2024 and timed at 1:16 p.m., the Operative and Procedure Report indicated Resident 1 underwent a GT insertion due to oropharyngeal (the middle part of the throat behind the mouth) dysphagia (difficulty swallowing) and tracheostomy due to acute respiratory failure (not enough oxygen in the body to sustain life) requiring long term mechanical ventilation. During an interview on 3/14/2024 at 4:37 p.m., Registered Nurse (RN 1) stated on 3/4/2024, the Licensed Vocational Nurse (LVN 1) informed her of Resident 1's fall from the bed to the floor. RN 1 stated when she went to assess Resident 1 after the fall, there were no landing mats noted on the floor. RN 1 stated because of Resident 1's high risk for fall and history of previous falls, there should have been landing mats on the floor. During an interview on 3/14/2024 at 5:34 p.m., LVN 1 stated she was assigned to Resident 1 on 3/4/2024. LVN 1 stated at around 8 p.m., she was informed by Certified Nurse Assistant (CNA) 1of Resident 1's fall from the bed to the floor. LVN 1 stated upon arrival to Resident 1's room, she found Resident 1 on the floor. LVN 1 stated Resident 1 was on the bare floor and there were no landing pads underneath him, nor were there any or bed alarm. LVN 1 stated she was not aware of Resident 1's Care Plan and interventions which included bed alarm, and landing mats. LVN 1 stated it was her second day working on the unit and was not aware on how to access residents' Care Plans. LVN 1 stated she was not aware that Resident 1 was a high risk for falls because the outgoing nurse did not report it to her during shift report, and it was not mentioned during the huddle at the beginning of the shift. LVN 1 stated she was not aware of what interventions should be implemented for residents who are a high fall risk. LVN 1 stated she should have looked at Resident 1's Care Plan prior to assuming care of Resident 1 since she was not familiar with the resident. LVN 1 stated the purpose of a Care Plan is to prevent accidents and incidents from occurring or reoccurring. LVN 1 stated she does not know what the facility's protocol for falls and fall prevention. During an interview on 3/14/2024 at 6:22 p.m., CNA 1 stated on 3/4/2024 at around 8 p.m., she was walking by Resident 1's room and saw Resident 1 laying on the bare floor. CNA 1 stated she did not see any landing mats underneath Resident 1, nor did she hear a bed alarm going off. During an interview on 3/15/2024 at 11:45 a.m., Resident 1's Responsible Party (RP 1) stated on 3/4/2024 at approximately 8:52 p.m., she received a call from the SNF indicating Resident 1 had an unwitnessed fall from the bed to the floor. RP 1 stated in the early morning of 3/5/2024 she received a second call from the SNF indicating Resident 1 vomited and had ALOC which required the resident's transfer to the GACH. RP 1 stated this was Resident 1's third fall since 10/2023. RP 1 stated after Resident 1's second fall in 11/2023 she requested a bed alarm, landing mats, two siderails up, and bed bolsters (air filled raised pads placed at the edge of the bed to prevent residents from rolling out of the bed) implemented in Resident 1's care. RP 1 stated in 2/2024, when (Family Member) FM 2 went to visit Resident 1 in the facility, he noticed there was no landing mats, no bed alarm, nor siderails. RP 1 stated she brought this to the facility's attention, but her requested interventions were never implemented. During an interview on 3/16/2024 at 3:16 p.m., CNA 2 stated on 3/4/2024 she was assigned to Resident 1 but did not witness the fall. CNA 2 stated she was not aware that Resident 1 was a high fall risk or what interventions to implement if a resident is a high fall risk. CNA 2 stated Resident 1 did not have landing mats or a bed alarm when she cared for him on 3/4/2024. During an interview on 3/13/2024 at 2:11 p.m., the ADON stated the facility does not currently have a program in place to prevent falls. The ADON stated the facility does not use special identifiers in the resident's room to identify those residents who are a high risk for falls. The ADON stated the facility has a Special Needs binder located at each nursing station which identifies the residents who are a high fall risk with interventions to prevent the residents from falls. The ADON stated the licensed nurses are responsible for knowing the resident's fall risk assessment and Care Plan interventions while caring for the resident. The ADON stated the licensed nurses should discuss the residents who are at risk for falls at the daily huddle meetings and upon shift report and are responsible for relaying the information to the care team. The ADON stated the licensed nurses are responsible for implementing resident's centered Care Plan with interventions based on the fall risk assessment. During an interview on 3/13/2024 at 3:36 p.m., CNA 4 stated she does not know how to identify residents who are assessed at high risk for falls other than asking the licensed nurses. CNA 4 stated residents who are a high fall risk are not mentioned during the huddle meetings. During an interview on 3/18/2024 at 3:38 p.m., LVN 2 stated the MDSN reviews and updates the care plans as needed. LVN 2 stated she can input information on the CPs if the resident has a change of condition but does not have time to review each resident's individual CP prior to caring for the resident because of all the other tasks she must complete throughout her shift. LVN 2 stated the purpose of a CP is to help the care team provide care for each resident individually and help prevent incidents and accidents from occurring and reoccurring. LVN 2 stated if we do not review the CPs then we (licensed nurses) do not know what interventions need to be implemented for each resident and communicated to the care team. LVN 2 stated she was not aware of the facility's fall protocol. B. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including history of seizures, hemiplegia and hemiparesis affecting right dominant side, lack of coordination, and muscle weakness. During a review of Resident 3's H&P, dated 2/29/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was sometimes understood and sometimes was able to understand others. The MDS indicated Resident 3 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 3 was totally dependent on staff for toileting, showering, lower body dressing, sitting to lying, lying to sitting on the side of the bed, chair/bed to chair transfer, and toilet transfer. The MDS indicated Resident 3 required substantial/maximal assistance from staff for oral hygiene, upper body dressing, personal hygiene, and rolling left to right in bed. The MDS indicated Resident 3 had bilateral (both sides) upper body impairment and lower extremity impairment on one side. During a review of Resident 3's Readmission Note dated 1/25/2024 and timed at 11:59 p.m., the Readmission Note indicated Resident 3 was readmitted to the SNF from a GACH (where he had been transferred to on 1/20/2024 due to seizures.) During a review of Resident 3's readmission Fall Risk Evaluation, dated 1/25/2024, the Fall Risk Evaluation indicated Resident 3 was assessed as a high fall risk. During a review of Resident 3's untitled Care Plan, dated 3/1/2024, the Care Plan indicated Resident 3 had a risk for falls related to generalized muscle weakness, unsteady gait/balance, and seizure disorder. The Care Plan goal indicated Resident 3 would be free from falls through the target date of 4/25/2024. The Care Plan interventions included bed in lowest position. During a concurrent observation and interview on 3/18/2024 at 4:09 p.m., with CNA 5, in Resident 3's room, Resident 3 was observed lying in bed. CNA 5 stated the only way she identifies the residents at high fall risk if the residents' beds are low. CNA 5 stated Resident 3 was not a fall risk because the bed was not at the lowest position. During a review of Nursing Station 1's Special Needs Binder on 3/18/2024, Resident 3 was not found on the Special Needs List as a high risk for falls. C. During a review of Resident 4's Face Sheet, the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis affecting right dominant side, aphasia (inability to communicate with others), functional quadriplegia (complete immobility due to severe physical disability or frailty), vascular (affecting blood vessels) dementia, muscle weakness, and abnormal posture. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 was sometimes understood and was sometimes able to understand others. The MDS indicated Resident 4's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 4 had functional impairment in one upper extremity and had bilateral functional impairment in both lower extremities. The MDS indicated Resident 4 was totally dependent on staff for toileting, bathing, lower body dressing, sit to lying, sit to stand and chair/bed to chair transfers. The MDS indicated Resident 4 required substantial/maximum assistance from staff for rolling left to right in bed, upper body dressing, personal hygiene, and required supervision from staff for eating. The MDS indicated Resident 4 was incontinent of urine and stool. The MDS indicated Resident 4 used a wheelchair for mobility. During a review of Resident 4's untitled Care Plan dated 5/3/2023, the Care Plan indicated Resident 4 was at risk for falls related to functional quadriplegia, dementia, and incontinence. The Care Plan goal indicated Resident 4 would be free from falls though the review date of 3/7/2024. The CPs interventions included bed in lowest position and follow facility fall protocol (no specific person-centered fall interventions were documented on the Care Plan.) During a review of Resident 4's quarterly Fall Risk Evaluations dated 10/6/2023, and 1/18/2024 the Fall Risk Evaluations indicated Resident 4 was assessed as a high fall risk. During a concurrent observation and interview with CNA 5 on 3/18/2024 at 3:09 p.m., in Resident 4's room, Resident 4 was observed lying in bed watching TV. Resident 4's bed was observed to be not in lowest position. CNA 5 stated Resident 4's bed was not in the lowest position. CNA 5 stated Resident 4 did not require landing mats because she was not a high fall risk (CNA 5 was not aware Resident 4 was a high fall risk). During a review of Nursing Station 1's Special Needs List on 3/18/2024, the Special Needs List indicated Resident 4's special needs (fall precaution interventions) included bed at the lowest position for safety and bilateral landing pads on the side of the bed for safety while Resident 4 was in bed. During an interview on 3/19/2024 at 11:06 a.m., LVN 3 stated the only way she knows to check if a resident is a high fall risk is by checking the Special Needs Binder at each nursing station. LVN 3 stated if a resident is not listed on the Special Needs Binder, then they must not be a high risk for falls. LVN 3 stated she does not know what interventions are to be put in place for a resident based on the level of the fall risk (low, medium, high). LVN 3 stated she was not aware of the facility's fall protocol. During an interview on 3/19/2024 at 12:33 p.m., the DSD stated the licensed nurses should verbally communicate with each other about the residents who are a fall risk and what interventions should be implemented, during the change of shift and during the huddle. The DSD stated the licensed nurses can also refer to the Special Needs Binder at each nursing station to help them identify which level of fall risk each resident is and what interventions are required. The DSD stated the facility staff is responsible for updating the Special Needs Binder as needed. During an interview on 3/19/2024 at 1:36 p.m., the ADON stated there is a systemic problem regarding communication between the care team about the residents who are a high risk for falls, what Care Plan interventions are to be implemented based on their needs and implementing their Care Plan interventions for each resident. The ADON stated we educate the staff on how to identify those residents who are a high fall risk and what Care Plan interventions need to be implemented based on their needs, but it is up to the staff to follow through and apply the interventions to the residents. During a review of the facility's LVN Job Description dated 12/17/2021, the LVN Job Description indicated essential duties of the LVN include examining the resident and his/her records and charts, implementing, and maintaining established policies and procedures, and assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident are performed in furtherance of the resident care planning policy. During a review of the facility's ADON Job Description dated 12/17/2021, the ADON Job Description indicated the essential duties of the ADON include assisting in the development of preliminary and comprehensive assessments of the nursing needs of each resident are performed in furtherance of the resident care planning policy. During a review of the facility's P&P titled, Fall Management System, revised 12/2023, the P&P indicated it is the policy of this facility to provide an environment that remains as free from accident hazards as possible. The P&P indicated it is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The P&P indicated residents with high risk factors identified on the Fall Risk Evaluation will have an individualized Care Plan developed that includes measurable objectives and timeframes. The P&P indicated the Care Plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, revised 12/2023, the P&P indicated it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered (to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives) Care Plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure a resident who had a history of severe urinary tract infection ([UTI] an infection [bacteria] involving any part of the urinary system, including the urethra, bladder, ureters, and kidney) with kidney injury and a high risk for reoccurrence of UTI with an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) received care in accordance with the resident ' s plan of care and the physician's orders for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1's urinary catheter was removed after two weeks of admission and bladder retraining started as per the discharge instructions from the general acute care hospital (GACH 1). 2. Ensure Resident 1 received consistent care of cleaning indwelling urinary catheter with soap and water every shift per the physician's order and the plan of care titled, Indwelling Urinary Catheter, to prevent UTI, intervention includes foley catheter care every shift. These deficient practices resulted in Resident 1 experiencing an altered mental status ([AMS] a change in mental function), requiring a transfer to GACH 2 and was diagnosed with sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death) secondary to UTI. Findings: During a review of Resident 1 GACH 1 ' s discharge instructions dated 1/27/2023, the discharge instructions indicated Resident 1 would continue receiving Tamsulosin (a drug used to treat urinary problems caused by an enlarged prostate (gland in the male reproductive system) for two weeks (on 2/10/2023) with the removal of the urinary catheter and voiding trial (to see if the resident can urinate freely) at the skilled nursing facility (SNF). During a review of Resident 1 SNF ' s Nurses Progress Note (NPN) dated 1/27/2023, the NPN indicated the attending physician was notified of Resident 1 ' s admission to the facility, medication orders were confirmed, and admitting orders were carried out. During a review of Resident 1 ' s Admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with the diagnosis including obstructive, reflux uropathy (inability of urine to flow through the bladder) and with an indwelling urinary catheter in place. During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/3/2023, the MDS indicated Resident 1 had an intact cognition (thought process) skill for daily decision-making. According to the MDS, Resident 1 required extensive assistance with activities of daily living (ADLs). MDS indicated Resident 1 had an indwelling urinary catheter. During a review of Resident 1 ' s physician ' s orders dated 1/27/2023 and 1/30/2023, the orders indicated to clean the indwelling urinary catheter with soap and water every shift. During a review of Resident 1 ' s care plan (CP) titled, Indwelling Urinary Catheter dated 1/30/2023, the CP indicated one of the staff ' s interventions included to provide indwelling catheter care every shift (three times a day). During a review of Resident 1 ' s Treatment Administration Record (TAR) for 1/2023, the TAR indicated Resident 1 received urinary catheter care from 1/30/2023-1/31/2023, and documented as follows: 1. On 1/31/2023, Resident 1 received urinary catheter care on the day and evening shift, night shift was blank. During a review of Resident 1 ' s TAR for 2/2023, the TAR indicated Resident 1 received urinary catheter care from 2/1/2023-2/17/2023, and documented as follows: 1. On 2/1/2023, Resident 1 received urinary catheter care on the day and night shift, the evening shift was blank. 2. On 2/2/2023, Resident 1 received urinary catheter care on the day and night shift, the evening shift was blank. 3. On 2/4/2023, Resident 1 received urinary catheter care on the day and night shift, the evening shift was blank. 4. On 2/7/2023, Resident 1 received urinary catheter care on day and evening shift, night shift was blank. 5. On 2/10/2023, Resident 1 received urinary catheter care on day and evening shift, night shift was blank. 6. On 2/11/2023, Resident 1 received urinary catheter care on day shift, evening and night shift was blank. 7. On 2/12/2023, Resident 1 received urinary catheter care day and night shift, evening shift was blank. 8. On 2/13/2023, Resident 1 received urinary catheter care on day and night shift, evening shift was blank. 9. On 2/17/2023, Resident 1 received urinary catheter care on the day shift only. During a review of Resident 1 ' s NPNs and TARs for 1/2023 through 2/2023 there were no documentation the staff were assessing Resident 1 ' s urine characteristics, which included color, consistency, smell, and if sediment (when crystals, bacteria, or blood exit through the urine; hematuria [blood in the urine] a common cause of sediment in the urine) was present which is often indicative of UTI. During a review of Resident 1 ' s NPN dated 2/17/2023, the NPN indicated the GACH 1 ' s registered nurse case manager (RNCM) GACH 1 ' s RNCM) faxed an order on 2/17/2023 to the SNF for the removal of Resident 1 ' s indwelling urinary catheter. During a review of Resident 1 ' s physician ' s orders dated 2/17/2023, the orders indicated to discontinue (to remove) the indwelling urinary catheter today (2/17/2023) and start bladder retraining for 14 days related to status post ([S/P] afterwards) urinary catheter removal which was seven days after GACH 1 had order for the catheter to be removed and bladder training started. During a review of Resident 1 ' s NPN dated 2/18/2023, the NPN indicated paramedics were called to transport Resident 1 to GACH 2 due to Resident 1 ' s change in mental status. During a review of Resident 1 ' s physician order dated 2/18/2023, the order indicated to transfer Resident 1 to GACH 2 for further evaluation and treatment related to altered mental status. During a review of Resident 1 ' s GACH 2 ' s history and physical (H/P) dated 2/18/2023, the H/P indicated Resident 1 ' s chief reason for visit was AMS. According to the H/P, Resident 1 was recently hospitalized at another GACH 3 in 1/2023 for enterococcus (bacteria that live in the intestinal tracts of warm-blooded animals, including humans) UTI and was treated with Levaquin (an antibiotic) as well as having an acute kidney injury ([AKI] a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days). The SNF did not remove the catheter until yesterday (2/27/2023) and the family member (FM 2) visited the Resident 1 and found him confused and slow to respond (AMS) and the paramedics were called and transferred the resident to the hospital. In GACH 2 ' s emergency room (ER), the resident ' s laboratory (lab) tests results were abnormal and urinalysis ([UA] test of the urine checking on appearance, concentration, and contents of the urine) was consistent with UTI. Resident 1 ' s laboratory results dated [DATE] were as follow: a. Complete blood cell count ([CBC] a blood test that measures many different parts and features of the blood, including red blood cells [RBCs], which carry oxygen from the lungs to the rest of the body. White blood cells [WBCs], which fight infections and other diseases) lab report indicated a white blood cell (WBC) value of 17.51 K/ul (unit of measurement, thousands per cubic milliliter) indicating a high value. The normal reference range (NRR) for WBCs was 4.8-10.8 K/ul. b. The UA indicated the urine was cloudy with a large amount of blood and bacteria in the urine. The NRR for a UA, the urine should be clear, negative for blood and many bacteria in the urine. Leukocyte Esterase, urine (a screening test used to detect a substance that suggests there are white blood cells in the urine; may mean you have a urinary tract infection) was positive and blood in the urine was positive and the NRR should be negative. A review of GACH 2 ' s H/P, under the Assessment and Plan, the H/P indicated Resident 1 transferred from the SNF with AMS which met sepsis criteria based on the elevated leukocytosis and lactate with a diagnosis of sepsis secondary to UTI. Resident 1 was admitted to GACH 2 and treated with an intravenous (into the vein) antibiotic (ceftriaxone) to treat the urosepsis. During a telephone interview with Resident 1 ' s family member (FM 1) on 2/23/2023 at 11:54 a.m., FM 1 stated they were informed by GACH 1 that Resident 1 ' s urinary catheter would be removed within 2 weeks of admission at the SNF and the SNF did not follow the orders and Resident 1 became altered and had to be transfer to the hospital (GACH 2) and was diagnosed with severe UTI. During an interview on 2/24/2023 at 12:17 p.m. with the Registered Nurse Supervisor (RNS), the RNS confirmed Resident 1 ' s discharge instructions regarding the urinary catheter was not ordered upon admission to the facility (1/27/2023). The RNS stated the urinary catheter should have been removed on 2/10/2023 but was left in place seven days longer than it should have been thus placing the resident at risk for infection. The RNS confirmed there was missing documentation on Resident 1 ' s TAR specific to urinary catheter care for the months of 1/2023 and 2/2023. The RNS stated due to the missing documentation, the urinary catheter care was not done as it should have been, thus placing the resident at risk for infection. During a telephone interview on 3/1/2023 at 9:20 a.m. with the RNCM from GACH 1, the RNCM stated Resident 1 ' s indwelling urinary catheter was supposed to have been removed within two weeks of admission to the SNF (on 2/10/2023) as a discharge order from GACH 1. The RNCM stated he had to inquire to the facility to find out what happened and why Resident 1 ' s catheter was still in place. The RNCM stated he informed the facility ' s staff the discharge instructions from GACH 1 indicated for the catheter to have been removed. The RNCM sent a faxed order to the facility on [DATE] to remove the catheter that day. During a telephone interview on 3/13/2023 at 10:30 a.m. with the Director of Nursing (DON), the DON stated when the facility receives GACH ' s discharge instructions, the admitting nurse reconciliates (verifies) the instructions with the SNF admitting physician. The DON stated if there was missing documentation on the treatment administration record (TAR) regarding urinary catheter care, the care was not completed. The DON stated if the urinary catheter was not removed and the urinary catheter care was not implemented as ordered, Resident 1 was at risk for urinary tract infection and possible sepsis. The DON stated Resident 1 had an altered mental status associated with having an UTI infection and required a transfer to the GACH. During a review of the facility ' s policy and procedure (P/P) with a revised date of 10/2010 and titled, Urinary Catheter Care, the P/P indicated the date and time the catheter care was given should be recorded in the resident ' s medical record. During a review of the facility ' s P/P with a revised date of 9/2012 and titled, Admission Notes, the P/P indicated the admitting nurse must document the time the physician ' s orders were received and verified.

Based on observation, interview, and record review, the facility's staff failed to maintain and implement its infection control policies and procedures (P/P) and COVID-19 (a highly contagious [moving easily from one person to another] respiratory disease caused by [CONDITION(S)]-CoV-2 [a member of a large family of viruses called coronaviruses; these viruses can infect people and some animals]; spread mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks) Mitigation Management Plan ([MMP] a set of actions to slow the spread of COVID-19) which indicated how to mitigate, manage, and prevent the spread of COVID-19 infection within the facility with the elements specified by the California Department of Public Health (CDPH) , which included proper staff training on infection control for prevention of infection for one of three sampled residents (Resident 2) and 59 of 60 inhouse residents, by failing to ensure: 1. Resident 2, was asymptomatic (without symptoms) had not been exposed to COVID-19 and resided in the green zone (area for residents who are COVID-negative and have no known exposure and/or symptoms of COVID-19), was moved in the yellow zone (area for residents who have been exposed, or with unknown exposure, and exposed residents who have tested negative; temporarily quarantined [no participation in communal dining and group activities] residents closely monitored for COVID 19 infection) due to Resident 2's roommate being too noisy. 2. Green zone staff were not using red zone's bathroom and breakroom to prevent the spread of COVID-19, as per the facility's policy titled, Infection Control Guidelines for all Nursing Procedures, the MMP, and CDC ([Centers for Disease Control and Prevention; protects people from health threats) guidelines]) for COVID-19 mitigation. 3. Proper food storage in the red zone and staff did not congregate in the red zone breakroom. 4. The Infection Preventionist ([IP] a nurse trained to prevent the spread of infectious diseases), was trained and certified to assist in the mitigation of COVID-19 in the facility. These deficient practices resulted in the staff not adhering to its infection control P/P and the MMP risk of transmitting COVID-19 to 59 of the 60 inhouse residents, the staff, and community. During a review of the facility's census, the census indicated the facility had 60 in-house residents and one resident was housed in the red zone (on isolation for COVID-19 positive) and yellow zone consist of 5 residents and the green zone had 54 residents. On 12/23/2021 at 4:16 p.m., an Immediate Jeopardy ([IJ], a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) was declared for Infection Control F880 and the facility's Administrator and Director of Nursing (DON) were notified of the findings. On 12/26/2021 at 6:16 p.m., the IJ was lifted in the presence of the DON, after an on-site verification of the implementation of the written Plan of Action ([POA] interventions to immediately correct the deficient practice) through observation, interview, and record review. The acceptable POA included the following: 1. On 12/23/2021 at 11:45 a.m., the Director of Staff Development (DSD) immediately removed the pot of soup, four containers of food with foil coverings from the refrigerator from red zone break room and discarded them in the trash. The two coat racks with several employee personal belongings such as purses, backpacks, and jackets were also removed from red zone break room. 2. On 12/23/2021 at 11:50 a.m., the housekeeping staff checked, cleaned, and sanitized the red zones break room's area which included the microwave, refrigerator, tables, chairs, and the area for both the red and yellow zone break rooms. 3. CNAs were provided Inservice Red Zone lounge immediately done by the DSD on 12/23/2021 regarding the use and personal items in the red zone for employee break/bathroom. 4. On 12/23/2021, the DON and the Infection Preventionists' nurse immediately in-serviced all staff in the facility including CNAs, licensed nurses - LVNs and RNs, rehabilitation staff, activity staff, dietary staff, housekeeping, laundry staff, social services, receptionist, and medical records staff. The inservice covered proper cohorting (grouping of people, such as health care workers and residents potentially exposed to designated disease) of residents/room changes and red zone employee lounge. Ongoing inservices will be provided for the staff on vacation, sick leave, and days off. The projected completion date will be 1/3/2022. 5. On 12/23/2021, Resident 2 was tested for COVID-19 via rapid response test (a test to identify individuals with an adaptive immune response to [CONDITION(S)]-CoV-2,) with negative result and no signs and symptoms of COVID-19 such as fever or chills, muscle or body aches, cough, headache, shortness of breath or difficulty breathing, new loss of taste and/or smell, fatigue, sore throat, nausea or vomiting or any diarrhea. Social services director explained to Resident 2 regarding the need for a room change and Resident 2 agreed. 6. On 12/23/2021 at 12 p.m., room changes were immediately done from Rooms 32A to 31A, residents who were fully vaccinated, to a green zone. The resident (Resident 2) would continue to be monitored for signs and symptoms of COVID-19, such as fever, chills, muscle or body aches, cough, headache, shortness of breath or difficulty breathing, new loss of taste and/or smell, fatigue, sore throat, nausea or vomiting or any diarrhea every shift as ordered. The licensed nurse will observe and notify the physician of any changes in the resident's condition. 7. On 12/23/2021 at 12:15 p.m., the housekeeping staff cleaned, and sanitized Resident 2's room and the resident was moved backed in the green zone. 8. On 12/23/2021 at 7:15 p.m., room changes were made for rooms [ROOM NUMBER] (fully vaccinated residents per CDC [Centers for Disease Control and Prevention; protects people from health threats] guidelines moved to green zone) to create a red zone room. 9. On 12/24/2021 all [CONDITION(S)] (process of removing excess water, solutes, and toxins from the blood when kidneys can no longer perform these functions naturally as a substitute for the normal function of the kidney) residents who were fully vaccinated were moved in the green zone, per CDC guidelines. Findings: During a concurrent observation and interview, on 12/23/2021 at 10:35 a.m., while in the yellow zone with Licensed Vocational Nurse 1 (LVN 1), Resident 2, a green zone resident, was observed sitting in a wheelchair in room [ROOM NUMBER] a yellow zone room. LVN 1 stated the yellow zone rooms start from room [ROOM NUMBER] to room [ROOM NUMBER]. Resident 2, a green zone resident, was being housed in the middle of the yellow zone. During a review of Resident 2's Admission Record (face sheet), dated 12/13/2021, the face sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's Minimum Data Set (MDS), an assessment and care planning tool, dated 12/18/2021, the MDS indicated Resident 2 had clear speech, the ability to express ideas and wants, and clear comprehension (understanding). According to the MDS, Resident 2 used a wheelchair for mobility, required extensive assistance with bed mobility (how resident moves to and from lying position, turns side to side), dressing, and personal hygiene. During a review of Resident 2's clinical laboratory COVID-19 PCR (the polymerase chain reaction test for COVID-19 [a test that analyzes the upper respiratory specimen), dated 12/15/2021 indicated Resident 2 was negative for COVID-19. During a review of the facility's daily census record, dated 12/22/2021, the census record indicated Resident 2 was house in a green zone room. The daily census record indicated the day (12/22/2021) Resident 2, a green zone resident, was moved into a yellow zone room, there were two unoccupied green zones room available for Resident 2 (rooms [ROOM NUMBERS]) to be placed into instead of a yellow zone room. During a review of Resident 2's licensed progress note (LPN), dated 12/22/2021 and timed at 10:45 p.m., the LPN indicated the social service received a message from the registered nurse supervisor (RN 1) stating the resident (Resident 2) was not able to sleep because his roommate (Resident 3) was very noisy. Resident 2 requested a room change so he could get some rest. According to the LPN, Resident 2 was moved to an empty room without a roommate for the time being. The LPN dated 12/23/2021 and timed at 12:05 p.m., the LPN indicated Resident 2 had a room change the day prior. The LPN indicated the IP and the social service director met with the resident (Resident 2) that morning 12/23/2021 to collect a rapid COVID-19 test so Resident 2 can transfer back to a permanent room in the green zone. During a concurrent observation and interview on 12/23/2021 at 11:30 a.m., in the red zone with LVN 2, a red zone sign was observed on the door indicating it was a red zone breakroom. A certified nursing assistant (CNA 1), a green zone staff, was observed exiting the red zone breakroom and returning to work in the green zone. CNA 1 stated she went to the bathroom in the red zone but was working in the green zone. While interviewing CNA 1, CNA 2, a green zone staff was observed going into the red zone breakroom and hung up his backpack. There were several backpacks, coats, and personal belongings observed hanging on two coat racks on the wall. On further observation of the red zone breakroom, a large pot of soup, several containers of cookies, various desserts, and four foil pans of food were on a table next to the microwave. During an interview on 12/23/2021 at 11:50 a.m., with CNA 2, CNA 2 stated he worked in the green zone. CNA 2 stated he used the red zone breakroom to store his backpack. CNA 2 agreed eating in the red zone breakroom could cause cross contamination (the process by which bacteria or other microorganisms [organism that can be seen only through a microscope] are unintentionally transferred from one substance or object to another, with harmful effect). During an interview on 12/23/2021 at 12:20 p.m., with the infection preventionist (IP), the IP stated she was not certified as an IP but planned to take the certification exam soon. The IP confirmed the staff were inserviced and made aware red and green zone cannot cross over while working, but the green zone staff failed to listen and used the red zone breakroom and bathroom while working in the green zone. The IP stated she did not know how the large pot of soup, cookies, and food got into the red zone breakroom. The IP stated consuming foods in the red zone breakroom may put staff and residents at risk of contracting COVID-19. During an interview on 12/23/2021 at 4:10 p.m. with the director of nursing (DON), the DON was informed of a green zone resident being housed in the yellow zone, two green zone's CNAs observed using the red zone breakroom and food stored in the red zone breakroom. The DON stated, Staff have tried to do the right thing, but things happen. During a telephone interview on 12/28/2021 at 1:45 p.m., with the facility's community Public Health Nurse (PHN 1), PHN 1 stated the facility's staff were inform about zoning and that the red zone's staff breakroom and bathroom should be separated from the yellow and green zones to limit the risk of contracting COVID-19. During a review of the facility's undated COVID-19 Mitigation Management Plan (MMP), the MMP indicated the yellow zone residents are those who have been in close contact with known cases of COVID-19; newly admitted or readmitted residents who have not been fully for individuals who have symptoms of possible COVID-19 pending test results; and for residents with indeterminate tests. According to the facility's MMP, the designated red zone rooms were listed as rooms [ROOM NUMBERS], with Station 2 as the nursing station and a designated red zone break room. The MMP indicated clinical and other staff who have direct resident contact with a COVID-19 positive resident would be assigned only to those residents and there should be no rotation of staff between wings/cohorts during the period they are working each day unless no other alternative was possible. The MMP indicated for the staff to be geographically cohort by assigning dedicated staff to specific units, and utilizing alternate break rooms and entry points for staff assigned to COVID-19 residents. The MMP also indicated the IP has a full-time position and has received the required training to have the ability to train HCPs on infection prevention and control as well as on the prevention Healthcare Associated Infections. During a review of the facility's P/P revised on 8/2021 and titled, Infection Control Guidelines for all Nursing Procedures, the P/P indicated the purpose of the policy is to provide guidelines for general infection control while caring for residents. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including the facility protocols for isolation (standard and transmission-based) precautions; and the facility exposure control plan. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on managing infections in residents, including methods of preventing their spread; how to recognize and report signs and symptoms of infection; and prevention of the transmission of multi-drug resistant organisms.

Based on interview and record review, the facility failed to ensure adequate supervision was provided during care for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls and required a two-person assist with mobility in bed, moving from the bed to other surfaces, personal hygiene, and toilet use, was rendered care by a one-person assist while being cleaned and repositioned in bed resulting in Resident 1 falling from the bed to the floor as she was left unsupervised by any staff while the Certified Nursing Assistant (CNA) left Resident 1's bedside to get supplies from the restroom. This deficient practice resulted in Resident 1 falling from the bed to the floor and sustaining [MEDICATION NAME] head trauma ((BHT) physical injury to the head caused by impact by a [MEDICATION NAME] object or surface) with a back of [MEDICAL CONDITION] (a deep cut) and a right forehead abrasion (open wound acquired by the skin rubbing against a surface). Resident 1 required a transfer to a general acute care hospital (GACH) and received staples (used to close wounds) to the back of head. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 8/4/2020, indicated Resident 1 was totally dependent and required a two-person physical assist for bed mobility, toilet use, and bathing. A review of Resident 1's Fall Risk assessment, dated 5/27/2020 indicated Resident 1 was assessed as a high risk for falls evidenced by 1 to 2 previous falls in the past 3 months, regular incontinence, and taking 3 to 4 medications that may cause dizziness in the past 7 days. A review of Resident 1's undated Special Needs Report indicated Resident 1 was totally dependent and required a two-person assist for bed mobility, transfers, and toilet use. A review of Resident 1's care plan titled, Requires Assistance with Activities of Daily Living ((ADLs) self-care activities performed on a daily basis), dated 5/27/2020 indicated to manually assist Resident 1 as needed with showering, toileting, and locomotion. A review of a Situation, Background, Assessment, Recommendation ((SBAR) internal communication), dated 9/23/2020 and timed at 9:20 p.m. indicated Resident 1 had an unwitnessed fall and sustained a small skin abrasion measuring 0.5 centimeters ((cm) unit of measurement) by 0.1 cm to the right forehead. The SBAR indicated Resident 1 was found lying on the floor bleeding from the back of the head. The SBAR indicated Certified Nursing Assistant 3 (CNA 3) had her back turned, while providing care by herself, heard a thud and turned to observe Resident 1 on the floor bleeding from the back of the head. The SBAR indicated paramedics were called and arrived to the facility at 9:30 p.m. and transported Resident 1 to the GACH. A review of Resident 1's GACH Emergency Department (ED) Patient Discharge Instructions, dated 9/24/2020 indicated Resident 1's reason for the visit was a fall/trauma/major. The ED notes indicated Resident 1 had a computed tomography ((CT) imaging that uses computers to produce 3 dimensional pictures of the inside of the body) scan of the head due to a fall with [MEDICATION NAME] head trauma. The ED record indicated there was no intercranial hemorrhage (bleeding inside the brain). Resident 1's GACH's discharge [DIAGNOSES REDACTED]. A review of Resident 1's Physician's Summary Report, dated 9/24/2020 indicated an order to monitor the staples used to close the back of [MEDICAL CONDITION] for any signs and symptoms of infection and to apply Vitamin A and D ointment (ointment applied to the skin to promote healing) to the right forehead for skin abrasion after, cleanse with normal saline (medical solution used to cleanse wounds), pat dry, and leave open to air daily for 21 days. A review of Resident 1's Nursing Progress Note, dated 9/23/2020 and timed at 9:40 p.m., indicated at 9:20 p.m., CNA 1 heard a thud and turned to observe Resident 1 on the floor bleeding from the back of the head. CNA 1 called for help and Registered Nurse Supervisor (RNS) and Licensed Vocational Nurse 3 (LVN 3) entered Resident 1's room and observed the resident lying on the floor with LVN 4 applying a pressure dressing to the back of Resident 1's head. A review of Resident 1's Nursing Progress Note, dated 9/24/2020 and timed at 2:11 a.m., indicated Resident 1 would be transferred back to the facility from the GACH after receiving two staples to close the back of [MEDICAL CONDITION]. A review of Resident 1's Skin Observation Tool, dated 9/24/2020 and timed at 11:17 a.m., indicated LVN 2 observed Resident 1's back of [MEDICAL CONDITION] with two staples intact with minimal bleeding, no drainage, and no swelling. The Skin observation tool also indicated a right forehead skin abrasion with no bleeding. A review of Resident 1's care plan titled, At risk for infection at laceration site, dated 9/24/2020, indicated Resident 1 had two staples to the back of the head. The staff's interventions indicated to monitor the back of Resident 1's head for signs of infection. During an interview, on 11/6/2020 at 11 a.m., Resident 2 (Resident 1's roommate) stated, I was here when she (Resident 1) fell out of the bed. I don't know how she fell but I can see her because the curtain was open. They are supposed to have two nurses, on that day they had one nurse for her. During an interview, on 11/6/2020 at 12:10 p.m., CNA 2 stated two nurses were needed for repositioning and cleaning for Resident 1. During an interview, on 11/6/2020 at 12:20 p.m., LVN 2 stated Resident 1 needed two nurses to provide repositioning and cleaning. During a telephone interview, on 11/6/2020 at 12:30 p.m., (ARP) stated, In September she (Resident 1) fell from the bed while being cleaned up. RP 1 stated Resident 1 had to be taken to the hospital. They stapled the wound on her head and did a CT scan. The RP stated she was told while Resident 1 was being changed, CNA 3 went into the bathroom to get towels and left Resident 1 unattended and while in the bathroom she heard a thud and Resident 1 was on the floor. During an interview, on 11/6/2020 at 12:50 p.m., the Director of Nursing (DON) stated , CNA 3 stated she was preparing the resident (Resident 1) to be changed. CNA 3 put the resident in the middle of the bed and turned her back to get a towel and heard a thud and saw the resident was on the floor. The DON acknowledged there was no one assisting CNA 3 and a two-person assist was not utilized during Resident 1's care. The DON stated Resident 1 was taken to a GACH. During a telephone interview, on 11/6/2020 at 1:15 p.m., LVN 1 stated Resident 1 was always a two-person assist with mobility in bed, moving from the bed to other surfaces, personal hygiene, and toilet use. LVN 1 stated Resident 1 had staples placed in the back of her head for wound closure. During an interview, on 11/6/2020 at 3 p.m., LVN 4 stated, A CNA was shouting for help and when I got to the resident's (Resident 1) room, the resident was on the floor bleeding. LVN stated there was only one staff repositioning and cleaning Resident 1 and there was supposed to two staff to perform these actions because the Resident 1's arms are contracted (a condition of shortening and hardening of muscles and tendons) and can roll to the right or left when not supported. The resident had to have staples put in the back of her head and also had an abrasion to the right forehead. During an interview, on 11/9/2020 at 9:30 a.m., LVN 3 stated there were always two CNA's required to be present while repositioning and cleaning Resident 1. LVN 3 stated there was a special needs report posted next to the time clock which alerted nurses to any special needs a resident may have such as requiring two staff to assist each other while repositioning and cleaning Resident 1. CNA's and staff are required to review the special needs report before providing care to residents. During an interview, on 11/10/2020 at 10:08 a.m., CNA 3 acknowledged she left Resident 1's bedside to retrieve towels from the restroom and Resident 1 fell from the bed at that time. CNA 3 stated, Resident 1 was in the middle of the bed but her legs could have been more to the right and her legs are heavy. She may have just rolled out of bed. CNA 3 stated Resident 1's upper bedrails were in an up position and the bed was elevated to the waist level. CNA 3 acknowledged it was not safe to have left Resident 1's bedside and not have other staff assist her with repositioning and cleaning Resident 1. CNA 3 stated, I reviewed the residents files, but I didn't review Resident 1's. I should have reviewed the special needs report also. I guess I forgot. I must have skipped it. CNA 3 acknowledged she has never used a two person assist since 5/26/2020 while performing care on Resident 1. A review of the facility's policy and procedure (P/P), revised 12/2007 and titled, Falls and Fall Risk, Managing, indicated staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A review of the facility's P/P, revised 7/4/14 and titled, Accident and Resident Safety Reporting, indicated the facility would provide an environment that is free as possible from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The P/P indicated the facility would implement interventions to reduce hazard(s) and risk(s).

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was at risk for falls and required a two-person assistance with bed mobility, was turned and repositioned in bed by two staff members to prevent falls with injuries. This deficient practice resulted in Resident 1 falling from the bed onto the floor. While lying on the floor on [DATE] at 5:12 a.m., Resident 1 could not breathe and a 911 (medical telephone emergency) was called. Registered Nurse 1 (RN 1) provided cardio-pulmonary resuscitation ((CPR) an emergency procedure including chest compressions with artificial ventilation to restore spontaneous blood circulation). The paramedics arrived the facility at 5:18 a.m. and pronounced Resident 1's death at 5:46 a.m. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care-screening tool, dated [DATE], indicated Resident 1 had no cognitive (thought process) problems, no impaired decision-making, was able to make needs known and able to understand others. The MDS indicated Resident 1 was assessed as requiring a two-person assistance with bed mobility, transferring, totally dependent on locomotion on and off the unit, and extensive assistance with personal hygiene. A review of Resident 1's care plan titled, Spinal Instrumentation, initiated on [DATE], identified a problem with impaired physical mobility related to [DIAGNOSES REDACTED]. Resident 1's re-evaluation date of ,[DATE] goals indicated the resident would not develop further contractures (permanent shortening of a muscle or joint) through the next review date. The staff interventions included a positioning device as ordered, and position and turn according to tolerance. A review of Resident 1's care plan titled Falls, initiated on [DATE], identified a problem with risk for fall and injury related to poor body trunk control due to [DIAGNOSES REDACTED]. The staff interventions were to have the call light close and answer promptly, monitor resident for steadiness and balance, instruct resident not to make any sudden position changes, and assist in all areas of ADL's (activities of daily living) as needed. A review of the skilled charting daily nursing notes dated [DATE] and timed at 1:41 p.m., indicated Resident 1 was alert and conversant, noted with normal vital signs. According to the skilled charting, Resident 1 received a two-person assistance with bed mobility, transferring and was cooperative with care. A review of the skilled charting daily nursing notes dated [DATE] and timed at 3:20 p.m., indicated Resident 1 was alert with no mentation changes noted, and normal vital signs. According to the skilled charting, Resident 1 received a two-person assistance with bed mobility, and transferring. A review of the skilled charting daily nursing notes dated [DATE] and timed at 1:09 p.m., indicated Resident 1 was alert and verbally responsive with no short term or long term memory problems, noted with normal vital signs. According to the skilled charting, Resident 1 was able to assist with ADLs with a two-person assistance. A review of the skilled charting daily nursing notes dated [DATE] and timed at 11:50 p.m., indicated Resident 1 was alert and verbally responsive with no short term or long term memory problems, noted with normal vital signs. According to the skilled charting Resident 1 was able to assist with ADLs with a two-person assistance. A review of the skilled charting weekly nursing notes dated [DATE] and timed at 10:24 p.m., indicated Resident 1 was alert and verbally responsive with no short term or long term memory problems, noted with normal vital signs. According to the skilled charting, Resident 1 was able to assist with ADLs with a two-person assistance. A review of a Situation, Background, Assessment and Recommendation ((SBAR) internal communication form) written by Licensed Vocational Nurse 2 ((LVN 2) who was not present at the facility during the incident) indicated on [DATE] at 5:12 a.m., status [REDACTED]. The licensed nurse checked the resident's carotid pulse (a pressure artery that passes near the surface of the neck), and there was no pulse and no respiration. The SBAR indicated around 5:10 a.m., CNA 1 answered call light, the resident (Resident 1) was lying on her left side and requested to turn on her back. CNA 1 spoke to Resident 1 that she was going to pull the bedsheet from the left side to reposition Resident 1. Resident 1 moved independently to the right side to hold the bedside rail. Suddenly, Resident 1 rolled over, and fell to the floor on the right side of the bed. CNA 1 immediately called for help and went to the resident's side. Resident 1 stated she could not breathe. CNA 1 stayed with Resident 1 until Registered Nurse Supervisor (RN 1) and other staff came for assistance. At 5:13 a.m., 911 (emergency dispatch) was called, RN 1 immediately started cardio-pulmonary resuscitation ((CPR) an emergency procedure including chest compressions with artificial ventilation to restore spontaneous blood circulation), assisted by charge nurses using ambu bag (hand held mask used for manual ventilation) for assisted breathing with no palpable carotid pulse with irregular breathing noted. Paramedics arrived the facility at 5:18 a.m. and took over the CPR. CPR was unsuccessful and the paramedics pronounced Resident 1's death at 5:46 a.m. A review of Resident 1's Fall Risk Assessment, dated [DATE] and timed at 5:12 a.m., written by LVN 2 (who was not present at the facility at this time), indicated Resident 1 had a score of 12 (total score above 10 represents high risk for fall). According to the Fall Risk Assessment, Resident 1's level of consciousness was alert and oriented. A review of Resident 1's physical restraint initial evaluation, dated at [DATE] and timed at 5:12 a.m., indicated Resident 1 was at risk for falls with a fall screening score of 12. According to the physical restraint initial evaluation, Resident 1 was noncompliant with safety, refused fall reduction devices, and wanted the bed in a high position. The physical restraint initial evaluation indicated Resident 1 had both upper side rails up as an enabler. A review of Resident 1's physician order, dated [DATE] at 5:12 a.m., indicated to transfer Resident 1's body to a mortuary service. A review of an employee discipline form, signed by the Director of Nursing (DON), Director of Staff development (DSD) and the facility's Administrator (ADM), indicated a notice of suspension for Certified Nursing Assistant 1 (CNA 1) due to incident of Resident 1. According to the employee discipline form, CNA 1 was suspended from [DATE] to [DATE]. A review of CNA 1's signed declaration indicated on [DATE], CNA 1 pulled Resident 1's bed sheet to reposition the resident. CNA 1 wrote Resident 1 held the bed rail to help with the repositioning, the resident suddenly rolled over and fell to the floor to the right side of the bed. CNA 1 wrote staff were called immediately for help and Resident 1 stated she could not breathe and CNA 1 stayed with Resident 1 until other staff arrived. A review of an in-service class attendance record, dated [DATE] and timed at 9 a.m., indicated the DSD trained CNA 1 regarding the facility's Falls and Repositioning policies. On [DATE] at 2:43 p.m., during an interview, LVN 1 stated she was told by a staff member (CNA 2) about Resident 1 needing help with CNA 1. LVN 1 stated she entered Resident 1's room and saw CNA 1 kneeling on the floor to the right side of the bed with holding Resident 1's head on her lap. LVN 1 stated Registered Nurse 1 (RN 1) entered Resident 1's room and started CPR right away with assistance from other facility staff. LVN 1 stated Resident 1 was paralyzed, and required a two-person assistance to be turned or repositioned. LVN 1 stated LVN 2 was not present during the incident, and LVN 2 came into work for the morning shift after 7 a.m. LVN 1 stated the paramedics came and continued CPR but Resident 1 died . On [DATE] at 4:25 p.m., during an interview, the DON stated CNA 1 was suspended from work duties for three days due to failure to ask for assistance during the repositioning of Resident 1. The DON stated Resident 1 was a two-person assist and CNA 1 was repositioning the resident by herself. The DON stated CNA 1 was aware of Resident 1's need for a two-person assistance during repositioning. On [DATE] at 2:40 p.m., CNA 2 stated he was in another resident's room, and heard CNA 1's call for help, and he went into Resident 1's room and saw Resident 1 on the floor on her back. CNA 2 stated he went to the other nursing station to find RN 1, and they went together back to Resident 1's room. According to CNA 2, Resident 1 did not look good, and had no color. CNA 2 stated RN 1, LVN 1 and other staff members were participating in Cardiopulmonary Resuscitation ((CPR) lifesaving technique useful in many emergencies, in which someone's breathing or heartbeat has stopped) efforts to revive Resident 1 until the paramedics arrived. CNA 2 stated Resident 1's room did not have floor pads next to her bed when she fell . On [DATE] at 9:17 a.m., during an interview, RN 1 stated CNA 2 summoned her from another resident's room. RN 1 stated when she arrived to Resident 1's room, other facility staff members were trying to arouse her and the resident did not respond. RN 1 stated she initiated CPR on Resident 1 while calling 911 on her personal cell phone. RN 1 stated other staff members were assisting her with CPR on the resident until paramedics arrived to the facility. RN 1 stated the paramedics took over CPR efforts for Resident 1 and they were unable to revive the resident despite their efforts. RN 1 stated she contacted Resident 1's physician, and responsible party and informed them of the situation. RN 1 stated after Resident 1 died , the coroner was contacted. RN 1 acknowledged Resident 1 being paraplegic and required two-person assist. According to RN 1, Resident 1 had use of her upper body, but was unable to move her lower body due to the [MEDICAL CONDITION]. On [DATE] at 10:33 a.m., during an interview CNA 1 stated she entered Resident 1's room, because Resident 1 pressed the call light for help. According to CNA 1, Resident 1 requested help to be repositioned on her back. CNA 1 stated she removed Resident 1's pillow from underneath her head, while on the left side of Resident 1's bed. According to CNA 1, she was in the midst of walking around Resident 1's bed, when the resident suddenly fell over to the right side of the bed onto the floor. CNA 1 stated she was unable to prevent Resident 1's fall from the right side of the bed, because the resident was out of reach. CNA 1 stated she was alone with Resident 1 and yelled out for help, and CNA 2 responded because he was only next door. CNA 1 stated LVN 1 came to Resident 1's room, and RN 1 along with other staff. CNA 1 stated CPR was initiated by other staff on Resident 1, until the paramedics arrived. On [DATE] at 10:02 a.m., during a telephone interview, the DON stated a fall risk assessment was not completed for Resident 1 prior to [DATE]. The DON acknowledged Resident 1's [MEDICAL CONDITION], but stated an assessment was not completed for the resident because this was the first time Resident 1 had fallen since her admission to the facility. A review of the facility's policy titled, Repositioning, dated ,[DATE], indicated review the resident's care plans to evaluate for any special needs of the resident. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. According to the policy, check the care plan, assignment sheet, or the communication system to determine the resident's specific positioning needs including special equipment, resident level of participation and the number of staff required to complete the procedure. A review of the facility's policy titled, Fall Risk Assessment, dated ,[DATE], indicated the nursing staff, attending physician and consultant pharmacist would review medications that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or [MEDICAL CONDITION]. The staff with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance continence, and cognition.

Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) used a physical assistance of another staff to safely handle Resident 72's reposition in bed during provision of care, to prevent the resident from injury for one of three sampled residents with injuries. This deficient practice resulted in Resident 72 sustaining a right eyebrow laceration (a cut or tear of the skin) with bleeding requiring application of wound closure strips (special kind of adhesive tape that holds the wound close), bruising, and pain on and around the eyebrow. Findings: On 6/30/19 at 8:20 a.m., Resident 72 was observed in bed with dried brown/red colored tape strips on the right eyebrow. There was dark bluish skin discoloration to the right eyebrow and skin surrounding the right eye. Resident 72 was unable to respond to questions. A review of Resident 72's Admission Record (Face Sheet), indicated the facility readmitted Resident 72 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 72's Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 6/1/19, indicated Resident 72, had severe impairment in cognitive skills (ability to learn, remember, understand and make decisions) for daily decision-making and required extensive assistance with two or more-persons physical assistance for bed mobility (how the resident moves to and from lying position, turns side to side while in bed) and transfers between surfaces, and had functional impairment in both upper and lower extremities. A review of Resident 72's care plan developed on 3/6/19, for risk of fractures (break of bones) due to the [DIAGNOSES REDACTED]. According to the Interdisciplinary Team (IDT- a group of healthcare providers from different fields working together or toward the same care goal for the residents) Review and Recommendations, dated 4/3/19, Resident 72 had a history of [REDACTED]. A review of the Licensed Nurses' Notes dated 6/29/19, timed at 7:54 a.m., indicated while CNA 1 was providing care to Resident 72, the resident grabbed the side rail and pulled herself onto the side rail resulting on a right eyebrow skin tear. Resident 72's physician was notified and ordered to apply gauze to the right eyebrow with pressure to stop bleeding and, after the bleeding stops, apply wound closure strips (and change them every three days and as needed. The physician also ordered to apply padding to Resident 72's side rails for safety. A review of the facility's Investigation Report, dated 6/29/19 at 7:54 a.m., indicated Resident 72 sustained a skin tear to the right eyebrow measuring 0.8 centimeters (cm-unit of measurement) by 1.0 cm with some [DIAGNOSES REDACTED] (redness) around the tear with minimal bleeding. Resident 72 complained of pain rated three of ten on a zero to ten pain rating scale (zero indicating no pain and 10 the worse pain possible) and was medicated with Tylenol. The nurses applied pressure to stop the bleeding and tape strips to Resident 72's right eyebrow skin tear. On 6/30/19 at 8:40 a.m., during an interview, CNA 1 stated I was removing the resident's diaper on 6/29/19, morning to get her ready for a shower and I did not want anyone to occupy the shower room before me. I turned the resident onto her left side, away from me towards the side rail, too quickly and forcefully that Resident 72 hit her face at the side rail. I felt bad about it all day long. CNA 1 stated she should have been patient with the resident. CNA 1 stated Resident 72 normally was able to hold onto the side rail and assist with repositioning. CNA 1 stated the facility had a special binder named Special Needs, where the licensed nurses documented how many staff members were required to provide activities of daily living (ADL- bed mobility, surface transfer, grooming, eating, hygiene and toileting) to the resident. CNA 1 stated, I did not check Special Needs List and did not ask my charge nurse how many staff members Resident 72 required for mobility in bed. On 6/30/19, at 1:19 p.m., during an interview with CNA 1 and a concurrent review of the Special Needs List, indicated Resident 72 required extensive assistance with two staff physical assist with bed mobility, transfers, and toilet use. On 6/30/19 at 11:58 a.m., during an interview, LVN 2 stated CNA 1 reported that Resident 72 hit her head at the side rail. LVN 2 stated she medicated Resident 72 with Tylenol (pain medication). A review of the facility's policy titled Safety and Supervision of Residents, dated 3/2/15, indicated: 1. It is the facility to provide an environment as free from accident hazards as possible. To provide resident with safety, supervision and assistance to prevent accidents are facility-wide priorities. 2. Employees shall be trained on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents.

Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1) received adequate supervision during shower time. The resident who was severely cognitively impaired (has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and dependent on staff to bathe, fell from the shower chair when staff stepped away to throw the adult brief into the trash can. This deficient practice caused Resident 1 to fall from a wheelchair, sustain a (3 x 3 inch) laceration (a deep cut or tear in skin or flesh) to the forehead, (1 x 1 ) left knee abrasion, transported to the General Acute Care Hospital (GACH) and received 14 stitches. Findings: On (MONTH) 23, (YEAR), a facility reported incident was received in the Department indicating Resident 1 fell out of a shower chair and sustained a 3 inches by 3 inches [MEDICAL CONDITION] (a deep cut or tear in skin or flesh) during a shower. A review of the Record of Admission indicated Resident was admitted to the facility on [DATE], [DIAGNOSES REDACTED]. A review of the Minimum Data Set (a standardized assessment and care-planning tool) dated 9/6/2018, indicated Resident 1 rarely/never made herself understood or had the ability to understand others. The resident was severely impaired (never/rarely made decision) in cognitive skills for daily decision making, had moderately impaired vision with no behavioral symptoms. The resident required extensive assist from staff for bed mobility and total dependence with bathing, transfer, personal hygiene, dressing and toilet use. Each activity of daily living required one-person physical assist except bed mobility and transfers, which required two or more persons physical assistance. The functional limitation in range of motion (full movement potential of a joint, usually its range) that interfered with daily functions or placed the resident at risk of injury included, impairment on one side of the lower extremity and impairment on both sides of the upper extremity. Active [DIAGNOSES REDACTED]. A review of the Resident 1's Fall Risk Evaluation dated 9/7/18 indicated the resident was assessed as high risk for potential falls. A review of the Interdisciplinary Team Care Conference Record Person Centered Care Plan Summary dated 9/13/2018, indicated the resident was at risk for fall and injury but no limited to: [MEDICAL CONDITION], anxiety disorder and muscle weakness. A review of the Resident 1's Care Plan for At Risk for Fall Occurrence, revised 10/22/2018, indicated the resident was at risk for fall occurrence with contributing /casual risk factors included dementia affecting safety awareness and judgement, gait imbalance and mood/behavioral disorders. The approach plan indicated to anticipate and meet the resident needs and not leave resident unattended. A review of Resident 1's Physician order [REDACTED]. According to the Interdisciplinary Team Review and Recommendations note dated 10/22/2018, indicated the resident was assessed with [REDACTED]. On 11/02/2018, at 4:15 p.m., Resident 1 was observed lying in a low bed with mats on each side of the bed. The resident mumbled the same sound several times and was unable to complete an interview due to severe cognitive impairment. The resident was unable to follow simple commands. A large dressing after the fall was observed in the middle of the residents' forehead. On 11/02/2018, at 4:30 p.m., during interview Staff 1 stated Resident 1 was being assisted on 10/22/18 by one staff (staff 2) who was getting the resident ready for a shower, Resident became agitated and fell . The resident had no history of behaviors or falls. Staff 2 was off duty and unavailable for interview. On 11/13/2018, at 2:30 p.m., during an interview, Staff 2 stated after taking Resident 1 to the shower room via shower chair on 10/22/18, she removed the resident's diaper by pulling it from the bottom. Staff 2 stated she went a few steps away from the resident to throw the diaper in the trash. When Staff 2 turned around, she saw the resident falling from the shower chair. The resident hit her head after her knees hit the floor. Staff 2 further stated the Resident 1 follows simple commands with no behaviors and does not try to get out of the chair. Staff 2 stated she do not know what happen this time. A review of the investigation report indicated a written statement from Staff 2 dated 10/22/2018, indicated after staff 2 removed the diaper Resident 1 became agitated and restless. The resident started moving in the shower chair, when Staff 2 attempted to throw the diaper away, the resident pushed herself out of the chair and fell to the floor. A review of the policy and procedure (P & P) titled Shower/Tub Bath revised (MONTH) of 2010 indicated the following: a. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. b. Should the resident become ill, faint, or uncooperative during the procedure, turn off the shower and summon the supervisor by using the emergency call system.

Based on interview and record review, the facility failed to provide adequate supervision to prevent falls for one of six sampled residents (Resident 1). Resident 1 who was assessed at a high risks for falls due to a history of multiple falls in the facility, was not properly supervised. These deficient practices, resulted in Resident 1 having multiple falls in the facility on the following dates [DATE], a second fall on [DATE], a third fall on [DATE], a fourth fall on [DATE], a fifth fall on [DATE], a sixth fall on [DATE], a seventh fall on [DATE], an eighth fall on [DATE], and a ninth fall [DATE] and was transferred to the general acute care center (GACH). Resident 1 was admitted to the GACH with a displaced comminuted (the broken bone has shattered into several smaller pieces) interochanteric fracture (broken bone) of the femur (upper part of the thigh) resulting in Resident 1's death four days later. On [DATE] at 5:58 p.m., an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared under F600, F609, and F689. The facility's administrator (ADM) and the Director of Nursing (DON) was notified of the immediacy and seriousness of the residents' health and safety being threatened. The facility submitted a Plan of Action (POA) for the correction of the IJ on [DATE] which included the following: Nursing consultant immediately in serviced all staff available on [DATE] and after the team continued thru observation, interview, and record review regarding fall clinical protocol, fall risk management, assessing falls and their causes, abuse and neglect clinical protocol, abuse policy, and unusual occurrence reporting the IJ was lifted on [DATE] at 2:35 p.m. DON/ Designee will review daily fall incidents. The following areas are being reviewed, revised, and updated. 1) Physical restraint, 2) Fall risk evaluation, 3) Pain assessment, 4) Care plan. Any resident identified with fall incidents will resulting to injury will be reported to the Department of Public Health within the time frame according to the regulation. The facility policy was revised on [DATE] regarding reporting of unusual occurrence according to the regulation. Upon admission, the registered nursing (RN) supervisor will complete fall risk assessment and initiate standard fall prevention protocol. If a fall occurs, follow the procedure for post fall incident. 1) Nursing will complete reassessment using the facility's fall risk assessment and the falling star worksheet immediately after the incident. 2) Meet with the interdisciplinary team (IDT) department heads/representative after the assessment has been completed. 3) If the residents' fall risk assessment score is three points higher from initial assessment, the resident is deemed appropriate for the falling star program. Nursing staff responsibilities are 1) Complete facility fall risk assessment and initiate standard fall prevention protocol for all residents. 2) If a fall occurs nursing will reassess the resident using fall risk assessment and complete falling star worksheet. 3) Once resident is deemed appropriate for the falling star program, nursing will generate falling star monitoring log. 4) Document daily rounds (Every two hours) in the falling star monitoring log assigned certified nursing assistant/charge nurse to provide oversight (monitoring and accountability). 5) Document in the participants care plan. Activity department to 1) Identify program participant by placing yellow star by the door name. 2) Place yellow star to the participants' medical chart. 3) Place yellow armband. 4) Place laminate yellow star at the back of the wheelchair. Rehabilitation staff to create falling star intervention measures that will be placed at the residents' bedside. 1) Place bed alarm, 2) Bed position to the lowest level, 3) Patient rounding (pain, positioning, ease of access, toileting, document other falling star monitoring log), 4) Pressure pad alarm in the wheelchair, 5) Hand off- communication between staff. DON/ ADM/ Director of staff development (DSD) conducted in service on [DATE] to all available staff including license nurses, Certified nursing assistants, housekeeping, laundry, and rehabilitation department to review revised policy regarding reporting of unusual occurrences according to the regulation for compliance and revision updating of 1) Physical restraint, 2) Fall risk evaluation, 3) Pain assessment, 4) Fall intervention, and 5) Care plan of resident with fall. Will conduct in-service for all shifts to be in compliance with revised policy. All staff meeting will be conducted on [DATE] by DON/DSD/ADM regarding revised reporting of unusual occurrence. Residents will be monitored by reevaluating participants during the monthly safety meeting whenever appropriate. If the participant does not have any fall incidents within 30 days from the time of the program initiation, resident will be discharged from the program and will continue to initiate the standard fall prevention measures (If the resident has a history of multiple fall, resident will remain until 90 days on the program). DON/ADM will monitor compliance by reviewing daily fall incident. Any fall incident resulting in an injury will be report to the Department of Public Health according to the revised policy and procedure. DON/ADM will review revised protocol regarding reporting of fall incident during monthly QAPI meeting for additional input. DON/DSD will ensure staffing is adequate for resident care on all shifts, and continue with IDT meetings and/or monthly safety meetings to discuss residents post fall measures, identify revisions if necessary. Ongoing reassessment of intervention plans / or policy change if necessary. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated [DATE], indicated the resident had a Brief Interview for Mental Status ((BIMS) test for mental capacity) score of 9 (,[DATE]= moderately impaired (thought process) skills). The MDS indicated Resident 1 required extensive assistance due to impairment to bilateral (both sides) upper extremities and was dependent in care of a one- person physical assist for toilet. The MDS indicated Resident 1 used a walker and wheelchair for mobility. According to the MDS, Resident 1 had falls since admission. A review of the Fall Risk Assessment, dated [DATE] indicated Resident 1 scored 22 (total score above 10 represents high risk for fall). According to the Fall Risk Assessment, the history of falls was within the last three (3) months indicated Resident 1 sustained three or more falls. A review of a care plan titled, At risk for fall occurrence, last revised on ,[DATE], related to [MEDICAL CONDITION], dementia, use of multiple medications. The staff's interventions included they would anticipate and meet Resident 1's needs, provide assistance as needed, prompt response to the call lights and monitoring Resident 1's whereabouts, not leaving her/him unattended, and use of pressure pad alarm in wheelchair. A review of a Situation, Background, Assessment and Recommendation ((SBAR) internal communication form) indicated on [DATE] at 7:24 p.m., status [REDACTED]. A review of a SBAR form indicated on [DATE] at 2:09 p.m., status [REDACTED]. A review of the facility's incident report, dated [DATE], indicated Resident 1 was observed by unidentified nursing staff lying on the left side on floor next to the bed, Resident 1 sustained an abrasion (scrape) to the left knee. A SBAR dated [DATE] and timed at 10:46 p.m., indicated Resident 1 was observed sitting on floor next to her bed, complaining of pain to her tailbone (small, triangular bone at the base of the spine). A review of the facility's incident report, dated [DATE], indicated Resident 1 was observed lying on floor next to bed, the Resident 1 had pain to the tailbone. A review of the facility's incident report, dated [DATE], indicated Resident 1 was being toileted by an unknown CNA and fell to her knees. A review of a SBAR, dated [DATE] and timed at 3:25 p.m., status [REDACTED]. A review of the facility's incident report, dated [DATE], indicated Resident 1 was found down on floor on her buttocks by a staff member. A review of a SBAR indicated on [DATE] at 10:16 a.m., status [REDACTED]. Resident 1 sustained two abrasions to left lower backside. A review of the facility's incident report, dated [DATE], indicated Resident 1 was found by an unidentified nurse in a seated position on floor, Resident 1 sustained multiple abrasions to left lower back. A review of Resident 1's Medication Regime Review (MRR) for a fall, dated [DATE], indicated [MEDICATION NAME] (medication used to treat nerve and muscle pain) increased risk for falls due to dizziness and sedation. Monitor patient closely. A review of a SBAR indicated on [DATE] at 9:57 a.m., status [REDACTED]. A review of the facility's report, dated [DATE], indicated Resident 1 was in the bathroom with an unidentified CNA and assisted to the floor sitting on her bottom. A review of a SBAR indicated on [DATE] at 8:45 p.m., status [REDACTED]. The SBAR indicated no head injury for Resident 1 observed by CNA 1. A review of the facility's investigative report, dated [DATE], indicated Resident 1 had a witnessed fall to the ground from a standing position. CNA 1 attempted to prevent the fall but was unsuccessful. Resident 1 was lying on her left side partially in the room and partially in the bathroom. A review of a GACH Emergency department (ED) report, dated [DATE] and timed at 9:38 p.m., indicated Resident 1 was brought in from the skilled nursing facility (SNF) status [REDACTED]. Resident 1's physical exam indicated a left lower extremity was externally rotated and mildly shortened. The GACH's radiology results, dated [DATE] and timed at 10:12 p.m., indicated Resident 1's left femur (thigh bone) was moderately displaced and had an extra-articular intertrochanteric (point where the hip and thigh attach) fracture. The fracture showed a lateral angulation (type of fracture where the bone points off in a different direction). A review of the Critical Care medicine consultation note, dated [DATE] and timed at 8:19 p.m., indicated Resident 1 had a fall at the SNF with left trochanteric fracture and came to the GACH for surgical fixation. During a pre-surgical with spinal anesthesia, Resident 1 went into [MEDICAL CONDITION] (condition in which the heart suddenly and unexpectedly stops beating, blood stops flowing to the brain and other vital organs) three (3) times requiring intubation (placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway) on ventilator (a machine designed to move breathable air into and out of the lungs). A review of the GACH significant event note, dated [DATE], indicated Resident 1 was extubated (removal of the breathing tube), and pronounced deceased at 9:30p.m. On [DATE] at 5:03 p.m., during an interview, CNA 1 stated, I heard the bed alarm in Resident 1's room and I went to help the resident go to the restroom. I assisted her to the toilet and as I was turning off the wheelchair alarm, Resident 1 fell through the doorway. It happened so fast, I was only able to hold her, so that she did not hit her head. The Assistant Director of nursing (ADON) and the RN Supervisor (RN 1) came in to help. We took her vital signs and then the physical therapist (unidentified) came in and looked at her. The fire department transported her to the hospital (GACH). She was awake, but was complaining of left hip pain. On [DATE] at 5:44 p.m., during an interview the ADON stated, I heard staff yell for help, so I went to the room and the resident (Resident 1) was on the floor in the bathroom with the CNA (CNA 1). The resident (Resident 1) was complaining of hip and leg pain. I held her legs to stabilize and to help keep her from moving and being in pain until the paramedics arrived to transport her to the hospital. The Director of Nursing (DON) was notified of the fall. We notified the Administrator (ADM), DON and Physical therapy by a group text. A review of the facility's policy titled, Fall risk Assessment, dated ,[DATE], indicated the nursing staff, attending physician and consultant pharmacist will review for medications that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or [MEDICAL CONDITION]. The staff with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance continence, and cognition. The staff will seek environmental factors that may contribute to falling, such as lighting and room layout. A review of the facility's policy titled, Falls and fall risk managing, dated ,[DATE], indicated if falling recurs, despite initial interventions, the staff will implement additional or different interventions, or indicate why the current approach remains relevant.