Every finding on record at Broadway Villa Post Acute

Based on observation, interview and record review, the facility failed to maintain an effective pest control program for a census of 143 residents when two flies were observed in the facility.This failure decreased the facility's potential to prevent the spread of disease or infection.Findings:A review of Resident 1's admission record indicated admission to the facility in March, 2021 with the diagnosis of acute posthemorrhagic anemia, hemiplegia, unspecified affecting the right nondominant side and peripheral vascular disease. A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 7/22/26, indicated he had no memory impairment.A record review indicated Resident 1 was admitted to the emergency room on 7/16/26.A record review of the emergency room documents dated 7/16/26 indicated he presented to that facility with, Excoriation marks ulcers between his toes bilaterally. Also noted that there appears to be maggots in one of his sores in his toe.During an observation on 7/31/26 at 12:25 p.m., a fly was observed flying around the facility's doctor's lounge. A concurrent observation and interview on 7/31/26 at 12:28 p.m. with the Director of Nursing (DON), the DON confirmed the presence of a fly, and that maggots come from fly eggs. A concurrent observation and interview on 7/31/26 at 12:36 p.m. with a Maintenance Director (MD), the MD confirmed the presence of a fly and killed it with a fly swatter. A concurrent observation and interview on 7/31/26 at 2:24 p.m. with Certified Nursing Assistant 1 (CNA1), a fly was observed flying in the hallway in front of room [ROOM NUMBER]. CNA 1 confirmed the presence of the fly. An observation on 7/31/26 at 12:56 p.m. of Resident 1's room indicated his bed was next to the window, and a strip of fly trap tape was hanging in the window. A review of the maintenance logs indicated on 7/17/26, a window screen was repaired in Resident 1's room. A review of the facility's policy and procedure titled, Pest Control, revised 3/2023, indicated, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

Based on interview and record review, the Interdisciplinary Team (IDT, a group of healthcare professionals from different specialties who work together to create and implement a unified, patient-centered care plan) failed to initiate a care plan for one resident (Resident 1) of five sampled residents when a care plan was not initiated when Resident 1 was diagnosed with a Deep Vein Thrombosis (DVT, a blood clot that forms in a deep vein of the upper body) in the right upper arm.This failure decreased the facility's potential to meet Resident 1's person-centered nursing needs regarding care for his DVT.Findings:A review of Resident 1's admission record indicated he was admitted on [DATE] with the diagnosis of cerebral infarction (stroke) and right-sided hemiplegia (severe paralysis on the right side of the body). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 7/22/26, indicated he had no memory impairment.A review of Resident 1's radiology interpretation dated 5/27/26 at 4:42 p.m. indicated, Right Venous Doppler Upper Extremity.Right axillary vein thrombosis. The axillary vein is non-compressible with no observable flow.Venous flow is diminished throughout the extremity requiring augmentation to demonstrate patency.signed by [physician] at May 27 2026 1:54 p.m.A review of Resident 1's order progress note dated 5/27/26 at 3:33 p.m. indicated, .Eliquis(C) Oral Tablet 5 mg [milligram] (Apixaban) Give 2 tablet by mouth two times a day for right axillary vein thrombosis until 6/3/26 [at 4:59 p.m.] AND Give 1 table by mouth two times a day for right axillary vein thrombosis until 9/4/26 [at 11:59 p.m.].Per MD [physician] order for US [ultrasound] impression result of right axillary vein thrombosis.A review of Resident 1's IDT progress note dated 5/28/26 at 12:53 p.m. indicated, [Resident 1] was noted to have edema [swelling] in the right arm. Ultrasound findings revealed right axillary vein thrombosis, and Eliquis(C) was initiated per physician orders. A review of Resident 1's admission record on 7/31/26 indicated the diagnosis of DVT was not included in the diagnosis information.A review of all of Resident 1's care plans on 7/31/26 indicated a care plan for Resident 1's diagnosis of DVT in the right upper arm was initiated on 7/20/26.In an interview on 7/31/26 at 2:10 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 asked what a DVT was when the surveyor asked if she knew Resident 1 had a DVT in his right arm. In a concurrent record review and interview with the Director of Nursing (DON) on 8/20/26 at 2:17 p.m., the DON confirmed the facility was notified Resident 1 had a DVT in his right arm on 5/27/26 and acknowledged a care plan should have been initiated within 48-72 hours of notification. The DON agreed that Resident 1's care plan for his right upper arm DVT was not initiated timely.A review of the facility's policy and procedure titled Care Planning revised July 2021 indicated, It is the policy of this facility that the.IDT.shall develop a comprehensive Person-Centered Care Plan for each resident based on resident's needs to attain or maintain his.highest practicable physical.well-being.The care plan is developed by the IDT.The Care Plan will reflect the Interdisciplinary approach to Person-Centered Care and considering the different individual needs or concerns identified during the assessment proves of the resident.

Based on observation, interview, and record review, the facility nurses failed to provide foot care for one resident (Resident 1) of five sampled residents when:Resident 1's toenails were long and growing over the top of his toes; and,Licensed Nurses (LN) did not carry out Resident 1's order to change his right lower extremity dressings as needed between 7/12/26 and 7/15/26.These failures resulted hospital staff discovering diffuse tissue damage on Resident 1's right foot and maggots between Resident 1's toes when Resident 1 was sent to the hospital on 7/15/26.Findings:1. A review of Resident 1's admission record indicated he was admitted on [DATE] with the diagnosis of cerebral infarction (stroke), right-sided hemiplegia (severe paralysis on the right side of the body), a history of diseases of the skin and subcutaneous tissue (the deepest layer of skin), and a need for assistance with personal care.A review of Resident 1's Skin Observation- Shower sheets dated 6/17/26, 6/20/26, 6/27/26, 7/4/26, 7/8/26, 7/11/26, 7/15/26, 7/22/26, 7/25/26, 7/29/26 indicated Resident 1 did not get his toenails clipped nor did he need them to be clipped.A review of Resident 1's pictures of his right foot taken at a local hospital on 7/16/26 at 3:32 a.m. indicated his toenails were thick, yellowish, and so long that they grew over the top of his toes.In an interview on 7/31/26 at 2:10 p.m., Certified Nursing Assistant 2 (CNA 2) acknowledged CNAs were responsible for completing the Skin Observation- Shower sheets accurately otherwise LNs would not know if the resident has any skin changes or would not know what treatment the resident would need.In a concurrent record review and interview on 7/31/26 at 2:35 p.m., Licensed Nurse 1 (LN 1) reviewed Resident 1's shower sheet dated 7/29/26. LN 1 stated Resident 1's shower sheet indicated he did not have any new or old skin concerns, and he did not need his toenails clipped.In a concurrent record review and interview on 8/5/26 at 8:12 a.m. with Treatment Nurse 2 (TXN 2), TXN 2 reviewed Resident 1's pictures of his right foot taken at the hospital. TXN 2 stated, Those are what [Resident 1's] toenails looked like so I do believe these are his feet. In a concurrent record review and interview on 8/5/26 at 12:08 p.m., the Assistant Director of Nursing (ADON) stated facility nurses cut resident fingernails and toenails once a week or as needed.In a concurrent record review and interview on 8/5/26 at 1:16 p.m., the Director of Staff Development (DSD) reviewed Resident 1's shower sheets and Resident 1's right foot pictures taken at the hospital. The DSD stated the CNAs should have indicated he needed his toenails clipped but they were not.A review of the facility's policy and procedure titled Body Assessment Protocol revised October 2021 indicated, Nursing Assistants will check resident's skin every shift and shall report any skin integrity impairment to the licensed nurse for follow-up.2. A review of Resident 1's care plan focused on his skin impairment in the right lower extremity related to a venous statis ulcer (an open sore formed as a result of long-term poor blood flow in the veins) was initiated on 1/16/26. Nursing interventions to assist Resident 1 to be free from injury included: administer treatments as ordered; and keep skin clean and dry.A review of Resident 1's Treatment admission Record (TAR) dated July 2026 indicated the following order Right Lower Extremity- PPX [prophylactic, to prevent disease or infection before it occurs] Cleanse with Hibiclens(tm) [a skin cleanser used to destroy microorganisms] and NS [normal saline, a sterile solution]. Pat dry. Wrap with CoFlex(tm) 2 [a two-layer compression bandage system designed to treat venous leg ulcers and manage swelling] as needed [PRN]. Order Date 7/10/26 [at] 12:08 [p.m.] D/C [discontinue] Date 7/15/26 [at 2:04 p.m.].A review of Resident 1's skin/wound progress note dated 7/11/26 at 2:08 p.m. indicated, RLE [Right lower extremity] noted with moisture present to entire leg wrap. Patient noted with towel around lower leg/ankle area of RLE when nurse entered room. Leg unwrapped, cleansed and dried thoroughly per orders. Dorsal aspect [top of foot] of 2nd, 3rd, and 4th toes to R [right] foot noted with maceration [softening, swelling, and breakdown of skin tissue caused by prolonged exposure to moisture], pale skin color with soft, flaky skin texture.Multiple layers of.gauze placed over macerated area, then leg wrapped with 2 layer compression wrap per orders. Patient tolerated well.A review of Resident 1's wound review progress note dated 7/15/26 indicated the NP assessed and changed Resident 1's bilateral lower extremity dressings at 11:15 a.m. The progress note indicated the NP's treatment recommendation for Resident 1's wound on his right, lower extremity included cleaning it with normal saline and Hibiclens(tm); applying PolyMem(tm) (a wound covering that cleanses, fills, absorbs, and moistens wounds to accelerate healing and reduce pain) in between the toes for weeping edema; and then applying a two-layer wrap. Nursing staff were expected to change the dressing weekly and as needed if dislodged, saturated, or soiled.A review of Resident 1's progress notes dated 7/15/26 only indicated the NP's dressing change was the only dressing change conducted on 7/15/26.A review of Resident 1's TAR dated July 2026 did not indicate any PRN dressing changes on 7/15/26.A review of Resident 1's nursing progress note dated 7/15/26 at 9:28 p.m. indicated, Patient was noted to be hypotensive and pale this afternoon while he was up in wheelchair. Patient was then sent out [to the hospital] via 911 [emergency services].A review of Resident 1's hospital emergency department document dated 7/15/26 at 9:44 p.m. indicated Resident 1 arrived by ambulance from the facility and was treated for hypovolemic shock (a medical emergency caused by severe fluid loss making it difficult for the heart to pump enough blood to the body). Resident 1 was stabilized then transferred to a different hospital's intensive care unit (ICU) on 7/16/26 at 2:10 a.m.A review of Resident 1's hospital's ICU wound and ostomy team consultation dated 7/16/26 at 3:30 a.m. indicated, Right foot presents with diffuse tissue damage to dorsal foot and between toes, scatted areas of non-granular tissue [tissue that lacks healthy, connective tissue and new blood vessels necessary for healing] and slough [dying tissue that traps bacteria]. Moderate amount of serous/tan drainage. Maggots were photo documented in wound upon admission.A review of an IDT progress note dated 7/17/26 at 3:56 p.m. indicated, [Resident 1] was visited by wound rev [review] on 7/15/26 approximately 11:15 a.m. and [Resident 1] tolerated visit and wound care.It appears the weeping from right leg saturates foot d/t [due to] resident sitting upright in wheelchair throughout the day. The treatment team has difficulty with maintaining cleanliness of resident's wounds and drainage d/t the resident's insistence of sitting outside throughout the day exposed to the elements plus refusals of proper skin care.In an observation on 7/31/26 at 10:41 a.m. in the facility hallway, Resident 1 was observed leaving his room via motorized wheelchair and went outside of the facility.In an interview on 8/5/26 at 7 a.m. with TXN 1, TXN 1 confirmed she changed Resident 1's right lower leg dressings on 7/11/26 because they needed to be changed. TXN 1 stated when she changed dressings on a PRN basis, she documented the reason for the dressing change and any observations out of the resident's baseline. TXN 1 added that at times Resident 1 would have so much weeping that he would wrap a towel around his foot which was the reason why she changed his right lower leg dressing on 7/11/26.In an interview on 8/5/26 at 8:12 a.m., TXN 2 clarified the documentation she conducted for Resident 1 on 7/13/26 was an update of old skin issues for that week. TXN 2 stated she did not look at Resident 1's right leg and assessed it on 7/13/26 because the dressing was intact. TXN 2 confirmed Resident 1's dressing on his right lower leg and foot was changed on 7/11/26 and 7/15/26. TXN 2 stated Resident 1 only had scheduled dressing changes every Wednesday each week but added he also had an order to change his dressings as needed (if dislodged, saturated, or soiled). TXN 1 stated when she and the NP assessed Resident 1's right foot on 7/15/26 at approximately 11 a.m., they only observed weeping and a scab on his third metatarsals. TXN 2 stated after the dressing change was completed for both of his lower legs and feet, Resident 1 got in his wheelchair and left the facility to go outside. The surveyor and TXN 2 conducted an internet search together and found that fly eggs could hatch into maggots between eight to 12 hours in hot and moist conditions.In an interview on 8/5/26 at 10:40 a.m., the NP verified she assessed and changed the dressings on Resident 1's bilateral lower extremities. The NP stated there was a fine line between normal tissue and moisture- associated skin damage (inflammation, irritation, or erosion of the skin caused by long-term exposure to bodily fluids or moisture). The NP acknowledged she observed maceration; she was more concerned about the uncontrolled edema.In an interview on 8/20/26 at 2:17 p.m., the Director of Nursing (DON) stated Resident 1 signed himself out of the facility and goes off the facility property three to four times per day. The DON further stated Resident 1 liked to go to the park next to the parking lot.In an interview on 8/20/26 at 2:47 p.m., TXN 2 confirmed Resident 1's July 2026 MAR indicated the only PRN dressing change documented for Resident 1 was on 7/11/26. TXN 2 further stated bedside nurses were able to carry out PRN dressing changes and were expected to if the dressing was saturated or soiled.A review of the facility's policy and procedure titled Body Assessment Protocol revised October 2021 indicated, It is the policy of this facility to monitor each resident's skin status on an ongoing basis. The primary purpose of monitoring is to develop a system for expected resident outcome as it relates to skin care management.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received nursing care that was resident-centered and in accordance with nursing professional standards of practice when he experienced seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) in April 2026 (his second seizure) and in May 2026, both requiring transfer to the hospital and:1. His anti-seizure medication, Keppra, was completed (reached the 30-day stop date; date medication administration ends) on 5/18/26; Keppra was not reordered and nursing staff did not call his physician to ensure this was intentional, and not an error,2. Nursing staff discontinued one of two Keppra orders (a duplicate), both ordered on 5/29/26; nursing staff discontinued the continuous Keppra order, maintaining the Keppra order with a 30-day stop date, and;3. Keppra was stopped on 6/29/26; nursing staff did not contact the physician until 7/1/26 to ensure this was intentional, and not an error.These failures:1. Prevented Resident 1 from receiving antiseizure medication from 5/19/26 through 5/23/26, when he experienced another seizure, necessitating transfer to the hospital,2. Prevented Resident 1 from receiving anti-seizure medication for approximately three days, beginning on 6/29/26, placing him at increased risk of additional seizures; and3. Potentially prevented Resident 1's physician the opportunity to review his medications and reorder the Keppra timely. A review of Resident 1's admission Records (front page of the medical record that contains a summary of basic information about the resident) indicated he was a seventy-eight-year-old male who was admitted to the facility on [DATE] with diagnoses including seizures, epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures), Diabetes mellitus (DM- disorder characterized by difficulty in blood sugar control and poor wound healing), and Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).A review of Resident 1's Minimum Data Set (MDS; a resident assessment tool), dated 5/28/26, indicated he had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14, indicating he was cognitively intact. The MDS indicated his Active Diagnoses included, .Seizure Disorder or Epilepsy.A review of Resident 1's electronic medical record (EMR) revealed a nurses' note for a Change of Condition Assessment, dated 4/14/26 at 9;38 p.m., that indicated, . Mental Status Evaluation: Altered level of consciousness. Nursing observations. Not able to answer questions, not able to state his name. He only stairs (sic). He is noted clammy [skin moist with sweat] . gurgly [wet sounding] sound on exhalation [breathing out] .A review of hospital discharge note [physician synopsis of the hospital course] subtitled, Problem-Based Discharge Summary dated 4/18/26 at 12:08 p.m. indicated, [Resident 1] .had a witnessed. seizure in the ED [emergency department] . Neurology consultation [medical doctor who specializes in diagnosing/treating disorders of the brain and nervous system] . recommended initiation of maintenance (ongoing) antiepileptic [antiseizure] therapy [medication]. Given this represents his second seizure, chronic prophylaxis [preventative care] is indicated. He was started on levETIRAcetam (Keppra) 500 mg. Plan: Continue levETIRAcetam 500 mg twice daily indefinitely [for an unlimited period of time] . A review of the hospital discharge instruction to Resident 1 subtitled, Home Care, dated 4/18/26 at 12:36 p.m., indicated, Follow these tips when caring for yourself at home. If medicine was prescribed to prevent seizures, take it exactly as directed. Missing doses will increase your risk of having another seizure.A review of the facility's order summary report, dated 4/18/26, indicated Resident 1's physician ordered, levetiracetam [Keppra] oral tablet 500 milligrams [mg] . give 1 tablet by mouth two times a day for. seizure for 30 days. The physician order was started on 4/18/26 and contained an end date of 5/18/26.A review of Resident 1's nurse progress notes (nurse documentation of care and treatments), dated 5/16/26 at 1:39 p.m. indicated the IDT (interdisciplinary team of healthcare professionals including nursing, social workers, pharmacy, and dietary staff) team met to discuss Resident 1's self-care and mobility issues, but did not document the impending discontinuation of his antiseizure medication, Keppra. A review of Resident 1's Medication Administration Records (MARs; a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 5/1/26 - 5/31/26, indicated Resident received his last dose of Keppra on 5/18/26 at 8 a.m.A review of Resident 1's EMR revealed a nursing assessment titled, .Skilled Evaluation, subtitled, Comments, dated 5/18/26 at 9:33 p.m., indicated, . No seizure activity noted this shift. The evaluation did not contain documentation that Resident 1 was no longer receiving antiseizure medication.A review of Resident 1's medical record revealed a nurses' note for a Change of Condition Assessment, dated 5/23/26 at 5: 35 p.m., that indicated, . At around 1650 [4:50 p.m.] he [Resident 1] was found seizing [having a seizure] that lasted more than 30sec [seconds]. remained unresponsive until 1705 [5:05 p.m.]. MD was notified and patient sent out to ED.A review of hospital discharge note subtitled, Hospital Course, dated 5/29/26 at 2:35 p.m., indicated, The patient presented with status epilepticus [medical emergency characterized by prolonged seizure activity] requiring IV [intravenous] Lorazepam [a benzodiazepine medication] and loading [administration of an initial, larger dose of medication at the start of a treatment] with LevETIRAcetam (Keppra). Under subtitle, Problem-Based Discharge Summary, the physician documented, .Treated with levETIRAcetam (Keppra) with resolution of seizures and no recurrence during hospitalization. discharge on maintenance (ongoing) therapy [antiseizure medication] .A review of the facility's order summary report, dated 5/30/26, indicated Resident 1 had two orders for Keppra: Keppra. 500 mg. Give 1 tablet by mouth two times a day related to. seizures. The order date was 5/29/26 and had no end date (indefinite order). The second Keppra order indicated, .LevETIRAcetam [Keppra] . 500 mg. Give 1 tablet by mouth two times a day. for 30 Days. The order date was 5/29/26 and the end date was 6/29/26.A review of Resident 1's MAR, dated 6/01/26 - 6/30/26, indicated one of the duplicate Keppra orders was discontinued: Keppra. 500 mg. give 1 tablet . two times a day. The order was dated 5/29/26 and had a discontinuation date of 6/02/26 (four days later). The MAR indicated Resident 1 received two doses of Keppra on 6/01/26 under that order.A continued review of Resident 1's MAR, dated 6/01/26 - 6/30/26, indicated the following Keppra order was maintained (not discontinued): levETIRAcetam oral tablet 500 mg. give 1 tablet by mouth two times a day for. seizure for 30 days. The MAR indicated Resident 1 received his last dose of Keppra on 6/28/26 at 4 p.m. The MAR indicated Resident 1 did not receive Keppra on 6/29/26 - 6/30/26.A review of Resident 1's MAR, dated 7/01/26 - 7/31/26 indicated he did not receive Keppra on 7/01/26.A review of Resident 1's nursing care plan, dated 4/19/26, indicated, [Resident 1] has. Seizures. Care plan interventions indicated, Give seizure medication as ordered. The care plan did not address the discontinuation of Resident 1's Keppra. During an interview on 6/30/26 at 2:10 p.m., Resident 1 stated staff did not inform him about changes to his medications. He stated his antiseizure medications had been decreased and he wondered if that caused his recent seizures.During a concurrent interview and record review on 7/01/26 at 4 p.m., the Director of Nursing (DON) reviewed Resident 1's electronic medical record. The DON stated Resident 1 was sent to the hospital after having a seizure on 4/14/26. She stated he returned from the hospital 4/18/26 and was ordered to receive Keppra 500 mg twice a day for 30 days. The DON confirmed that after Resident 1 received his last dose of Keppra at the end of May 2026, he suffered another seizure four to five days later. The DON stated Resident 1 was transferred to the hospital and when he returned on 5/29/26, he was restarted on Keppra for 30 days. She confirmed he received his last dose of Keppra at the end of June 2026.During a concurrent telephone interview and record review on 7/02/26 at 3:28 p.m., Pharmacist C and Pharmacist D reviewed Resident 1's electronic medical record. Pharmacist C stated it was unusual to order Keppra with a discontinuation timeframe of 30 days; she stated Keppra did not usually have a stop order. She stated Keppra was usually not taken for a short period of time. The Pharmacist stated it was possible the discontinuation of Keppra contributed to his seizure activity. She stated stopping Keppra placed him at risk of further seizures.During an interview on 7/02/26 at 4 p.m. with the DON and Administrator, the DON confirmed Resident 1's healthcare team did not document addressing the discontinuation of his antiseizure medication at the IDT meeting, dated 5/16/26. The DON confirmed the nurse's Skilled Evaluation, dated 5/18/26 did not contain documentation that Resident 1's Keppra had been discontinued or that his physician was notified and questioned about it. When asked if any nurse progress notes contained information that nursing staff notified the physician that Resident 1's Keppra had been stopped, she confirmed that physician notification was not located in the notes.During an interview on 7/02/26 at 4:15 p.m. with the Administrator and DON, the Administrator stated Keppra had been discontinued mistakenly during a medication recap (recapitulation; review of physician orders and MARS to ensure accuracy). He stated the nurse discontinued the duplicate Keppra order that did not have a stop date, which lead to Keppra being stopped and doses being missed .A review of the nurse job description titled, Registered Nurse., subtitled, Essential Duties and Responsibilities, dated 12/17/21, indicated, Confer with the Medical Director and the attending physician regarding specific residents assigned to you. Consult with the physician concerning resident evaluation.Examine the resident and his/her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical. problems.A review of the nurse job description titled, License Vocational Nurse., subtitled, Essential Duties and Responsibilities, dated 12/17/21, indicated, Confer with the Medical Director and the attending physician regarding specific residents assigned to you. Consult with the physician concerning resident evaluation.Examine the resident and his/her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical. problems.A review of facility policy titled, Comprehensive Person-Centered Care Planning, subtitled, Policy, revised 12/2023, indicated the, . IDT shall develop a comprehensive person-centered care plan for each resident. to meet a resident's medical. needs. provide . care that meet professional standards of quality care. Under subtitle, Procedure, the policy indicated, . 6. plan of care will be reviewed and/or revised by the IDT. 7. The facility IDT includes. A. Resident Physician or Non-Physician Practitioner. B. Registered Nurse with responsibility for the resident. E.resident.An online review of the Federal Drug Administration's (FDA) product information titled, Highlights of Prescribing Information, subtitled, Warnings and Precautions, revised 3/2024, indicated abrupt discontinuation of Keppra could cause, .Withdrawal Seizures: KEPPRA must be gradually withdrawn. (https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/021035s115,021505s053lbl.pdf#page=32)

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received nursing care that was resident-centered and in accordance with professional nursing standards and his goals of care, as indicated in his Nursing Care Plan (a document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) when:1. Nursing staff did not inform him when changes were made to his medication regimen, and;2. Nursing staff did not medicate him for pain per physician orders.These failures: 1. Caused Resident 1 to feel out of control and horrible, 2. Caused his pain to go untreated for over twelve hours, contributing to his pain severity being an eight on the pain scale (The Pain Scale is a pain assessment tool; pain is described as 1-10 out of a possible ten. Zero is no pain and 10/10 is the worst pain imaginable), and; 3. Potentially prevented him from attaining his highest possible level of functioning and well-being, thereby negatively impacting his quality of life. A review of Resident 1's admission Record (front page of the medical record that contains a summary of basic information about the resident) indicated he was a seventy-eight-year-old male who was admitted to the facility on [DATE] with diagnoses including seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures), diabetes mellitus (DM, disorder characterized by difficulty in blood sugar control and poor wound healing), and parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/28/26, indicated he had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14, indicating he was cognitively intact. The MDS indicated his Active Diagnoses included, .Seizure Disorder or Epilepsy.A review of the facility's order summary report, dated 4/18/26, indicated Resident 1's physician ordered the following anti-seizure medication: levetiracetam [Keppra] oral tablet 500 milligrams [mg] . give 1 tablet by mouth two times a day for. seizure for 30 days.A review of Resident 1's Medication Administration Records (MARs; a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 5/1/26 - 5/31/26, indicated Resident received his last dose of Keppra on 5/18/26 at 8 a.m.A review of the facility's order summary report, dated 5/30/26, indicated Resident 1's physician ordered the following anti-seizure medication: .LevETIRAcetam [Keppra] . 500 mg. Give 1 tablet by mouth two times a day. for 30 Days. The order date was 5/29/26.A review of Resident 1's MAR, dated 6/1/26 - 6/30/26, indicated Resident 1 received his last dose of Keppra on 6/28/26 at 4 p.m. The MAR indicated Resident 1 did not receive Keppra on 6/29/26 - 6/30/26.A review of Resident 1's MAR, dated 7/1/26 - 7/31/26 indicated, indicated Resident 1's Keppra was reordered on 7/01/26.A review of Resident 1's MAR, dated 6/01/26 - 6/30/26, indicated the following physician order, dated 5/29/2-26: Hydrocodone-Acetaminophen [Norco; a narcotic pain medication] oral tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain (4-10/10) [on the pain scale] . The MAR indicated Resident 1 took Norco approximately two to four times a day during June 2026. His pain was documented as four to eight out of ten. A review of Resident 1's MAR, dated 7/1/26 - 7/31/26, indicated he received Norco on 7/02/26 at 1:52 a.m. No other Norco administration was documented prior to 7/02/26 at 2:35 p.m. (over twelve-hours).A review of Resident 1's nursing care plan, revised 2/17/26, indicated, [Resident 1] is currently prescribed an Opioid [narcotic] for pain management. (Hydrocodone-Acetaminophen) . Care plan interventions indicated, Administer opioid as prescribed.A review of Resident 1's nursing care plan, revised 5/29/26, indicated, [Resident 1] has acute/chronic pain. The care plan goals indicated, . Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain.During an interview on 6/30/26 at 1 p.m., the Director of Nursing (DON) stated if changes were made to a resident's medication, the IDT team (interdisciplinary group of healthcare professionals including nursing, social workers, pharmacy, and dietary staff) discussed it at the daily Stand-Up meeting (meetings where healthcare teams connect at the start of the day to share relevant and time-sensitive information). The Charge Nurse (nurse caring for the resident) or Unit Manager (Nurse manager) would then speak to the resident about the changes.During an interview on 6/30/26 at 1:25 p.m., Licensed Nurse A (LN A) stated she was the Quality Assurance nurse (nurse who evaluates clinical practices, audits patient charts, and enforces regulatory compliance to improve patient safety). She stated if changes were made to a resident's Plan of Care, the Unit Manager would discuss the changes with the resident; the changes and discussion with the resident would be documented in the nurse's progress notes (nurse documentation of care and treatments).During an interview on 6/30/26 at 3 p.m., LN E stated she was the Unit Manager that evening and her duties included educating residents. She stated if a resident had a new physician order for a medication, she would talk to the charge nurse to inform them and she normally talked to the resident about it as well. She stated she would document the medication change and subsequent conversations with the nurse and resident in the progress notes. During an interview on 6/30/26 at 2:10 p.m., Resident 1 stated he wanted to be informed by staff about his care and changes to his medications. He stated if he was not informed about his medications, he had no control and had no way of knowing if the nurse was making a mistake. He stated he felt frustrated and horrible when he was not informed about his medications. When asked if any nurse had explained that some of his medications had been changed, Resident 1 stated, no.During an interview on 7/2/26 at 1:45 p.m., Resident 1 stated he had not gotten his Norco (pain medication) since the previous day. He stated the nurse told him, they ran out of Norco and she would reorder some. He stated he had requested Norco that day at 9 a.m. and again at 2 p.m. and his pain was currently at a level of eight (out of ten).During an interview on 7/2/26 at 2:10 p.m., LN B stated Resident 1's Norco had run out the previous day; she stated she had reordered it at that time but it had not yet arrived. She stated Resident 1 requested the Norco but none was given on her shift (day shift: approximately 7 a.m. through 3 p.m.) as she was awaiting its delivery from the pharmacy. When asked if she could have administered Norco from the Emergency supply (Emergency Kit; supply of medication designed to prevent treatment delays when regular pharmacy services are unavailable), she stated, yes, and stated she had not done so.During a follow-up interview on 7/02/26 at 2:35 p.m., Resident 1 stated he was not informed Norco was available in the emergency supply. He stated he usually took Norco every four hours and his pain level remained at eight. He stated after he received Norco, his pain usually decreased to about four, which he stated was, better than eight.During an interview with the Administrator and DON on 7/02/26 at 4 p.m., the DON confirmed the nursing progress notes did not contain documentation that he had been educated about medication changes. The Administrator stated he expected nursing staff to inform Resident 1 if medication changes were made.During the same interview on 7/02/26 at 4 p.m. the DON confirmed Resident 1's Norco was on order (from the pharmacy) since the previous day. She confirmed Resident 1 had not been given Norco since approximately 1:52 a.m., when it was administered form the Emergency Kit.A review of the facility policy titled, Resident Rights, revised 12/2016, indicated, 1. Federal and state laws guarantee certain basic rights to all residents. These rights include the resident's right to: . e. self-determination. o. be notified of his or her medical condition and of any changes in his or her condition. p. be informed of, and participate in, his or her care planning and treatment.A review of facility policy titled, Comprehensive Person-Centered Care Planning, subtitled, Policy, revised 12/2023, indicated the, . IDT shall develop a comprehensive person-centered care plan for each resident. to meet a resident's medical. and psychosocial needs that. provide effective and person-centered care that meet professional standards of quality care. Under subtitle, Definitions, the policy indicated, . Person-centered care - means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.A review of the nurse job description titled, Registered Nurse., subtitled, Essential Duties and Responsibilities, dated 12/17/2021, indicated, . Prepare and administer medications as ordered by the physician.A review of the nurse job description titled, License Vocational Nurse., subtitled, Essential Duties and Responsibilities, dated 12/17/2021, indicated, . Prepare and administer medications as ordered by the physician.

Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment, affecting all residents who receive food from the kitchen, when there were gouged, cracked and broken tiles on the floors of the kitchen and dry goods storage room (storing shelf-stable food and ingredients like flour, grains, canned goods, and spices).These failures prevented thorough cleaning of the floor, creating an environment for bacteria (tiny, single-celled living organisms often called germs), mold and pests to thrive and can result in risks for food contamination and spread of foodborne illness (any illness resulting from eating contaminated/spoiled foods). Findings:During a concurrent observation and interview on 04/7/2026 at 9:36 a.m. with the Dietary Manager (DM) , while on initial tour of the kitchen, there were gouges noted in the kitchen floor between the stove and the cook's tray line counter, and cracked and broken tiles on the floor of the dry good storage room. The DM confirmed the presence of the gouges and cracked/broken tiles and stated there is a plan to make repairs to damaged floors. A review of the facility policy titled, Quality of Life- Homelike Environment, revised 5/2017, indicated, .Resident are provided with a safe, clean. environment. The facility staff and management shall maximize, to the extent possible.clean, sanitary and orderly environment.

Based on observation, interviews, and record reviews, the facility's direct care and maintenance staff failed to provide a homelike environment for one resident (Resident 47) of 29 sampled residents, when the wall and its baseboard molding that her bed's headboard was pushed up against needed repair.This failure decreased the facility's potential to provide Resident 47 with a clean and homelike environment.Findings:A review of Resident 47's Brief Interview for Mental Status (BIMS) dated January 2023 indicated Resident 47 was rarely/never understood.A review of Resident 47's Face Sheet, indicated she had a medical diagnosis of severe vascular dementia (a chronic condition caused by reduced blood flow to the brain which results in a decline in thinking skills). This document indicated Resident 47's had a Responsible Party (RP, a person who manages healthcare decisions for another because they are no longer able to).During an interview on 4/9/26 at 4 p.m., Resident 47's RP stated he visited Resident 47 at the facility and observed issues on the wall behind her mother's bed. Resident 47's RP stated he complained about this to a facility staff a long time ago and nothing had been done about it.During a concurrent observation and interview with the Maintenance Director and two other maintenance staff, on 4/9/26 at 4:25 p.m., Resident 47's bed away from the wall. The baseboard molding of the wall was damaged. Four photos taken by this surveyor showed dust and debris had collected on the floor at the base of the damaged baseboard molding. The Maintenance Director stated he was not aware of this issue. During an interview on 4/10/26 at 12:03 p.m., the Maintenance Director stated he expected staff to write their concerns regarding repairs on the maintenance log. A review of the facility's policy and procedure (P&P) titled, Environmental Services Policy and Procedure, Floor Maintenance Room Maintenance, dated July 2024, indicated, The facility shall maintain all floor maintenance rooms in a clean, safe, organized, and sanitary condition to ensure resident and staff safety, and comply with Title 22 and CMS (Centers for Medicare Medicaid) environmental standards. Floor maintenance rooms shall be used only for approved housekeeping equipment and supplies and shall not create hazards or risk of contamination.A review of the facility's P&P titled, Quality of Life-Homelike Environment, dated May 2017, indicated, Residents are provided with a safe, clean, comfortable, and homelike environment .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary, and orderly environment.

Based on interview and record review, the facility's licensed nurses (LNs) failed to provide pain management to one resident (Resident 4) out of six residents when Resident 4 was experiencing severe pain from a displaced, comminuted fracture (a severe break where the bone is broken in three or more pieces that are significantly shifted from their normal alignment) of the shaft (the long cylindrical section) of the left humerus (long bone of the upper arm).This failure resulted in Resident4 enduring unnecessary suffering and experience prolonged physical distress.Findings: A review of Resident 4's admission record indicated admission to the facility on 2/4/26 with a diagnosis of a displaced, comminuted fracture of shaft of humerus.A review of Resident 4's progress notes, dated 2/4/26, indicated Resident 4 arrived at the facility at 6:20 p.m. The note further indicated Resident 4 opted for non-surgical intervention for her fracture, which included wearing a sling around the neck 24 hours per day, strict non-weight bearing to her left arm, and pain medication administration. A review of Resident 4's physician orders, dated 2/4/26 at 3:58 p.m., indicated LNs were to administer Oxycodone HCI [pain medication used to treat severe pain] 5 mg [milligram-a unit of measure]. Give 1 tablet by mouth every 6 hours as needed for severe pain 7-10/10 [refers to a pain level of 7-10 on a 10-point scale where 10 is the most severe]. Use [acetaminophen (an over-the-counter pain relief medication)] as first line agent and oxycodone as 2nd line agent .A review of Resident 4's pain management care plan, dated 2/4/26, indicated Resident 4 had a goal to verbalize adequate pain relief or ability to cope with incompletely [sic] relieved pain. To meet this goal, LNs were required to Administer medication as per orders. Monitor for effectiveness.Anticipate need for pain relief and respond immediately to any complaint of pain.Follow pain scale to medicate as ordered.A review of Resident 4's Medication Administration Record (MAR), dated February 2026, indicated Resident 4 reported a pain level of 10 and was medicated with Oxycodone HCI 5 mg on 2/4/26 at 7:50 p.m. The MAR further indicated no additional oxycodone was administered to Resident 4 on 2/4/26. On 2/5/26, Resident 4 was administered oxycodone three times only with noted pain scale levels of 9, 8 and 9 respectively.A review of Resident 4's oxycodone administration history and effectiveness, dated 2/4-2/16/26 indicated Resident 4 experienced temporary relief of pain after being given oxycodone as evidenced by Resident 4 reporting recurring levels of severe pain (8-9). LNs did not identify that Resident 4 was reporting a pattern of recurring severe pain which consistently returned prior to the next scheduled dose throughout the day on 2/5/26 and into the morning of 2/6/26. By allowing the medication to wear off completely before the next six-hour window, LNs staff forced Resident 4 to experience a state of unnecessary physical distress instead of advocating to the physician for a more frequent dosing schedule to maintain a steady therapeutic level.A review of Resident 4's progress note, dated 2/5/26, at 8:05 a.m., indicated Resident 4 requested additional oxycodone on 2/4/26 at approximately 11:30 p.m. The note indicated a licensed nurse notified Resident 4 that the oxycodone was unavailable at that time but might arrive at midnight or at the 3 a.m. pharmacy delivery. Resident 4 was offered alternative pain relief, which included an ice pack and scheduled acetaminophen. Resident 4 refused the acetaminophen, stating she did not use those medications, but agreed to attempt to rest and notify the nurse if the pain persisted. Despite Resident 4's refusal of the first line agent (acetaminophen) and the unavailability of the second line agent (oxycodone), the LN failed to attempt access to the Emergency Medication Kit (E-Kit: a secure electronic system provided by a pharmacy which contains a small supply of medications for immediate therapeutic needs when the regular pharmacy is unavailable) at that time. The note further indicated Resident 4's pain persisted, and Resident 4 requested oxycodone again on 2/5/26 at approximately 4:30 a.m.; however, the oxycodone had not been delivered at midnight or 3 a.m. When the LN updated Resident 4 on the continued delay, Resident 4 became upset and frustrated, stating the situation was unacceptable. Only at this time, five hours after the initial request, did the LN attempt to access the E-Kit. The LN was instructed to call a mobile number for a code, but a second call at 5:15 a.m. revealed a system outage and gave instructions to call back in one hour. The LN finally obtained the code and administered the oxycodone at 7:16 a.m., resulting in Resident 4 experiencing unmanaged, severe pain for nearly eight hours.During a phone interview on 2/27/26, at 8 a.m., Resident 4 stated when she arrived at the facility on 2/4/26 and her pain level was a 15 (on a 1-10 pain scale) that never really went away. Resident 4 stated her pain level was consistently elevated during her first two days at the facility, I never really got relief from the pain. I would rather have ten 10-pound babies than experience pain like that again. Resident 4 stated she has never cared to take acetaminophen pain relief medication, as she felt it never worked for her. Resident 4 did accept the ice pack as ordered but stated it really did not have any effect on her pain level. Resident 4 stated, The experience was physically and mentally detrimental to my healing.During an interview at the nursing station on 2/27/26 at 10:46 a.m., LN 2 stated if pain medication was ordered but not received at the facility, he would get a code from the pharmacy to open the E-kit. LN 2 further stated if he were unable to obtain the medication, he would notify the Director of Nursing (DON), the Assistant DON (ADON), or the Unit Manager. LN 2 stated the LN should notify the physician that the resident was unable to receive the ordered medication especially if the resident's pain could not be relieved.During an interview on 2/27/26 at 10:55 a.m., LN 3 stated narcotics were kept in the electronic E-kit. LN 3 stated if ordered medications did not arrive with the next medication delivery, LN 3 would call the pharmacy to find out why medication was not delivered, notify the physician of the situation and obtain different orders.During an interview with the DON, ADON, and the Administrator (ADM) on 2/27/26 at 2:40 p.m., the DON and the ADON confirmed they had not been notified that Resident 4 had been experiencing unrelieved pain on the evening of 2/4/26, nor the early morning of 2/5/26. Both the DON and ADON acknowledged staff failed to escalate the clinical situation or seek assistance with pharmacy delays when Resident 4 continued to report severe pain. The ADM stated he would have offered to send Resident 4 back to the hospital due to her uncontrolled pain.During a phone interview on 2/27/26 at 3:52 a.m., the physician (MD) stated he did not want any of his residents in pain. If staff are unable to obtain pain medication for a resident, I would want them to call me. The MD stated it was not good physically or mentally for a resident to have unrelieved pain.A review of the facility's policy titled Recognition and Management of Pain, dated January 2020, indicated, It is the policy of this facility that pain management is provided to residents that require such services, consistent with professional standards of practice.and the resident's goals and preferences.If the pain management program is not effective, the licensed nurse will contact the resident's physician.Consult physician for additional interventions if pain is not relieved by current orders.A review of the facility's policy titled E-Kit, dated November 2023, indicated, It is the policy of this facility to maintain an Emergency Kit (E-KIT) containing essential medication and supplies to ensure timely and appropriate care for residents when medications are urgently needed and cannot be obtained from the pharmacy in a reasonable timeframe. The E-KIT may be used for.Situations where a delay in medication therapy could cause harm to the resident.Purpose.To support timely intervention, reduce risk of complications and maintain continuity of care.

Based on observation, interview and record review, the facility's nursing staff failed to implement care plan interventions for three residents (Resident 1, Resident 2, Resident 3) out of three sampled residents when fall risk interventions were not executed following an actual fall. These failures decreased the facility's potential to effectively implement their fall prevention program, thereby placing Residents 1,2 and 3 at risk for recurrent falls and further injury.Findings:A review of Resident 1's admission record indicated admission to the facility on 1/19/26 with a diagnosis of muscle weakness, repeated falls, and Diastolic Heart Failure (a condition where the heart cannot fill up with enough blood due to stiffness, making the heart unable to meet the body's needs).A review of Resident 1's fall risk assessment dated [DATE] indicated Resident 1 had a history of three or more falls in the past three months and was hospitalized within the last 30 days. The remainder of the assessment tool was blank and made it unclear whether Resident 1 was considered a fall risk upon admission.A review of Resident 1's fall risk care plan, dated 1/20/26, indicated Resident 1 was at risk for falls. In order to prevent injury from falling, staff were required to place fall mats by Resident 1's bed.A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 1/26/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15, which indicated Resident 1's cognition (related to processes of reasoning and thinking) was fully intact.A review of Resident 1's progress note dated 1/22/26 at 7:22 p.m., indicated Resident 1 experienced an unwitnessed fall while transferring himself from the bedside commode to his bed. Resident 1 was found with his upper torso on the bed, while his lower extremities were on the floor. Resident 1 reported to the staff that he slipped while I tried to get up. Resident 1 sustained a skin tear which measured 1-centimeter (cm-a unit of measure) by 1 cm to his right forearm.A review of Resident 1's progress note dated 2/13/26 at 3:12 p.m., indicated Resident 1 fell while attempting to stand and use his urinal at bedside. This fall resulted in Resident 1 hitting his head and sustaining injuries to the bridge of his nose and head along with multiple skin tears to both knees and shin areas on his legs. Resident 1 was transported to the local hospital for evaluation. A progress note, dated 2/13/26, at 6:24 p.m., indicated Resident 1 was being treated for a nasal fracture, orbital fractures (eye sockets) and a brain bleed.A review of Resident 1's care plan, dated 2/13/26, indicated Resident 1 had an actual fall with injuries. To maintain a goal of healing injuries without complications, staff were expected to place fall mats by Resident 1's bed and begin a toileting schedule.A review of Resident 1's progress note, dated 2/16/26, at 2:40 p.m., indicated the Interdisciplinary Team (IDT-a collaborative group of healthcare professionals from different fields who work together toward shared, resident-centered goals) met to discuss Resident 1's fall on 2/13/26. The note indicated neither Resident 1 nor his partner, who was in the room at the time of the fall, pushed the call bell for help. Resident 1's partner reported to the IDT that Resident 1 frequently fell at home and Emergency Medical Services needed to be called to assist in getting Resident 1 off the floor. The IDT recommended placing floor mats on both sides of Resident 1's bed.During a concurrent observation and interview in Resident 1's room on 2/27/26 at 12:34 p.m., Resident 1 was sitting upright in bed with a cervical collar (a medical device worn around the neck to support the head and neck portion of the spine) in place. Resident 1 had multiple healing wounds to his face, arms and legs. Resident 1 stated he believed he fell because he passed out while attempting to stand to urinate. Resident 1's girlfriend (GF) was present during the interview and stated Resident 1 fell at home prior to admission to the facility and required hospitalization due to hitting his head during the fall. During our conversation, Resident 1 had intermittent spasms that caused his left leg to contract to a near full contraction. The GF stated Resident 1 has had these contractions for some time, but they were more pronounced since the recent fall. Resident 1 confirmed GF's statement. Fall mats were not observed by Resident 1's bed, however, it was noted fall mats were present by his roommate's bed. The GF stated she asked staff about fall mats to protect Resident 1 if he fell again and was told As long as [Resident 1] asks for help, they [floor mats] are not needed.A review of Resident 2's admission record indicated admission to the facility on 7/25/24 with a diagnosis of muscle weakness, a history of falling, and Transient Cerebral Ischemic Attack (a brief period of stroke-like symptoms caused by a temporary interruption of blood flow to a part of the brain).A review of Resident 2's progress note, dated 2/7/26, indicated Resident 2 experienced an unwitnessed fall. Resident 2 was found lying on her side in the bathroom next to the toilet. The note indicated Resident 2 fell while she was sitting on the toilet and she sustained a cut to the left side of her forehead. A review of Resident 2's care plans included:A care plan initiated on 7/25/24 for her fall risk, was revised on 2/10/26 following her fall on 2/7/26. The intervention required staff to provide a bedside commode to assist Resident 2 with safe toileting and achieve her goal of remaining fall free.A subsequent care plan dated 2/9/26 indicated an actual fall and directed staff to ensure Resident 2 wore non-skid footwear during all activities that involved walking to prevent further incidents.During a concurrent interview and observation in Resident 2's room on 2/27/26 at 12:25 p.m., a bedside commode was not observed at Resident 2's bedside. Resident 2 confirmed a commode had not been placed in her room previously. A pair of household slippers were observed to be positioned near Resident 2's bed. The slippers were well worn with very slippery soles and no grip. Resident 2 stated she wore those slippers when she got out of bed and when she walked. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis of the Aorta (a condition where fatty deposits, calcium, cholesterol and other substances-collectively known as plaque-build up along the inner walls of the body's largest blood vessel carrying oxygen away from the heart to other organs) and Age related Osteoporosis (a condition where bones become increasingly porous, thin and brittle due to the natural aging process).A review of Resident 3's progress notes, dated 2/10/26, indicated Resident 3 was found on the floor next to her bed and sustained a skin tear to her right cheek and multiple abrasions (scratches) to her upper back.A review of Resident 3's care plan, dated 5/16/25, indicated Resident 3 was at risk for falls. To meet the established goals of being free from falls and will not sustain serious injury, nursing staff were expected to keep Resident 3's call bell within her reach. A revision to this care plan on 2/12/26 indicated staff were to place fall mats on the left side of Resident 3's bed.During a concurrent interview and observation in Resident 3's room on 2/27/26 at 12:12 p.m., Resident 3 was lying in her bed. Resident 3's call light was not observed to be within her reach. This surveyor asked Resident 3 where her call light was located and Resident 3 could not find it. This surveyor then requested Certified Nursing Assistant 1 (CNA 1) to assist in locating Resident 3's call light. The call light was found tucked under the blanket and pillow on Resident 3's right hand side. In addition, there were no fall mats on either side of Resident 3's bed as per her care plan.During an interview on 2/27/26, at 2:21 p.m., CNA 2 stated fall risk status was communicated during shift change report. CNA 2 stated he took special care to ensure residents who were identified to be at risk for falls had their bed in a low position, their call lights within reach and fall mats were in place. During an interview at the nurse's medication cart on 2/27/26, at 2:32 p.m., Licensed Nurse 1 (LN 1) stated fall risk status was communicated during shift change report, and it was also printed on a report that was reviewed and carried throughout the shift. LN 1 stated fall risk interventions should include a low bed and the placement of fall mats. LN 1 was not sure if any fall risk identifiers are placed outside the resident's room.During a concurrent interview and record review of Resident 1, Resident 2, and Resident 3's medical records in the physician's lounge with the Assistant Director of Nursing (ADON) and the Administrator (ADM) on 2/27/26 at 2:40 p.m., the following were discussed:Resident 1's fall risk assessment was reviewed. Although the form was blank, the ADM stated Resident 1's fall risk score was 10, which placed Resident 1 at a moderate risk to fall prior to his fall on 2/13/26. Neither the ADON nor the ADM were able to provide documentation of Resident 3 having been placed on a toileting schedule as per Resident 1's revised 2/13/26 care plan. Furthermore, this surveyor notified the ADM and the ADON there were no fall mats in Resident 1's room as per revised 2/13/26 fall care plan. The ADM and ADON reviewed Resident 2's interventions listed in her care plan regarding her fall risk. The ADM and ADON were then shown a picture of Resident 2's slippers found at her bedside which had no grip on the soles which she stated she used. The ADM and ADON were also notified that a bedside commode was not observed at bedside or in Resident 2's bathroom as indicated in her care plan. The ADM and ADON reviewed Resident 3's interventions listed in her care plan regarding her fall risk. The ADM and ADON were notified no fall mats were observed on either side of Resident 3's bed and Resident 3's call light was difficult to find. The ADM stated nursing staff were encouraged to use resident care plans but added he cannot say how often they are used.A review of the facility's policy and procedure titled Falls and Accidents Prevention revised November 2022 indicated, Purpose.To investigate the circumstances surrounding each resident fall.and implement actions to reduce/prevent the incidence of additional falls.and minimize potential for injury.

Based on interview and record review, the facility failed to implement measures to prevent a fall for one (Resident 1) of ten sampled residents when nursing staff did not ensure Resident 1 wore non-slip socks during an assisted transfer from his bed to a shower chair.This failure resulted in Resident 1 sustaining a laceration to the left foot and a 5th digit fracture.Findings:A review of Resident 1's admission record indicated he was admitted in August 2024 with diagnosis of acute kidney failure (a rapid loss of the kidney's ability to filter waste), epilepsy (a brain disorder causing recurring seizures) and instability of the left knee. A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/9/25, indicated Resident 1 had no memory impairment. The MDS further indicated Resident 1 was dependent on staff for assisted bed to chair transfers.A review of Resident 1's Fall Risk Assessment, dated 1/9/26, indicated Resident 1 required the use of assistive devices for gait and balance.A review of Resident 1's care plan, related to Resident 1's impaired physical mobility related to decreased muscle strength, coordination or balance indicated staff were expected to make sure the resident wears non-slip shoes or socks.A review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) note dated 12/27/25 at 1:34 p.m., indicated, laceration to bottom of left pinky toe with floppy left pinky toe. Non-resistive to ROM [range of motion]. 0.9 x 2.0 x 0.2 cm [centimeters, a unit of measurement], bleeding noted. MD [physician] notified; RP [Responsible Party] notified. A review of Resident 1's nursing note dated 12/27/25 at 4:08 p.m. indicated, CNA [Certified Nursing Assistant] reported to this nurse that resident injured toe during transfer. Upon assessment resident noted with laceration to plantar aspect [bottom surface of foot] of L [left] 5th toe. Measurements are 2.0 cm L [length] x 0.8 cm W [width] x 0.2 cm D [depth]. Toe also appears floppy, feels disconnected with no resistance. Patient denies pain. Laceration cleansed with NS [normal saline, a solution used to clean wounds], patted dry [thin cotton fabric used to clean and protect wounds], layered gauze applied to wound bed to help with bleeding, moderate amount. Wrapped with kerlix(R) and secured with tape. Patient charge nurse informed, also notified of possible need for x-ray. A review of Resident 1's hospital discharge paperwork dated 12/27/25 at 11:17 p.m. indicated Resident 1 sustained an Open Toe Fracture.During an interview on 1/14/26 at 10:06 a.m., CNA 1 stated she attempted the transfer with Resident 1 from his bed to the chair when he fell. CNA 1 stated Resident 1 had pulled himself up using the transfer pole and got dizzy. CNA 1 then put the bed down and to prevent his leg from not getting caught, he moved it and that's when his toe got caught on the floor. CNA 1 stated Resident 1 was not wearing any non-stick socks or shoes because he was going to the shower. During an interview on 1/14/26 at 1:05 p.m., Resident 1 stated, I was going down the [transfer] pole and my foot slipped on the linoleum, which made me slide down.My left leg is my bad leg and I have no mobility. During an interview on 1/14/26 at 1:34 p.m. the Charge Nurse stated, Because [Resident 1] is unstable, I would expect the resident to be wearing no- slip socks while transferring from bed to shower chair. During an interview on 1/14/26 at 2:09 p.m. the Director of Staff Development (DSD) stated, When teaching [staff] safe transfers, I always mention socks. Socks should be on at all times when a resident will have their feet on the ground.During an interview on 1/14/26 at 2:25 p.m. the Director of Nursing (DON) stated, The expectation is to wear the non-slip socks during transfers. We follow policy. During an interview on 1/14/26 at 3:16 p.m., Resident 1 stated, I wear them [the non-slip socks] when they tell me to. During a review of the facility's policy titled, Transfer of a Resident, Safe, revised January 2025, stipulated during transfer the resident wears proper footwear that fits well and has nonskid soles.

Based on interview and record review the facility failed to report an injury of unknown origin within the required timeframe for one of one resident. The facility was visited by the police for an allegation of abuse related to this injury, and the facility failed to follow up and report the incident to State agencies as required. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safetyFindings: On 12/24/25 at 9:16 a.m., the Department received a report from Adult Protective Services (APS) with an allegation of abuse. EMS (Emergency Medical Services) reported to APS they transported a Resident to the hospital with, bruising and pain to his hand, consistent with a grabbing injury.During an interview on 12/24/25 at 3:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated she was conducting her investigation first to determine if the facility needed to make a report to the State about this injury of unknown origin. The ADON stated she was aware the police visited the facility to look into an allegation of abuse. The ADON stated she did not send in a report to the Department because another agency had already reported the allegation of abuse. The ADON confirmed the allegation had not been reported to the Department by the facility.During a review of the facility's policy titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised 1/15/25, the policy indicated the facility would ensure that, all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property. All alleged violations are to be reported, immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury and not later 24 hours if the alleged violation involves neglect, exploitation, mistreatment or misappropriation of property and does not result in serious bodily injury.

Based on interview and record review, the facility failed to prevent abuse for one resident (Resident 1) when Resident 2 pushed and hit Resident 1.This failure resulted in Resident 1 sustaining two skin tears.Findings:A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness, and a need for assistance with personal care.A review of an admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis which included unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia, and muscle weakness.A review of Resident 1's progress note dated 8/17/25 at 7 a.m. indicated, .[Resident 1] stated, '[Resident 2] had pushed me and punched me as I was falling.' [Resident 1] noted with new skin tears to Left Elbow (2 cm [centimeters, a unit of measurement] x [by] 2 cm) and Right forearm (1 cm x 0.5 cm) .A review of Resident 2's progress note dated 8/17/25 at 7 a.m. indicated, .Resident [2] redirected and asked if she hit [Resident 1]. [Resident 2] stated, 'yes.'In an interview on 9/8/25 at 12:48 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) both the DON and ADON acknowledged Resident 2 did hit Resident 1.A review of the facility's policy and procedure titled Resident Rights .Abuse Prevention revised November 2023 indicated, It is the policy of this facility that each resident has the right to be free from abuse .Resident must not be subjected to abuse by anyone, including, but not limited to .other residents .Abuse is defined as the willful infliction of injury .This presumes that instances of abuse of all residents, even those in a coma, cause physical harm .

Based on observation, interview and record review, the facility failed to ensure immediate resident assistance when call light system was inoperable or inaccessible for six (6) residents (Residents 1, 2, 3, 4, 5, and 6) of 17 residents. This failure had the potential for delayed resident care and emergency response times. Findings: A record review of Resident 1's Admission Record , printed 4/18/25, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including monoplegia (paralysis in which only one limb, an arm or a leg, has lost complete voluntary muscle movement) of lower limb affecting left side, muscle weakness, obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from flowing normally), and benign prostatic hyperplasia (a condition where the prostate gland grows larger than normal due to a non-cancerous increase in cell growth). Resident 1 was discharged from the facility on 4/10/25. A review of Resident 1's MDS-C (Minimum Data Set-a standardized tool that all nursing homes participating in Medicare or Medicaid use to assess residents) , dated 2/18/25, indicated Resident 1 had a BIMS (Brief Interview of Mental Status) provides a quick assessment of a resident's cognitive function, particularly in skilled nursing facilities (SNFs) and long-term care facilities) score of 15, indicating intact cognition. A review of Resident 2's Admission Record , printed 4/21/25, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (a term for lung diseases that cause airflow obstruction and make it difficult to breathe), muscle weakness, need for assistance with personal care, and shortness of breath. A review of Resident 2's MDS-C , dated 4/18/25, it indicated Resident 2 had a BIMS score of 14, indicating intact cognition. A review of Resident 3's Admission Record , printed 4/21/25, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, muscle weakness, dementia ( general term for the progressive decline in mental ability, including memory, language, and reasoning, that interferes with daily life), and anxiety disorder. A review of Resident 3's MDS-C , dated 4/7/25, indicated Resident 3 had a BIMS score of 3, indicating severely impaired cognition. A review of Resident 4's Admission Record , printed on 4/21/25, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and other abnormalities of gait and mobility (gait refers to the pattern of walking, while mobility is the ability to move freely). A review of Resident 4's MDS-C , dated 2/12/25, indicated Resident 4 had a BIMS score of 3, indicating severely impaired cognition. A review of Resident 5's Admission Record , printed 4/21/25, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses including dementia, osteoporosis (a bone disease that causes bones to become weak and brittle, increasing the risk of fractures(broken bones)), and fracture of the right femur (thigh bone). A review of Resident 5's MDS-C , dated 3/4/25, indicated Resident 5 had a BIMS score of 5, indicating severe cognitive impairment. A review of Resident 6's Admission Record , printed 4/21/25, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis (a chronic neurological disorder where the body's immune system mistakenly attacks the protective sheath (myelin) covering nerves in the brain and spinal cord, disrupting communication between the brain and body), neuromuscular dysfunction of the bladder (a condition where bladder control is lost due to damage to the nerves and muscles that regulate bladder function), paralytic syndromes (conditions characterized by paralysis, or the loss of muscle function), anxiety disorder, and chronic pain syndrome. A review of Resident 6's MDS-C , dated 4/14/25, indicated Resident 6 had a BIMS score of 3, indicating severe cognitive impairment. During a phone interview on 4/18/25 at 10:08 a.m., Resident 1's family member stated Resident 1 called on multiple occasions because facility staff had not answered call light after an hour or more. Resident 1 said he was left in urine-soaked clothing and bedding at these times, and Resident 1's family had to call the facility to prompt staff to attend to Resident 1. During an interview on 4/18/25 at 10:17 a.m. with Resident 2, Resident 2 indicated he had problems with his call button since his arrival in the facility, and when he pressed his call button it made noise , but no light would come on at the hallway door to alert staff. Resident 2 stated on multiple occasions he waited over an hour for assistance, including when he needed pain medications. A review of document titled, Broadway Villa Daily Census , dated 4/20/25, indicated Resident 2 now occupied the same bed as Resident 1 had before his discharge on 4/10/25. During a concurrent observation and interview on 4/21/25 at 10:06 a.m. with Certified Nursing Assistant 1 (CNA 1), a resident bedroom was observed. The beds occupied by Resident 3 and Resident 4 were seen with call buttons on the floor behind the right side of each bed. CNA 1 stated they must have fallen off the bed and acknowledged neither of these call lights were accessible to the residents. When CNA 1 asked the residents if they needed anything, Resident 3 stated I didn't know where my call light was . During a concurrent observation and interview on 4/21/25 at 10:10 a.m. with Licensed Vocational Nurse 1 (LVN 1) in a bedroom occupied by Resident 5, LVN 1 observed Resident 5's call button was not on the bed but laying on the right side of the bed on the floor. LVN 1 gave the call button back to Resident 5, who yelled give me my call light! During a concurrent observation and interview on 4/21/25 at 10:25 a.m. with Licensed Vocational Nurse 2 (LVN 2) in a resident bedroom, Resident 6's bed was seen with no call button or cord attached to the wall. LVN 2 stated it had been removed a couple of days prior, and that Resident 6 now had a manual metal call bell. LVN 2 could not locate the metal call bell anywhere within reach of Resident 6's bed. LVN 2 didn't know why Resident 6's regular call light was removed and could not say how Resident 6 would alert staff if he needed help. During an interview on 4/21/25 at 10:30 with Resident 2, Resident 2 stated he heard his roommate (Resident 6) calling out for help quietly, and Resident 2 reminded Resident 6 to use his call light. Resident 2 stated he was not aware Resident 6 no longer had a call light. During a concurrent interview and record review on 4/21/25 at 11:45 a.m., the facility Maintenance Assistant ([NAME]) reviewed the Weekly Nurse Call System Testing , dated 3/3/25, which indicated the facility changed out the call light cord at the bed formerly occupied by Resident 1 (now occupied by Resident 2) on 3/17/25. The [NAME] stated that call light system repair and maintenance was communicated by floor staff to maintenance department via radio, and the work completed was not always recorded in any maintenance log. During a phone interview on 4/21/25 at 12:30 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 6's call button was missing for two days, and she didn't know why. CNA 2 stated she forgot to mention it to maintenance at the end of her shift. During an interview with the Director of Nursing and the Assistant Director of Nursing on 4/21/25, the ADON stated Resident 6's call bell was found underneath his bed and was replaced to the bedside table. The DON stated Resident 6's call button and cord had been removed from the wall because Resident 6 had expressed suicidal ideation (the thought process of having ideas about the possibility of dying by suicide), and it was a safety intervention. The ADON or DON could not say how Resident 6's call bell got underneath the bed, and acknowledged Resident 6 had no means to get staff attention without it. During a review of facility policy and procedure (P & P) titled Call Light/Bell , revised 2/2023, it indicates It is the policy of this facility to provide the resident with a means of communication with nursing staff .answer the light/bell within a reasonable time .place the call device within the resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor. During a review of untitled, undated facility P & P regarding nursing rounds, it indicated CNA's are expected to round on all assigned residents at least every two hours during waking hours and every hour during night shifts. Each round should include visual safety checks (bedrails, call lights within reach, floor clear of hazards) .

Based on observation, interview and record review, the facility failed to ensure a safe environment for three of seventeen sampled residents when three residents (Resident 7, 8 and 9) were left unsupervised while smoking cigarettes. This failure had the potential to cause resident burn injuries and a facility fire hazard. Findings: During a review of Resident 7's Admission Record , printed 4/21/25, it indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular and often rapid heart rhythm that can lead to serious complications like stroke and heart failure), aphasia (a language disorder that makes it difficult to express thoughts or understand spoken or written language), depression, muscle weakness, abnormalities of gait and mobility (deviations from normal walking patterns and movement abilities), nicotine dependence (a highly addictive chemical compound naturally found in tobacco plants, responsible for the addictive nature of tobacco products like cigarettes, cigars, and smokeless tobacco), dyspnea (shortness of breath) and ataxia (a neurological disorder characterized by the loss of coordination of voluntary movements, often affecting balance, walking, and speech). A review of Resident 7's MDS-C (Minimum Data Set Section C-focuses on cognitive patterns. It assesses a resident's mental status, including short-term and long-term memory, recall abilities, and their capacity to make daily decisions. The section also evaluates for signs of delirium) , dated 4/14/25, indicated Resident 7 has a BIMS (Brief Interview for Mental Status, a standardized tool used to screen for cognitive impairment, especially in long-term care facilities. BIMS scores range from 0 to 15, with higher scores indicating better cognitive function) of 7, indicating moderate cognitive impairment. A review of Resident 7's Care Plan Report , undated, indicated observe smoking while in designated area . During a review of Resident 8's Admission Record , printed 4/21/25, it indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (Hemiparesis is a condition of partial muscle weakness on one side of the body, while hemiplegia is the complete paralysis of one side of the body), vascular dementia (a type of dementia caused by damage to the brain's blood vessels, leading to impaired blood flow and oxygen deprivation to brain cells), emphysema (a chronic lung disease, part of Chronic Obstructive Pulmonary Disease (COPD), characterized by damage to the air sacs (alveoli) in the lungs), nicotine dependence, depression, history of falling, bilateral open-angle glaucoma (a progressive optic neuropathy that affects both eyes, causing damage to the optic nerve and leading to vision loss), and history of transient ischemic attack (a temporary disruption of blood flow to the brain, causing symptoms similar to a stroke but that resolve completely within 24 hours). A review of Resident 8's MDS-C , dated 3/18/25, it indicated Resident 8 had a BIMS of 9, indicated moderate cognitive impairment. A review of Resident 8's Care Plan Report , undated, indicated monitor to assess compliance with facility smoking policy/individual plan , and observe smoking while in designated area . During a review of Resident 9's Admission Record , printed 4/21/25, it indicated Resident 9 was initially admitted to the facility on [DATE], with diagnoses including hemiplegia, personal history of transient ischemic attack, dysarthria and anarthria (anarthria is a severe form of dysarthria, a motor speech disorder. While dysarthria causes impaired speech, anarthria results in the complete inability to articulate words), nicotine dependence, psychosis, muscle weakness and abnormalities of gait and mobility (deviations from normal walking patterns and movement abilities). A review of Resident 9's MDS-C , dated 2/6/25, indicated Resident 9 has a BIMS of 15, indicating intact cognition. A review of Resident 9's Care Plan Report , undated, indicated provide 1:1 observation while smoking . During a concurrent observation and interview on 4/21/25 at 10:20 a.m., a staff member and a resident were observed entering the building from the outside smoking patio. There were three residents remaining outside on the patio (Resident 7, Resident 8, and Resident 9), smoking cigarettes. Resident 8 stated, we come out here and smoke whenever we feel like it, sometimes without staff . No staff was seen returning to the smoking area for 15 minutes. During an interview on 4/21/25 at 1:00 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the ADON stated some smoking residents do not comply with smoking policy or care plan, and this is a concern due to burning risks. ADON stated if competent residents want to smoke during unscheduled times, they are supposed to sign-out of the facility. The ADON stated the three residents smoking earlier with no supervision had not signed out of the facility. During a review of facility policy and procedure (P & P) titled Smoking and Safety Measures , revised 12/2023, it indicated, designated smoking times are 10:00, 14:00, 16:00 .smoking sessions will be 15 minutes in length , and smoking may only occur with facility staff present .

Based on observation, interview, record review, and facility policy review, the facility failed to have a physician order for the use of a continuous positive air pressure (CPAP) and failed to properly clean and store CPAP and nebulizer equipment for 1 (Resident #57) of 3 sampled residents reviewed for respiratory care. Findings included: A facility policy titled, BiPap [bilevel positive airway pressure]/CPAP, revised 05/2024, specified, It is the policy of this facility that BiPap/CPAP be administered as ordered by the physician under the following procedures. Per the policy, Procedures: 1. Verify settings per MD [medical doctor] order and 4. BiPap/CPAP checks will be done before use. 5. BiPap/CPAP settings are preprogrammed by Pulmonologist and preset by company providing the equipment for the facility. An Admission Record indicated the facility readmitted Resident #57 on 11/24/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of obstructive sleep apnea. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2025, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #57's care plan, included a focus area revised 05/09/2024 that indicated the resident was at risk for altered respiratory status related to obstructive sleep apnea. Interventions directed staff to apply BiPAP at night as ordered. Resident #57's Order Summary Report for active orders as of 01/22/2025, revealed no order for the use of a BiPAP and/or CPAP machine. During a concurrent observation and interview on 01/20/2025 at 10:17 AM, the surveyor noted Resident #57 had a CPAP machine with the tubing connected to nasal pillows lying on top of the nightstand. There was a nebulizer machine next to the CPAP machine with the tubing and medication cannister connected lying on top of the over-the-bed table on top of books. There was no bag or container to store the CPAP nasal pillows or nebulizer equipment in. Resident #57 stated they used the CPAP every night and the nebulizer as needed when they were short of breath. According to Resident #57, the staff took care of the equipment. During an observation on 01/21/2025 at 2:10 PM, the surveyor noted Resident #57's CPAP nasal pillows and nebulizer equipment were in the same position as on 01/20/2025. During an observation on 01/22/2025 at 10:46 AM, the surveyor noted the CPAP head piece with the nasal pillows hanging on the left bed cane with the tubing attached. The nebulizer machine on the nightstand had the tubing and medication cannister attached lying on the over-the-bed table. During an interview on 01/22/2025 at 11:29 AM, Resident #57 stated they used the nebulizer machine about a week ago, and only got it when they requested. The resident stated they used the CPAP every night, and the staff put tap water in it but that it should be distilled water. During an observation and interview on 01/22/2025 at 1:21 PM, Licensed Vocational Nurse (LNV) #2 stated Resident #57 used the CPAP at night and sometimes during the day. LVN #2 stated she thought the resident had an order but after looking in the computer system, she confirmed that the resident did not have an order for the use of the CPAP. LVN #2 stated she was unsure how it was supposed to be cleaned or stored. LVN #2 stated she would have to find out what the facility policy was on the orders, storing, and cleaning. LVN #2 stated staff should put distilled water in the machine, and it was available in the medication room. LVN #2 stated Resident #57 used the nebulizer as needed and she did administer a treatment on 01/22/2025. LVN #2 stated the cannister and mouthpiece should be rinsed and stored in a plastic bag in between use. LVN #2 stated she did not rinse out the nebulizer equipment after use that afternoon and confirmed there was not a bag to store it in. During an interview on 01/23/2025 at 9:35 AM, the Assistant Director of Nursing (ADON) stated the facility needed an order for a resident to use a CPAP or BiPAP machine that included the settings from the hospital or home, but she would have to look at the policy to see how often the mask and tubing should be changed. The ADON stated it should be stored in a bag when not in use. The ADON stated she would also have to refer to the facility policy on cleaning the nebulizer equipment but stated it needed to be bagged. During an interview on 01/23/2025 at 10:00 AM, the Director of Nursing (DON) stated the facility needed to have orders for a resident to use a CPAP machine that included the cleaning and maintenance of it. The DON stated that when the resident was done using the CPAP or nebulizer, it should be rinsed out then weekly cleaned with soap and water. The DON stated it should be stored where it was accessible, as long as it was not on the floor. The DON stated nebulizer equipment should be stored in a cool dry place and not on the floor. The DON stated he expected the staff to rinse and store the CPAP and nebulizer equipment between each use. During an interview on 01/23/2025 at 10:23 AM, the Administrator stated the facility should have orders for the CPAP machine and the staff should clean and store the respiratory equipment appropriately.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 2 (Resident #64 and Resident #79) of 26 sampled residents. Findings included: A facility policy titled, Accuracy of Minimum Data Set (MDS) Assessments, revised 04/2024, indicated, [Facility name] is committed to completing accurate and timely MDS assessments for all residents in compliance with the Resident Assessment Instrument (RAI) User Manual, Federal Regulations under the Code of Federal Regulations (CFR), Title 42 S483.20, and California Department of Public Health (CDPH) guidelines. The policy further indicated, Each assessment must accurately reflect the resident's current clinical status, functional abilities, and care needs. 1. An Admission Record indicated the facility admitted Resident #64 on 03/11/2021. According to the Admission Record, the resident had a medical history that included a diagnosis of nicotine dependence. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/23/2024, revealed Resident #64 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #64 did not use tobacco. Resident #64's care plan, included a focus area initiated 08/08/2022, that indicated the resident was at risk for injury related to smoking. The care plan indicated Resident #64 refused smoking cessation interventions. During an observation on 01/22/2025 at 2:03 PM, Resident #64 was noted outside smoking. During an interview on 01/20/2025 at 10:51 AM, Resident #64 stated they smoked. During an interview on 01/23/2025 at 9:00 AM, the Infection Prevention Nurse / MDS Coordinator stated Resident #64 smoked and acknowledged it was not coded on the resident's MDS assessment, but that it should have been since the resident smoked since their admission to the facility. During an interview on 01/23/2025 at 10:00 AM, the Director of Nursing (DON) stated he and the MDS Coordinator were responsible to ensure the accuracy of the MDS assessment. The DON confirmed that Resident #64 smoked, and it should have been captured on the MDS assessment. During an interview on 01/23/2025 at 10:23 AM, the Administrator stated the MDS assessment should be accurate for billing purposes, and it should reflect the care that the facility provided. The Administrator stated Resident #64 had been a long-term smoker and should have been coded for tobacco use on the MDS assessment. 45555 2. An Admission Record indicated the facility admitted Resident #79 on 05/11/2022. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/09/2025, revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not receive a restorative nursing program. Resident #79's care plan, included a focus area revised 10/19/2023, that indicated the resident had a potential for a decline in range of motion (ROM) and strength. Interventions directed staff to provide restorative nursing three times a week for bilateral upper and right lower extremity bike to maintain strength and tolerance to functional activities, Resident #79's Order Summary Report for active orders as of 01/22/2025, revealed an order dated 08/25/2022, for restorative nursing aide (RNA) three times a week for bilateral upper extremity and right lower extremity bike to maintain strength and tolerance to functional activities, and an order dated 11/11/2024, for RNA three times a week for sound leg bridge; residual leg bridge against a towel roll; residual limp/hip adduction/abduction in side lying; prone quad set with hip flexion, and prone hip adduction using towel roll; and sit to stand at the hallway hand rail with bilateral upper extremity support wearing prosthetic limb. Resident #79's Restorative Nursing administration record for the timeframe 01/01/2025 - 01/31/2025, revealed the resident received restorative nursing services on 01/02/2025, 01/04/2025, 01/07/2025 01/09/2025, 01/11/2025, 01/14/2025, 01/16/2025, 01/18/2025, and 01/21/2025 for a minimum of 15 minutes each day. Resident #79's RNA Weekly Summary dated 01/09/2025 revealed the resident received active range of motion exercise three times a week for 15 minutes. During an interview on 01/23/2025 at 9:01 AM, MDS Licensed Vocational Nurse (LVN) #1 stated the accuracy of the MDS was important because it reflected the resident and the MDS person was responsible for the accuracy of the MDS. MDS LVN #1 stated Resident #79 did receive restorative services. After review of the resident's MDS with an ARD of 01/09/2025, MDS LVN #1 confirmed he completed the resident's MDS, and restorative services was not coded on Resident #79's MDS. During an interview on 01/23/2025 at 9:35 AM, the Assistant Director of Nursing (ADON) stated the MDS needed to be accurate for billing purposes and for resident care. The ADON stated the accuracy of the MDS was the responsibility of the MDS Coordinator The ADON stated the facility did not for restorative services, so they did not code it on the MDS. During an interview on 01/23/2025 at 10:00 AM the Director of Nursing (DON) stated it was best practice for the MDS to be accurate. The DON stated he and the MDS Coordinator were responsible to ensure the accuracy of the MDS. The DON stated Resident #79 received restorative services and confirmed that it was not captured on the most recent MDS. During an interview on 01/23/2025 at 10:23 AM, the Administrator stated the MDS assessment should be accurate for billing purposes, and it should reflect the care that the facility provided. The Administrator stated he unsure about restorative services being coded on the MDS, the facility did not bill for restorative services, so they did not code it on the MDS.

Based on interview, record review, and facility policy review, the facility failed to hold insulin as ordered by the physician when the resident's blood sugar was out of parameters for 1 (Resident #57) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Pass Observation, revised 09/2024, specified, D. Vital signs and blood sugar need to be monitored according to facility policy and/or the physician's order with medication given based on results. An Admission Record indicated the facility readmitted Resident #57 on 11/24/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2025, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received insulin seven of seven days of the assessment period. Resident #57's care plan included a focus area revised 05/11/2023 that indicated the resident had type 2 diabetes mellitus. Interventions directed staff to administer diabetes medication as ordered by the doctor and monitor for side effects and effectiveness. Resident #57's Order Summary Report for active orders as of 01/22/2025, included an order dated 11/16/2024, for insulin glargine 100 units per milliliter with instructions to inject 35 units subcutaneously every morning and at bedtime with instructions to hold if the resident's blood sugar was less than 180 milligrams per deciliter (mg/dL). Resident #57's Medication Administration Record [MAR] for 12/01/2024 - 12/31/2024, revealed insulin glargine was administered to the resident when the resident's blood sugar was less than 180 mg/dL on the following days for the 8:00 AM dose: -12/04/2024 - blood sugar 167 mg/dL, -12/05/2024 - blood sugar 178 mg/dL, -12/08/2024 - blood sugar 165 mg/dL, -12/11/2024 - blood sugar 178 mg/dL, -12/14/2024 - blood sugar 152 mg/dL, -12/16/2024 - blood sugar 149 mg/dL, -12/17/2024 - blood sugar 145 mg/dL, and -12/30/2024 - blood sugar 177 mg/dL. Resident #57's MAR for 01/01/2025 - 01/31/2025, revealed insulin glargine was administered to the resident when the resident's blood sugar was less than 180 mg/dL on the following day for the 8:00 AM dose: -01/11/2025 - blood sugar 167 mg/dL, -01/12/2025 - blood sugar 179 mg/dL, and -01/17/2025 - blood sugar 145 mg/dL. During an interview on 01/22/2025 at 1:21 PM, Licensed Vocational Nurse (LVN) #2 stated that when giving a medication with parameters, she would get the needed vital, such as a blood pressure, pulse, or blood sugar, and verify it with the order. LVN #2 stated if the results were out of the parameters, then she would hold the medication and document it on the MAR. LVN #2 stated Resident #57 had parameters for their insulin glargine to hold it if the blood sugar was less than 180 mg/dL. After review of Resident #57's MAR for 12/2024 and 01/2024, LVN #2 confirmed that she signed that she administered the insulin when it should have been held on 12/04/2024, 12/05/2024, 12/11/2024, 12/16/2024, 12/17/2024, 12/30/2024, 01/11/2025, 01/12/2025, and 01/17/2025. During an interview on 01/22/2025 at 1:53 PM, the Assistant Director of Nursing (ADON) reviewed Resident #57's MAR and confirmed that the resident's insulin should have been held. During a follow-up interview on 01/23/2025 at 9:35 AM, the ADON stated that when administering medications with parameters, the nurse should review the parameters and hold the medication if out of parameters. The ADON stated giving a medication when it should have been held could cause an adverse reaction later. The ADON stated the nurse should have followed the order and held the resident's when their blood sugar was below 180 mg/dL. During an interview on 01/23/2025 at 10:00 AM, the Director of Nursing (DON) stated that when administering medications, the nurse should follow the ordered parameters, and they would either hold the medication or give it depending on the parameters. The DON stated that in general it could have adverse effects when given when it should not be. The DON stated the nurse should have held the insulin when the resident's blood sugar was below 180 mg/dL. During an interview on 01/23/2025 at 10:23 AM, the Administrator stated medications should be administered according to the physician order, and staff should get clarification if needed.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were stored properly for 1 (Resident #37) of 6 sampled residents reviewed for accidents. Findings included: A facility policy titled, Self-Administration of Medications, revised 11/2023, specified, Storage and location of drug administration will comply with state and federal requirements for medication storage. An Admission Record indicated the facility readmitted Resident #37 on 06/28/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Observation on 01/20/2025 at 9:50 AM, 01/21/2025 at 11:40 AM, and 01/22/2025 at 11:25 AM revealed a container of Citrucel (an over-the-counter fiber laxative used to relieve constipation) on the nightstand in the corner of Resident #37's room with instructions written on the lid to put one spoonful in water. Resident #37's Order Summary Report for active orders as of 01/22/2025 revealed no order for the Citrucel. During an interview on 01/22/2025 at 11:25 AM, Certified Nursing Assistant #3 stated she did not realize the container of Citrucel was in the resident's room. During an interview on 01/22/2025 at 1:21 PM, Licensed Vocational Nurse (LVN) #2 stated Resident #37 should not have medications at their bedside. LVN #2 entered Resident #37's room and removed the Citrucel from the nightstand. LVN #2 stated the resident's family must have brought it in and did not tell them. According to LVN #2, she did not think the resident had an order for the Citrucel. During an interview on 01/23/2025 at 9:35 AM, the Assistant Director of Nursing (ADON) stated medication should not be left at the bedside unless the resident had an order to self-administer medications, and then the facility would refer to their policy. The ADON stated the resident's family should have told the facility that the Citrucel was brought in, but it should have been caught by the staff and followed up on. During an interview on 01/23/2025 at 10:00 AM, the Director of Nursing (DON) stated medications should not be left at the bedside unless the resident had been assessed for self-administration. The DON stated the resident did not have an order for medications to be left at the bedside and did not have an order for the Citrucel. The DON stated it should not have been left in the room but should have been identified by the staff and an order received for its use if it was appropriate. During an interview on 01/23/2025 at 10:23 AM, the Administrator stated the Citrucel in Resident #37's room should have been identified and removed.

Based on interview, document review, and facility policy review, the facility failed to ensure the daily staffing posted included the facility name and the actual hours worked by the licensed and unlicensed staff for 32 of 32 days reviewed. Findings included: A facility policy titled, Policy on Posting Nursing Hours Per Patient Day (NHPPD) Numbers, effective 04/2024, revealed, Purpose To ensure compliance with California state and federal regulations regarding the public posting of Nursing Hours Per Patient Day to maintain transparency and accountability in staffing levels. Per the policy, b. The posting must include: i. Total NHPPD. ii. Actual hours worked by RNs [registered nurses], LVNs/LPNs [licensed vocational nurses/licensed practical nurses], and CNAs [certified nursing assistants]. The facility daily staff posting for the timeframe 12/20/2024 to 01/20/2025, revealed the posting did not include the name of the facility or the actual hours worked by the staff. During an interview on 01/23/2025 at 8:41 AM, the Staffing Supervisor confirmed the daily staff posting did not include the facility's name or the actual worked by the staff. During an interview on 01/23/2025 at 8:53 AM, the Director of Nursing stated he was not aware the name of the facility was not posted on the daily staff posting and that he did not know the actual worked hours for the staff had to be included. Per the DON, the Staffing Supervisor was responsible for ensuring the posting included all the required information. During an interview on 01/23/2025 at 10:41 AM, the Administrator stated he expected the daily staffing posting to include the information required.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 3) was treated with dignity and respect when a Certified Nursing Assistant (CNA) made an inappropriate comment to Resident 3. This failure resulted in Resident 3 feeling uncomfortable and insulted. Findings: A review of Resident 3's admission record indicated she was admitted on [DATE] with the diagnoses of malignant neoplasm (a cancerous tumor [abnormal growth of tissue] that forms when cells grow and divide uncontrollably) of the left female breast. A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/27/24, indicated Resident 1 had no memory impairment. During an interview, on 1/14/25 at 2:50 p.m., Resident 3 stated that while providing care CNA 1 had made a comment regarding her tumors something like, Why is your boob so big? Resident 3 stated the comment was inappropriate and it was none of CNA 1's business. During a phone interview, on 1/14/25 at 3:17 p.m., CNA 1 stated while caring for Resident 3 she had made an inappropriate comment about Resident 3's breasts. CNA 1 acknowledged she needed to be more careful with her communication. During an interview, on 1/14/25 at 4:28 p.m., with the Assistant Director of Nursing (ADON), the ADON stated it was her expectation staff treated residents with dignity and respect. The ADON stated she had been made aware of the comment made by CNA 1 to Resident 3 and agreed it was inappropriate. During a review of a facility document titled, Resident Rights, it indicated, As a resident of this nursing facility .You have the right to be treated with respect and dignity .

Based on observation, interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills to provide nursing services to ensure resident safety and meet the healthcare needs of the residents, according to the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 1) the facility employed four Licensed Psychiatric Technicians (LPTs - LPTs B, H, L and M) to work in the role of Licensed Vocational Nurses (LVNs), of a total scheduled LVN workforce of 18, assigning the LPTs care of residents with complex clinical care needs, some with more than 35 different medical diagnoses. 2) the facility failed to ensure LPTs B, H, L, and M had the appropriate competencies and skills to provide care to the resident population; and 3) the facility failed to provide sufficient Certified Nursing Assistants (CNAs) to meet resident needs according to its facility assessment. These failures resulted in LPTs B, H, L and M working outside their scope of practice when they were tasked with providing professional nursing care to residents with complex medical diagnoses, without the required training and education, placing 103 of 103 residents at risk of not achieving their highest practicable physical, mental, and psychosocial well-being, and placing them at risk of serious harm or death. One LPT (LPT L), newly graduated and without clinical experience, provided care to a full resident assignment (i.e.: an independent resident assignment, not assisting another nurse) after only six days of orientation. These failures had the potential to affect all facility residents (average daily census of 102 residents during May and June 2022). The insufficient number of CNAs placed residents at risk of not having their needs met. Due to the facility's failure to ensure sufficient nursing staff when the facility employed four LPTs to work as LVNs and the facility's lack of documented competencies and skills for the LPTs, creating the likelihood of serious harm, injury, impairment or death to residents, the Administrator and the Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) on 6/23/22, at 12:33 p.m. The Administrator and the DON were also provided a completed IJ template. The facility submitted an acceptable IJ removal plan which was approved on 6/23/22 at 3:33 p.m. The IJ was removed on 6/24/22 at 3:33 p.m. upon onsite verification of the implementation of the facility's IJ removal plan, which included the removal of the LPTs from the facility's staffing schedule. Findings: 1) A review of the facility's current staffing list, provided during the survey, indicated four Licensed Psychiatric Technicians (LPTs) employed by the facility: LPT L, hired on 4/25/22, LPT M, hired on 5/11/22, LPT H, hired on 5/17/22, and LPT B, hired on 5/23/22. According to the California Board of Vocational Nursing and Psychiatric Technicians (BVNPT), an LPT is an entry-level health care provider who is responsible for care of mentally disordered and developmentally disabled clients. A psychiatric technician practices under the direction of a physician, psychologist, rehabilitation therapist, social worker, registered nurse or other professional personnel. The licensee is not an independent practitioner. (What is a psychiatric technician (PT?), California Board of Vocational Nursing and Psychiatric Technicians, 2022, https://www.bvnpt.ca.gov). A review of the BVNPT online license records indicated LPT H obtained her psychiatric technician license on 1/8/16, LPT M on 9/22/16, LPT B on 7/20/18 and LPT L on 3/29/22. A search of the BVNPT indicated LPTs H, M, B and L did not have a vocational nurse license. A review of the facility's staffing schedule for June 2022, provided by the Administrator during the entrance conference on 6/20/22, indicated LPTs B, H, L and M were assigned multiple shifts providing care to facility residents. The schedule indicated LPTs B and H worked morning shifts (6:30 a.m. to 3 p.m.), LPT L afternoon shifts (2:30 p.m. to 11 p.m.) and LPT M night shifts (10:30 p.m. to 7 a.m.). The schedule indicated the following shifts and assignments for LPTs B, H, L and M for June 2022: LPT B: 6/1 (Unit 2 - Orientation), 6/2 (Unit 1 - Orientation), 6/3 (Unit 1 - Orientation), 6/4 (Unit 1 - Orientation), 6/7 (Unit 1 - Orientation), 6/9 (Unit 1 - Orientation), 6/10 (Unit 1), 6/13 (Unit 1), 6/14 (Unit 1), 6/15 (Unit 1), 6/16 (Unit 1), 6/19 (Unit 1), 6/20 (Unit 1), 6/21 (Unit 1), 6/22 (Unit 1), 6/25 (Unit 1), 6/26 (Unit 1), 6/27 (Unit 1) and 6/28 (Unit 1). LPT H: 6/2 (Unit 4 - Orientation), 6/3 (Unit 2 - Orientation), 6/4 (Unit 4 - Orientation), 6/5 (Unit 4 - Orientation), 6/9 (Unit 2 - Orientation), 6/10 (Unit 4 - Orientation), 6/11 (Unit 2 - Orientation), 6/14 (Unit 2 - Orientation), 6/15 (Unit 2 - Orientation), 6/16 (Unit 2 - Orientation), 6/20 (Unit 2), 6/21 (Unit 2), 6/22 (Unit 2), 6/23 (Unit 2), 6/26 (Unit 4), 6/27 (Unit 2), 6/28 (Unit 2), and 6/29 (Unit 2). LPT L: 6/3 (Unit 3), 6/4 (n/a), 6/8 (Unit 2), 6/9 (Unit 2), 6/10 (Unit 2), 6/12 (Unit 1), 6/13 (Unit 1), 6/14 (Unit 2), 6/15 (Unit 2), 6/18 (Unit 1), 6/19 (Unit 1), 6/20 (Unit 2), 6/21 (Unit 2), 6/24 (Unit 1), 6/25 (Unit 1), 6/26 (Unit 2), 6/27 (Unit 2), and 6/30 (Unit 1). LPT M: 6/11 (Unit 3), 6/13 (Unit 3), 6/16 (Unit 3), 6/17 (Unit 3), 6/18 (Unit 4), 6/19 (Unit 1), 6/22 (Units 1 and 2), 6/23 (Units 1 and 2), 6/24 (Unit 4), 6/25 (Unit 4), 6/28 (Unit 4), 6/29 (Units 3 and 4) and 6/30 (Unit 4). A review of the facility's floor plan indicated the facility was divided into two stations: North and South, and each station comprised two units. The North Station comprised Units 1 and 2. The South Station Units 3 and 4. Unit 1 comprised 13 rooms: #101, #102, #104, #106, #108, #109, #206, #208, #210, #212, #501, #502 and #503, for a total of 38 beds. Unit 2 comprised 11 rooms: #111, #202, #204, #401, #402, #403, #404, #405, #406, #407 and #408, for a total of 25 beds. Unit 3 comprised 12 rooms: #504, #505, #506, #507, #508, #601, #602, #604, #606, #608, #609 and #610, for a total of 37 beds. Unit 4 comprised 13 rooms: #611, #612, #614, #616, #617, #618, #619, #620, #622, #623, #624, #625 and #626, for a total of 39 beds. In total, the facility was licensed for 144 skilled nursing beds. A review of the facility's staffing schedule for June 2022 indicated a total of 22 Licensed Vocational Nurses (LVNs) and LPTs providing direct resident care (floor, lead and treatment nurses), excluding on-call and part-time LVNs. LPTs B, H, L and M represented approximately 18% of the staffing (LVNs and LPTs). During an observation and concurrent interview on 6/20/22, at 4:07 p.m., LPT H, assigned residents in Unit 2, was sitting at the South Nurse's Station, and stated she was new to her job and had previously worked (at another facility) as a psychiatric technician (not a nurse). LPT H stated she felt her current job was too much and she could not get her medications passed (timely). She stated she began her medication pass at 7:30 a.m. but had not finished until 12:30 p.m. LPT H stated she had approximately twenty residents to care that day. During an interview on 6/22/22, at 3:05 p.m., LPT B, assigned residents in Unit 1, stated he had about 32 residents under his care. LPT B stated his job at the facility was equivalent to a nurse. During an interview on 6/22/22, at 3:40 p.m., the Director of Nursing (DON) stated nursing care at the facility was provided by RNs, LVNs, and LPTs. The DON confirmed LPTs B, H, L and M were employed in the facility in the role of LVNs. The DON stated LPTs had the same resident assignments and responsibilities as LVNs. The DON stated LPTs were responsible for medication management, assessments and wound care and other tasks. The DON stated They [LPTs] can do whatever LVNs can do. During an interview on 6/23/22, at 9:52 a.m., LPT H stated she had resident assignments just like a nurse. LPT H stated she shadowed a nurse for about 2 weeks as part of their training. They stated their workload/assignment was too much, and she felt overwhelmed. LPT H stated she did not know how to assess residents. LPT H stated she had to assess residents complaining of chest pain even when they had not done such assessments before. LPT H stated she did not feel prepared to work in the role of a licensed nurse. A review of e-mail communication dated 6/23/22, at 10:23 a.m., addressed to the Department, from Confidential Complainant N (CCN), indicated CCN was an LPT at the facility and was working in the role of a licensed nurse. CCN stated it was unsafe for patients. CCN stated they had no training to work as a nurse. A review of confidential complaints received by the Department about the facility indicated in addition to CCN's complaint, the Department received another 22 confidential complaints about insufficient or unqualified nursing staff at the facility for the period May and June 2022. According to the BVNPT, the course content of LPTs and LVNs are distinct. The course content of LPT programs comprises the following courses: 1) Anatomy & Physiology; 2) Communicable Diseases; 3) Communication; 4) Developmental Disabilities; 5) Gerontological Nursing; 6) Leadership; 7) Medical/Surgical Nursing; 8) Mental Disorders; 9) Normal Growth and Development; 10) Nursing Fundamentals; 11) Nursing Process; 12) Nutrition; 13) Patient Education; 14) Pharmacology; 15) Psychology and 16) Supervision; while the course content of LVN programs comprises the following courses: 1) Anatomy & Physiology; 2) Communicable Diseases; 3) Communication; 4) Critical Thinking; 5) Culturally Congruent Care; 6) End-of-Life Care; 7) Ethics and Unethical Conduct; 8) Gerontological Nursing; 9) Leadership; 10) Maternity Nursing; 11) Medical-Surgical Nursing; 12) Normal Growth and Development; 13) Nursing Fundamentals; 14) Nutrition; 15) Patient Education; 16) Pediatric Nursing; 17) Pharmacology; 18) Psychology; 19) Rehabilitation Nursing and 20) Supervision. (What is the course content of a PT program? and What is the course content for a VN program?), California Board of Vocational Nursing and Psychiatric Technicians, 2022, https://www.bvnpt.ca.gov). According to the BVNPT, LPTs are employed in different facilities. LPTs are employed in State Hospitals, Day Treatment Centers, Developmental Centers, Correctional Facilities, Psychiatric Hospitals & Clinics, Psychiatric Technician Programs, Geropsychiatric Centers, Residential Care Facilities and Vocational Training Centers while LVNs are employed in Acute Medical/Surgical Hospitals, Convalescent Hospitals (Long Term Care, Skilled Nursing), Home Care Agencies, Outpatient Clinics, Doctor's Offices, Ambulatory Surgery Centers, [CONDITION(S)] Centers, Blood Banks, Psychiatric Hospitals, Correctional Facilities and Vocational Nursing Programs. (Where are PT employed? and Where are LVNs employed?, California Board of Vocational Nursing and Psychiatric Technicians, 2022, (https://www.bvnpt.ca.gov). A review of e-mail received on 6/23/22, at 5:50 p.m., from the BVNPT, in response to a query from the Department about the scope of practice of LPTs, indicated the LPT and LVN professions are not interchangeable, and an LPT cannot be hired to work as an LVN, as follows: A licensed psychiatric technician (PT) cannot work or be hired as a licensed vocational nurse (LVN). The PT and LVN scopes of practice are significantly different. Each licensee must work under their own scope of practice. A review of the facility's job descriptions for LPTs and LVNs indicated different scope of practices, as follows: Facility policy titled Licensed Psychiatric Technician, dated 2/22/22, indicated: The primary purpose of your job position is to provide direct patient/resident care to specific residents under the medical direction and supervision of the residents' attending physician or the Medical Director of the facility, with an emphasis on basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan or treatment plan, and contributes to the evaluation of individualized interventions related to the care plan and treatment plan. Facility policy titled Licensed Vocational Nurse, undated, indicated The primary purpose of your job position is to provide direct patient/resident care to specific residents under the medical direction and supervision of the residents' attending physician or the Medical Director of the facility, with an emphasis on assessment, illness prevention and healthcare management. You will also assist in modifying the treatment regimen to meet the physical and psychosocial needs of the resident, in accordance with established medical practices and the requirements of this state and the policies and goals of the facility. During concurrent interviews and record review on 6/22/22, at 11:15 a.m. and 12:40 p.m., and on 6/24/22, at 10 a.m., the facility's Staffing Coordinator (SC) provided copies of and reviewed the staffing/assignments sheets and labor reports for the 30-day period of 5/22/22 to 6/20/22, which he stated reflected the actual nursing shifts and assignments worked by RNs, LVNs, LPTs, and CNAs during the period. The Staffing Coordinator confirmed LPTs B, H, L and M worked a full 8-hour shift on the days below with the respective unit assignments (includes only shifts where the LPTs worked independently with a full resident assignment; excludes shifts where the LPTs were splitting resident assignments with another nurse or were orienting): LPT B: 6/7 (Unit 1 - 32 residents), 6/8 (Unit 1 - 31 residents), 6/10 (Unit 1 - 32 residents), 6/13 (Unit 1 - 32 residents), 6/14 (Unit 1 - 33 residents), 6/15 (Unit 1 - 33 residents), 6/16 (Unit 1 - 33 residents), 6/19 (Unit 1 - 32 residents) and 6/20 (Unit 1 - 33 residents). (All morning shifts). LPT H: 6/16 (Unit 2 - 18 residents) and 6/20 (Unit 2 - 21 residents). (All morning shifts). LPT L: 5/22 (Unit 3 - 32 residents), 5/23 (Unit 3 - 32 residents), 5/24 (Unit 4 - 21 residents), 5/25 (Unit 4 - 19 residents), 5/28 (Unit 3 - 32 residents), 5/29 (Unit 4 - 20 residents), 5/31 (Unit 4 - 18 residents), 6/3 (Unit 3 - 32 residents), 6/4 (Unit 3 - 32 residents), 6/8 (Unit 2 - 17 residents), 6/9 (Unit 2 - 17 residents), 6/10 (n/a), 6/12 (Unit 1 - 30 residents), 6/13 (Unit 1 - 32 Residents), 6/14 (Unit 2 - 18 residents), 6/15 (Unit 2 - 18 residents), 6/18 (Unit 1 - 33 residents), 6/19 (Unit 1 - 32 residents) and 6/20 (Unit 2 - 21 residents). (All afternoon shifts). LPT M: 5/30 (Unit 1 - 35 residents), 5/31 (Unit 3 - 32 residents), 6/10 (n/a), 6/11 (Units 3 and 4 - 50 residents), 6/12 (Unit 3 - 30 residents), 6/13 (Unit 3 - 30 residents), 6/16 (Unit 3 - 30 residents), 6/17 (Units 1 and 2 - 54 residents), 6/18 (Unit 4 - 37 residents) and 6/19 (Unit 3 - 30 residents). (All night shifts). A review of the FACILITY ASSESSMENT TOOL (a document in which the facility indicates the acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] PSYCHIATRIC/MOOD DISORDERS: [CONDITION(S)] (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, [CONDITION(S)] Disorder (i.e., [CONDITION(S)]/Depression), [CONDITION(S)], Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. HEALTH/CIRCULATORY SYSTEM: Congestive Heart Failure, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Hypertension, [CONDITION(S)], Peripheral Vascular Disease, Risk for Bleeding or Blood Clots, [CONDITION(S)] IDVT), Pulmonary, [CONDITION(S)]-Embolism (PTE). NEUROLOGICAL SYSTEM: [CONDITION(S)] Disease, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Multiple [CONDITION(S)], Alzheimer's Disease, Non- Alzheimer's Dementia, [CONDITION(S)] Disorders, [CONDITION(S)], TIA, Stroke, Traumatic Brain Injuries, [CONDITION(S)], [CONDITION(S)] Disease, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)]. VISION: visual Loss, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)]. HEARING: Hearing Loss. MUSCULOSKELETAL SYSTEM: Fractures, [CONDITION(S)], Other Forms of Arthritis. NEOPLASM: [CONDITION(S)], Breast Cancer, [NAME] Cancer, Colon Cancer. METABOLIC DISORDERS: Diabetes, [CONDITION(S)] Disorders, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Obesity, Morbid Obesity. RESPIRATORY SYSTEM: Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), Pneumonia, Asthma, Chronic [NAME] Disease, Respiratory Failure. [CONDITION(S)] SYSTEM: [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] Bowel or Bladder, Renal Failure, End Stage Renal Disease, [CONDITION(S)], Obstructive [CONDITION(S)], Urinary Incontinence. DISEASES OF BLOOD: [CONDITION(S)]. INFECTIOUS DISEASES: Skin and Soft Tissue Infections, Respiratory Infections, Urinary Tract Infections, Infections with Multi-Drug Resistant Organisms, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] Dificile, Influenza, Scabies, [CONDITION(S)]. DIGESTIVE SYSTEM: Gastroenteritis, [CONDITION(S)], [CONDITION(S)] Ulcers, Gastroesophageal Reflux, [CONDITION(S)], [CONDITION(S)] Disease, [CONDITION(S)] Bowel Disease, Bowel Incontinence INTEGUMENTARY SYSTEM: Skin Ulcers, Deep Tissue injuries. A sampled review of the resident assignments of LPTs B, H, L and M, for three randomly selected shifts during the 30-day period of 5/22/22 to 6/20/22, indicated that LPTs B, H, L and M provided direct care to residents who had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] LPT B - 6/16/22 - Morning Shift - Unit 1 - 33 Residents. A review of the facesheets of 31 of the 33 Residents listed in the census for 6/16/22, for Unit 1, indicated only 4 residents (13%) had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents assigned to LPT H had each between 6 and 36 different medical diagnoses. LPT H - 6/16/22 - Morning Shift - Unit 2 - 18 Residents. A review of the facesheets of 16 of the 18 Residents listed in the census for 6/16/22, for Unit, 2 indicated none had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents assigned to LPT H had each between 14 and 29 different medical diagnoses. LPT M - 5/31/22 - Night Shift - Unit 3 - 32 Residents. A review of the facesheets of 29 of the 32 Residents listed in the census on 5/31/22, for Unit 3, indicated only 3 residents (10%) had a primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents assigned to LPT M had each between 8 and 30 different medical diagnoses. LPT L - 5/25/22 - Afternoon Shift - Unit 4 - 19 Residents. A review of the facesheets of 14 of the 19 Residents listed in the census on 5/25/22, for Unit 2, indicated 3 residents (15%) had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents assigned to LPT M had each between 9 and 28 different medical diagnoses. A review of the FACILITY ASSESSMENT TOOL also indicated the following clinical classification of the resident population and the percentage of residents in each classification in the last 12 months, with Behavioral Symptoms comprising less than 10% of the total, as follows: Rehabilitation 11.83% Extensive Services 2.15% Special Care High 9.68% Special Care Low 11.83% Clinically Complex 21.51% Behavioral Symptoms 9.68% Reduced Physical Function 33.33% A review of the FACILITY ASSESSMENT TOOL further indicated the staffing resources to meet the needs of the resident population. Under Staffing Plan, it indicated that direct resident care will be provided my Registered Nurses, Licensed Vocational Nurses and Certified Nursing Assistants. The facility's staffing plan did not include the use of Licensed Psychiatric Technicians. During an interview on 6/23/22, at 9:21 a.m., the Medical Director (MD) was asked about the facility program where LPT's (not licensed nurses) provided resident care. The MD stated the practice of utilizing LPT's was discussed at the March (2022) Quality Assessment (QA) meeting (leadership meetings that addressed quality issues). He stated staffing was challenging at the facility, due to Covid, and the State of California, allowed it (LPT's providing patient care in skilled nursing facilities). The MD stated the facility had done its due diligence (regarding the LPT program) and the DON was providing supervision. When asked how the facility vetted the LPT program for safety, the MD stated, I can't comment. When asked to describe the planning details of the program, the MD stated, I can't give it and stated, they (leadership) told me about it. When asked if he was aware the LPT's were operating outside their scope of practice, the MD stated, I don't think so. 2a) During an interview on 6/22/22 at 3:05 p.m., LPT B stated he started job training three weeks prior, and he was still on training. LPT B stated LN I (a licensed vocational nurse, not an RN) was currently training him, and he had about thirty-two residents under his care. He stated LN I was not with him the entire time when he was passing medications. LPT B stated he felt his training was being done hastily, there is not enough staff to ensure quality of care, and everyone is so busy. During an interview on 6/22/22 at 3:30 p.m., Assistant Director of Nursing (ADON) verified LPT B had 32 residents to take care of today. Review of LPT B's employee file indicated he was hired at the facility 5/23/2022 and review of resident assignment sheets indicated he began orientation approximately 5/27/2022. The assignment sheets indicated LPT B additionally oriented on 5/28/22, 6/1/22, 6/2/22, 6/3/22 and 6/4/22 (approximately six shifts). The assignment sheets indicated LPT B was taken off orientation status (that included training and supervision of a licensed nurse) and worked independently (with a full assignment, not assisting another licensed nurse) on 6/7/2022 and was back on orientation 6/8/22. The assignment sheets indicated LPT B worked independently on 6/10/22, 6/13/22, 6/14/22, 6/15/22, 6/16/22, 6/19/22, and 6/20/22. Review of LPT B's competency check-off list (list of skills to mark off when proficiency was demonstrated) titled, Licensed Psychiatric Technician Comprehensive Clinical Competency Review - Skills Checklist (undated) indicated he did not have competencies for: A) two of six skills (Completing incident report and Linking progress notes to risk management) under the category of Safety/Falls Prevention; B) six of twelve skills (Sterile dressing changes, negative pressure wound therapy, pressure injury staging, pressure ulcer risk assessment, staple and suture removal, and wound care insert) under category Skin/Pressure Injury Management; C) three of eight skills (knowledge of antimicrobial stewardship, immunizations, and discontinuing isolation precautions) under the category of Infection Control; D) nine of fourteen skills (Entering physician orders, completing incident reports, short and long term care plans, documenting follow up pain scale for all pain medication administration, identification and completion of UDA's [user-defined assessments], change of condition process and assessment, skin assessments, monthly summaries, and IV MAR [intravenous medication administration report] and TAR [treatment administration report] and electronic MAR) under the category of Documentation/Assessment skills/Care planning, including, Completing Incident Reports and Change of Condition Process (skills that include addressing/treating/documenting unusual incidents or decline in resident status); and E) no skills were checked as completed under category, Admissions and Discharges/Transfers. The name of the observer (DON or Designee) line and the signature of Observer (DON or Designee) line were both blank. No trainers had signed or dated the document. 2b) During an observation and concurrent interview on 6/20/22 at 4:07 p.m. LPT H and Licensed Nurse E were sitting at the South Nurse's Station. When asked about her training, LPT H stated she had approximately three weeks of training with approximately five different staff. LPT H stated, everyone does it (training) a little different. LN E stated she and LPT H each had approximately twenty residents to care of that day. During an interview on 6/23/22 at 9:37 a.m., LPT H stated she had worked at a crisis home prior to working at the facility. LPT H stated she cared for up to five patients (per shift) at the crisis home and her duties included passing medication, creating behavioral care plans (directing behavioral care) and training staff. LPT H stated she was utilized differently at this facility and stated she had, no idea what I was walking into (by working at this skilled nursing facility). LPT H stated she was interrupted frequently, the workload was too much, and it was, impossible to pass meds (medications) on time. She stated it sometimes took her four and a half hours to get resident medication passes completed (nurses generally have a two-hour window to pass medications; one hour before, and up to one hour after a scheduled medication time). During the same interview on 6/23/22 at 9:37 a.m., LPT H was asked about her clinical education while in psychiatric technician school. LPT H stated she had been placed at a hospital that served the needs of people with developmental disabilities, her school's clinical training was observational only, and the students did not have the opportunity to practice hands-on care (providing direct patient care). LPT H stated she felt, over (her) head working in her current position (as an LPT in a skilled nursing facility) and she needed, extensive training. She stated her current training included shadowing (following/observing/being trained by) a nurse for approximately two to two and a half weeks. LPT H stated she would need a lot of training to feel comfortable working at this facility. LPT H stated her training was not yet completed but she was pretty much, on her own last Monday, 6/20/22. Review of the facility's staff assignment sheet indicated LPT H was off orientation and independently assigned to, Station . 2 on 6/20/22 for day shift (approximately 6:30 a.m. to 3 p.m.). Review of the resident census (dated 6/20/22) indicated Station 2 had approximately twenty-five residents for whom LPT H was responsible. During the same interview on 6/23/22 at 9:52 a.m., LPT H was queried about specific nursing skills. When asked if she knew how to access and utilize an emergency kit (E-Kit, a small supply of medications routinely utilized in skilled nursing and kept on-hand to rapidly treat symptoms), LPT H stated she did not know how to get medications from an E-kit. LPT H stated she did not know how to assess residents (comprehensive health assessment that gives a nurse insight into a residents' physical status through observation, the measurement of vital signs and self-reported symptoms). LPT G stated she had been asked to assess a resident who had been complaining of chest pain (indicating a potential heart attack). She stated she had needed to ask a licensed nurse to help her break down (identify and prioritize) the steps required to assess chest pain (for example: check heart rate and blood pressure, check oxygen level, determine presence of sweating or shortness of breath, obtain a description of the pain; then call the doctor with the results). During the same interview and concurrent record review on 6/23/22 at 9:52 a.m., LPT H was asked about her ongoing training at the facility. LPT H reviewed her skills competency list and stated she (rather than her trainer) had checked-off items on the list. LPT H confirmed all areas on the list were not checked off (indicating she was not yet competent in those skills). LPT H stated she had checked off many of the items on the list the previous day. When asked if filling out the competency list herself was more like a self-assessment (rather than a competency check by an experienced trainer), LPT H agreed that it was. Review of LPT H's skills list titled, Licensed Psychiatric Technician Comprehensive Clinical Competency Review - Skills Checklist (undated) indicated she did not have competencies for: A) eight of eleven skills (gastric residual, feeding tube placement, safety precautions, continuous pump feedings, feeding via syringe, tube insertion and care, cardiopulmonary distress, weight variances) under the category of Enteral Feeding (tube feedings) /Nutritional/Weight variances; B) twelve of fourteen skills (entering physician orders, progress notes, incident reports, care plans, narcotic administration, follow up pain scale, documenting non-pharmacological interventions prior to [CONDITION(S)] medications, checking for missed documentation in MAR, completing UDA's, change of conditions, skin assessments, monthly summaries, and IV MAR, and TAR and electronic MAR) under the category Documentation/Assessment Skills/Care Planning and C) six of sixteen skills (medication ordering/reordering, medication availability, E-Kit first dose medication, inhaler medications, self-administer medications, medication storage) under, Medications Management, including What medications can be found in first dose machine .E-kit. One skill was checked under category, Skin/Pressure Injury Management and no skills were checked as completed under categories, [CONDITION(S)] Medication Management, Safety/Fall Prevention, and ADLs/Rehab/Mobility/RNA program (restorative services). The name of the observer (DON or Designee) line and the signature of Observer (DON or Designee) line were both blank. No trainers had signed or dated the document. Review of facility polity titled, Nursing Staff Competency, subtitled, Procedures (undated) indicated, 3. Director of Staff Development, Nurse Manager or designee must validate all skills listed on the form for competent performance. 2c) Review of LPT L's skills list titled, Licensed Psychiatric Technician Comprehensive Clinical Competency Review - Skills Checklist (undated) indicated multiple competencies were not completed: A) seven of eleven skills under the category of Enteral Feedings/Nutrition/Weight Variances were not checked; B) Seven of fifteen skills under category ADLs/Rehab/Mobility/RNA Program were not checked; and C) Two of eight skills under the category of Infection Control were not checked, including Discontinuing Isolation Precautions. No skills were checked as completed under the categories of, Skin/Pressure Injury Management or Medication Management. The name of the observer (DON or Designee) line and the signature of Observer (DON or Designee) line were both blank. No trainers had signed or dated the document. Review of LPT L's assignment sheets indicated he began orientation at the facility 5/1/22 and it continued until 5/21/22 (approximately twenty days). An assignment sheet dated 5/11/22 indicated LPT L was taken off orientation for a shift and worked independently on Cart 3 (passing medications and caring for residents) when an experienced nurse called off (did not come in for their shift). The assignment sheets indicated LPT L oriented a[TRUNCATE

Based on interview and record review, the facility failed to recognize a resident's increased risk of falls and did not provide additional supervision to prevent a fall for 1 of 3 residents (Resident 1). This failure resulted in Resident 1 falling and requiring emergency transport to the hospital. Resident 1 was diagnosed with bleeding inside her skull and subsequently died . Findings: During a review of Resident 1's clinical record, the Face Sheet indicated the facility admitted Resident 1 on [DATE], with a diagnosis of [CONDITION(S)] (PD) (movement disorder that affects the nervous system), Multiple Fractures (a crack or break in bone) of Ribs, History of Falling, and [CONDITION(S)] (visual acuity -- vision that allows a person to see straight ahead of them) of ,d+[DATE] or less, in his or her better eye with correction). During a review of Resident 1's clinical record, the Care Plan for Activities of Daily Living (ADL - common ADLs include feeding oneself, bathing, dressing, grooming, transferring, walking) Self Care Performance, initiated on [DATE], indicated Resident 1, Requires SUPERVISION with staff to use toilet and goes to use toilet without supervision at times? I?m fine and able to do it? [sic]. The Care Plan also indicated Resident 1 required supervision with transfers (to move from one place to another). During a review of Resident 1's clinical record, the Care Plan for Falls, initiated on [DATE], indicated the interventions were to avoid rearranging furniture; call light within reach; wear appropriate footwear; and maintain clear pathway. During a review of Resident 1's clinical record, the Minimum Data Set (MDS - an assessment tool) Quarterly Assessment, dated [DATE], indicated Resident 1 had a BIMS (Brief Interview of Mental Status) score of ,d+[DATE], indicating Resident 1 had moderate cognitive (mental process involved in knowing, learning, and understanding things) impairment. The record also indicated Resident 1 needed supervision (oversight, encouragement, or cueing) and set-up help with transfer, toilet use, and walking in room and in corridor. During a review of Resident 1's clinical record, the Fall Risk Evaluation, dated [DATE], indicated Resident 1 had a total score of 9 indicating Resident 1 was a medium risk for falls. During a review of Resident 1's clinical record, the ADL Records, dated [DATE], [DATE], [DATE], and [DATE], indicated Certified Nurse Assistants (CNA) provided limited assistance (resident is highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with transfer. The ADL Record, dated [DATE], a.m. shift, indicated CNAs provided extensive assistance (resident involved in activity; staff provide weight-bearing assistance) with transfer. During a review of Resident 1's clinical record, the Rehabilitation Services Screen, dated [DATE], indicated Nursing recommended a Rehab (an abbreviation for Rehabilitation) Screen due to Resident 1 had a functional status change (change individual's ability to perform Activities of Daily Living). The record also indicated Resident 1 had a change in status for transfers, ambulation (walking), and balance. The Director of Rehabilitation (DOR) indicated, on her Summary under additional information, Resident has decline in functional balance, unsteady gait and increased risk of falls. During a review of Resident 1's clinical record, the Physical Therapist (PT) evaluation and Plan of Treatment, dated [DATE], indicated Resident 1 required minimal assist (patient is able to assume all her body weight, but requires guidance for initiation, balance, and/or stability during the activity) with transfer. Resident 1 also exhibited shuffling gait (walking). PT indicated Resident 1, presents with decreased mobility, gait and activity tolerance secondary to age/ PD ([CONDITION(S)]). She will benefit from skilled therapy with goal of improving quality/ endurance of gait, activity tolerance and reducing falls risk. W/o (without) skilled care this pt (patient) will likely continue decline and require additional assistance for adls. During a review of Resident 1's clinical record, the Interdisciplinary Team (IDT) note, dated [DATE], with the MDS, Director of Rehab (DOR), Director of Nursing (DON), and one Licensed Nurse as participants, indicated Resident 1 was picked-up under Medicare Part B for Physical Therapy services. During a review of clinical record for Resident 1, the Care Plan for Falls indicated a revision on [DATE]. There were no new focus problem and interventions added. During a review of Resident 1's clinical record, a Nurse's Note on [DATE] at 4:18 p.m., indicated a Nurse found Resident 1 on the floor in front of her bed, unconscious, face down, with a pool of blood coming out from her head. Resident 1 was sent to the acute hospital via 911, for further evaluation. Nurse's Notes on [DATE] at 11:08 p.m., indicated Resident 1 was admitted to the Intensive Care Unit for [CONDITION(S)] (bleeding inside the skull). During an interview on [DATE] at 3:20 p.m., the MDS Coordinator verified Resident 1 required supervision with transfer, toilet use, walks by herself in her room and around the facility. The MDS Coordinator stated she did not notice any decline in Resident 1's ADL function. During an interview on [DATE] at 1:20 p.m., CNA 2 stated Resident 1 needed supervision with walking, transfer, and toilet use but would provide physical help with transfer and would bring Resident 1 to the toilet at times. CNA 2 stated he did not notice any decline in Resident 1's ADL prior to the fall incident. During an interview on [DATE] at 3:25 p.m., CNA 1 stated Resident 1 required supervision with walking, transfer, and toilet use. CNA 1 also stated he would sometimes help Resident 1 stand depending on Resident 1's mood. When asked how supervision was provided when Resident 1 was in her room, CNA 1 stated he would check on Resident 1, every now and then. CNA 1 stated he did not notice Resident 1 having a decline. During an interview on [DATE] at 3:33 p.m., the DOR stated, while doing her rounds, she noticed Resident 1 moving slower than usual. The DOR stated, I know that her ADL can fluctuate so I took the initiative to screen her to see if she would benefit from therapy. The DOR stated, the result of the screen was documented on Point Click Care (PCC - an electronic record) which nurses and CNAs could view. During an interview with the DON on [DATE] at 10:58 a.m., the DON stated Resident 1 was very high functioning, walked around without assistance and went to the toilet by herself. Staff provided help only when Resident 1 asked for help. When asked how changes in resident's condition were communicated to staff, the DON stated IDT did rounds for any change in condition (CIC). Any change in condition was communicated to the nurses, and the nurses would communicate it to the CNAs. Changes were also discussed with the therapy team and at their daily stand-up meeting. The DON stated she did not notice Resident 1 having any change/decline even on the day Resident 1 fell . The DON stated Resident 1 was expected to be back from the hospital to the facility under Hospice care (comfort care without curative intent) but did not make it. Resident 1 expired in the acute care hospital. During a concurrent record review and interview on [DATE] at 2:42 p.m., the Nurse Supervisor verified the facility did not revise the ADL and Fall Care Plan addressing Resident 1's decline in transfer, walking and balance, after the Rehab Screen. The Nurse Supervisor stated, Result of the Rehab Screen is not considered a decline and not a red flag for nursing to make a revision of the Care Plan. If Rehab are saying that resident had a decline and if it was communicated to nursing, then we would have done a CIC and updated the Care Plan. Review of the facility Policy & Procedure titled, Managing Fall and Fall Risk, revised on ,d+[DATE], indicated, Resident-Centered Approach to Managing Falls and Fall Risk indicated, the staff, with the input of the attending physician, will implement a Resident-Centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Review of the facility Policy & Procedure titled, Care Plans, Comprehensive, revised on ,d+[DATE], under Policy Interpretation and Implementation #13, indicated, Assessments of residents are ongoing and care plans are revised as information about residents' conditions change. #14 indicated, The interdisciplinary Team must review and update the care plan: When there has been a significant change in the resident's condition.

Based on observations, interviews, and record review, the facility failed to provide the necessary services and specifically therapy to ensure a resident's ability to perform activities of daily living (ADLs) did not diminish while residing in the facility. This affected one (Resident #100) of three sampled residents reviewed for ADLs. Failure to provide physical therapy services resulted in Resident #100 having an avoidable decline in the ability to ambulate (walk). Findings: According to the medical record, Resident #100 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], indicated the resident was admitted to the facility from the acute hospital. Resident #100's Brief Interview for Mental Status (BIMS) was 15 out of 15, indicating the resident did not have any cognitive impairments. The resident required extensive assistance of one-person assistance for locomotion on unit/off the unit. Resident #100 required extensive assistance with transfers of two persons. The activity of walking in the room/corridor did not occur. The MDS indicated Resident #100 had not received any physical therapy (PT) or occupational therapy (OT). A review of Resident #100's care plan for ADL Self Care Performance Deficit dated 07/18/18 indicated Resident #100 required extensive assistance with toilet use, transfers, bed mobility, personal hygiene, and dressing. He required total assistance with bathing. The care plan did not indicate his assistance needed with ambulation. A review of Resident #100's acute hospital records indicated the resident was in the hospital from 06/26/18 until 07/18/18. A review of a Hospitalist Progress Note, dated 07/16/18, indicated the assessment and plan for the acute osteo[DIAGNOSES REDACTED] of the cervical spine and left ankle or foot included physical and occupational therapy (OT). According to the hospital records, Resident #100 received physical and occupational therapy while residing in the acute hospital. A review of a hospital PT Daily Documentation Note dated 07/12/18 indicated, Pt (patient) has progressed to perform bed mobility with CGA (Contact Guard Assist). With contact guard assist, the physical therapist needs to merely have one or two hands on the body but provides no other assistance to perform the functional task. Additionally, the note stated transfer with min A (minimum assist), and ambulate 50' (50 ft) with FWW (front wheeled walker) and min A. He demonstrates impaired coordination and balance that affect(s) his ability to independently and safely complete bed mobility, transfers, standing, ambulation, and stair negotiation. Pt (patient) would benefit from skilled acute PT to address his impairments and d/c (discharge) with inc (increased) independence and a lesser burden of care. The note further indicated, Recommended Follow Up Care - Skilled Nursing Facility. Pt would benefit from skilled PT to address impairments of transfers, ambulation, and coordination/balance. A review of the acute hospital PT Daily Documentation Notes indicated Resident #100 had been ambulating up to 200 feet during his hospitalization with contact guard assist to minimum assist. Resident #100 required contact guard to minimum assist with his sit to stand transfer ability. A review of the Hospital Discharge (D/C) Instructions, dated 07/18/18, indicated Resident #100's rehab potential was good. The resident had a PICC (peripherally inserted central catheter) line for IV (intravenous) antibiotics. The admission orders [REDACTED]. The physician indicated the resident could ambulate per physical therapy guide. The skilled nursing facility's Admission Note, dated 07/18/18, indicated Resident #100 was admitted for PT/OT and IV antibiotics at the facility The facility's Initial Admission Note, dated 07/18/18, indicated Resident #100 presented with weakness to the left leg and right leg. The resident had range of motion limitations of his neck and arm, but none of his lower extremities. He did not have any weight bearing limitations. A review of Resident #100's physician's orders [REDACTED]. An IDT (interdisciplinary) Note, dated 07/19/18, indicated the IDT met with Resident #100 to welcome him to the facility. The note author further documented the resident looks forward to getting his therapy as he has orders for PT/OT. A Therapy Consultation/Screen note by the Director of Rehab, dated 07/19/18, indicated Reason for Screening: Patient admitted with rehab orders for PT/OT. Results of screening: Patient reportedly ambulating over 100ft (feet) at the hospital with minimal assistance. Is at a level of functional mobility at this time. Further Recommendations: Do not recommend rehab (rehabilitation) eval (evaluation) at this time. A physician's admission note dated 07/20/18, indicated Resident #100's prognosis was fair. The physician indicated the plan included physical and occupational therapy. A review of the Documentation Survey Report v2, which was a Certified Nursing Assistant (CNA) task report, for 07/18/18 - 07/31/18, indicated Not Applicable for walking on the corridor and walking in the room. A review of the Documentation Survey Report v2, which was a CNA task report, for 08/01/18 - 08/15/18, indicated Not Applicable for walking on the corridor and walking in the room. The report indicated under behavior symptoms that Resident #100 did not have any behaviors, and no rejection of care. During an interview and chart review on 08/16/18 at 1:41 PM, the MDS Coordinator reviewed Resident #100's MDS. She stated Resident #100 was mostly extensive assistance with ADLs. She stated the MDS indicated Resident #100 was not ambulating. The MDS Coordinator stated the CNAs were documenting on the CNA task report that he was not walking. She stated the Not Applicable on the CNA task report indicated the task was not completed with the resident. A review of the facility's nursing notes, with dates ranging from 07/21/18 until 08/03/18, indicated Resident #100 was on PT and OT. The nursing notes included, Resident is (on) PT/OT per P[NAME] (plan of care) and able to tolerate with the activities performed. Cont (continue) on PT/OT as ordered. please see therapy notes for (Resident 100's) response to tx (treatment). Please see therapy notes for progress. A review of Resident 100's medical record indicated he was not receiving and had not received any physical or occupational therapy at the skilled nursing facility. During an observation and interview on 08/13/18 at 3:44 PM, 08/15/18 at 10:11 AM and 08/16/18 at 1:52 PM, Resident #100 was observed lying in bed. He stated he had been in the hospital prior to coming to the facility. He stated that he had been on physical therapy while he was in the hospital. He stated no one at the facility had spoken to him regarding when he was going to start therapy. He stated, I just stay in bed all day. He indicated he was not ambulating with the staff, and he was only getting up to the chair to go to the bathroom. He was questioned about his functional status prior to the hospitalization . He stated he was walking on crutches because he had messed up his left foot when he fell off a step. During an interview on 08/16/18 at 9:49 AM, CNA #2 stated Resident #100 spent most of his time in bed. She stated on the CNA task in the computer it indicated whether Resident #100 was supposed to be ambulated. She indicated she had checked the computer for the resident's ADL ability, and she did not see anything about Resident #100's ability to ambulate. CNA #2 stated she would transfer the resident to the wheelchair or to the shower chair only. She indicated no one had ever directed her to walk with Resident #100. She stated she had never offered to ambulate Resident #100, only to transfer him to the chair to go to the toilet. During an interview on 08/16/18 at 12:10 PM, the Director of Nursing (DON) stated that prior to Resident #100's admission, she reviewed the hospital discharge summary. She stated the plan for Resident #100 was for IV (intravenous) therapy only, and Resident #100 would remain in the facility long term. She stated she was not aware the resident wanted therapy. She stated Resident #100 informed her this week that he wanted to go home. The DON stated a PT/OT evaluation and treatment was a standing order for every new admission. The DON indicated they have a Medicare meeting on a weekly basis to discuss the residents, but they did not discuss Resident 100's functional status or therapy needs, only nursing interventions. She indicated she thought they would have placed the resident on restorative nursing services, but the resident was not. During an interview on 08/15/18 at 3:20 PM and 3:54 PM, and 08/16/18 at 12:29 PM and 3:01 PM, the Director of Rehab (DOR) stated she had completed a therapy screening only for Resident #100 based on the therapy notes from the hospital. She indicated the purpose of the screening was to determine if a therapy evaluation was appropriate. When questioned about the difference between an evaluation and a screening, the DOR stated a therapy screening could consist of a documentation review, observation, and interview with the resident. She stated they would see if the evaluation was necessary based on the screening before an evaluation was completed. The DOR stated for Resident #100, she completed the therapy screening based only on the hospital therapy notes and determined an evaluation was not warranted. She did not make an observation of the resident's ADL abilities. She reviewed the hospital therapy notes and found Resident #100 was ambulating 100 ft with minimal assistance. The DOR did not conduct a therapy evaluation, although Resident #100 had a physician's orders [REDACTED]. When questioned how a resident was supposed to maintain their functional ability in the facility, she stated for long term residents, they have a RNA (Restorative Nursing Assistant) program. The DOR stated she did not refer Resident #100 to the RNA program because therapy would have needed to complete a therapy evaluation to make the RNA recommendation. During an interview and observation on 08/16/18 at 9:55 AM, Resident #100 was observed up in the wheelchair. He stated, I'm glad to be out of that bed. He stated therapy had seen him for the first time today. Resident #100 stated it was never his plan to stay at the facility long term and he wanted to be discharged back and possibly to his sister's home. He stated he had asked the nurses and CNAs multiple times when he was going to be starting therapy, but no one ever got back to him. Resident #100 stated no one had ever gotten him up to walk or even offered. During an interview on 08/16/18 at 3:08 PM, CNA #8 stated Resident #100 was weak. CNA #8 stated she had never seen Resident #100 walk, and she couldn't remember if she had ever offered to get him up to walk. It was her understanding he was not supposed to be walking because of his neck. She stated no one had ever told her that he was not supposed to be walking though, and maybe it's a bad assumption. During an interview on 08/16/18 at 3:18 PM, CNA #9 stated Resident #100 stays in bed most of the time. She stated Resident #100 did not ambulate, and she had never seen him walk. She indicated the resident was weak and unable to walk to the bathroom. She was questioned how she would know if a resident was supposed to be ambulating or able to ambulate. She would ask therapy or the resident's nurse, but she had never asked if Resident #100 was supposed to be ambulating. During an interview on 08/16/18 at 3:25 PM, Registered Nurse (RN) #1 stated Resident #100 was not able to ambulate because of his spinal surgery. She stated it was her understanding he would start therapy after he finished the IV antibiotics. RN #1 stated she had never spoken to therapy about Resident #100, but she stated it was passed on to her in report last week that he would start therapy after the PICC (peripherally inserted central catheter) line was removed. She stated Resident #100 had expressed to her that he wanted to start therapy. She further stated she had never seen him ambulate. After discussions with the DOR and DON, a PT evaluation was completed on 08/16/18. A review of the PT Evaluation & Plan of Treatment, dated 08/16/18, indicated Resident #100 was admitted from the acute hospital nearly a month ago with reports of supervision required with bed mobility, minimum assists with transfers and ambulation ability of 100 feet with front wheeled walking and contact guard assist/minimum assist. The note indicated he was now being referred to PT due to a new onset of decrease in functional mobility, decrease in strength and increased need for assistance from others as he had been refusing to get out of the bed, shower, ambulate to the bathroom from bed, sit in a bedside chair, and had volitionally elected to stay in bed. Under Patient Goals, I want to walk again. The document further indicated Resident #100 stated, he is now very motivated to get stronger and to get back to walking. He was previously independent with his ADLs. He had been walking with crutches for approximately 1 month before hospitalization due to a left ankle injury/pain. During an interview on 08/16/18 at 2:40 PM, Physical Therapist (PT) #1 stated Resident #100 began therapy today. He was questioned about the resident's ability to ambulate. He stated the Resident #100 was weak and required moderate assist with ambulation. PT #1 stated Resident #100 required the use of the parallel bars to ambulate and placed a lot of weight on his arms. He stated when the resident took his 6th step, his knees buckled. PT #1 stated at the time of the hospital discharge, Resident #100 was ambulating 100 ft with CGA using a front wheeled walker. PT #1 stated that today Resident #100 was only able to ambulate 3 feet. PT #1 stated it was his understanding today that the resident was refusing showers and had been refusing to get out of bed. He stated, For every day of total bed rest, you need 2 days of rehab. He stated Resident #100's functional status had declined since he was discharged from the hospital, because he just stays in bed all the time. PT #1 stated the resident had some quadricep and hip extensor weakness, which was normally something they see when a resident is bedfast, especially in the elderly, but that Resident #100 was not elderly. Pt #1 further stated, We know that he hasn't been walking, because of that, he has drastically regressed. A Behavior Note, dated 07/31/18, indicated, He is cooperative with care. No behaviors noted. There was no supporting documentation in the medical record that indicated Resident #100 had been refusing to ambulate during his length of stay in the facility. The CNA task notes, nursing notes, and care plans did not indicate the resident had been refusing to ambulate.

Based on observations, interviews, and record review, the facility failed to provide rehabilitative services including physical therapy in accordance with the physician orders [REDACTED]. This affected one (Resident #100) of two sampled residents reviewed for rehabilitative services. Failure to provide physical therapy services resulted in Resident #100 having an avoidable decline in the ability to ambulate (walk). See F676 for additional information regarding Resident #100 and a decline in activities of daily living. Findings: According to the medical record, Resident #100 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], indicated the resident was admitted to the facility from the acute hospital. Resident #100's Brief Interview for Mental Status (BIMS) was 15 out of 15, indicating the resident did not have any cognitive impairments. The MDS indicated Resident #100 had not received any physical therapy (PT) or occupational therapy (OT). A review of Resident #100's acute hospital records indicated the resident was in the hospital from 06/26/18 until 07/18/18. A review of a Hospitalist Progress Note, dated 07/16/18, indicated the assessment and plan for the acute osteo[DIAGNOSES REDACTED] of the cervical spine and left ankle or foot included physical and occupational therapy (OT). According to the hospital records, Resident #100 received physical and occupational therapy while residing in the acute hospital. A review of a hospital PT Daily Documentation Note dated 7/12/18 indicated, Pt (patient) would benefit from skilled acute PT to address his impairments and d/c (discharge) with inc (increased) independence and a lesser burden of care. The note further indicated, Recommended Follow Up Care - Skilled Nursing Facility. Pt would benefit from skilled PT to address impairments of transfers, ambulation, and coordination/balance. A review of the Hospital Discharge (D/C) Instructions, dated 07/18/18, indicated Resident #100's rehab potential was good. The admission orders [REDACTED]. The physician indicated the resident could ambulate per physical therapy guide. The skilled nursing facility's Admission Note, dated 07/18/18, indicated Resident #100 was admitted for PT/OT and IV antibiotics at the facility A review of Resident #100's physician's orders [REDACTED]. An IDT (interdisciplinary) Note, dated 07/19/18, indicated the IDT met with Resident #100 to welcome him to the facility. The note author further documented the resident looks forward to getting his therapy as he has orders for PT/OT. A Therapy Consultation/Screen note by the Director of Rehab, dated 07/19/18, indicated Reason for Screening: Patient admitted with rehab orders for PT/OT. Results of screening: Patient reportedly ambulating over 100ft (feet) at the hospital with minimal assistance. Is at a level of functional mobility at this time. Further Recommendations: Do not recommend rehab eval (evaluation) at this time. A physician's admission note, dated 07/20/18, indicated Resident #100's prognosis was fair. The physician indicated the plan included physical and occupational therapy. A review of the facility's nursing notes, with dates ranging from 07/21/18 until 08/03/18, indicated Resident #100 was on PT and OT. The nursing notes included, Resident is (on) PT/OT per P[NAME] (plan of care) and able to tolerate with the activities performed. Cont (continue) on PT/OT as ordered. please see therapy notes for (Resident 100's) response to tx (treatment). Please see therapy notes for progress. A review of Resident 100's medical record indicated he was not receiving and had not received any physical or occupational therapy at the skilled nursing facility. During an observation and interview on 08/13/18 at 3:44 PM, 08/15/18 at 10:11 AM and 08/16/18 at 1:52 PM, Resident #100 was observed lying in bed. He stated he had been in the hospital prior to coming to the facility. He stated that he had been on physical therapy while he was in the hospital. He stated no one at the facility had spoken to him regarding when he was going to start therapy. He stated, I just stay in bed all day. He indicated he was not ambulating with the staff, and he was only getting up to the chair to go to the bathroom. During an interview on 08/15/18 at 3:20 PM and 3:54 PM, and 08/16/18 at 12:29 PM and 3:01 PM, the Director of Rehab (DOR) stated she had completed a therapy screening only for Resident #100 based on the therapy notes from the hospital. She indicated the purpose of the screening was to determine if a therapy evaluation was appropriate. When questioned about the difference between an evaluation and a screening, the DOR stated a therapy screening could consist of a documentation review, observation, and interview with the resident. She stated they would see if the evaluation was necessary based on the screening before an evaluation was completed. The DOR stated for Resident #100, she completed the therapy screening based only on the hospital therapy notes and determined an evaluation was not warranted. She did not make an observation of the resident's ADL abilities. She reviewed the hospital therapy notes and found Resident #100 was ambulating 100 ft with minimal assistance. The DOR did not conduct a therapy evaluation, although Resident #100 had a physician's orders [REDACTED]. After discussions with the DOR, a PT evaluation was completed on 08/16/18. A review of the PT Evaluation & Plan of Treatment, dated 08/16/18, indicated Resident #100 was admitted from the acute hospital nearly a month ago with reports of supervision required with bed mobility, minimum assists with transfers and ambulation ability of 100 feet with front wheeled walking and contact guard assist/minimum assist. The note indicated he was now being referred to PT due to a new onset of decrease in functional mobility, decrease in strength and increased need for assistance from others as he had been refusing to get out of the bed, shower, ambulate to the bathroom from bed, sit in a bedside chair, and had volitionally elected to stay in bed. Under Patient Goals, I want to walk again. The document further indicated Resident #100 stated, he is now very motivated to get stronger and to get back to walking. He was previously independent with his ADLs. He had been walking with crutches for approximately 1 month before hospitalization due to a left ankle injury/pain. During an interview on 08/16/18 at 2:40 PM, Physical Therapist (PT) #1 stated Resident #100 began therapy today. He was questioned about the resident's ability to ambulate. He stated the resident was weak and required moderate assist with ambulation. PT #1 stated Resident #100 required the use of the parallel bars to ambulate and placed a lot of weight on his arms. He stated when the resident took his 6th step, his knees buckled. PT #1 stated at the time of the hospital discharge, Resident #100 was ambulating 100 ft with CGA using a front wheeled walker. PT #1 stated that today Resident #100 was only able to ambulate 3 feet. PT #1 stated it was his understanding today that the resident was refusing showers and had been refusing to get out of bed. He stated, For every day of total bed rest, you need 2 days of rehab. He stated Resident #100's functional status had declined since he was discharged from the hospital, because he just stays in bed all the time. PT #1 stated the resident had some quadricep and hip extensor weakness, which was normally something they see when a resident is bedfast, especially in the elderly, but that Resident #100 was not elderly. Pt #1 further stated, We know that he hasn't been walking, because of that, he has drastically regressed.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls for one of four sampled residents (Resident 1) when: Resident 1's bed alarm was not activated per the care plan, and Resident 1 got out of bed, walked to the facility's main entrance, then fell without staff's knowledge. This failure resulted in Resident 1 sustaining a fractured arm, neck fracture and hematoma (collection of blood in a localized area after a trauma that looks similar to a bruise) to the right side of the face, a rapid decline and death five days after the accident. Findings: On [DATE], review of Resident 1's admission documentation, dated [DATE] at 12:22 p.m., indicated the following: 1. The facility admitted Resident 1 on [DATE]. 2. Resident 1 arrived from the hospital for rehabilitation after a mechanical fall at home which resulted in a vertebral compression (spinal) fracture and herniated disc (bulging of the space between the spinal bones) of her lumbar area (low part of the back). 3. Resident 1 had no respiratory distress, was alert and oriented times ,[DATE] with some confusion, had no problems swallowing, did not complain of pain, and had normal vital signs (the body's basic functions such as heart rate, blood pressure, breathing, temperature). 4. The facility identified Resident 1 as a fall risk. The facility's "Fall Risk Evaluation", dated [DATE], indicated that Resident 1 scored a 10, which according to the facility's policy, "Fall Management System," made Resident 1 a high fall risk. Under "Gait/Balance/Ambulation", the evaluation indicated Resident 1 had a balance problem, decreased muscular coordination, change in gait when walking (i.e. shuffling), and required assistive devices when walking (forward walker, cane, wheelchair). The facility's policy, "Fall Management System", revised ,[DATE], also indicated that the facility is dedicated to providing an accident-free environment that include adequate supervision, assistive devices and developed nursing care plans. Resident 1's care plan, initiated [DATE], indicated that Resident 1 was at risk for falls and injury related to gait and balance problems from a compression fracture of the lower lumbar (L1). The care plan goal indicated that Resident 1 would not sustain serious injury. Resident 1's fall prevention care plan interventions included: "Bed Alarm - To alert staff if resident attempts to get out of bed without assistance - check placement and function Q (every) shift." The intervention was identified in the care plan as a nursing responsibility. The facility's report, dated [DATE], indicated that Resident 1 had an unwitnessed fall on [DATE] at 4 a.m., when the resident was found lying on her left side in front of the main door with a bump on the forehead with slight bleeding, and complaint of pain in her right arm. During an interview and concurrent record review on [DATE] at 10:45 a.m., Administrative Licensed Staff A stated that Resident 1 had died on [DATE] at 2:25 p.m. (five days after the fall on [DATE]). Administrative Licensed Staff A stated that on [DATE], at approximately 4 a.m., Resident 1 was found by staff lying on the lobby floor and an ambulance was called. The ambulance responded quickly and took Resident 1 to the hospital and she came back to the facility later that day. Administrative Licensed Staff A stated the Certified Nursing Assistant (CNA) assigned to Resident 1 on the date of the fall was Unlicensed Staff B. The nurse on duty had been Licensed Staff E, and two other CNA's (Unlicensed Staff C, Unlicensed Staff D) had been the first to discover Resident 1 on the floor. Interdisciplinary Team notes (IDT), dated [DATE] at 1:19 p.m., confirmed that Resident 1 returned to the facility on [DATE] at 11:40 a.m., with a hematoma to the right side of her face, a lump on her forehead, a fracture to her right arm and a C-1, C-2 (cervical vertebrae in the neck) fracture. Notes further indicated that Resident 1 was returned on comfort measures only. The death certificate, dated [DATE] at 2:25 p.m., documented the cause(s) of death were as follows: 1. Acute Respiratory Failure 2. Cervical Spine Fracture 3. Mechanical Fall 4. Cerebrovascular Disease During an interview on [DATE] at 2:05 p.m., Resident 2 (Resident 1's roommate at the time of the fall) stated that on [DATE] at 2 a.m., Resident 2 awoke and went to the bathroom. Resident 2 stated that Resident 1 had been awake at that time. Resident 2 stated she went back to sleep after going to the bathroom and did not wake up until approximately 7 a.m. in the morning, when she noted that Resident 1 was not in her bed. Resident 2 stated during the night she did not hear a bed alarm going off. Telephone interviews on [DATE] with Unlicensed Staff B at 2:32 p.m., Unlicensed Staff D at 2:52 p.m., and Unlicensed Staff C at 3:02 p.m., indicated the following: 1. Unlicensed Staff B stated that Resident 1 was his assignment on [DATE]. Unlicensed Staff B stated he heard a scream at approximately 4 a.m. and ran to the lobby where he saw Resident 1 lying on the floor. Two other staff had arrived ahead of him. Unlicensed Staff B had no recall of hearing a bed alarm prior to hearing Resident 1 scream, and stated that it was part of Resident 1's care plan to have a bed alarm. Unlicensed Staff B could not recall whether the bed alarm had been set or not and why it had not alarmed. Unlicensed Staff B stated that Resident 1 was incontinent (loss of bowel and / or bladder control) of bowel and bladder, and he checked her a couple times a night. He recalled that he had last monitored Resident 1 before his lunch break at 3 a.m. 2. Unlicensed Staff D stated as she returned from her break at 4 a.m. on [DATE], she heard someone say, "Oh". Unlicensed Staff D stated she ran to the lobby and saw Resident 1 lying on her side and another CNA, Unlicensed Staff C, standing next to her. Unlicensed Staff D stated she did not hear a bed alarm prior, during, or at anytime of the fall. 3. Unlicensed Staff C stated on [DATE] at approximately 4 a.m., she had just exited another patient's room into the hall and heard someone yelling, "Help, help." Unlicensed Staff C stated she was the first to arrive and saw Resident 1 lying on her left side by the facility's information desk in the lobby. Unlicensed Staff C described Resident 1 as alert and awake but she said nothing, and had both of her hands up by her mouth, and had some swelling on her forehead with a little blood. Unlicensed Staff C stated the "only shocking thing is her lying there by the desk. How'd she get there?" During a follow up telephone interview on [DATE] at 8:48 a.m., Unlicensed Staff C stated she did not hear a bed alarm, which, "are loud and can be heard all over," and which required being turned off manually, once they alarmed. During a telephone interview on [DATE] at 8:09 a.m., Licensed Staff E stated on [DATE] at 4 a.m., she was doing a treatment on another patient with the door was closed. She stated Unlicensed Staff C came and told her that a resident had fallen. Licensed Staff E stated she recognized Resident 1, and Unlicensed Staff B had seen the resident approximately an hour prior (3 a.m.). Licensed Staff E stated she did not hear a bed alarm which would be loud and continuous until manually turned off. Licensed Staff E confirmed that Resident 1 was a fall risk and required an alarm, which she stated the CNAs were responsible for maintaining. During a family interview, on [DATE] at 11:58 a.m., Resident 1's family member stated Resident 1 had originally been admitted for rehabilitation after a fall at home that resulted in a fracture of the lower back. Resident 1 was switched to long term care after the hospital's physical therapist told the family that it was "a 100% chance" Resident 1 would fall again if taken back home. Resident 1's family member stated that Resident 1 had walked at home with a cane, had no dementia, enjoyed conversing, and her "vitals were strong." Resident 1's family member stated that the distance from Resident 1's bed to where she fell was "a long way" and he was surprised that she had been able to walk, unassisted, the distance to the main door on [DATE]. He also stated that after the fall on [DATE], Resident 1 was in a lot of pain, declined rapidly, and did not speak again after [DATE]. An observation of Resident 1's room on [DATE] at 1:48 p.m., noted the room was located close to a nursing station and the front lobby. The distance from Resident 1's bed to the spot which staff found her lying on the floor was at least 50 feet. During a telephone interview on [DATE] at 9:17 a.m., Licensed Staff G verified via maintenance staff that Resident 1's room was approximately 50 feet to the nursing station and 20 feet to the lobby. Licensed Staff G stated that Resident 1's bed had an alarm which was in working order and could be heard in the hallway. On [DATE] at 9:40 a.m., when interviewed, Physician F stated: "If not for the fall (Resident 1) would not be dead."

Based on observation, resident, family, staff, Ombudsman, and physician interviews, and record review, the facility failed to protect and promote the resident's interests for 1 of 24 sampled residents, when Resident 1 complained of pain on an on-going basis and continually requested pain medication and her surrogate/representative rejected the use of pain medications, leading to the continuation of pain. Findings: During interview, on 5/14/12 at 3:10 p.m., Ombudsman Z stated that Resident 1 had on-going pain but was not receiving pain medications. She stated that the physician ordered pain medications but they were not given per family wish. During concurrent observations and interview, on 5/15/12 at 8:05 a.m., Resident 1 was in her room. She complained of pain and stated she was dying. When asked where her pain was, the resident pointed to her abdomen. Family Member U was present and stated that the resident did not have pain that she was just repeating the same thing over and over secondary to having a stroke. Family Member U stated that the resident was not on pain medications and was sensitive to many medications, with adverse effects from some of the medications. Additional inquiries to the resident about her condition were answered by Family Member U. Multiple, random observations and interviews, between 8 a.m. and 5 p.m. on 5/16/12, 5/17/12, 5/21/12, and 5/22/12, revealed the resident was in bed or sitting in a wheelchair in her room. When the resident saw anyone, she told them she was in pain. When asked where the pain was, she pointed to her abdomen. She sometimes requested pain medication and sometimes stated she was dying because of the pain. Resident 1's clinical record was reviewed on 5/16/12 at 4 p.m. Her face sheet indicated: a. She had [DIAGNOSES REDACTED]. b. She was not her own responsible party. c. Family Member BB was Resident 1's durable power of attorney for health care. Resident 1's MARs, Nurses Notes, and Interdisciplinary notes indicated that the resident had pain and further indicated that the family had discontinued attempts to control the resident's pain with medications. Acute Care Hospital Ethics Consultation notes, dated 10/13/11, indicated: a. The resident was frequently calling out, moaning, "and appears to be in pain. It is the impression of her nurse, attending physician, and psychiatrist that at least some of this pain is physical pain, based on her wincing and facial expressions and her response to abdominal contact." b. The concern of Family Members U and BB's regarding treatment for [REDACTED]." c. The resident had a dementia [DIAGNOSES REDACTED]." Since Resident 1 had not lost this decisional capacity, "she is entitled to make her own decisions" regarding pain management. d. "California State Law also obliges the hospital and its staff to treat pain." Acute care hospital notes, dated 10/23/11, indicated Family Member BB reported that Resident 1 "has always had some degree of abdominal pain." The report revealed Resident 1 had been complaining of "horrible pain and would like to die." Review of physician notes, dated 4/24/12, revealed Resident 1 was on Hospice for pain management, but Family Member BB "is asking to reduce and discontinue medications they have ordered." Interdisciplinary notes, dated 5/15/12, indicated Ombudsman Z stated, "The resident, even if she has dementia, and cries in pain, then the resident has a right to get pain medication under the law." Ombudsman AA stated, "Pain is defined for what the patient says it is." Physician S stated the resident has the "right to request treatment for [REDACTED]. During interview, on 5/22/12 at 9:15 a.m., Management Staff J stated Resident 1 was unable to participate in activities because she kept screaming in pain. Management J said that Resident 1's family did not allow her to have pain medication. She said it was very distressing to see the resident in so much pain. During interview, on 5/22/12 at 2:15 p.m., Resident 1's primary physician, Physician S, stated that it was her understanding that the resident was unable to cope with minor pain. Physician S stated that because of past experiences with medication side effects the family was refusing all pain medications for Resident 1. During interviews, on 5/22/12 at 3:30 p.m., Management Staff L and O both stated that Resident 1 had pain, staff was concerned, and staff were unable to treat the pain secondary to the wishes of the resident's responsible party. During interview, on 5/22/12 at 5 p.m., the facility Medical Director, Physician T, stated that he had assessed Resident 1 as having pain for the previous six months and was involved with the family and their decisions. Physician T stated that the resident was not receiving pain medications and she was in pain. "It's just not right!" Review of the facility "Pain Management" policy, revised 11/2012, revealed: a. It was the policy of the facility to provide programs "that assist each resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well being." b. "Resident pain is assessed and managed" to achieve the highest practicable outcome. c. Achieving each resident's highest practicable outcome was achieved by developing and implementing plans to manage the pain and/or try to prevent pain. The California Health and Safety Code 1254.7 reads: (a) It is the intent of the Legislature that pain be assessed and treated promptly, effectively, and for as long as pain persists.

Based on observation, resident, family, staff, Ombudsman, and physician interviews, record review, and policy review, the facility failed to maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 24 sampled residents (Resident 1), when Resident 1 was assessed as having pain, complained of pain and requested pain medication, and did not receive pain medication, with the continuation of pain, exhibited by facial grimaces, pointing to abdomen, and calling out, "Help. I'm in pain." Findings: During interview, on 5/14/12 at 3:10 p.m., Ombudsman Z stated that Resident 1 had on-going pain but was not receiving pain medications. She stated that the physician ordered pain medications but they were not given per family wish. Observation and interview, during the initial tour, on 5/15/12 at 8:05 a.m., revealed Resident 1 was in her room. She complained of pain and stated she was dying. When asked where her pain was, the resident pointed to her abdomen. Family Member U was present and stated that the resident did not have pain that she was just repeating the same thing over and over secondary to having a stroke. Family Member U stated that the resident was not on pain medications and was sensitive to many medications, with adverse effects from some of the medications. Multiple, random observations and interviews, between 8 a.m. and 5 p.m. on 5/16/12, 5/17/12, 5/21/12, and 5/22/12, revealed the resident was in bed or sitting in a wheelchair in her room. When the resident saw anyone, she told them she was in pain. When asked where the pain was, she pointed to her abdomen. She sometimes requested pain medication and sometimes stated she was dying because of the pain. Resident 1's clinical record was reviewed on 5/16/12 at 4 p.m. Her Face Sheet indicated she had [DIAGNOSES REDACTED]. Resident 1's MARs, Nurses Notes, and Interdisciplinary notes indicated that the resident had pain and further indicated that the family had discontinued attempts to control the resident's pain with medications. Acute care hospital notes, dated 10/23/11, indicated Family Member BB reported that Resident 1 "has always had some degree of abdominal pain." The 10/23/11 report revealed Resident 1 had been complaining of "horrible pain and would like to die for the past few months at the SNF." The resident's "Pain Risk Assessments," dated October 2011 and February 2012, indicated she was at high risk for pain. The resident verbalized pain and also had non-verbal cues present, such as grimacing. Her MDS, dated [DATE], indicated that the resident was observed to have indicators of pain daily. These indicators included vocal complaints of pain, facial expressions of pain, and protective body movements or postures. Resident 1's "Pain" care plan, revised 5/10/12, indicated her pain was exhibited by facial grimaces, guarding, and complaints of pain and she had chronic abdominal pain. The approach was to give [MEDICATION NAME] (a medication that reduces or eliminates pain) medications. The goal was to maintain an adequate level of comfort as evidenced by 1) No signs and symptoms of unrelieved pain; 2) No complaints of pain when questioned; 3) no grimacing; 4) a decrease in yelling out behaviors; and 5) reporting pain relief within 30-60 minutes of receiving pain medication or ordered treatment. Review of physician notes revealed: a. On 4/24/12, Resident 1 was on Hospice for pain management, but Family Member BB "is asking to reduce and discontinue medications they have ordered." Review of Resident 1's MARs revealed: a. During March 2012, the resident had pain ranging from mild to moderate on thirty (30) out of thirty-one (31) days. Resident 1 had repetitive episodes of calling out, "Help. I'm in pain," on all thirty-one (31) days in March. The episodes ranged from three times a day to seventeen times a day. Resident 1 had physician orders, dated 10/25/11, for Tylenol 650 mg, every six hours as needed for pain. The pain medication was given two times on 3/5/12 and once on 3/6/12 and no other time, until it was discontinued on 3/12/12. b. In April 2012, Resident 1 had pain ranging from moderate to severe on twenty-six (26) out of thirty (30) days. She had physician orders, dated 4/18/12, for [MEDICATION NAME] every evening for pain. The medication was given twice, held on the third day, and then discontinued. Resident 1 had physician orders, dated 4/24/12, for [MEDICATION NAME] every night for [MEDICAL CONDITION] pain. The [MEDICATION NAME] was discontinued on 5/1/12. c. From May 1, 2012 through May 22, 2102, Resident 1 had pain ranging from mild to moderate on nineteen (19) of twenty-two (22) days. Resident 1 had repetitive episodes of calling out, "Help. I'm in pain," on seventeen (17) of twenty-two (22) days in May. There were no orders for, and therefore the resident did not receive, any pain medications. Review of Interdisciplinary notes revealed: a. On 4/24/12, Family Member BB continued "demands to hold medications, decrease medications or d/c (discontinue) medications," due to the potential for side effects from the medications. Resident 1 was monitored every shift for side effects and no side effects were noted from Tylenol. The resident continued to call out and complain of abdominal pain. "Help! I'm in horrible pain.....I'm dying!" The resident's "comfort needs unable to be met in facility." The resident's primary physician disagreed that the resident should be sent to an acute hospital for further evaluation. b. On 4/25/12, the facility Medical Director (Physician T) ordered Resident 1 to be sent to an acute hospital for evaluation and treatment of [REDACTED]. When contacted, the resident's primary physician (Physician S) cancelled the order. c. On 5/1/12, in a meeting with physician, facility staff, family members, and Ombudsmen, Management Staff Q stated, "The facility has the obligation to respond to resident's pain as advised by Medical Director of facility." Family Member BB stated she did not want Resident 1 transferred. Physician S stated that the decision to hold medications and discontinue medications were made by the family based on the potential for side effects and not based on any signs and symptoms actually noted by the physician and nursing staff. Physician S stated, "The resident has the capacity to express she is in pain." d. On 5/15/12, there was another meeting with the physician, family, facility staff, and Ombudsmen. Ombudsman Z stated, "The resident, even if she has dementia, and cries in pain, then the resident has a right to get pain medication under the law." Ombudsman AA stated, "Pain is defined for what the patient says it is." Physician S stated the resident has the "right to request treatment for [REDACTED]. Management Staff J stated during an interview, on 5/22/12 at 9:15 a.m., that she visited Resident 1 in her room on a regular basis but the resident was unable to participate in the activities that she offered as she kept screaming in pain every time she offered her, or attempted to provide her with, activities. Management J said that Resident 1's family did not allow her to have pain medication. She said it was very distressing to see the resident in so much pain and unable to participate in her activities but she continued to visit her on a regular basis and kept offering her various in-room activities. During interview, on 5/22/12 at 2:15 p.m., Resident 1's primary physician, Physician S, stated that it was her understanding that the resident was unable to cope with minor pain. "I don't feel she has severe pain." Physician S stated that because of past experiences with medication side effects the family was refusing all pain medications for Resident 1. When asked if the resident had been assessed by a pain specialist or the pain clinic at a local acute hospital, Physician S stated that the pain clinic was for out-patient use only and the resident was not competent or qualified to benefit from the program and the pain clinic "doesn't visit." When asked, on 5/22/12 at 2:15 p.m., why the resident complained of pain and pointed to her abdomen during multiple observations, Physician S stated the resident's pain may be related to gas because the resident sometimes complained of pain and then belched. When asked how the gas was being treated, the physician did not remember what treatments were ordered. Physician orders, dated 10/24/11, indicated that [MEDICATION NAME] (medication used to treat the symptoms of gas such as uncomfortable or painful pressure, fullness, and bloating) was to be given as needed. Resident 1's April 2012 MAR indicated [REDACTED]. Her May 2012 MAR indicated [REDACTED]. During interviews, on 5/22/12 at 3:30 p.m., Management Staff L and O both stated that Resident 1 had pain, staff were concerned, and staff were unable to treat the pain secondary to the wishes of the resident's responsible party. During interview, on 5/22/12 at 5 p.m., the facility Medical Director, Physician T, stated that he had assessed Resident 1 as having pain for the previous six months and was involved with the family and their decisions. Physician T stated that the resident was not receiving pain medications and she was in pain. "It's just not right!" He stated that Resident 1 was screaming in pain in April 2012 and there was nothing the facility could do. He felt Resident 1 was being tortured by the pain. At this point the facility could not help the resident and she was morally inappropriate for the skilled nursing facility. As Medical Director, he ordered the resident to be transferred to an acute hospital for assessment and treatment and 911 was called. He stated that Physician S cancelled the transfer. Review of the facility "Pain Management" policy, revised 11/2012, revealed: a. It was the policy of the facility to provide programs "that assist each resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well being." b. "Resident pain is assessed and managed" to achieve the highest practicable outcome. c. Achieving each resident's highest practicable outcome was achieved by developing and implementing plans to manage the pain and/or try to prevent pain.

The facility violated the regulation by failing to ensure that Resident 1, who was at risk for falls and known attempts to get out of bed and the wheelchair unassisted, was provided adequate supervision by direct care staff and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. Resident 1 had six falls during a 30 day period from 8/26/11 to 9/16/11, with no effective interventions considered to prevent further falls from the bed and wheelchair. These failures contributed to Resident 1 sustaining a right femur fracture after falling while getting up unassisted from the wheelchair while outside on the patio. Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 1's care plan/risk for injury dated 8/25/11, indicated poor balance, limited mobility, lack of awareness, poor safety awareness, frequent falls/history of falls. The approaches were that the bed be kept in low bed position, a mat be on the floor beside the bed, use of non skid socks, rounds every two hours, and a wheelchair alarm. The goal was that Resident 1 will have no injuries related to falls. The Nursing Notes dated 8/25/11 at 10:00 p.m., indicated that Resident 1 was alert and oriented to self. Resident 1 needed extensive assistance from one person to transfer Resident 1 from the bed to the wheelchair and for movement while in bed. First Fall: The Nursing Notes dated 8/26/11 at 1:45 a.m. indicated that Resident 1 was awake most of the night and had attempted to get out of bed several times. Resident 1 was forgetful and confused.The notes indicated that the alarm went off and the nurse found Resident 1 on the floor. Resident 1 was not able to recall what had happened. The Interdisciplinary Team Notes dated 8/26/11 at 9:30 a.m. indicated they determined that Resident 1 has poor safety awareness and made a recommendation for physical therapy and occupational therapy to screen, a low bed (the bed frame or mattress sits on the floor), and pharmacy review of Resident 1's medications. Resident 1's Nursing Plan of Care dated 8/26/11 indicated that Resident 1's alarms were to be checked every shift, encourage resident to use call light for needs and there was to be "frequent visual checks." The nursing plan of care lacked specificity about how a confused and forgetful resident would remember to use the call light to communicate his or her needs. There were no effective interventions to prevent falls for a resident who got up unassisted. During an interview on 3/7/12 at 11 a.m., Staff B stated that she did not know what "frequent visual checks" would entail. Second Fall: Nursing Notes dated 8/27/11 at 10:30 a.m., indicated that Resident 1 was found lying on the floor in his room. The notes indicated that Resident 1 stated " I got up and fell down again." The notes do not indicate if the bed alarm sounded when Resident 1 got out of bed. The Nursing Post Fall assessment dated [DATE] indicated that Resident 1 was in bed prior to the incident. The New Interventions indicated encourage to use call light, increased observation as staff allows, and continue physical therapy and occupation therapy. These were the same interventions as the previous fall on 8/26/11. Resident 1's Nursing Plan of Care dated 8/27/11, indicated that Resident 1 was found on the floor from bed. The approaches/actions indicated physical therapy and occupational therapy treatment and evaluation as ordered. There were no new interventions considered for Resident 1 who attempted to get out of bed unassisted. The licensed staff did not evaluate the effectiveness of the previous interventions on the nursing plan of care dated 8/26/11. The staff did not implement the low bed on the nursing plan of care dated 8/26/11. During an interview on 3/7/12 at 11 a.m., Staff B stated that she did not know what "increased observation as staff allows" would entail. During an observation on 3/7/12 at 11:30 a.m., Resident 1's bed was in the low bed position that measured 16 inches from the floor to the top of the mattress. During an interview on 3/7/12 at 11 a.m., Staff B stated she was not aware of any intervention that would put the bed on the floor directly. During an interview by telephone on 3/12/12 at 11:30 a.m., Staff A stated that the facility will put a resident's mattress directly on the floor if indicated. Staff A stated that Resident 1 was a candidate to have his mattress directly on the floor but in his case the intervention was not implemented. When asked why the facility did not try placing Resident 1's mattress directly on the floor, Staff A was not able to provide an answer. Nurses notes dated 8/29/11 at 6:00 a.m., indicated Resident 1 attempted to get out of bed unassisted without using the call light or asking for assistance. Nurses notes dated 8/30/11 at 4:30 a.m., indicated Resident 1 made several attempts to get out of bed. Nurses notes date 9/4/11 at 6:00 a.m., indicated Resident 1 made several attempts to get out of bed at night. Resident 1 had an unsteady gait and wandering behavior. Third Fall: The Nurses Notes dated 9/5/11 at 9:30 a.m. indicated that Resident 1 got up and fell from the wheelchair. Resident 1 was found lying on the floor. The Nurses Notes dated 9/5/11 at 1:45 p.m. indicated that Resident 1 complained of right hip pain. On 9/5/11 Resident 1 got an x-ray of the right hip which was negative for fracture. The Interdisciplinary Team Notes dated 9/6/11 at 9:45 a.m., recommended a room change near the nurses station. There were no further effective interventions considered for Resident 1 who got up out of the bed and wheelchair unassisted. Resident 1's Nursing Plan of Care dated 9/5/11 did not indicate any new approaches or interventions. Fourth Fall: The Nurses Notes dated 9/6/11 at 9:06 p.m. indicated that Resident 1 was found lying on the floor at 6:30 p.m. The nurses notes indicated Resident 1 was last seen in the wheelchair. The Nursing Post Fall assessment dated [DATE] indicated previous interventions of bed and wheelchair alarms. The new interventions were increased observation as staff allows, encourage wife to visit during afternoon. The room change was supposed to be implemented on 9/5/11. The increased observation as staff would allow and the room change were the same interventions as indicated on the nursing plan of care dated 9/5/11. Resident 1's Nursing Plan of Care dated 9/6/11, indicated that Resident 1 was found on the floor. The approaches/actions indicated bed and wheelchair alarm, increased observation , encourage wife to visit on the evening shift, and room change close to the nurses station. The nursing plan of care lacked specificity regarding "increased observation as staff allows." There were no new effective interventions considered for adequate supervision for Resident 1 who had multiple falls and got up from the bed and wheelchair unassisted. Fifth Fall: The Nurses Notes dated 9/7/11 at 9:50 p.m. indicated a witnessed fall when Resident 1 stood up from the wheelchair and attempted to walk unassisted. The notes indicated that the staff were not able to get to Resident 1 in time to prevent the fall. The Nursing Post Fall assessment dated [DATE] indicated previous interventions of low bed, mats, wheelchair and bed alarms, and observation by staff. The new intervention was that the Social Service Designee would talk to Resident 1's wife about medications to prevent sun downing episodes(episodes of confusion when the sun sets). The Nursing Post Fall Assessment indicated to continue current nursing plan of care. The nursing plan of care lacked specificity regarding increased observation by staff and there was no low bed implemented. There were no new effective interventions considered for adequate supervision for Resident 1 who had multiple falls and got up from the bed and wheelchair unassisted. Sixth Fall: The Nurses Notes dated 9/16/11 at 4 p.m. indicated that Resident 1 got up unassisted from the wheelchair and fell . Resident 1 was found outside, on the patio lying on his right side. The X-ray report from Community Mobile Diagnostics, Inc of the Right Hip for Resident 1 dated 9/17/11 indicated a fracture of the right femoral neck with displacement (top of the right thigh bone). The Nurses Notes dated 9/17/11 at 4:30 p.m. indicated that Resident 1 was transported to the hospital per the physician's orders [REDACTED]. Resident 1's nursing plan of care dated 9/16/11, indicated that Resident 1 had a fall. The approaches/actions indicated: x-ray as ordered, increase visual monitoring, make sure wanderguard and bed alarm in place and working. The nursing plan of care lacked specificity regarding increased observation by staff. There were no new effective interventions considered for adequate supervision for Resident 1 who had multiple falls and got up from the bed and wheelchair unassisted. During an interview on 3/7/12 at 11 a.m., Staff B stated that the facility could do 1:1 staffing when a resident was a fall risk. Staff B stated there was a program called Care Specialists that enabled CNAs to work extra hours assigned to a specific resident for 1:1 supervision. During an interview by telephone on 3/12/12 at 11:30 a.m., Staff A stated there was no specific times for "frequent monitoring". Licensed staff and CNAs check in on a resident and do a visual check anytime they are in the vicinity of a resident that is a known fall risk. The staff will check a resident anytime they are near that resident's room as well as on their regular rounds. Staff A stated that the facility will put a resident on 1:1 supervision if indicated. Staff A stated that she did not think that Resident 1 was a candidate for 1:1 supervision. Staff A were asked the criteria was for 1:1 supervision. Staff A was not able to provide an answer. The Fall Prevention Policy and Procedure dated 5/2007 did not include specific preventative measures regarding how facility staff would provide adequate supervision to prevent accidents. The facility violated the regulation by failing to ensure that Resident 1, who was at risk for falls and known attempts to get out of bed and the wheelchair unassisted, was provided adequate supervision by direct care staff and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. Resident 1 had six falls during a 30 day period from 8/26/11 to 9/16/11, with no effective interventions considered to prevent further falls from the bed and wheelchair. These failures contributed to Resident 1 sustaining a right femur fracture after the sixth fall while getting up unassisted from the wheelchair while outside on the patio. The violation of this regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.