Every finding on record at Catholic Eldercare on Main

Based on observation, interview, and document review, the facility failed to ensure appropriate infection control technique was followed during 1 of 1 meal service for hand hygiene and beard net use. In addition the facility failed to follow infection control practices for cleanliness and storage of reusable steam table pans . This had the potential to affect all 146 residents residing in the facility.Findings include: Observation on 12/15/25 at 1:13 p.m. with the certified dietary manger (CDM) during the initial kitchen tour identified the following items stacked on a metal cart as ready for use: 1.) Five 1/4 steam table pans that were stacked and were still wet.2.) Two 1/8 steam table pans stacked and were still wet, and a deep steam table pan with food substance left on the surface, and wetness present on the inside.3.) Two full sheet pans stacked and still wet on the interior surface.4.) Twelve 2-inch steam table pans that had been stored while still wet and remained wet at the time of observation.Interview on 12/15/25 at 1:20 p.m. with the CDM identified the steam table pans should not have been removed from the drying rack and stacked while still wet, and the soiled items should have been caught and rewashed and dried before being placed on the storage rack for reuse. She identified her expectation that items placed on the storage rack for reuse be clean and dried appropriately for reuse. Interview on 12/15/25 at 1:23 p.m. with the registered dietitian (RD) identified her expectation for reusable cookware to be appropriately cleaned and dried before it was stacked on a rack as ready for reuse. Observation on 12/17/25 at 11:37 a.m. as the noon meal was plated and loaded onto carts for transport to the facility nursing units. DA-A was observed assisting to prepare and transport meal carts to the nursing units. DA-A had a hair net on the top of his head but had hair extending @ 1 inch on the front and sides of his head. DA-A also was noted to have long facial hair and no facial hair covering in place. When an unidentified staff person asked for shredded cheese for a meal tray, DA-A used his gloved hands to remove a large container of shredded cheese from the refrigerator, Remove the cover, and use his same gloved hand to reach into the container, remove a handful of cheese and place it into a dish and hand to a person on the tray line. With his same gloved hands, he recovered the container and returned it to the refrigerator. Then with no glove change or hand hygiene he proceeded with loading resident meal trays onto the cart. Interview on 12/17/25 at 11:45 a.m. with DA-A reported he had not thought about needing to change his gloves and perform hand hygiene prior to obtaining the requested shredded cheese, and reported he should have used a spoon or scoop to retrieve the cheese rather than his hand. He also reported he was not aware he needed to be wearing a beard cover, and he normally had not done so in the past. Interview on 12/17/25 at 11:55 a.m. with the CDM reported she was not certain about when male staff needed to utilize beard covers, and DA-A did not usually have his hair and facial hair in the appearance it was at this time and she had not noticed it, but agreed he should have both hair on his head and beard covered. Review of the 8/8/22 Dining Services policies and Procedures identified hairnets must be always worn over all of hair. Hair must be neat and clean and not interfere with good infection control technique. Sideburns, mustaches, and beards must be neatly trimmed. the policy failed to address the use of facial hair coverings. A policy on cleaning and storage of reusable cooking, steamtable pans was requested but not provided by the end of the survey period.

Based on observation and interview the facility failed to maintain a comfortable temperature between 71-81 degrees Fahrenheit (F) in 1 of 2 first floor dining areas. In addition, the facility failed to maintain acceptable temperature range in 1 of 1 split resident room for 2 of 2 residents (R41 and R45). Findings include:Observation/ interview on 12/15/25 at 1:30 p.m., during initial screening R41 was seated in her wheelchair in her room wearing a knitted scarf wrapped around her neck and wearing a blue quilled coat. She had her arms crossed her body and stated it was cold in her room, but it was better than the past couple of days when it was terribly cold outside. She reported she had told staff and asked to have her room warmer, but nothing had been done. she also reported it was hard to eat her meals in the room being used for the dining room because it was so cold, and she and the other residents had complained, but were told nothing could be done about it. Observation on 12/15/25 at 2:00 p.m. of the Atrium room being used for dining noted large floor to ceiling windows facing the yard area with snow against the lower portion of the windows. The ceilings were high, and ceiling fans were circulating the air, which was uncomfortably cold. Multiple tables were positioned throughout the room, and through the doors located at the end of the large room construction area was noted.Observation on12/15/25 at 4:45 p.m., R41 was transported into the Atrium room for the supper meal wearing her scarf around her neck and her quilted coat, she had the scarf pulled up around her lower face and sat with her arms across her body. She reported it was hard to eat because it was so cold and uncomfortable. Multiple residents waiting to eat their supper meal also voiced complaints that it was so cold, and the ceiling fans were making it worse. Multiple residents were noted to ask staff to turn off the fans but were told the fans were pushing the heat down, and it would be colder if they were turned off. One unidentified resident was brought into the dining area wearing, a heavy sweater, wrapped in a blanket and wearing gloves, which she kept on while trying to eat her supper. Multiple residents were wrapped in blankets and wearing heavy sweaters or coats. All but one resident present in the dining room complained it was difficult to eat because it was so cold and reported they had complained but were told nothing could be done about it. A visiting family member (requested to remain anonymous) reported it had been very cold for all the residents, and she had to get blankets and wrap around the residents to help them stay warm. She reported she had also voiced complaints to administration about how cold it was in the dining area, but nothing had been done about it. Observation/interview on 12/15/25 at 1:30 p.m. with R45 who was seated in her wheelchair in her room shared with R41. She was wearing a heavy knit sweater and covered with a blanket. She reported her room was very cold and there was cold air felt coming from the ceiling vent. She reported she had requested her room to be warmer, but nothing had been done, and multiple unidentified staff had told her room was the coldest room on the unit. R45 also complained about how cold it was in the dining area, and it was difficult to eat because she was so cold. She stated the only time she was warm was when she was in bed with all her blankets on. At 4:45 p.m. R45 was seated at a table in the dining room wearing a heavy sweater and covered with a blanket. A ceiling fan was above her and cold air movement was noted. She and multiple residents at tables throughout the room were asking for the fans to be turned off because they were so cold. Observation/interview on 12/16/25 at 12:30 p.m. identified R41 in her wheelchair in her room wearing her scarf around her neck and her quilted coat. She reported it had been cold in the dining room again this morning and the fans were still on. She stated she was hoping it would get warmer since the outside was warmer outside.R45 was seated in her wheelchair eating her noon meal in her room and stated she was not feeling well because the cold made her ache, because she had Parkinson's disease, and the cold made it worse. She reported she had been told maintenance was going to come and see what they could do to make her room warmer, but nothing had been done yet. Interview on 12/17/25 at 9:18 a.m. with the certified dietary manager (CDM) reported it had been uncomfortably cold in the Atrium room currently being used for dining during the construction period and residents had complained about the temperature, but she was told nothing could be done about it. She also reported residents had asked to have the ceiling fans turned off during meals, but administration had told her they had to remain on to regulate the heat in the room. she reported it had been very cold on a couple of days the past week when the outdoor temperature was in the single digits, and on one day they had not served in the Atrium because it was so cold. Interview on 12/17/25 at 9:19 a.m. with the maintenance director reported he had been contacted by the director of operations regarding the temperature in the Atrium during the supper meal on 12/15/25 because residents were complaining it was uncomfortably cold. He reported he had the housekeeping director check the controls to ensure the Atrium unit was running and upon his arrival the morning of 12/16/25, he entered the Atrium and confirmed it was very cold. He estimated the temperature was @ 65 degrees F. which was below the designated temperature range of 71 - 81 degrees. He reported he had reset the unit and used a temperature gun to confirm there was heat coming from the vents in the ceiling. The room was noted to be a comfortable temperature, and he reported he had been checking the temperature since that time, and it had remained at 75-79 degrees F. At 9:24 a.m. the maintenance director was observed using a temperature gun to check the temperature of air coming from the vents in the Atrium. The ceiling is 30 feet from the floor and the air coming from the vents registered 93 degrees, temperature at the table level was 82-84 degrees and beside the window was at 73 degrees. He reported he did not know what had happened to cause the unit to not be functioning properly, but it seemed to be working at the present time, and he would continue to monitor. He did voice agreement that turning the fans off on 12/15/25 during the supper meal would have been appropriate as the circulating air would have made the room feel colder to those residents seated at the tables. Regarding R41 and R45's shared room, he reported he had checked the problem with the heat, and a vent had been closed which limited the amount of heat going to the room. He had made the adjustment, and both residents had reported it had gotten more comfortable for them. Interview on 12/17/25 at 10:30 a.m. with both R41 and R45 voiced the temperature in both their room, and the dining area was much more comfortable now, but did not understand why it could not have been corrected sooner. A policy on environment and comfortable temperatures in common spaces and resident rooms was requested but not provided by the end of the survey period.

Based on interview and document review the facility failed to ensure the accuracy of 1 of 1 resident (R41) medical record when R41 had conflicting end of life (code status) documentation. :Findings include:R41's current, undated electronic medical record (EMR) identified R41 was marked as full code (wanting all lifesaving measures including cardiopulmonary resuscitation (CPR), R41's [DATE], Provider Orders for Life-Sustaining Treatment (POLST) identifiedA: Attempt Resuscitation/CPRB. Full TreatmentC. Documentation of Discussion-Patient has Capacity D. Signature by R41 dated [DATE] and by certified nurse practioner (CNP) dated [DATE]R41's current, electronically signed physician orders identified her code status as Do Not Resuscitate/Do Not Intubate (DNR/DNI). Interview on [DATE] at 12:14 p.m. with R41 identified she wanted full resuscitative measures performed if she was found to not be breathing or have a pulse. Interview on 12/16//25 at 12:45 p.m. with licensed practical nurse (LPN)-C reported would initially check the EMR face sheet banner, then the orders, and she also identified there was a reference book kept at the nursing station for staff to reference for code status of residents. LPN-C further identified there was supposed to be a copy of each resident's care plan posted on the inside of the room closet door to allow for quick access. LPN-C referenced R41's EMR and confirmed the current physician orders listed her code status as DNR/DNI which was not correct. She reported the error should have been caught at the time of admission on [DATE] and would need to be corrected immediately. LPN-C provided documentation of the date the order was changed on [DATE]. Interview on [DATE] at 12:50 p.m. with registered nurse (RN)-A reported in an emergency when code status needed to be confirmed she would initially go to the EMR, open the face sheet where code status was displayed on the resident banner. She reported there was also a hard copy kept in a binder at the nursing station for quick reference by staff. Upon review of R41's EMR she confirmed the current physician orders conflicted with the POLST and care plan and should have been caught and corrected at the time the orders were entered and reviewed in the record. Interview on [DATE] at 1:05 p.m. with the director of nursing (DON) identified his expectation for staff to confirm the POLST, EMR banner, physician orders and care plan were reviewed to ensure a resident's correct code status was identified and documented. He agreed R41 could have potentially not received resuscitative measures in an emergent situation. A policy related to Advance Directives and/or emergent situations regarding provision of CPR was requested but not provided by the end of the survey period.

Based on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, for 2 of 5 residents (R2, R157) reviewed for unnecessary medications.Findings include: R2R2's significant change in status Minimum Data Set (MDS) assessment, dated 10/1/25, indicated R2 had short term and long-term memory impairment with no hallucinations or delusions, no behaviors, wandering or rejection of care.During an observation and interview on 12/17/25 on 7:52 a.m., R2 was observed in the small dining room, feeding herself breakfast. She smiles at surveyor but does not answer questions. R2 appears comfortable. R2's Order Summary Report, printed 12/18/25, included the following orders: -quetiapine (an antipsychotic medication) 25 milligram (mg) tablet; take 12.5 mg by mouth three times a day with a start date of 2/10/25-sertraline (antidepressant medication to help treat depression) 50 mg by mouth once daily with a start date of 5/16/23. R2's December Medication Administration Record (MAR/TAR), printed 12/18/25, included the following: -quetiapine 25 mg tablet: take 12.5 mg by mouth three times a day for psychotic disorder with delusions due to known physiological condition with a start date of 2/10/25. Documentation indicated administered as ordered. -sertraline 50 mg: take 50 mg by mouth once a day for depression with a start date of 5/16/23. Documentation indicated administered as ordered. A document titled Informed Consent: Anti-Anxiety Medication was provided. The document indicated the medication was quetiapine 12.5 mg. The document lacked side effect information. The document lacked indication of whether consent was given or not within the provided boxes of I approve or I do not approve. Furthermore, the document lacked a date or signature of nurse.A document titled Informed Consent: Anti-Depressant Medication was provided. The document indicated the medication was sertraline 50mg which was increased on 5/16/23. The document lacked a date the form was completed. Furthermore, the document lacked any side effect information. R157R157's quarterly MDS assessment, dated 12/5/25, indicated R157 had severely impaired cognition impairment with no hallucinations or delusions, no behaviors, wandering or rejection of care.During an observation and interview on 12/15/25 at 5:09 p.m., R157 was observed seated in her wheelchair. R157 would alternate from scooting herself around in the dining room and eating supper. R157 was concerned about someone stealing her card. R157's Order Summary Report, printed 12/18/25, included the following orders: -quetiapine 25 mg tablet; take 75 mg by mouth at bedtime with a start date of 2/20/25-sertraline (antidepressant medication to help treat depression) 50 mg by mouth once daily with a start date of 5/2/24.R157's December Medication Administration Record (MAR/TAR), printed 12/18/25, included the following: -quetiapine 25 mg tablet: take 75 mg by mouth at bedtime for psychotic disorder with delusions due to known physiological condition with a start date of 2/20/25. Documentation indicated administered as ordered. -sertraline 50 mg: take 50 mg by mouth once a day for major depressive disorder with a start date of 5/2/24. Documentation indicated administered as ordered. A document titled Informed Consent: Anti-Psychotic (Neuroleptic) Medication was provided. The document indicated the medication was quetiapine 75 mg. The document was signed on 12/17/25 by responsible party. A document titled Informed Consent: Anti-Depressant Medication was provided. The document indicated the medication was sertraline 50mg. The document lacked any side effect information. The document was signed by responsible party on 12/17/25. During an interview on 12/17/25 at 11:08 a.m., health unit coordinator (HUC)-A stated they do all the uploading for the floor. HUC-A stated they do not have any consents for medications that have not been uploaded for R2 or R157. HUC-A reviewed R2 and R157 medical records. HUC-A stated there was not a signed consent for R2 for quetiapine or sertraline. HUC-A stated there was not a signed consent for R157 for quetiapine or sertraline. HUC-A verified the facility does not use paper charts and everything was kept in the electronic medical record. During an interview on 12/17/25 at 10:43 a.m., licensed practical nurse (LPN)-B stated when a resident starts on a new psychotropic medication, nursing gets a consent for the medication. LPN-B stated it was a paper consent which gets uploaded into the electronic medical record. LPN-B reviewed R2 medical record and stated they could not find a signed consent for quetiapine or sertraline. LPN-B reviewed R157 medical record and stated they couldn't find consents for sertraline or quetiapine. LPN-B stated both medications should have consents given prior to administering. During an interview on 12/17/25 at 12:26 p.m., registered nurse manager (RN)-D stated the expectation was to obtain consent for psychotropic medications prior to starting them. RN-D stated it was the floor nurse's responsibility to obtain the consents. RN-D reviewed R2 and R157 medical records and verified the consents where not in the chart. During a follow up interview on 12/18/25 at 8:28 a.m., RN-D stated he followed on the consents for R2 and R157. RN-D stated he found the consents in the drawer from previous nurse manager. Surveyor and RN-D reviewed. RN-D verified R2's Informed Consent for Anti-Anxiety Medication lacked side effect information, a date, signature of nurse and whether consent was given and stated the consent should have this information. RN-D verified R2's Informed Consent for Antidepressant Medication lacked side effect information and date which the form was completed and stated the consent should have this information. RN-D stated he found R157's consent forms for antipsychotic and antidepressant medication in the drawer also and did not have signatures. RN-D stated he followed up with the nurse on the floor who then talked to the family who signed the forms. RN-D verified the forms were not signed prior. RN-D verified the consent for sertraline did not contain any side effect information along with not indicating whether consent was given by checking the I approve or I do not approve box. During an interview on 12/18/25 at 11:12 a.m., director of nursing (DON) stated the expectation would be consents for medications be obtain. DON stated a verbal consent would be acceptable if it was document. DON stated the consent should include the following: medication, dose, reason why they are taking it, benefits, side effects and dated. DON reviewed R2's consent for sertraline and quetiapine and R157's consents for sertraline and quetiapine and verified the documents lacked required information. A facility policy titled Psychotropic Medication, reviewed 10/10/25, indicated the procedure to include obtain informed consent from resident and/or responsible party. See informed consent: psychotropic medications. If consent is given continue to follow policy, if denied contact prescriber.

Based on observation, interview and record review, the facility failed to ensure appropriate management of an indwelling catheter was provided for 1 of 1 residents (R5) reviewed for indwelling catheters. Findings include:R5's annual Minimum Data Set (MDS), dated [DATE] identified R5 with impaired cognition, required substantial assistance for personal hygiene, dressing, and rolling from side to side in bed. In addition, R5 had diagnoses of diabetes, aphasia (communication disorder affecting speech, understanding, reading and writing), dementia, schizophrenia and had an indwelling catheter (tube from bladder to outside the body into a bag).R5's physician orders (PO) dated 5/19/25 stated, Large drainage bag on when in bed (include daytime naps).During observation on 12/15/25 at 2:35 p.m., R5 was lying in bed sleeping. A small leg bag with urine was observed to be attached to R5's left leg, which was horizontal to level of bladder, however no large night urine drainage bag was not observed in room.During observation on 12/16/25 at 1:29 p.m., R5 was lying in bed sleeping. A s mall leg bag with urine was observed to be attached to R5's left leg which was horizontal to level of bladder. A large night urine drainage bag was not observed in room.During interview with licensed practical nurse (LPN)-A on 12/16/25 at 3:32 p.m., LPN-A stated R5 should have [large urine drainage bag] on any time if [R5] is in bed, otherwise urine can back up and risk infection.During interview with registered nurse (RN)-A on 12/16/25 at 3:38 p.m., RN-A stated R5 had a suprapubic catheter and was to have the large bed bag on when R5 is lying down in bed. RN-A stated nursing assistants were responsible for changing the small leg bag to the large one when R5 is to lay down in bed.During interview with nursing assistant (NA)-A on 12/17/25 at 10:07 a.m., NA-A stated expectation of the large drainage bag to be used when R5 lays down in bed and for the small leg bag to be used when R5 is up in a chair.During interview with RN-B on 12/17/25 at 10:13 a.m., RN-B stated expectation of nursing assistants to change the large urine drainage bag to the small leg bag when the aides assist the resident to get up out of bed. Also, RN-B stated aides are expected to switch the leg bag to the large drainage bag anytime the resident lays down to rest so the urine could always be draining below the bladder.During interview with RN-C on 12/17/25 at 10:31 a.m., RN-C stated expectation of large urine drainage bag to be attached to side of bed below the level of the bladder every time the resident is in bed. If [urine bag] is not below the bladder, the urine can get clogged [or back up] in the tube.During interview with infection control preventionist (IP) on 12/17/25 at 2:24 p.m., IP stated expectation of nursing assistants to change the catheter bags from the large drainage bag to the leg bag every morning unless it is care planned otherwise. When residents want to lay down, like after lunch, then the aides are to change the leg bag to the large drainage bag for gravity to assist with keeping urine below the bladder.During interview with director of nursing (DON) on 12/18/25 at 9:47 a.m., DON stated expectation for nursing assistants to change the leg bag to the large drainage bag when resident is in bed. Even for naps. DON stated, gravity is needed for flow of urine into the bag and not back up [into] the bladder.Facility policy titled Catheter, Indwelling with review date of 10/25/25 identified, Urinary drainage bag should be below the level of the bladder at all times.

Based on interview and document review, the facility failed to implement a palm protector for 1 of 1 resident (R78) reviewed for range of motion (ROM).Findings include:R78's quarterly Minimum Data Set (MDS) dated [DATE] indicated R78 was cognitively intact, had no behaviors or rejected personal cares, needed touching assistance with eating, and needed maximal assistance with toileting hygiene, dressing, bed mobility and transfers. MDS indicated R78 was at risk for skin breakdown, and ROM was not assessed.R78's face sheet dated 12/18/25 indicated diagnoses of benign neoplasm of meninges (non-cancerous tumor growing in the protective membranes covering the brain and spinal cord), chronic obstructive pulmonary disease (lung disease that blocks the airflow and make it difficult to breath) , hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move one side of the body) following cerebral infraction affecting right dominant side.R78's Occupational Therapy Evaluation and Plan of Treatment report dated 12/1/25, indicated R78's (ROM) of upper right extremity was within normal limits. R78's upper left extremity ROM was impaired.R78's Resident Profile and Care plan dated 12/16/25 lacked documentation about the Posey palm protector.R78's medication administration records and treatment administration records between 7/1/25 through 12/15/25 lacked documentation about the Posey palm protector.During observation and interview on 12/16/25 at 8:58 a.m., R78 stated her left hand became a clenched fist without noticing. R78 stated the therapist used to put a brace on her left hand, but Friday she had her last therapy session. R78 stated she was supposed to use the brace during the day and remove it at bedtime, but the nursing staff does not put on her brace. During interviewed R78's left hand was clenched while her palm protector was on a recliner next to her bed.During observation on 12/16/25 at 1:48 p.m., R78 was sitting in her custom-made wheelchair. She did not have the white Posey palm protector on. The palm protector was on the recliner chair.During interview on 12/16/25 at 1:50 p.m., the director of rehabilitation (DR) stated R78 had been evaluated and treated by the therapy department. DR provided a copy of an email dated 7/10/25 from an occupational therapist (OT) to nurse manager/registered nurse (RN)-F. OT informed RN-F she had provided an edema glove and a Posey palm protector for R78's left hand. The email indicated R78 could wear the palm protector during the day and the edema glove as needed. DR stated. when a resident completed their rehabilitation services, the therapist sends an email with recommendations to the appropriate nurse manager. DR stated the nurse manager was supposed to implement the recommendations. During interview on 12/17/25 at 12:24 p.m., RN-F verified there was no documentation on R78's orders, care plan, or the medication or treatment administration records. RN-F reviewed her emails and verified she had received the 12/5/25 email form the therapist. However, RN-F stated she did not read the email. Therefore, she did not implement the therapist's recommendation.During interview on 12/18/25 at 10:44 a.m., director of nursing (DON) stated the palm protector needed to be implemented as ordered and added to the care plan to prevent contractures and protect resident's skin. DON stated the facility would need to improve communication between the nursing and therapy department.Requested a facility policy about use of splints/pal protectors but none received.

Based on observation, interview and document review, the facility failed to ensure dental needs were coordinated with a dental provider for further care to reduce the risk of complication (i.e., cavities, oral pain) for 1 of 1 residents (R14) reviewed for dental care and services.Findings include:R14's significant change Minimum Data Set (MDS) assessment, 10/9/25, indicated R14's cognition was severely impaired without hallucinations or delusions present with no behaviors, rejection of care, or wandering present. Further, the MDS identified a section titled Section L-Oral/Dental Status indicated unable to examine. Section K: Swallowing/Nutritional Status indicated R14 had complaints of difficulty or pain with swallowing.R14's face sheet, printed 12/17/25, identified relevant diagnoses included: vascular dementia with anxiety, osteoarthritis, anxiety disorder and chronic knee pain.During an interview and observation on 12/15/25 on 2:48 p.m., R14 was observed propelling herself in the hallway in her wheelchair. R14 was observed to be missing numerous teeth. R14 answered questions nonsensically.During an observation on 12/16/25 at 12:27 p.m., R14 was observed eating in the dining room. R14's plate had meat and veggies that were diced up into small pieces. R14 was observed to have an untouched egg roll on her plate.R14's care plan, printed 12/18/25, identified the following: Oral/Dental: unable to perform oral examination due to elevated anxiety level with the following approaches: - notify NP [nurse practitioner] before any dental appointments to order pRN [sic] (as needed) antianxiety medicine to help her anxiety at dental appointments - observe for signs and symptoms of infection -obtain dental consult. - monitor and record percentage of food/fluid intake. -instruct resident in proper brushing techniques. - offer family the opportunity to come in and be present during dental exam to help decrease her anxiety level.- Provide assist of 1 staff (specify amount of assistance: e.g., setup, cueing, full staff performance) for oral hygiene every morning and evening(schedule).- Nutritional status use of mechanical altered diet related to decreased chewing ability - own teeth in poor condition; to include the following approaches: monitor for chewing and swallowing problems.R14's care sheet identified R14 was assist of 1 with toileting, transfers and dressing. Furthermore, R14 did not wear dentures.R14's progress notes, dated 1/16/25 to 12/15/25, reviewed and identified the following: -4/29/25: R14 noted to have increased anxiety/restlessness in the evening or during dental appointments.-4/22/25: R14 noted to have own teeth with several missing teethProgress notes lacked any dental visits, missed dental appointments, or refusal to attend a dental appointment.A Chart Progress Note, dated 4/3/25, identified R14 had completed a scheduled dental exam. R14's diagnoses/assessment indicated inflammed gingival tissue, and clinical finding of tissues are very inflamed [sic] and 6 months recall recommended. Noted Prophy completed with toothbrush and peridex, hand scaling instruments, floss and mechanical polish with oral hygiene recommendations: Recommended brushing 2x/day, flossing 1x/day with Listerine flosser, using saltwater rinses, using proxy brush. Furthermore, recall exam recommendations were exam to be every 6 months and prophylaxis visit every 3 months.No additional chart progress notes were found in R14's medical record.R14's Nutrition Risk Data Collection and Assessment, dated 10/10/25, indicated R14 had own teeth with other box mark, with notes some missing, broken, During an interview on 12/16/25 at 2:52 p.m., trained medication aid (TMA)-A stated R14 needed staff assistance with oral care. TMA-A stated they were unsure if R14 has missing teeth or wore dentures and stated that would be a better question for the nursing assistant.During an interview on 12/16/25 at 2:56 p.m., nursing assistant (NA)-E stated they were familiar with R14. NA-E stated R14 was assist of 1 with oral care. NA-E stated R14 did not wear any dentures. NA-E stated R14 was missing numerous teeth. During an interview on 12/17/25 at 10:46 a.m., licensed practical nurse (LPN)-B stated the health unit coordinator (HUC) typically coordinated all dental appointments for residents. LPN-B stated the nurse would assess if a resident was having dental pain and work with the provider if was determined the pain may be caused from an infection. LPN-B stated the HUC scheduled the on-going dental appointments.During an interview on 12/17/25 at 11:03 a.m., HUC-A stated they coordinated dental appointments. HUC-A stated they got a schedule of residents that will be seen by the in-house dental provider (dental provider that comes to the facility) to review. HUC-A stated they can and do request for residents to be see when needed. HUC-A reviewed R14's medical record and stated the last dental appointment was 4/3/25. Furthermore, HUC-A reviewed the visit note and stated R14 should have been seen in July for follow up. HUC-A verified R14 had not been seen. HUC-A verified they could not locate any notes the dental provider attempted to meet with R14 and wasn't able to for any reason. During an interview on 12/17/25 at 12:20 p.m., registered nurse manager (RN)-D stated the expectation would be if a dental provider made recommendations, then they would be followed if family agreed. RN-D stated dental health is important. During an interview on 12/18/25 at 11:09 a.m., director of nursing (DON) stated the expectation would be dental recommendations would be followed. During a follow up interview on 12/18/25 at 12:23 p.m., DON provided an email exchange, dated 12/18/25, between facility and dental provider that comes to facility which outlined the priority of how they see residents in the facility. Furthermore, the email verified R14 had not been seen in a while and had now been added to the list to be seen.A facility policy titled Long-Term Care Ancillary Services, reviewed 5/25, indicated resident will have access to dental examinations, cleanings, and necessary dental treatments.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., shower, and shaving) was provided for 1 of 3 residents (R171) reviewed for activities of daily living (ADL).Findings include:R171 was admitted to the facility on [DATE] with a diagnosis of jaw osteonecrosis due to drugs (condition where jawbone tissue dies and becomes exposed in the mouth), prostate cancer, depression, sleep apnea and polyneuropathy (damage to multiple peripheral nerves, causing numbness, weakness, and pain).R171's Resident Profile dated 12/18/25 indicated R171 required assistance with bathing, dressing, and toileting. Profile indicated R171 needed extensive assistance with grooming and set-up with eating. Resident Profile also indicated R171 was at risk for skin integrity loss and would require daily monitoring and wound treatment.R171's care plan indicated he needed assistance with grooming, bathing, toileting and dressing.During observation and interview on 12/15/25 at 5:51 p.m., R171 stated he wanted to shave this morning. The nursing assistant (NA) asked R171 if he had an electric razor, and he said no. NA left the room and returned with a disposable razor and asked R171 Where do you want it (the razor)? R171 stated the NA did not offer to help him. R171 stated he liked to be cleaned shaven and touched his overgrown facial hair and said I don't like this. I haven't shaved for 8 days. The overgrown facial hair was about 0.75 centimeters long. R171 also stated, he had not taken a shower while in the hospital or at the facility. R171 said a nurse told him he would shower once a week, but he had not yet received one. R171 added he had scalp dermatitis with severe dandruff. He said this morning I went to the clinic, and when I removed my sweater, it was like a snowstorm; dandruff flew all over the room. It was embarrassing.During interview on 12/16/25 at 12 p.m., R171 said he was about to leave to go to his clinic. He had not shaved and said he did not get a shower.During interview on 12/16/25 at 1:44 p.m., NA-F stated she helped R171 in the morning. NA-F stated she helped R171 to dress, comb his hair and did not offer help him to shave.During interview on 12/17/25 at 10:26 a.m., NA-H stated residents hd scheduled showers in the morning and afternoon shifts. NA-H stated in the mornings she helped residents to go to the bathroom, helped them with their briefs or to use the toilet. NA-H helped them to dress and wash their faces and teeth. Regarding shaving, NA-H stated the staff waited until the family brought their electric shaving machines. Otherwise, they used the disposable razors and offered their help to the residents. NA-H did not help R171 in the morning.During interview on 12/17/25 at 10:38 a.m., NA- G stated he helped R171 to get ready in the morning. NA-G stated he helped R171 to wash his face, brush his teeth and helped him to dress. NA-G stated he didn't notice if R171 needed to shave or not. During interview on 12/17/25 at 11:01 a.m., family member (FAM)-A said his father shaved yesterday, but not very well. FAM-A had a picture which showed several unshaved areas.During interview on 12/17/25 at 12:16 p.m., nurse manager/registered nurse (RN)-F stated R171 needed assistance with dressing, grooming, and bathing. RN-H stated R171 needed help with meal set up and shaving. RN-F stated she expected the staff to offer and help residents to shave. Regarding showers, RN-F stated R171 was scheduled for a shower on Tuesday afternoon. R171 was scheduled to receive a shower on 12/16/25, but there was no documentation it was given as scheduled. RN-F confirmed there was no documentation about resident receiving a shower since his admission. RN-H stated whether a resident received a shower, it needed to be documented.During interview on 12/18/25 at 10:09 a.m., director of nursing (DON) stated his expectation was to follow residents' care plan. DON stated the nurses and NAs get a notification on their care sheets about showers. The NAs give the shower, and the nurses complete a skin assessment. The nurses document skin concerns and would also document if a resident refused a shower or a bed bath. DON stated if the residents don't bring their own electric shaving machine, the facility provided a disposable razor. His expected the NAs to provide the necessary assistance to shave the residents. DON added, showers and shaving were a matter of good customer service.Requested a policy about ADLs but none received.

Based on observation, interview, and document review, the facility failed to ensure residents were free from physical restraints for 1 of 1 resident (R101) who utilized a pillow rolled to prevent resident from attempting to self-transfer from his bed. Findings include: R101's 12/4/25 accepted Quarterly Minimum Data Set (MDS) assessment identified he had severed cognitive impairment, moderate visual impairment, was dependent on staff for ADLs including eating. His most recent fall occurred on 11/22/25 when he had fallen from his chair in the common areas. He had diagnosis of Parkinson's disease with psychotic disturbance, dementia in Alzheimer's disease, impaired mobility and ADLs, and depression, he received daily psychotropics, Parkinson's disease medication, Tylenol, and topical analgesic medication. Had been admitted to hospice services 4/24/25 with a terminal diagnosis of -Parkinson's disease with dementia. No restrictive devices were identified in the assessment.R101's current undated care plan identified he received hospice services, and the care plan was integrated with the facility care plan. The intervention identified placement of a pillow on the left side of the Broda chair for comfort due to his leaning to the left. He was to be assisted back to the nursing station following visits to allow for visual monitoring. Target behaviors were identified with monitoring and documentation to be completed. Medications were to be administered as ordered with monitoring for effectiveness and potential side effects. Safety related to falls always included incline his wheelchair except during meals to prevent falls. Position by nursing station to allow for supervision. When falls occur investigate root cause through IDT meeting protocol. The care plan did not include any type of restraint or device to restrict movement. R101's current undated care plan identified he had his most recent fall on 11/22/25 related to an attempt to self-transfer, and the most recent interventions was positioning resident close to the nursing station to allow for supervision and verbal reminders. He had severe cognitive impairment) related to [dementia, Parkinson's disease, Alzheimer's disease, Major depressive disorder, with psychotic symptoms, affecting orientation, memory, and/or decision-making. Hospice services identified a terminal diagnosis of Parkinson's Disease with Dementia with intervention to place a soft pillow on the left side of the Broda chair when he was seated for comfort as he leaned on the left side of the chair. Safety measures included to ensure that he was assisted back to the nursing station or where staff can visually monitor after visits. Ensure call light is within reach; reinforce its use. Target behaviors were identified, but there was no mention of assessment for use of any restrictive devices to reduce the risk of falls. Interview on 12/17/25 at 12:47 p.m. with licensed practical nurse (LPN)-D identified resident was currently receiving hospice services and was becoming weaker. She reported he did not indicate he had pain but was confused and would attempt to self-transfer at times which had resulted in him falling. LPN-E reported resident was dependent for activities of daily living (ADLS) including eating and when up in his chair was positioned where he could be observed because he would become restless, call out for his wife, and had fallen previously. During observation/interview on 12/17/25 at 1:11 p.m. with nursing assistant (NA)-E, R101 was lying in bed with the bed in low position, a neck pillow behind his neck, his chin on his chest, a body type pillow positioned on his left side between the grab bar and his body, (the bed was against the wall), and a square pillow folded and placed against his right side, preventing him from rolling back toward the room side of the bed. When asked about the pillows NA-E reported the pillow on R101's left side was for comfort as he was on his left side a lot and the pillow positioned on the right side was due to his attempts to throw his legs off the side of the bed and attempt to sit up to self-transfer. She reported the pillow was for safety to keep him from trying to get up and falling and even with the soft touch call light he could be on the floor before staff were able to get to him. She also identified when he was in his Broda chair he was placed close to the desk or in a common area where he was able to be observed by staff due to his risk of falls. Observation on 12/17/25 at 1:16 p.m. with LPN-D noted R101 tipped toward his left side resting against a pillow and a square pillow folded and positioned against his back on the room side of the bed. She reported at times he would call out for help, and swing his feet out of the bed, and attempt to sit up, stating he was looking for his wife. She reported she didn't think the pillow was a restraint as it was used for his safety. LPN-D reported she did not think there had been an assessment completed for any restrictive devices. Observation/Interview on 12/17/25 at 1:26 p.m. with the director of nursing (DON) reported he was not aware of any type of restraint in use for R101. He accompanied this writer to R101's room and observed the pillow positioned behind resident on the room side of his bed to keep him from turning toward the edge of his bed. He confirmed if the pillow prevented the resident from putting his legs out of bed or turning it would be considered a restraint if it had not been assessed, and he was not aware it had been. He removed the pillow on the room side of the bed and reported he would need to talk with staff about the use of a pillow to keep him from turning to the room side of the bed as it would need to be assessed as a restraint. Interview on 12/17/25 at 2:48 p.m. with R101's spouse reported she had received a call from the DON a short time ago, but she did not understand what he was talking about. She reported a pillow was used for comfort on resident's left side as he was positioned on his side a lot and he was very thin. She reported the family was concerned about him falling because as he was weak and did not realize he could no longer get up by himself. She reported she was not aware of the square pillow being used, but she did know staff had told her they placed a pillow under the sheet at night so he would not attempt to put his legs off the bed, sit up and possibly fall. She reported she was aware when he was in his chair, he was kept close to the desk so that staff could watch to make sure he did not fall out of his chair again because he was restless and would attempt to get up. Interview on 12/18/2025 at 8:35 a.m. with hospice RN-E identified R101 was seated in a Broda chair and placed at the nursing station due to anxiety and agitation where he could be observed as a precaution for falls. RN-E reported R101 had restless type behaviors and received Seroquel scheduled due to anxiety and restless and at night to help him rest. He identified he was not R101's primary nurse and he was not aware of what the facility staff were doing when he was in bed for comfort and/or safety. Interview on 12/18/25 at 9:15 a.m. with registered nurse (RN)-D (hospice RN) identified she was at the facility four days/week and felt the communication was good. She also reported she spoke frequently with the medical provider on any areas of concern or need for possible medication changes. RN-D reported R101 had falls with the most recent occurring on November 22, 2025, when he had fallen from his chair in the common area. She identified interventions to keep him safe included having him within sight and voice range of the nursing station to remind him to sit back down. She identified most of his falls took place when he was still ambulatory, but he also liked to roll to the edge of bed. She reported she had had discussions with the DON and facility staff regarding the possible intervention of a perimeter mattress, and there had been discussion on the use of restraints especially with the family, but she was not aware of anything in use. She reported the perimeter mattress was the responsibility of facility under the periderm, and hospice would negotiate if hospice Medicare was to cover the cost, or the facility periderm would need to cover the cost. RN-D identified she had reached out to her supervisor r/t discussion as to who could provide the perimeter mattress but had not heard back at the current time. She stated, she felt it was a safety concern for him to have a perimeter mattress. and she had also had discussions with family members regarding possible opportunities for potential safety measures and they agreed. RN-D also reported she had not documented everything in matrix as she did not want to promise anything until she was able to speak with her supervisors to determine the plan of action. Review of the 5/2/25 policy Fall Prevention: Physical Restraint/Mobility Devices identified the facility's intent to remain restraint free. When circumstances and all other options have been exhausted, devices may be medically necessary to protect residents from physical injury or for psychological comfort. Prior to any device or restraint usage, the nurse, as part of a multi-disciplinary team, will complete the following steps:1.) Interventions to consider when a resident has falls or is a risk for falls. a. Observe for gait and balance impairments, transfer abilities-PT referral if indicated. b. medical observation/assessment by nurse, then NP or MD. Assess for possible infection, dehydration, hypoxia, constipation, toxic drug levels, recent trauma, etc. c. Drug review by pharmacy- review recent medication changes. d. Check for environmental hazards. e. Cognitive evaluation. f. Observe w/c positioning/bed mobility-OT referral if indicated. g. Check for sensory or perceptual impairments. h. Check for emotional factors or changes in routine-Psychology referral if indicated. i. 1:1 time. j. Diversional activities. k. Assisted exercise, transfer, and/or toileting2.) If falls or threatening behavior persist- consult with medical provider for the medical symptom3.) Consider the least restrictive intervention/restraint4.) Implement the intervention, device, or restraint5.) Reassessment for mobility devices6.) Reassessment for physical restraints-reassess need for intervention and possibilities for reduction at quarterly care conferences or with a Significant Change. Document on care conference summary sheet.

Based on observation, interview and document review, the facility failed to provide adaptive equipment for 1 of 1 resident (R78) reviewed for adaptive equipment and observed having difficulty eating during meal observation.Findings include:R78's quarterly Minimum Data Set (MDS) dated [DATE] indicated R78 was cognitively intact, had no behaviors or rejected personal cares, needed touching assistance with eating, and was dependent with toileting hygiene, dressing, bed mobility and transfers. MDS indicated R78 was at risk for skin breakdown, and limited range of motion (ROM) was not assessed.R78's face sheet dated 12/18/25 indicated diagnoses of benign neoplasm of meninges (non-cancerous tumor growing in the protective membranes covering the brain and spinal cord), chronic obstructive pulmonary disease, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move one side of the body) following cerebral infraction affecting right dominant side.R78's Resident Profile dated 12/16/25 indicated she needed assistance to eat and directed staff to cut her meal into small pieces. R78's profile lacked documentation regarding the use of adaptive equipment for eating. R78's care plan dated 12/16/25 lacked documentation regarding adaptive equipment for eating. R78's electronical medical record EMR) lacked documentation about the use of Dycem and/or lipped plate.During observation on 12/16/25 at 8:58 a.m., R78 was in bed eating breakfast. R78 had 2 bowls of oatmeal on her bed side table. She was loosely holding a spoon on her right hand. R78's right arm had noticeable shaking. While trying to scoop the oatmeal, she would push the bowl with the spoon around the table. At some point, the bowl fell sideways between the bed table and the resident's lap. R78 used her spoon in her right hand and her left forearm to push the bowl back on the bed side table. R78 stated this is how I eat. Fun, huh? Adding, they are too busy to help.During interview on 12/16/25 at 2:33 p.m. nursing assistant (NA)-H stated R78 didn't like to be helped, but when her arm shook a lot, she would let us help her. NA-H stated she had never seen R78 use any adaptive equipment for eating. During interview on 12/16/25 at 1:50 p.m., the director of rehabilitation (DR) stated R78 was evaluated in the month of December by an occupational therapist. DR provided a copy of an e-mail dated 12/2/25 from the occupational therapist (OT) to the nurse manager/registered nurse (RN)- F. The e-mail indicated OT had provided R78 a piece of Dycem to help stabilize the patient's lipped plates.During interview on 12/17/25 at 12:24 p.m., RN-F stated she was not informed about the recommendation to use Dycem or a lipped plate. During the interview RN-F checked her e-mail and said she received the e-mail but did not open it. RN-F stated she did not implement the therapist's recommendations.During interview on 12/18/25 at 10:44 a.m., director of nursing (DON) stated the therapist's recommendations for adaptive equipment needed to be implemented to maintain resident's quality of life. DON added the facility needed to improve communication between the nursing and therapy department.Requested a policy about the use of adaptive equipment and none was received.

During observation, interview and record review, the facility failed to accommodate resident needs by ensuring the call light was accessible for 2 of 2 residents (R5, R101) reviewed for call lights.Findings include:R5R5's annual Minimum Data Set (MDS), dated [DATE] identified R5 with impaired cognition, required substantial assistance for personal hygiene, dressing, and rolling from side to side in bed. In addition, R5 had diagnoses of diabetes, aphasia (communication disorder affecting speech, understanding, reading and writing), dementia, schizophrenia and had an indwelling catheter (tube from bladder to outside the body into a bag).R5's Care Plan dated 5/16/22 identified: Answer call lights per protocol.During observation on 12/15/25 at 2:35 p.m., R5 was lying in bed sleeping. Their call light was resting on top of nightstand out of sight and out of reach of resident.During interview with licensed practical nurse (LPN)-A on 12/16/25 at 3:32 p.m., LPN stated, Call light should be in reach at all time [for] safety.During interview with registered nurse (RN)-A on 12/16/25 at 3:38 p.m., RN-A stated R5 was capable of using a call light and had used it in the past. RN-A stated expectation of call lights to be in reach so she can call anything she may need something.R101R101's quarterly MDS dated [DATE], identified impaired cognition, dependent on staff for bathing, toileting, dressing, personal hygiene, and rolling from side to side in the bed. In addition, R101 had diagnoses of Alzheimer's, Parkinson's, psychosis, and was on hospiceDuring observation and interview on 12/18/25 at 8:32 a.m., R101 was lying in bed, positioned on left side to face the wall. Both arms were bent towards torso with wrists were touching his face. A soft call light was placed on the bed next to his head out of reach and sight of resident. LPN-B looked at R101 and stated the call light was out of his reach.During interview with nursing assistant (NA)-B on 12/17/25 at 12:46 p.m., NA-B stated call lights should be in reach for anything to call for help. If out of reach, they [residents] might not be able to get help.During interview with NA-C on 12/17/25 at 12:55 p.m., NA-C stated expectation of call lights to be in reach of residents when they are in their rooms. If they [residents] can't reach it then it is not right. Their needs are not met.During interview with director of nursing (DON) on 12/18/25 at 9:44 a.m., DON stated expectation of all nursing staff to ensure call lights were in reach of all residents, so they [residents] can ask for help if needed.Facility policy titled Call Light, reviewed 9/17/2025 identified, The call light must be placed within reach of the resident while in their room.

Based on observation, interview, and document review, the facility failed to assess resident for safety and the ability to self-administer medications (SAM) for 2 of 2 resident (R109 and R170) reviewed for self-administration of medications.Findings include: R109's comprehensive Minimum Data Set (MDS) dated [DATE] identified R109 with intact cognition, required substantial assistance with toileting, showers, and dressing. Diagnoses included diabetes, morbid obesity, and an infection of the bone. R109's physician order (PO) for Miconazole powder, twice a day as needed dated 5/13/25, failed to indicate leaving it at bedside for self-administration. R109's care plan lacked indication of R109's ability to self-administer Miconazole. During observation on 12/15/25 at 2:23 p.m., R109 was sitting in wheelchair at bedside. On his rolling nightstand was a container of Miconazole Nitrate 2% antifungal powder with prescription label dated 5/13/25. R109 stated he used it as needed for skin infection. R109 also stated facility was aware of it and had been using it since admission in May of 2025. They know all about it. The bottle has [facility] name on it. R109 stated, I have not been asked about it when I admitted or how often I use it or if I need a refill. During observations on 12/15/25 at 5:08 p.m., and 12/16/25 at 2:33 p.m., the Miconazole Nitrate 2% antifungal powder was on R109s rolling nightstand. During observation and interview with registered nurse (RN)-B on 12/17/25 at 10:19 a.m., RN-B observed the miconazole on R109's rolling nightstand. RN-B said, [R109] should not have this in his room with a self-administration order and it being on his care plan. RN-B looked up R109's PO and verified there was an order for Miconazole, but no order to leave it in his room. No assessment was done. During interview with RN-A on 12/17/25 at 10:28 a.m., RN-A looked in R109 PO and stated, [order] is not in there to be left at bedside. During interview with RN-C on 12/17/25 at 10:31 a.m., RN-C stated expectation of nurses to assess every resident on admission to facility to see if they can self-administer. Then nurses are to request a physician order. The order itself needs to say if they [residents] can self-administer or frequency and to keep at bedside. During interview with director of nursing (DON) on 12/18/25 at 9:42 a.m., DON stated facility expectation of receiving a physician order first to leave medication at bedside. Then an assessment for safety is conducted and care plan is updated. For R109, It was not done and should have been. R170 R170 was admitted to the facility on [DATE]. Admitting diagnoses included acute embolism (blood cloth) and thrombosis (blood clot blocking blood flow) of left femoral vein, urinary tract infection, essential hypertension (abnormally high blood pressure that's not the result of a medical condition), and unspecified diarrhea. R170's Resident Profile indicated she needed maximal assistance with dressing, needed minimal assistance with transfers, ambulation with contact guard assistance, and moderate assistance with toileting hygiene. R170's profile also indicated she had pain and received pain medications per physicians or nurse practitioner orders. R170's Clinical Physician orders dated 12/22/25 indicated R170 had an order dated 12/13/25 for Benzocaine gel 20%. Special instructions: Apply a small amount of the gel to the affected area using a cotton applicator. Every 2 hours. R170's electronic medical record (EMR) lacked an assessment for self-administration of medications. In addition, there was no documentation in the progress notes about the Anbesol gel. During observation and interview on 12/15/25 at 3:33 p.m., R170 stated she had tooth pain, and the staff gave her a gel. R170 stated, I think it is Anbesol, and I can put it on myself. They told me to put it on my finger and rub it around my teeth, but I am squirting the gel because it needs to get in all crevices to work. R170 had a small basket on her bed side containing a tube of Anbesol maximum strength 20% gel inside a small Ziploc bag. The Anbesol's label indicated, apply a small amount using a cotton applicator every 2 hours as needed. R170 stated they told me to put some on the tip of my finger and nothing else. I don't know how often I can use it. They did not give me cotton applicators. They didn't give me any directions. During interview on 12/18/25 at 9:04 a.m., R170 stated her tooth pain was better, but nobody had asked her about it. The Anbesol gel was on her bed side table. During interview on 12/18/25 at 8:40 a.m., registered nurse (RN)-E stated upon admission to our transitional care unit (TCU), all residents were asked if they wanted to self-administer their medications, but most of the residents wanted the nurses to administer their medications. RN-E stated, if a resident wanted to self-administer a medication, the admission nurse would do a self-administration of medications (SAM). RN-E said after the assessment was completed, a doctor's order for self-administration was obtained. During interview on 12/18/25 at 9:13 a.m., nurse manager/RN- F stated a SAM was needed to be done to assure residents could self-administer a medication. RN-F stated a doctor needed to give an order for self-administration of medications. RN-F verified R170 did not have a SAM or a physician order to self-administer medications. During interview on 12/18/25 at 10:53 a.m., director of nursing (DON) stated medications shouldn't be left at bed side. DON stated residents needed to be assessed to determine if they were able to self-administer their medications. DON stated the residents needed to be educated about proper use of the medication, and nurses needed to make a progress note on residents' EMR. Facility policy titled Self-administration of Drugs dated 10/10/25 indicated residents have the right to self-administer drugs if the facility's interdisciplinary team had determined that the practice was safe. Policy's procedure indicated: At the time of admission or when requested, nursing completed observation to assess for self-administration of medications. Obtain provider order to self-administer medication if indicated. The assessment will be documented in the resident's care plan and reviewed at least quarterly or upon significant change in the resident's condition. If deemed eligible, the resident's care plan be updated. A signed consent form will be required from the resident or their legal representative, acknowledging their responsibility in self- administering medication. Medications approved for self-administration will be stored securely at a designate place according to care plan.

Based on observation, interview and document review, the facility failed to comprehensively reassess and, if needed, develop interventions with unsupervised eating to reduce the risk of accidental choking or asphyxiation for 1 of 1 resident (R67) who ate unsupervised in their room and had two documented episodes of choking. This constituted an immediate jeopardy (IJ) situation for R67. The IJ began on 9/14/24 when R67 choked for a second time on oral food, and the facility failed to comprehensively reassess R67's risk of choking, implement any interventions for increased supervision while eating or safe swallowing (i.e., speech therapy), or reeducate R67 and her responsible party on the risks of choking if R67 remained eating unsupervised as she had been despite choking. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 10/17/24 at 4:09 p.m. The IJ was removed on 10/18/24, but noncompliance remained at an isolated scope with potential for more than minimal harm that is not immediate jeopardy (Level D). In addition, based on observation, interview and document review, the facility failed to comprehensively assess for fall risk upon admission and with subsequent, repeated falls to determine what, if any, interventions were needed to ensure safety and reduce the risk of injury for 1 of 3 residents (R107) reviewed for accidents. R107 sustained actual harm when they fell multiple times after admission obtaining a head laceration and fracture hip. However, the facility had implemented corrective measures prior to the onsite survey, so these findings (falls) are being issued as past noncompliance. Findings include: CHOKING: R67's quarterly Minimum Data Set, dated dated [DATE], indicated R67 was admitted to the care facility on 12/9/22, had severe cognitive impairment, no swallowing problems and required partial to moderate assistance with eating and oral care. The MDS further indicated R67 was receiving hospice care. R67's facesheet, printed 10/17/24, indicated R67 had several medical diagnoses including dementia with behavioral disturbances, hemiplegia and hemiparesis following cerebral infarction (stroke), and dysphagia (difficulty swallowing) following cerebral infarction. R67's Orders, printed 10/17/24, indicated R67's diet order was mechanical soft, dated 3/23/24. R67's Progress notes, dated 3/4/24 through 10/17/24, indicated R67 had two choking episodes requiring staff intervention on 3/12/24 and 9/14/24. On 3/12/24 it was documented R67 was found in her room in a semi-Fowlers position, mouth wide open, not talking, trying to cough but couldn't. R67 required the Heimlich maneuver when finally a[n] object jumped out which was a piece of toast. The documented response was diet changed to mechanical soft with choking precautions for residents safety. On 3/12/24 it was documented the licensed dietician (LD) met with R67 who did not want to stop eating toast, however it was discussed cutting toast and other foods into small pieces, and alternating food and fluids. Also discussed cutting the crust off the bread. On 9/14/24 it was documented R67 was out in the small dining area when she was noted to be holding her neck and struggling to breathe when staff managed to get the food out that was stuck in resident throat. Approximately 20-30 minutes later, R67 became unresponsive for 5-10 minutes. On 9/16/24 it was documented R67 was visited by speech therapy, however a bedside ST [speech therapy] eval[evaluation] not completed d/t [due to] resident's active hospice status. OK for nursing staff to downgrade solids and liquids as needed for safety. R67's Associated Clinic of Psychology note, dated 3/13/24, indicated it was discussed with R67 that she could continue to eat preferred foods such as toast with a staff member present in her room, however lacked any discussion of the risks of choking or asphyxiation with R67 and her responsible party if R67 continued to eat unsupervised. R67's Care Plan, dated 3/13/24, indicated R67 was at risk for choking resident has no upper teeth, root tips on lower and had Dx [diagnosis)] = dementia, psychosis Res [resident] declines to get up for meals - eat in bed, declines staff sitting in room during meals ok'd [okayed] supervision. Risks and benefits discussed. A dcoument labeled, Approaches, also dated 3/13/24, indicated for staff to check R67's vital signs and lung sounds for 48 hours after a choking episode, to notify family, hospice and R67's nurse practitioner with significant changes, to check on R67 frequently throughout mealtime to ensure R67 is safe and free from choking, and to position R67 in a 90 degree position for each meal. The Care Plan lacked any clarity on what frequently meant or how often it would be expected for staff to check on R67. The Care Plan further lacked any updates after R67 second choking episode on 9/14/24. R67's electronic medical record (EMR) lacked documented evidence a discussion of the risks and benefits of R67 continuing to eat toast and a mechanical soft diet, unsupervised, after a second choking episode was discussed with R67 and her responsible party. R67's EMR further lacked a comprehensive reassessment and if warranted care plan updates were completed after R67's second choking episode. During observation on 10/14/24 at 5:34 p.m., R67 was sitting up in bed, unsupervised, with an over the bed table across her lap with her dinner set up. On her plate was two slider sized buns with sliced meat and multiple tator tots, not cut into small pieces. R67 was alone in her room with staff present in the main dining room area assisting other residents with dinner. During observation and interview on 10/16/24 at 10:16 a.m., nursing assistant (NA)-C brought R67 peanut butter and jelly toast, stating because it was R67's favorite. R67 was sat up in bed and NA-C left the room. During an interview on 10/16/24 at 11:41 a.m., NA-C stated he was aware of R67's choking episode but had been off that day, stating she had choked on a piece of toast. NA-C stated that despite R67 choking on toast, it didn't happen very often so R67 was still given toast to eat unsupervised in her room. During an interview on 10/16/24 at 12:05 p.m., speech therapist (ST)-A confirmed she was aware of R67's choking episodes but did not do an evaluation of R67's swallowing on 9/16/24 because she was on hospice, stating if she was not on hospice her choking episode would have warranted a full evaluation. ST-A stated R67 remained on a mechanical soft diet after her choking episode, and it was recommended for the nursing staff to downgrade [R67's] diet [to puree] as needed. During an interview on 10/17/24 at 7:55 a.m., social worker (SW)-A stated she recalled R67's choking episodes back in March but did not remember anything about R67 choking last month. SW-A stated she remembered having a conversation with nurse manager and registered nurse (RN)-A after R67's choking episode back in March and being told they should be offering R67 whatever brings her joy. SW-A confirmed R67 was not evaluated by speech therapy back in March after her first choking episode or last month after her second choking episode, nor by the dietician after her most recent choking episode and was unable to find any documented evidence of a risk versus benefit being competed with R67 for her responsible party regarding offering food choices to R67 that would bring her joy versus safety or what those safer food options would be. During an interview on 10/17/24 at 8:04 a.m., registered nurse (RN)-I stated it was a standing order for all residents that nursing staff could downgrade their diet if needed, meaning if a resident was coughing a lot while eating or drinking, they could downgrade their diet to mechanical soft or puree. RN-I stated they would change the diet and follow up with the doctor. During an interview on 10/17/24 at 2:06 p.m., RN-I stated when R67 was eating in her room, staff would try to check on her every 15-20 minutes. During an interview on 10/17/24 at 2:30 p.m., NA-E stated R67 was independent with eating after she was set up and stated staff would check back every 20-30 minutes to see how well she was eating. NA-E stated R67 loved eating toast for breakfast and was unaware of any choking episodes or problems R67 had with chewing or swallowing, again stating she was independent with eating. NA-E stated each resident had a care sheet hanging in their closet to explain what type of diet they were on and how they transfer and other cares however R67's was missing. During an interview on 10/17/24 at 8:44 a.m., RN-A stated there was a standing order for all residents that nursing staff can downgrade a diet if a resident was coughing, having difficult chewing, or choking on their food, stating nursing staff could change the diet and they would have speech therapy follow up and evaluate. RN-A stated R67 had coughing episodes, stating, I would not really call them choking episodes however agreed that requiring the Heimlich Maneuver and struggling to breathe would be considered a choking incident. RN-A stated after R67 required the Heimlich Maneuver back in March they attempted to change R67's diet to puree but she refused to eat stating they settled on a mechanical soft diet. RN-A stated her goal would be to have R67 out of bed for every meal, but she often refuses to get up and will often refuse to eat if a staff member is in the room with her, stating R67 will eat when she is ready. RN-A stated staff had been educated to ensure R67's head of bed was elevated when she was eating, as much as she [R67] will let us. RN-A stated she had talked with R67's responsible party at her last care conference on 9/11/24 (three days before her second choking episode). RN-A confirmed there was no documented risk versus benefits, no comprehensive reassessment of R67 after her second choking episode, and no changes to her care plan despite current interventions not preventing a second choking episode. During an interview on 10/17/24 at 8:11 a.m., R67's hospice nurse (HN) stated she was on call when R67 choked last month stating she received a call that R67 choked on a piece of bread and stated R67 didn't require the Heimlich Maneuver but at one point couldn't breathe and went into a state of unresponsiveness. HN stated the day after the choking incident R67 did not eat or take any of her medications, stating I think she was afraid to choke again. The HN stated because it was an isolated event and R67 was on hospice, a speech evaluation was not done and further stated at a care conference back in March they had discussed R67's diet and the risks associated with it but had not discussed it since her most recent choking episode. During an interview on 10/17/24 at 11:53 a.m., the director of nursing (DON) stated he could not recall R67's choking incident which happened last month and stated he would have expected the dietician to be involved, hospice to be notified and a speech therapy evaluation to be completed, even with R67 on hospice, confirming the dietician did not evaluation R67 nor was a speech therapy evaluation done after the choking episode in September. The DON further stated he would have expected a comprehensive assessment of what R67 would be willing to do/eat and what she wouldn't, along with the risk associated, and stated this should all have been documented in the EMR. The DON further stated he would have expected for a new plan to be developed since the current interventions in place did not prevent a second choking episode. During an interview on 10/17/24 at 12:08 p.m., R67's responsible party and family member (FM)-A stated she was not aware that R67 was still eating toast for breakfast and thought R67 was on a pureed diet. FM-A stated, I guess she can't have toast anymore and they would have to determine what else R67 would be willing to eat for breakfast. FM-A stated she did not believe that R67 would logically be able to make the decision on her own regarding the risks versus benefits of continuing to eat toast and other non-pureed foods. FM-A further confirmed the risks of potentially choking to death were not discussed with her and while she acknowledged R67 was on hospice she did not want her to die in a horrific manner from choking. During a follow-up interview on 10/17/24 at 2:35 p.m., nurse manager and RN-A stated they had tried cutting up R67's toast and cutting the crust off per the dietician's March note but R67 would not eat it that way. RN-A stated there was not a time frame for how often to check on R67 when she was eating, and stated she tires easily when she eats so staff were not sure when she would be eating or sleeping. RN-A further stated they had not documented the attempts to cut R67's crust off her toast and she had not discussed the choking episodes with R67's provider but believed the floor nurses had updated the provider. During an interview on 10/18/24 at 10:55 a.m., the medical director (MD) stated he was not made aware of R67's choking episodes until today. The medical director stated he would have advised to change her diet to puree and recommended that she eat in a supervised environment, even with a pureed diet, stating it was an issue with personal preference but also safety. The MD Further stated there was no reason R67 could not have a speech therapy evaluation. The immediate jeopardy that began on 9/14/24, was removed on 10/18/24, when the facility comprehensively reassessed R67, changed her diet to puree, documented discussing the risks of eating unsupervised with R67's responsible party, and educated staff on the care plan changes for R67, but the noncompliance remained at the lower scope and severity because of the continued risk for potential harm with R67 continuing to eat unsupervised. 33925 FALLS (past noncompliance): R107's admission Minimum Data Set (MDS), dated [DATE], identified R107 admitted to the care center from the acute hospital. The MDS outlined R107 had severe cognitive impairment, demonstrated no physical or verbal behaviors, and had no rejection of care episodes. The MDS continued and listed a section labeled, Section J - Health Conditions, which identified R107 did not have a terminal prognosis along with several questions related to R107's fall history (i.e., falls in the month(s) prior to admission), however, these were all answered with, 9. Unable to determine. However, after admission to the care center, the MDS recorded R107 had sustained one fall without injury. The MDS corresponding CAA (Care Area Assessment) Summary Report, completed 8/1/24, identified the various triggered CAAs for R107 which included one labeled, CAA 11. Falls. This identified R107 was at risk for falls related to impaired cognition, pain, and impaired mobility. The CAA recorded, One fall during look back without injuries with a matt [sic] placed on the floor next to his bed when he is in bed for safety/injuries. Receives supervision assist with bed mobility, toileting, and transfers currently in therapy, plan is for short term care per wife . Staff to place call light within his reach at all times when in his room and encourage him to use. Fall risk assessments per facility protocol. The CAA directed care planning would be completed adding, Proceed to care planning for fall and injury prevention. On 10/14/24 at 1:50 p.m., R107 was observed seated in a standard wheelchair in the commons area of the locked unit (i.e., memory care) with good posture and no leaning or slouching. R107 had a tan-colored bandage on his right hand and stated he had scratched it but was unsure how. R107 was unable to recall how long he had been at the care center and abruptly replied, I don't live here. R107 stated he was unsure what, if any, lunch meal they had that day, either. R107's current care plan, dated 8/26/24, identified R107's assessed problems, respective goals, and subsequent interventions to meet those goals. A total of three sections were labeled, Category: FALLS, and each outlined R107's various rationale for fall risk including but not limited to a history of falling, gait/balance problems, self-transfer attempts. All these sections were recorded as still in effect (i.e., not resolved) and these problem statements and interventions in chronological order outlined: Problem Start Date: 07/20/2024, outlined R107 as being at risk for falls and was last edited on 10/1/24, and a goal was listed which read, Will remain free from falls and fall-related injuries, with a goal date recorded, 11/21/2025. The section included multiple interventions to help R107 meet the goal including staff to do hourly well-checks to ensure safety, offer toileting or food if persistently self-transferring, and a low bed for safety. However, all the interventions listed within this section listed a start date of 8/21/24 or later. The problem statement and interventions were all initiated by registered nurse unit manager (RN)-A. Problem Start Date: 07/22/2024, outlined R107 as being at risk for falls and was last edited on 7/22/24, and a goal was listed which read, Will remain free from falls and fall-related injuries, with a goal date recorded, 10/22/2025. The section included multiple interventions to help R107 meet the goal including pharmacy consults per protocol, promoting scheduled rest periods, reinforcement to request assistance, not leaving unattended while in the bathroom, safety checks on shoes, monitoring for foot pain, ensuring proper lighting, providing non-skid material in the wheelchair and, When falls occur investigate root cause through IDT [interdisciplinary team] meeting protocol, and, When falls occur nursing to monitor using CEOM [Catholic Eldercare on Main] fall protocol. All the interventions listed had a start date recorded, 07/22/2024. R107's progress note, dated 7/19/24, identified R107 admitted to the care center locked unit on 7/19/24 for long term care placement. R107 was recorded as having a history of alcohol-induced dementia, chronic obstructive pulmonary disease (COPD), and prior stroke. The note outlined, Resident alert, memory is impaired with poor insight and judgement . has Foley Catheter . He is totally dependent on staff for ADL including dressing, grooming, bathing, and transferring. A subsequent note, dated 7/21/24, identified R107 was alert with impaired memory and poor insight. The note added, He attempt to self transfer with out adequate or calling for help [sic]. He is easy to redirect . is totally dependent on staff for ADL . Later, on 7/21/24, another note identified a bed rail was added to his bed to promote increased independence with mobility adding, Bed rail necessary for use as mobility device, and Nurse manager updated. On 7/22/24, the notes outlined R107's Foley catheter was removed, and routine bladder scans were started. On 7/23/24, R107 was found with bloody urine adding, When this writer arrived patient was standing in the middle of his room, urinating and his urine and mixed [sic] with large amount of blood. VS WNL [vital signs stable] . Further, another progress note, dated 7/24/24, was recorded with R107 now being COVID-19 positive with symptoms of nasal drainage and emesis. R107's 'SBAR [situation, background, assessment, response]' progress note, dated 7/26/24 at 5:36 p.m., identified R107 sustained a fall without injury. The note outlined, [nursing assistant] approached this staff at [3:00 p.m.] to say pt [patient] was on the floor in his room. This staff found pt laying on the floor near his bed. Pt denied pain. This staff noted that pt didn't have one of his gripper socks on . stated that he was self-transferring. Neuro's intact X1, ROM [range of motion] X4 . R [response]: This staff informed the Evening Supervisor, the Nurse Triage line, the POA [power of attorney]. This staff placed a floor mat in pt's room next to pt's bed. This staff updated pt's care plan to the fall. R107's corresponding Event Report, dated 7/26/24 but closed 8/21/24, identified R107 had sustained a fall without injury in his room adding, Pt found on the floor near his bed by the NAR. R107 was recorded as lying in bed just prior to the fall and the fall itself was unwitnessed. R107 demonstrated no pain from the fall and the section provided to record what, if any, injury was obtained answered, N/A. A section labeled, Possible Contributing Factors, identified R107's impaired cognition and infection (COVID-19) with a checkmark placed next to each, respectively. R107 was recorded as being on an antibiotic and a subsequent section was labeled, Interventions - Immediate measures taken, which had a checkmark placed next to, Rest, and Other - Floor mat to floor next to bed. The report included multiple follow-up progress notes which outlined R107 was at baseline. However, R107's medical record lacked recorded evidence the IDT had reviewed this incident or what, if any, interventions aside from a mat on the floor were considered or implemented. Further, the record lacked any completed comprehensive fall evaluations or assessments upon admission to the care center (on 7/19/24), including with all potential risk factors and what, if any, immediate interventions were assessed as needed despite R107 being recorded in the progress notes as having cognitive impairment with poor insight, needing total assistance with ADLs, and being found standing up in the middle of the room after his Foley catheter was removed (i.e., self-transfer). R107's SBAR progress note, dated 8/19/24 at 6:54 p.m., identified R107 sustained an unwitnessed fall with injury. The note outlined, . was found in room on the floor with his wheel chair upside down. He had a cut over his left eye and blood on the floor. Resident was assessed and transferred to chair, pressure applied to site and bleeding stopped . ROM is intact, he was able to move all extremities, a neuro assessment and vitals started. Resident spouse was notified and along with [medical provider]. There was no corresponding Event Report for this incident identified in the medical record. A series of subsequent progress notes, dated 8/20/24 through 8/23/24, reiterated the fall had occurred along with nearly all of them having outlined R107 had returned to baseline, and with a dressing in place over his left eye now adding a purple discoloration was present, too. However, a note dated 8/21/24 at 4:44 p.m., had R107 recorded as having some delusional thinking. The note outlined, . pt wanted this staff to close the garage door and get his wife. However, again, R107's medical record lacked documented evidence the IDT had reviewed this incident for any root-cause analysis review nor what, if any, other interventions were considered or implemented by the IDT. Further, the medical record continued to lack any completed comprehensive fall evaluations or assessments despite R107 having sustained two falls and demonstrating delusional thinking during similar evening hours (i.e., 4:00 to 7:00 p.m.). There was no evidence documented to provide rationale for what, if any, comprehensive causative factors were considered or evaluated to ensure effective, proactive interventions to reduce his fall risk despite the care plan being updated on 8/21/24 with interventions (i.e., low bed) which were not documented as being a factor in the progress note about the fall with injury. R107's SBAR progress note, dated 8/26/24 at 5:30 a.m., identified R107 sustained a fall due to self-transferring. The note outlined, Resident was found on the floor when aide notified nurse around 0523 when he was being check on [sic]. Resident was found in the supine position at the foot of his bed . incontinent of bowel; and bladder when he was found . bed was in lowest position when he was found on the floor with w/c [wheelchair] in the middle of the room . showed no signs of having pain at the time . was resistive to care at the time he was being assisted . Will report to AM staff to notify [medical provider], family, and continue to monitor. However, a subsequent note dated 8/26/24 at 7:10 a.m. (little over 90 minutes later), identified R107 was found sitting up in bed at 0640 and complaining of right hip pain. The note outlined, . [R107] had grimacing on his face and notified staff his right hip/side is in excruciating pain . complained of pain to touch and with ROM on his right hip . cognition is impaired with primary DX [diagnosis] of dementia and history of fall. The note identified the medical provider was updated, and an order for pain medication and an x-ray obtained. A subsequent note, dated 8/26/24 at 2:38 p.m., identified R107 was being transferred to the hospital with . Right femoral intertrochanteric fracture possibly post fall. A subsequent note, also dated 8/26/24, identified R107 had dementia adding, Pt has a dx of Dementia and fell today this am, fracturing his right femur . Pt's [family] talked with MD at the hospital and plans on pt having surgery to fix his right femur. R107 was readmitted to the care center from the hospital on 8/30/24. R107's corresponding North Memorial Health Admission History and Physical, dated 8/26/24, identified R107 who presented to the hospital . after an unwitnessed fall with right hip pain, found to have a hip fracture. He has bruising scattered throughout his body but only c/o [complains] pain in his right leg. Denies other concerns, though he is not oriented. A series of imaging was obtained, including an x-ray of the femur, which identified, Acute fracture of the proximal femur. R107 was recorded as preparing for surgery intervention to preserve quality of life and needed to be hospitalized for surgical management. R107's John Hopkins Fall Risk Assessment Tool, dated 8/31/24, was completed after R107 returned from the hospital and included multiple questions answered to help determine a risk-based score for falls such as previous number of falls and changes in condition. This assessment tool scored R107 as 23.0 which outlined, High Fall Risk. This evaluation was the first one completed as identified within the medical record. When interviewed on 10/16/24 at 1:21 p.m., NA-D stated they had worked with R107 multiple times at the care center and described him as needing total assist with cares. NA-D stated staff often have to use encouragement to get him to allow cares and verified R107 was no longer ambulatory since he fractured his femur adding, He used to [walk[ but not anymore. NA-D stated staff tried to just keep checking on him often since he returned from the hospital, and explained R107 used to try to self-transfer more often which caused his falls. NA-D stated R107 had used a low bed since he admitted to the care center and obtained the bedside mat after one of his falls adding, Not everybody get floor mat. NA-D stated if a fall happens, they report to the nurse who then must evaluate them before staff can get them up adding any new interventions or care following a fall would be communicated to the NA staff using shift-to-shift verbal report and the care card. NA-D stated these were kept both in the room and on the computer for the NA to reference on how to care for each resident adding it was our responsibility to view them each shift. NA-D stated R107 currently used a low bed, mat on floor and was being routinely checked on adding he was less mobile than prior. On 10/16/24 at 1:36 p.m., licensed practical nurse (LPN)-A was interviewed, and explained when a resident admits they are assessed for their fall risk using a John Hopkins tool which then helps develop the care plan. LPN-A verified the floor nurses are responsible to do the tool. LPN-A stated if a fall happens after admission, the nurses will check the resident' vital signs, assist them up, and initiate neurological checks if the fall was unwitnessed. LPN-A stated any immediate interventions to help prevent further falls would be dependent on what the situation is adding every fall is kind of different. LPN-A explained the nurse should be updating the medical provider along with doing three items post-fall which included starting a short-term fall care plan, stating an event, and completing the paper-based data collection tool. LPN-A explained the paper-based tool was used to record initial data adding it was kind of brief with not too many lines to do before it gets routed to the nurse manager who, from there, takes the data and meets with IDT where they talk about it. LPN-A explained the event and short-term care plan were like a template which could help guide the nurses on actions or possible interventions. LPN-A recalled R107 having sustained a fall and explained he now used a low bed along with a bedside mat to prevent injury adding they can't remember off hand when each intervention was added. LPN-A stated staff always try to keep an eye on him and ensure the call light was in reach, too, as R107 still, at times, could be a busy man and try to move around. LPN-A stated R107's mobility since the femur fracture had decreased a little bit and he was no longer ambulatory. Further, LPN-A stated any root-cause analysis of the falls, including potential proactive intervention development, would be the nurse managers to do with IDT as they do their analysis and determine the cause. On 10/17/24 at 10:06 a.m., registered nurse unit manager (RN)-A and the director of nursing (DON) were interviewed, and R107's medical record was reviewed. DON explained, upon admission, the nurse was responsible to complete the fall risk assessment on each resident which DON verified was the John Hopkins tool. The completed tool is then reviewed by the MDS nurse or unit manager, and the evaluation is then repeated quarterly thereafter with the fall risk care plan being developed from it. DON verified the care plan and fall risk assessment were the only two items used within the medical record to demonstrate the facility' comprehensive fall risk evaluation process. DON verified the fall risk assessment was not completed upon admission and should have been, however, attributed the development of a care plan (dated 7/20/24, 7/22/24) as belief someone had done an evaluation. RN-A stated they likely initiated the care plan for R107 on 7/20/24 but added, I don't remember. RN-A explained they initiated the 7/22/24 falls care plan for R107 but expressed they didn't recall if they reviewed any completed fall risk evaluations or not with it. RN-A stated the main reason they initiated it was R107 had a history of falls adding the interventions placed on both the initial care plans, dated 7/20/24 and 7/22/24, were placed while we [got] to know him as the team didn't know him right away. RN-A and DON both verified the first completed John Hopkins fall risk evaluation was completed upon R107's return from the hospital after he sustained a broken femur and DON added, I think there was a miss there. DON stated they felt a possible Internet global failure around the same time may have contributed to it being missed for so long but were unsure. RN-A explained R107 had used a low bed from day one as R107's family was insistent of it. The interview continued with DON and RN-A who reviewed R107's falls. On 7/26/24, R107 sustained a fall without injury and the incident information was provided. R107's Catholic Eldercare Resident Incident Report, dated 7/26/24, identified R107 was found on the floor near his bed by the NA. R107's vital signs were stable, and he denied pain with no injury apparent. The form identified a temporary care plan and event were initiated per protocol; and the use of a blue mat at bedside was added to the care plan immediately after the fall. DON acknowledged the form and explained the temporary care plans were used then typically resolved after 72 hours. DON stated they attempted to locate the temporary care plan for R107's fall on 7/26/24 but, so far, had been unable to find it. When questioned on the IDT review process, DON stated the IDT review could be completed solely by the nurse

Based on observation, interview, and document review the facility failed to ensure residents clothing was covered during storage and delivery to the residents. The uncovered linen had the potential to affect all residents. Findings include: During observation and interview on 10/14/24 at 1:13 p.m. laundry aide (H)-C was observed pushing a large metal uncovered laundry cart down a resident hallway on the first floor containing various cleaned resident clothing items. H-C stated she had worked at the facility as a laundry aide for a long time and they had never covered the personal laundry carts. During observation and interview on 10/15/24 at 1:28 p.m. H-A verified she was delivering cleaned personal linen on the second floor in an uncovered cart. H-A stated the carts used to deliver personal clothing were never covered. During interview on 10/15/24 at 1:34 p.m. the director of environmental services-housekeeping and laundry, (H)-B, stated he had been in his position since 2016, and they had never covered the carts used to deliver personal clothing. H-B added, we only cover the cart use the bed linen and towels. It's the process we have. During interview on 10/17/24 at 1:27 a.m., the director of nursing (DON) stated the personal clothing carts should be covered to minimize possible cross contamination. Facility policy titled Laundering Linen and Resident Clothing, revised on 9/2/16, indicated all linen and resident clothing was cleaned and handled in such manner that prevents contamination and decreased the risk of spreading infection. The policy also indicated, clean linen and clothing will be sorted and folded in laundry and placed on covered shelves or racks for transport to nursing stations.

Based on observation, interview and document review, the facility failed to ensure appropriate wheelchair foot supports were provided or, if needed, therapy consulted to promote adequate wheelchair positioning to avoid complication (i.e., pain, edema) for 1 of 1 resident (R51); failed to ensure proactive skin interventions were consistently implemented to reduce the risk of skin tears or bruising for 1 of 1 resident (R110); and failed to assess and revise an insulin administration schedule to promote acceptable diabetes management and improve blood glucose levels for 1 of 1 resident (R161) reviewed for dialysis and who missed multiple doses of insulin related to scheduled dialysis treatments. Findings include: WHEELCHAIR POSITIONING: R51's quarterly Minimum Data Set (MDS), dated [DATE], identified R51 had severe cognitive impairment and demonstrated no rejection of care behaviors during the review period. Further, the MDS outlined R51 had no range of motion limitations in her upper or lower extremities, used a wheelchair for a mobility device, and was dependent on staff for nearly all mobility-related activities (i.e., transfers, bed mobility). On 10/14/24 at 12:37 p.m., R51 was observed seated in a high-back, tilted wheelchair in the hallway on her unit. R51 extended her hand to shake the surveyor' hand and did not verbally respond aloud when asked her name. R51's body was seated upright in the wheelchair, however, there were no attached pedals or platform on the wheelchair and, as a result, her feet dangled downward without touching the floor. Later, on 10/14/24 at 4:47 p.m., R51 was again observed in the same wheelchair while in the dining room waiting for the supper meal. R51 continued to not have any pedals or platform attached to the wheelchair and, again, her feet dangled downward without being able to reach the floor. R51's care plan, dated 6/2023, identified R51 had impaired mobility due to left hip pain, weakness and variable understanding of directions and behaviors. The care plan identified R51 was non-ambulatory and used a Broda wheelchair adding, WHEELCHAIR: total assist of one around obstacles and to get to all destinations. The care plan lacked rationale or instruction on R51's lack of wheelchair pedals or platform. The following day, on 10/15/24 at 8:56 a.m., R51 was again observed seated in the tilted wheelchair while at a small table in the breakfast area. R51 continued to not have any pedals or platforms in place on the chair causing her feet to be unsupported and dangle downward. Later on 10/15/24 at 11:40 a.m., R51 was seated in her same wheelchair in the dining room but now had bilateral foot pedals attached and in place. However, R51's legs were crossed and her feet were positioning behind the affixed pedals dangling downward again. R51 was assisted with eating the noon meal by nursing assistant (NA)-B with no attempts to place R51's feet back onto the pedals observed. When interviewed on 10/15/24 at 12:32 p.m., NA-B stated R51 needed help with eating and most cares. NA-B stated they did not help R51 with morning cares that day and directed the surveyor to NA-C as they were assigned her care. NA-B stated they were unsure if R51 typically used foot pedals or a platform on their wheelchair adding, I wouldn't be able to go into detail like that. NA-B stated they were unsure if there was a reason or rationale why R51 couldn't use pedals and reiterated aloud, I'm not too sure. When interviewed on 10/15/24 at 12:43 p.m., NA-C stated they often worked with R51 and described her as needing whole help with cares. NA-C stated R51 had used the tilting one wheelchair for awhile and expressed she is supposed to use pedals at all times. NA-C stated they did not place the pedals on the wheelchair when they got R51 up and added, Must be my nurse [who did]. NA-C stated placing the pedals must have skipped from the memory adding further, She's supposed to have them on. However, NA-C stated R51 seemed to be just letting her feet dangle behind the pedals and not actually use them more in the past months. NA-C stated R51 used to be on hospice care but was removed from it a few months ago now adding therapy had, at one time, worked with R51 on her wheelchair positioning but it had been a long time ago. NA-C stated they had never reported R51's dangling feet but felt the nurses were aware of R51 dangling her feet more and not using the pedals adding, I think they see it. R51's most recent therapy note, dated 1/22/24, identified R51 was seen by occupational therapy (OT) with dictation, Per RN, resident to be d/cing [discharged ] from hospice. Therapy provided 16 tilt-in-space [wheelchair] with standard foam cushion. Therapy to remain available for further needs. The note was authored by certified occupational therapy assistant (COTA)-A. However, R51's medical record was reviewed and lacked evidence therapy had been consulted or R51 had been assessed for wheelchair positioning despite direct care staff seeing R51 not use the provided foot pedals causing her legs to dangle unsupported. On 10/15/24 at 12:55 p.m., COTA-A was interviewed, and verified they are available to see patients in the long-term care units. COTA-A explained therapy places a note into the EMR when patient's are seen, including for wheelchair positioning, and reviewed R51's medical record. COTA-A verified they gave R51 the tilt-in-space wheelchair back in January 2024 and expressed pedals would have been provided at the same time adding, It comes with cushion and foot rest. COTA-A stated if R51's legs were now dangling and not being supported on the pedals, then perhaps a calf pad or rest could be used adding, I can go approach them [nursing] and see if that will work. COTA-A stated they could not recall anyone from nursing reaching out to them about R51's wheelchair positioning and verified if concerns were seen, such as unsupported feet or legs, then someone should consult therapy adding legs left dangling or unsupported could be a safety issue. When interviewed on 10/15/24 at 2:30 p.m., registered nurse unit manager (RN)-A verified they had reviewed R51's medical record. RN-A explained R51 had been on hospice care prior and they were aware R51 often crossed their legs while seated in the wheelchair, however, they had just then contacted therapy about possibly getting a smaller wheelchair so R51's feet could a a little closer to the ground and better supported. RN-A stated they were unsure why staff had not been using the supplied pedals for R51's chair, as observed on 10/14 and 10/15, and verified the pedals should have been attached so in case [R51] gets tired and want to put your feet down to rest. RN-A stated none of the nursing staff had reported concerns to them about R51's feet often being behind the pedals, when attached, and unsupported and expressed, They [staff] should say something. RN-A verified R51's feet should not be left dangling and unsupported while seated in the wheelchair adding, We agree on that. A facility' policy on wheelchair positioning was requested, however, none was received. SKIN PROTECTION: R110's quarterly Minimum Data Set (MDS), dated [DATE], identified R110 had severe cognitive impairment and demonstrated no rejection of care behaviors. R110's Physician Order Report, dated 9/16/24 to 10/16/24, identified R110's medical conditions along with both her current physician and nursing orders for care. This identified R110 had a history of vitamin deficiency and cellulitis (soft tissue swelling) to the left hand. R110's orders, including both physician orders and nursing orders, were listed with their respective start and, if applicable, stop dates. This included, RISK FOR SKIN INJURY: Bilateral protectors on at all times . Every Shift; Nights, Days, Evenings. The order had a start date listed, 05/13/2021 - Open Ended. On 10/14/24 at 12:34 p.m., R110 was observed seated in wide-back wheelchair by the doorway on the unit with a stuffed animal in her hands. R110 was asked her name and responded aloud, I don't know. R110 hands along with the lower part of her arms and wrists were visible, and her right hand had light brown-colored discoloration present on top of the hand. R110 did not have any visible cloth or other protectors on her arms or hands at this time. On 10/14/24 at 1:15 p.m., R110's family member (FM)-D was interviewed. FM-D stated R110 had poor cognition and often would get bruises on her hands. FM-D stated R110, at times, would have cloth-type protectors on her arms and hands but others times not adding, Sometimes [they] have them on. FM-D stated they believed maybe they were only used when bruises were noticed but was not sure. FM-D stated R110 seemed to bruise pretty easy though. Later on 10/14/24, at 4:52 p.m., R110 was again observed seated in her wheelchair. R110 was placed next to the dining room table and, again, had no visible protectors (i.e., geri-sleeves) on her hands or arms at this time. When observed on 10/15/24 at 11:39 a.m., R110 was again seated at the dining room table in her wheelchair. R110 did not have any visible protectors on her hands or lower arms at this time. R110's skin care plan, dated 3/15/24, identified R110 was at risk for skin breakdown due to limited mobility, moisture exposure and cognitive impairment. The plan listed several interventions for R110 including use of a ROHO cushion in her wheelchair, daily skin checks by the nursing assistant (NA) staff, and elevating her heels off the bed surface. However, the care plan lacked direction or guidance on the ordered protectors. R110's Treatment Administration History (TAR), dated 10/2024, identified R110's physician and nursing orders along with spaces for staff to record their administration or refusal via initial. The TAR outlined an order which read, RISK FOR SKIN INJURY: Bilateral protectors on at all times, along with a frequency listed, Every Shift. The order was signed off every day within the month period so far as being completed (despite R110 being observed without them on for multiple days). On 10/16/24 at 9:14 a.m., R110 was again observed seated in her wheelchair while at the table. R110's hair was wetted and combed and she was dressed in a long sleeved shirt, however, her hands were visible and both had a tan-colored, cloth protector in place covering the hand' skin. When interviewed on 10/16/24 at 9:21 a.m., NA-D stated they were assigned to R110 and helped her with morning cares. NA-D stated R110 wore geri-sleeves on her hands and arms which were used to protect her skin adding R110 had a couple pairs of them in her room for staff to use. NA-D verified they placed the sleeves on R110 that morning and expressed aloud, She's supposed to have them [on] all the time. NA-D stated application of them was on her care card and the NA staff should be doing it. Further, NA-D reiterated R110 should be using the geri-sleeves at all times as R110 did, at times, get bruises on her hands adding, Yea, sometimes she does. R110's medical record was reviewed and lacked evidence why R110's ordered skin protectors (i.e., geri-sleeves) had not been used as observed on 10/14/24 and 10/15/24. On 10/16/24 at 10:40 a.m., registered nurse unit manager (RN)-A was interviewed. RN-A stated the skin protectors for R110 were there as just like an extra layer of skin and verified the cloth-type protectors seen on R110 that day (10/16/24) are what the provider order referenced adding they were an extra layer of protection. RN-A stated R110 used to be more mobile and would obtain cuts and bruises on her hands which is why they were added. RN-A stated they expected them to be on R110 as ordered or care planned adding, The care plan should be followed. A facility' policy on non-pressure skin management was requested, however, none was received. 47495 DIABETES MANAGEMENT: R161's significant change Minimum Data Set (MDS), dated [DATE], indicated R161 was admitted to the care facility on 8/14/24, was cognitively intact and required supervision for activities of daily living (ADLs). R161's Facesheet, printed 10/17/24, indicated R161 was admitted to the care facility with multiple diagnoses including end stage renal disease and type 2 diabetes mellitus with ketoacidosis (a serious complication of diabetes.) R161's Order History, dated 10/15/24, indicated R161 had an order for Novolog U-100 insulin aspart solution; 100 units per milliliter (ml), administered per sliding scale (amount administered based on current blood glucose reading) three times a day before meals at 8:00 a.m., 12:00 p.m., and 4:00 p.m. R161's care plan, dated 8/29/24, indicated R161 went to dialysis on Mondays, Wednesdays and Fridays with a start time of 11:30 a.m. The care plan further directed staff to monitor/record/report blood glucose per facility schedule and policy and MD [doctor] order. R161's admission provider note, dated 9/5/24, indicated R161 was hospitalized [DATE] - 8/14/24 for diabetic ketoacidosis (a life-threatening complication of diabetes that occurs when the body doesn't have enough insulin to allow blood sugar into cells for energy.) The provider note further indicated R161 was hospitalized a second time on 8/23/24 - 8/31/24 for dialysis initiated due to renal failure. R161's medication administration record (MAR), dated 10/1/24 - 10/15/24, indicated R161 did not receive her noon dose of Novolog insulin on 10 out of 15 days in October, including Mondays, Wednesdays, and Fridays when out at dialysis. The MAR further indicated that R161's blood glucose level was over 200 19 times from 10/1/24 - 10/15/24. During an interview on 10/14/24 at 1:02 p.m., R161 stated she had concerns about the management of her diabetes and blood glucose levels. R161 stated she left the facility around 10:20 a.m., on Mondays, Wednesdays and Fridays for dialysis and took a bag lunch with her but no medications, voicing a concern for missing her noon administration of insulin. During a follow up interview on 10/16/24 at 9:38 a.m., R161 again voiced concerns about her elevated blood glucose levels, stating she needed to keep her blood glucose levels below 200 because she needed surgery for a dialysis fistula, but would be unable to until for hemoglobin A1C (a blood test that measures a person's average blood sugar levels over the past two to three months) dropped from 10% to 8.5%. During an interview on 10/16/24 t 9:16 a.m., registered nurse (RN)-H stated R161 went to dialysis three times a week on Mondays, Wednesdays, and Fridays, and while she was out a dialysis she would not get her 12:00 p.m. blood glucose check and insulin administration if needed. RN-H stated he had not updated R161's provider about her missing the 12:00 p.m. blood glucose check and insulin administration because they could check her blood glucose when she returned (at approximately 4:00 p.m.) and R161 was able to voice her preferences. RN-H stated he did not have any concerns with R161's blood glucose lately, noting the provider would be notified if her blood glucose was above 400 per R161's insulin order. During a follow up interview on 10/16/24 at 11:20 a.m., RN-H stated he had spoke with R161's provider that morning and her insulin administration schedule had been adjusted to accommodate her scheduled dialysis. New blood glucose checks and sliding scale insulin administration times were changed to 6:00 a.m., 10:00 a.m., and 5:00 p.m. During an interview on 10/16/24 t 1:25 p.m., R161's dialysis nurse (DN) stated R161 had voiced concerns to her about her unmanaged blood glucose levels. The DN stated R161 had had really high fluid gains and unmanaged blood glucose levels could have a tremendous affect on her fluid gains and the effects of her dialysis. During an interview on 10/17/24 at 9:58 a.m., R161 stated she had not been told about the change in her insulin administration schedule, stating, Oh, good, that will help so much! During an interview on 10/18/24 at 11:35 a.m., the director of nursing (DON) stated it would be expected that staff are notifying the provider if a medication is missed, stating if insulin is missed just once, the provider should have been notified. In the case of R161, the DON stated the provider should have been notified to make a plan for ensuring R161 was receiving her insulin on scheduled dialysis days. A policy on medication administration and notifying a provider of missed scheduled medications was requested and not received.

Based on observation and interview, the facility failed to promote a dignified home-like environment during dining services in 4 of 6 dining rooms reviewed. Finding include: R48's significant change Minimum Data Set (MDS) assessment, dated 8/24/24, indicated R48 had intact cognition with no hallucinations or delusions with an admitted [DATE]. During observation on 10/14/24 at 5:08 p.m., on 2nd floor main dining room residents were seated and had been served their meals. It was observed each resident had a hard plastic tray in front of them which contained a plate of food that was sitting on a plate warmer. The drinks (which ranged from juice to coffee to milk) were also placed on the hard plastic tray along with the silverware. In the middle of the table were hard plastic dome shaped lids (which would have been used to cover the food plates). At 5:12 p.m., a staff member walked up to a resident who was sitting with her head down and prompted her to eat. During observation on 10/14/24 at 5:14 p.m., on 2nd floors smaller dining room, it was observed all residents had been served their meals. One unidentified staff member was seated assisting a resident to eat. It was observed that each resident had a hard plastic tray in front of them which contained a plate of food that was sitting on a plate warmer. The drinks (which ranged from juice to coffee to milk) were also placed on the hard plastic tray along with the silverware. In the middle of the table were hard plastic dome shaped lids, upside down, with disposable plastic lids that had been used to cover the soup bowls and drinks. On 10/15/24 at 11:50 a.m., it was observed that staff were starting to serve resident meals. The staff would take the meals from a lunch cart which was an enclosed cart on wheels with slots, that held hard plastic trays that contained resident meals. The hard plastic trays each contained a paper slip that identified who the meal was intended for, a plate of food that was sitting on a plate warmer and was covered with a hard plastic dome shaped lid. The drinks were covered with a plastic lid and the silverware on the tray was rolled in a napkin. At 11:53 a.m., all residents in the dining room had been served their meal. Each resident had a hard plastic tray in front them which contained a plate that sat on a plate warmer, drinks and silverware. The hard plastic dome shaped lids, that were once covering the plates, sat in the middle of the tables and contained the disposable plastic lids that once covered the drinks. On 10/15/24 at 12:10 p.m., the dining cart was delivered to the 2nd floor small dining room by dietary aid. The dining cart was an enclosed cart on wheels with slots, that held hard plastic trays that contained resident meals. The cart had a few trays sitting on the top of the cart. The hard plastic trays (both inside and on the top of the cart) contained a paper slip that identified who the meal was intended for, a plate of food that was sitting on a plate warmer and was covered with a hard plastic dome shaped lid. The drinks were covered with a plastic lid and the silverware on the tray was rolled in a napkin. At 12:13 p.m., the first tray was served to a resident. At 12:17 p.m., a dietary aid delivered another dining cart to the floor that contained 5 more trays. At 12:19 p.m., all residents in the dining room have been served. Each resident had a hard plastic tray in front them which contained a plate that sat on a plate warmer, drinks and silverware. The hard plastic dome shaped lids, that were once covering the plates, sat in the middle of the tables and contained the disposable plastic lids that once covered the drinks. On 10/16/2024 at 11:46 a.m., the dining cart was delivered to the 2nd floor main dining room. The dining cart observed appeared the same as previous observations. Staff, including administrator, served meals to residents. At 11:51 a.m., all residents in the dining room were served their meal. As previous meals observed, each resident had a hard plastic tray in front them which contained a plate that sat on a plate warmer, drinks and silverware. The hard plastic dome shaped lids, that were once covering the plates, sat in the middle of the tables and contained the disposable plastic lids that once covered the drinks. On 10/16/2024 12:03 p.m., staff were serving trays to residents in the 2nd floor smaller dining room. Residents had a hard plastic tray in front of them which contained a plate that sat on a plate warmer, drinks and silverware. The hard plastic dome shaped lids, that were once covering the plates, sat in the middle of the tables and contained the disposable plastic lids that once covered the drinks. During observation on 10/17/24 at 12:15 p.m., on 1st floor dining room, residents were observed to be eating lunch. Each resident had a hard plastic tray in front them of which contained a plate that sat on a plate warmer, drinks and silverware. The hard plastic dome shaped lids, that were once covering the plates, sat in the middle of the tables and contained the disposable plastic lids that once covered the drinks. During interview on 10/16/24 at 10:39 a.m., R48 stated she has thought of ways to make it feel more like home here, but they don't listen, and further stated, we are in a nursing home. R48 stated she eats her meals in the dining room. R48 indicated she feels that it is probably easier for staff to serve the meals on the trays and indicated this is not her preference. On 10/16/2024 at 1:07 p.m., registered nurse (RN)-D indicated they don't know why the meals in the dining rooms are served on the plastic trays. RN-D indicated there is not really a reason. On 10/16/2024 at 12:48 p.m., when asked about serving resident meals in the dining rooms on the hard plastic trays, administrator indicated no rational for this. Administrator verified this is how all meals are served except on 3rd floor. On 10/17/24 at 12:57 p.m., director of nursing (DON) stated, that will be a dietary question, when asked about serving resident meals on hard plastic trays and declined to further comment. A facility policy, Serving Meals and Feeding the Resident, revision date 7/21/16, was provided. The policy lacked indication on how the facility would promote a dignified home-like environment during dining services.

Based on observation, interview and document review, the facility failed to ensure dental needs were coordinated with a dental provider for further care to reduce the risk of complication (i.e., cavities, oral pain) for 1 of 1 residents (R88) reviewed for dental care and services. Findings include: R88's quarterly Minimum Data Set (MDS), dated [DATE], indicated R88 had intact cognition with no hallucinations or delusions with an admitted [DATE]. Further, R88's face sheet, printed 10/17/24, identified R88's primary payer as, Medicaid. R88's care plan, printed 11/5/23, identified R88 has natural teeth and may require assistance with oral care r/t [related to] Parkinson disease [a disease that affects the central nervous system that affects both motor and non-motor systems of the body], impaired mobility with a goal of adequate oral hygiene will be maintained. The care plan listed several interventions to help R88 meet this goal which included, assess condition of oral cavity, teeth, tongue, lips and set-up/supervision and cueing for mouth care and hygiene. The care plan lacked identification of coordination with dental appointments, or identification of missing teeth. During interview on 10/14/24 at 2:12 p.m., R88 indicated that she sees the dentist that provides in-house services at the facility. R88 stated she has not seen them in 5 or 6 months and was supposed to have a follow up visit with them as she is missing 2 or 3 teeth on the right side of her mouth. R88 stated she is waiting for either implants or a partial [denture] on that side. R88 indicated that she does not have pain and is able to chew on the opposite side of her mouth, but the facility hasn't updated her on when her appointment is or if was arranged. R88 indicated she was sure she was supposed to have the appointment by now and stated she asked a staff about it but unsure when that was or who it was. R88's Chart Progress Note from her dental appointment, dated 4/19/24, indicated R88 had an appointment on 4/19/24 for a dental appointment. The note indicated on a previous visit R88 had a tooth extracted (removed). During 4/19/24, R88 had a cavity filled along with routine teeth cleaning. The note recommended that R88 to be seen in 3 months by the dentist for follow up. R88's Progress notes, dated 3/17/24 to 10/17/24, were reviewed and revealed the following: -4/22/24: Dentist: S: Seen by Dentist with no new orders. Progress notes, dated 3/17/24 to 10/17/24, lacked indication of any coordination on follow up on dental appointment. During interview on 10/16/24 at 11:00 a.m., nursing assistant (NA)-A indicated that if they notice any dental concerns with a resident, they notify the nurse for further assessment. On 10/16/24 at 11:14 a.m., registered nurse (RN)-E indicated that dental appointments could vary depending on a residents insurance. RN-E indicated that they are not sure about this as the HUC (Health Unit Coordinator) manages the appointments. RN-E stated that if a dental concern gets reported to a nurse, the nurse assesses the concern and if an appointment needs to be made then the HUC sets up the appointment. RN-E stated she is not aware of any dental pain with R88. RN-E verified that R88's last dental appointment was 4/19/24 and the recommendation was a follow-up in 3 months. On 10/17/24 at 9:30 a.m., health unit coordinator (HUC)-A verified that they are responsible for setting up dental appointments. HUC-A stated when a resident moves in, consents are signed, and that information gets faxed to the dental provider that comes to the facility (in-house dental provider). The dental provider adds the resident to the calendar and updates the facility on when they are coming. HUC-A stated after a dental visit, the after-visit summary (AVS) is reviewed by nursing to see if there are any new orders and then they upload the document into the electronic medical record (EMR). HUC-A stated the nurse will initial the AVS after reviewing it. HUC-A stated that once a resident is seen by the in-house dental provider, the dental provider manages the resident's dental schedule. HUC-A verified she does not track routine or follow up dental appointment for residents seen by the in-house dental provider and she only gets them initially set up and if they need to be seen for an urgent reason. HUC-A stated she was not sure why R88 was not seen as the dental provider manages that schedule. During follow-up interview with HUC-A on 10/17/24 at 10:24 a.m., HUC-A stated she called the in-house dental provider and verified the last visit with R88 was 4/19/24. HUC-A verified she was over-due for the appointment. HUC-A stated the dental provider added her to the schedule and will hopefully be seen the next time they are at the facility or in December. During interview on 10/17/24 at 11:37 a.m., RN-D verified that she oversees the schedule for dental appointments along with the HUC. RN-D stated the dental provider sends a list of residents that will be seen to review prior to arrival. RN-D stated that all after visit summaries from dental appointments are reviewed by nursing to help ensure if it is recommended that they are seen in 3 months for follow up then the resident is. RN-D stated she does not have a tracking system to track when residents should be seen for routine or follow up appointments by the dental provider. RN-D stated she does not know why R88 has not been seen since 4/19/24 if the recommendation was to be seen in 3 months. RN-D stated I don't have access to the system. During interview on 10/17/24 at 12:38 p.m., director of nursing (DON) indicated that a resident family can always take the resident to an outside dental appointment and should be documented in progress notes or care conferences. DON indicated that the after-visit summaries are reviewed by nursing and then go to the HUC to be uploaded. DON verified that if it is recommended to be seen in 3 months for a follow up dental appointment, then a resident should be seen in 3 months. DON stated she was going to look for documentation on another dental appointment. No additional documentation was received. A policy on dental appointments was requested and not received.

Based on observation, interview and document review the facility failed to monitor for resident specific target behaviors related to antipsychotic medications use for 1 of 5 residents (R105) reviewed for unnecessary medications. Findings include: R105's quarterly Minimum Data Set (MDS), dated [DATE], indicated R105 had moderately impaired cognition with no hallucinations or delusions and no behavioral symptoms including physical or verbal behavioral symptoms directed at others or behavioral symptoms not directed toward others. Further, it indicated R105 had received an antipsychotic medication during the seven-day look back period. R105's Physician Order Report, dated 10/16/24, included the following orders: -quetiapine (antipsychotic medication used to treat mental/mood disorders) tablet 25 milligrams (mg) take 12.5 mg one time a day at 8:00 a.m. for delusional disorder with a start date of 2/28/24 -quetiapine tablet 25 mg take one tablet by mouth once in the evening at 8:00 p.m. for delusional disorder with a start date of 2/28/24 The Physician Order Report lacked documentation of an direction to monitor target behaviors or identification of target behaviors. R105's care plan, printed 10/15/24, identified R105's orthostatic blood pressure to be monitored monthly while on anti-psychotic medications and side effect monitoring for antipsychotic medication. The document lacked mention of target behaviors for antipsychotic use or identification of what, if any, target behaviors R105 exhibited. R105's Medications Administration Record (MAR/TAR), printed 10/17/24, for October was reviewed. The document verified R105 received quetiapine. The document indicated an entry for Target Behavior Monitoring: increased anxiety fears; unrealistic fears/concerns; delusions; hallucinations with a start date of 10/17/24. The document lacked evidence of target behavior monitoring prior to 10/17/24. On 10/14/24 at 2:24 p.m., R105 was observed sitting in her room. R105 was calm, pleasant and pinning her clothes getting them ready to sew. R105 stated how much she enjoys sewing. On 10/15/24 at 12:21 p.m., R105 was observed sitting in her room in her rocking chair eating lunch. R105 reports she was enjoying her lunch and really liked her desert. At 2:32 p.m., R105 was sitting in her rocking chair and sewing/pinning an item of clothing. On 10/16/24 at 10:30 a.m., R105 was observed sleeping in her rocking chair in her room with her sewing items in her lap. No behaviors such as agitation, aggression or paranoia observed. At 2:15 p.m., R105 was observed sitting in her chair in her room sewing. R105 stated she was having a good day and denied any concerns. On 10/17/24 at 9:24 a.m., R105 was observed in her room. R105 would take an item of clothing out of her closet, lay it on her bed and then hang it back up. R105 was observed smiling throughout this time. R105 stated she was having a good day and getting ready to pin some things. On 10/17/24 at 9:52 a.m., nurse practitioner (NP)-A verified that target behaviors should be monitored if a resident is prescribed an antipsychotic medication. NP-A stated this is important in determining many things such as: if the medication is effective, if the medication is needed, should it be scheduled, do they need a PRN (as needed medication). On 10/17/24 at 10:37 a.m., pharmacist consultant (PC)-A verified that if a resident is prescribed antipsychotic medications, target behaviors (along with other things) should be monitored. PC-A stated target behaviors should be monitored because we want to monitor the effectiveness of the medication to why she is receiving it. PC-A verified the monitoring of target behaviors was added to the MAR/TAR on 10/17/24. On 10/17/24 at 11:36 a.m., registered nurse (RN)-D indicated it was important for antipsychotic medications to be monitored. RN-D verified this included monitoring of target behaviors. RN-D stated this is helpful because then you know the reason for the medications, if they are having side effects and if it is effective. On 10/17/24 at 12:36 p.m., director of nursing (DON) verified antipsychotic medications absolutely need to be monitored. DON verified that it is important target behaviors are monitored with antipsychotic medications as this helps determine the effectiveness of the medication. DON verified monitoring target behaviors also helps with gradual dose reductions. DON verified there was no target behavior monitoring for R105's quetiapine before today and the behavior monitoring was added today. DON stated it was previously on the TAR but must have fallen off at some point. A facility policy titled Psychotropic Medication, dated 1/1/24, The document has a procedure for the facility to follow when a resident has an order for psychotropic medication. Number 4 identified Add problem to care plan listing behavior to be treated. List measurable goal in the care plan. The document further indicated Initiate a psychotropic drug monitoring graph. List the specific behavior(s). Each shift is to document frequently of behavior. This information is used to monitor effectiveness of drug.

Based on interview and document review, the facility failed to consistently assess a resident's pain level prior administration of an as-need narcotic pain medication, in addition, the facility failed to assess for and implement if requested non-pharmacological pain interventions for 1 of 2 residents (R106) reviewed for pain management. Findings include: R106's quarterly Minimum Data Set (MDS), dated [DATE], indicated R106 had intact cognition with no hallucinations or delusions. R106's diagnoses included polyneuropathy (damage or disease affecting nerves in roughly the same areas on both sides of the body), muscle weakness, radiculopathy (the pinching of the nerves at the root), other symptoms and signs involving the musculoskeletal system-wheelchair dependent and alcohol dependence with withdrawal. and required, at least, substantial/maximal assistance with dressing, sitting up or transferring. Further, under Section J - Health Conditions, the MDS identified R106 consumed no scheduled pain medication but received as-needed (i.e., PRN) pain medication along with non-medication intervention for pain; furthermore, R106 reported pain on a frequent basis which occasionally effected sleep, rarely or not at all interfered with day-to-day activities with a verbal descriptor scale of moderate pain. R106's face sheet, printed 10/17/24, indicated R106's diagnoses included: chronic pain, history of neuralgia (nerve damage or irritation that causes sharp, shock-like pain) and neuritis (inflammation of nerves that can cause pain), insomnia (inability to sleep), other osteoporosis without current pathologic fracture left foot (condition which causes bones to become weak and brittle), urinary incontinence (loss of bladder control), and adult failure to thrive (a syndrome that describes a general decline in health in older adults). R106's care plan, printed 10/17/24, included the following interventions: -[R106] has complaints of chronic pain R/T [related to] polyneuropathy of lower extremities with the following approaches: acknowledge to the resident that her pain is unique and believable; assess effects of pain on the resident (disturbances in sleep, activity, self-care, appetites, psychosocial, etc.); assess past effective and ineffective pain relief measure; caution resident against using unproven cures such as alcohol consumption; handle gently and try to eliminate any environmental stimuli; monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors; monitor and record any non-verbal signs of pain: (e.g., crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc.). -Pain with alteration in comfort r/t site: broken toe on left foot r/t to fall; neuropathic pain to bilateral lower extremities (from the knees down); chronic pain; pancreatitis r/t alcohol abuse with the following approaches: review pain interventions-implement or adjust interventions as needed, pharmacological-scheduled and PRN analgesics [medications that treat pain], non-pharmacological; rate pain before and after receiving PRN. Document any refusal of pain medications (PRN or scheduled) -Will offer activities that resident will find intriguing and of interest and make sure to invite her to those. Offer M technique hand massage, aromatherapy, and/or healing touch for physical psychosocial comfort. During interview on 10/15/24 at 8:47 a.m., R106 was observed lying in bed. She stated she doesn't sleep well due to the constant pain she is in. R106 indicated she has pain from her toes to the middle of her back and in her hands. R106 indicated she gets half a tab of oxy, and it doesn't treat my pain but keeps me going. R106 indicated the facility don't do anything for my pain .nobody does anything about it. R106 indicated she did physical therapy previously but that doesn't help with nerve pain. R106 stated she might be interested in therapy again, so she doesn't lose any more strength as she feels she has lost a lot. R106 became upset during interview and talking about pain and continued to state, they don't do anything they want me like this. R106's October Medication Administration Record (MAR/TAR), printed 10/16/24, included the following orders and administrations: - acetaminophen [Tylenol] (pain reliever) tablet 325 milligrams (mg) tablet administer 650 mg oral [by mouth] every 6 hours PRN. DX [diagnosis]: other chronic pain. Started 7/2/24. -No administration or refusals documented in the month of October - tizanidine (muscle relaxer) 2 mg capsule administer 2 mg oral three times a day PRN. DX: neuralgia and neuritis. Started 7/16/24. -No administration or refusals documented in the month of October - Offer lavender aromatherapy patch (found in the aromatherapy drawer at the nursing station). Apply one patch on the clothing or clean dry skin daily twice a day PRN. Started 9/24/24. -No administration or refusal documented in the month of October - oxycodone (narcotic pain medication) 5 mg tablet administer 1/2 oral every 12 hours PRN. DX: other chronic pain. Started 7/10/24. -Administered two times a day for the month of October except for 3 days when it was given one time a day. Of those administrations, 5/26 had a pain scale and 2/26 had a location of pain listed. The remaining administrations, 21/26 administrations, did not have a pain scale listed and 24/26 administrations did not have a location of pain listed. - Monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factors every shift. Started on 10/23/24. -all marked as completed, -A review of the full medical record lacked any additional information related to the of the pain, such as, location, frequency, effect on function, intensity, alleviating factors, aggravating factors despite being marked completed on every shift in October. A review of R106's Pain Assessment Observation Details completed from 10/1/24-10/15/24 revealed the following; No Pain Assessment Observation Detail completed for R106 on 10/15/24. R106's Pain Assessment Observation Detail, dated, 10/14/24 at 8:37 p.m., Pain Assessment Interview: questions are answered with radio-button answers: Presence of pain: no The rest of the assessment was left blank. R106's Pain Assessment Observation Detail, dated, 10/13/24 at 9:43 a.m., Pain Assessment Interview: questions are answered with radio-button answers: Presence of pain: yes Pain frequency: almost constantly Pain effect on sleep: occasionally Pain interference with therapy activities: does not apply Pain location: left blank Pain interference with day-to-day activities: occasionally Verbal scale rating: moderate No Pain Assessment Observation Detail completed for R106 on 10/11/24 and 10/12/24. R106's Pain Assessment Observation Detail, dated, 10/10/24 at 10:10 a.m., Pain Assessment Interview: questions are answered with radio-button answers: Presence of pain: yes Pain frequency: almost constantly Pain effect on sleep: occasionally Pain interference with therapy activities: does not apply. Pain location: bilateral lower extremities Pain interference with day-to-day activities: occasionally Verbal scale rating: moderate No Pain Assessment Observation Detail completed for R106 on 10/8/24 and 10/9/24. R106's Pain Assessment Observation Detail, dated, 10/7/24 at 11:29 a.m., Pain Assessment Interview: questions are answered with radio-button answers: Presence of pain: yes Pain frequency: almost constantly Pain effect on sleep: occasionally Pain interference with therapy activities: does not apply. Pain location: n/a [not applicable] Pain interference with day-to-day activities: almost always Verbal scale rating: moderate No Pain Assessment Observation Detail completed for R106 on 10/6/24. R106's Pain Assessment Observation Detail, dated, 10/5/24 at 9:39 p.m., Pain Assessment Interview: questions are answered with radio-button answers: Presence of pain: yes Pain frequency: almost constantly Pain effect on sleep: frequently Pain interference with therapy activities: almost constantly Pain location: generalized pain Pain interference with day-to-day activities: almost always Verbal scale rating: moderate R106's Pain Assessment Observation Detail, dated, 10/4/24 at 11:10 a.m., Pain Assessment Interview: questions are answered with radio-button answers: Presence of pain: yes Pain frequency: almost constantly Pain effect on sleep: occasionally Pain interference with therapy activities: almost constantly Pain location: BLA Pain interference with day-to-day activities: almost always Verbal scale rating: moderate No Pain Assessment Observation Detail completed for R106 on 10/3/24. R106's Pain Assessment Observation Detail, dated, 10/2/24 at 8:26 p.m., Pain Assessment Interview: questions are answered with radio-button answers: Presence of pain: yes Pain frequency: occasionally Pain effect on sleep: occasionally Pain interference with therapy activities: does not apply. Pain location: bilateral toes Pain interference with day-to-day activities: left blank Verbal scale rating: left blank A review of the Pain Assessment Observation Details completed for October lacked indication of non-pharmacological interventions offered or discussed. The documents further lacked coordination of the timing of administration of PRN oxycodone and other medications being offered prior to administration of narcotic medication. R106's Permission Form for the use of Healing Touch, dated 10/24/23, was signed by R106. R106'2 Consent for the use of Aromatherapy, dated 5/21/24, was signed by R106. Progress notes reviewed from 9/1/24 to 10/17/24 identified the following: -10/1/24: note indicated resident rated her pain at 8/10. The note lacked indication of any intervention offered. -9/23/24: resident had 2.5 mg oxycodone at 11:00pm. The note lacked indication of reason for medication, pain level or location, or non-pharmacological interventions offered. -9/20/24: administer PRN oxycodone. The note lacked indication of reason for medication, pain level or location, or non-pharmacological interventions offered. -9/17/24: Returned to res's room at 1250 to administer PRN oxycodone . The note lacked indication of reason for medication, pain level or location, or non-pharmacological interventions offered. -9/9/24: resident reported she is unable to complete shower due to pain in lower legs. PRN Oxycodone administered. The note lacked indicated of pain level or non-pharmacological interventions offered. The progress notes, dated 9/1/24 to 10/17/24, lacked documentation of Healing Touch, aromatherapy or other non-pharmacological interventions being offered or declined during the period reviewed. Furthermore, the notes lacked evidence of a discussion with R106 of preferences of non-pharmacological interventions being offered. R106'2 Quarterly care conference note, dated 9/12/24, reviewed care for the last quarter. The note lacked evidence of discussion of R106's pain. Furthermore, it lacked evidence of discussion of pain interventions of non-pharmacological interventions. During an interview on 10/16/2024 at 11:14 a.m., registered nurse (RN)-E stated that residents pain level is measured on a pain scale. RN-E stated the pain level should be documented in the comment section on the medication administration record when a pain medication is administered. RN-E stated the pain level can also be documented in a progress note along with any non-pharmacological interventions offered. During an interview on 10/16/2024 at 12:33 p.m., RN-F indicated they are familiar with R106. RN-F verified that a pain level should be assessed prior to giving as needed pain medication. RN-F verified other interventions should be attempted prior to giving as needed pain medications. RN-F verified that non-pharmacological intervention would be documented on the medication/treatment administration record (MAR/TAR) and the pain level would be documented in the comment section in the MAR when giving the medication. On 10/16/2024 at 12:54 p.m., RN-D stated the expectation was that prior to administration of pain medication that an assessment should be completed. The assessment includes the type of pain, location of pain, pain scale, non-pharmacological interventions offered, effectiveness of the non-pharmacological interventions and then offer a PRN (as needed) pain medication. RN-D stated it is also important to follow-up to see if the PRN medication was effective. RN-D stated it is expected the pain scale to be documented in the comment section when administering R106's PRN oxycodone medication. RN-D did not answer regarding non-pharmacological intervention documentation when asked. RN-D reviewed administration of last 14 days (10/2/24 to 10/16/24) and verified a pain scale was entered 5 times out of 26 times PRN oxycodone was administered. During interview on 10/17/24 at 9:54 a.m., nurse practitioner (NP)-A stated that a pain assessment and non-pharmacological interventions should be offered prior to administration of pain medications. NP-A stated a pain scale should be completed, documented, and then to attempt and document non-pharmacological interventions prior to administration of pain medications. NP-A stated residents can refuse non-pharmacological interventions, but it is important we are asking and documenting. NP-A indicated it is important we are assessing and re-assessing pain to see what is working and not working and should be documenting all of it. NP-A indicated that pharmacists can be a good resource also for suggestions. During interview on 10/17/24 at 10:37 a.m., pharmacist consultant (PC)-A indicated that it is important for non-pharmacological to be offered and documented on prior to giving as needed pain medication. PC-A stated it is important that pain levels are monitored prior to administration of a pain medication along with after administration of the pain medication. During a follow-up interview on 10/17/24 at 11:28 a.m., RN-D verified there was no PRN use or documented refusal of lavender aromatherapy in October. RN-D verified tizanidine PRN was not administered in October. During interview on 10/17/24 at 12:52 p.m., director of nursing (DON) verified the expectation is that non-pharmacological interventions are offered prior to administration of PRN pain medication along with assessing the residents' pain which includes a pain scale. DON verified this had not been done for R106. DON verified the order was not entered correctly as the order should prompt to enter a pain scale when it is clicked on for administration. DON stated he was going to follow up on this. DON stated the care plan may indicate any non-pharmacological interventions and they might be documented in progress notes. DON stated they were going to follow up and provide further information if available. No further information was provided. A facility policy Pain Management, dated 11/20/20, indicated non-pharmacological interventions for pain management will include distracting activities such as preferred music, watching a chosen show, 1:1 for calming, heat or cold as indicated, orders for PT or OT, healing touch and other non med modalities as resident indicates interest. Furthermore, the daily IDT meeting will be used to discuss residents who have pain that is not easily managed. Documentation will be entered into the EHR when these reviews take place.

Based on interview and record review the facility failed to identify, keep resident appraised of ongoing efforts or resolve an ongoing grievance for 1 of 3 residents (R2) reviewed. R2 had a roommate who would cry and scream out at night. In addition, the roommate would wander into R2's side of the room and R2 would have to call the nurses station almost daily to have the roommate removed. Finding Include: R2's nursing progress note dated 1/6/24 at 5:37 a.m. indicated R2 was awake most of the night and concerned about the new roommate. R2 indicated the roommate was disturbing her with noise. She requested the roommate should be moved. R2's nursing progress note dated 1/6/24 at 3:06 p.m. indicated R2 complained of not being to sleep at night due to disturbances by roommate. Family member (FM)-A spoke with staff about the possibility of relocating the roommate due to the resident not being able to sleep. Staff informed FM-A and R2 that frequent checks would be conducted to prevent disturbances and handle the situation accordingly. R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 had a Brief Inventory of Mental Status (BIMs) score of 15 indicating no cognitive impairment. R2 required extensive assistance for activities of daily living. R2's pertinent diagnoses included Multiple Sclerosis, acute respiratory failure, displaced comminuted fracture of shaft of humerus right arm, age related osteoporosis and muscle weakness. R2's social service progress note dated 1/26/24 indicated R2 expressed difficulty adjusting to her new roommate during the care conference. Social worker (SW)-A offered Associated Clinic of Psychology (ACP) visits for psychosocial support. R2 declined the visits. R1's nursing progress note dated 1/7/24 at 5:03 a.m. indicated R1 was very confused all night trying to enter other resident's room. R1's nursing progress note dated 1/11/24 at 10:24 p.m. indicated it was noted that R1 was going into roommates' side of the room (R2) and needed assistance to go back to her room. R1's admission MDS dated [DATE] indicated R1 had a BIMs score of 0 indicating severe cognitive impairment. R1's potential indicator of psychosis indicated R1 hallucinated. R1's behavior significantly interfered with her cares and was significantly intrusive on the privacy or activity of others. The MDS did not indicate that R1 wandered. R1 required substantial assistance of one staff member with activities of daily and required on supervision or touching assistance with transferring. R1's pertinent diagnoses were heart failure, major depressive disorder, recurrent, severe with psychotic symptoms, age-related cognitive decline, hallucinations, delirium, and delusional disorder. R1's nursing progress note dated 1/16/24 at 2:12 p.m. indicated R1 was noted to into roommates' room and needed assistance to go back to her own room. R1's nursing progress note dated 1/18/24 at 7:21 a.m. indicated R1 woke at 4:30 a.m. and roommate called that she is yelling and disturbing. She was brought to the wellness desk. R1's nursing progress note dated 1/21/24 at 10:53 p.m. indicated R1 kept going into roommates' room and R2 kept calling the nurses statin to have the nurse help get her out. R1's nursing progress note dated 1/24/24 at 2:44 p.m. indicated in the early a.m. R1 was making loud noises. R1's nursing progress note dated 1/24/24 at 2:11 p.m. indicated in the early a.m. R1 was making loud noises. R1's nursing progress note dated 1/27/24 at 7:11 a.m. indicated R1's daughter left the facility about around 2:00 a.m. After the daughter left R1 was sitting up on her bed taking to herself and screaming. Her roommate was complaining and requesting something be done. R1 refused to leave the room. Staff was checking on R1 every 30 minutes, she later came out of room at 5:00 a.m. R1's nursing progress note dated 1/29/24 at 1:58 p.m. indicated R1 had elevated anxiety in the early a.m., making loud noises. R1's nursing progress note dated 1/30/24 at 11:41 a.m. indicated in the early a.m. R1 was making loud noises. R1's nursing progress note dated 1/30/24 at 8:50 p.m. indicated R1's family was at the facility until 7:00 p.m. even though family was there R1 was calling out and yelling every once in a while. R1's nursing progress note dated 1/31/24 at 12:31 p.m. indicated R1 was making loud noises early in the morning. R1 had two episodes of yelling and screaming. R1's roommate called several times to complain that R1 was disturbing her sleep. R1's nursing progress note dated 2/1/24 at 12:34 p.m. indicated early in the a.m. R1 was making loud noises calling out of her room. R1's nursing progress note dated 2/1/24 at 10:22 p.m. indicated at 3:00 p.m. R1 was yelling. Nurse went in and she was sitting at the edge of her bed and did not want to lay down and said she wanted to go home upstairs and that she was looking for her children or someone to help take her room. Staff assisted her into her wheelchair. Not long after that her roommate called that and stated R1 had wandered into her room, and she was helped to the lobby. While out she was yelling and calling out. After dinner she wheeled herself back to the room and went to the roommate's room and was touching her food and her belongings. Roommate stated that it is so frustrating and depressing for her because she yells out at night, and she cannot sleep, and she roams into her personal space with which she is not comfortable. R1's nursing progress note dated 2/7/21 at 12:51 p.m. indicated R1 was yelling and calling out early in the a.m. Upon interview on 2/21/24 at 3:41 p.m. R2 stated her roommate R1 screamed and cried daily. R2 stated most nights she had to call the nurses to either remove R1 from her side of the room or take her away due to the crying and screaming. R2 stated she mentioned the screaming and lack of sleep at her last care conference on 1/26/24 and was told she should see a psychologist to cope. At [AGE] years old why should I see therapy for another person screaming? Upon interview on 2/21/24 at 3:55 p.m. R2's family member (FM)-A stated the roommates screaming and wandering into R2's room had been happening for over a month. He stated no plan was ever discussed with him for a resolution. Upon interview on 2/21/24 at 4:18 p.m. RN-B stated she worked the p.m. shifts most often and R2 would call almost every shift to have R1 removed her side or the room or complaining of disturbances by R1. RN-B stated the staff did the best they could and would try to remove R1 from the room, but at times she would refuse and become combative with staff. RN-B stated she believed R1's family was offered a room in the memory care department, however they refused. Upon interview on 2/22/24 at 10:34 a.m. social worker (SW)-A stated R2 had mentioned the screaming of her roommate and how it made it difficult for R2 to sleep. SW-A stated she did not do a formal grievance. She stated the RN-A heard from other residents about the disturbances as well and believed RN-A was working on a resolution. SW-A stated R1's family would visit daily to help assist R1 and R1 was offered a room on the memory care unit, however the family refused. Upon interview on 2/22/24 at 11:45 a.m. licensed practical nurse (LPN)-A stated R1 would be screaming loudly between 6:00 and 7:00 a.m. waking R2 up. She stated staff would attempt to get R1 out of her room if R1 would allow. LPN-A was uncertain what the facility was doing about R1's behaviors and disruption of R2. Upon interview on 2/22/24 at 12:32 p.m. RN-A, the nurse manager stated she did not receive any formal complaints from residents on the unit but did overhear conversation between some residents about R1' s screaming and wandering RN-A stated she was aware that R2 often called the nurses on duty to remove R1 due to disturbances. RN-A stated she believed SW-A was working on a formal grievance as R2 and FM-A reached out often to SW-A. Upon interview on 2/23/24 at 10:15 a.m. the director of nursing (DON) stated he was aware staff had to often redirect R1 due to disturbances and most of R1's disturbances occurred in the p.m. or overnight. The DON was not aware of any formal grievance or any resolutions. Upon interview on 2/23/24 at 10:30 a.m. the Administrator stated the facility had reached out the nurse practitioner and a couple of medications were made for R1. She stated the facility had mentioned the memory care unit the family, but the family declined. The Administrator denied any formal grievance or formal resolution regarding R2's concerns of lack of sleep due to R1. A grievance policy was requested; however, none was received.

Based on interview and document review, the facility failed to ensure staff obtained a blood pressure or provided a full assessment to identify a change in condition for 1 of 2 residents (R1) reviewed for quality of care. R1 had a change in condition that staff were monitoring on [DATE]; however, when staff attempted to obtain a blood pressure with a machine on three different occasions, the machine did not register the resident's blood pressure due to movement and staff did not attempt an alternative to obtain a blood pressure. The survey resulted in immediate jeopardy (IJ) to resident safety as R1 was sent to the hospital on [DATE] and died . The IJ began on [DATE]. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 12:59 p.m. The IJ was removed on [DATE]. Non-compliance remained at a lower scope and severity G, actual harm that is not immediate jeopardy. Findings include: R1's facesheet printed on [DATE], noted R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], noted R1 had poor cognition and required extensive assistance with dressing, bed mobility, and was totally dependent on staff for transfers. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], registered nurse (RN)-B documented a progress note at 11:05 p.m. that R1 returned from a leave of absence at 4:00 p.m. via medical transport. At 5:00 p.m. nursing assistant (NA)-A reported that R1 was not swallowing her food and was staring blankly. RN-B noted R1 had to be told many times to swallow her food which she eventually did, R1 had no verbal response to questions. RN-B documented she called R1's daughter and determined R1 was experiencing [CONDITION(S)] due to as needed (PRN) pain medication that was administered that afternoon. RN-B noted she attempted to call the provider but that it required an email message be left and she had no ability to send an email. Further, RN-B noted she was unable to get a blood pressure reading due to movement. In the vital sign report, R1's acceptable pulse rate range is between ,d+[DATE] beats per minute, her acceptable blood sugar range is from ,d+[DATE], and her acceptable blood pressure range is from ,d+[DATE] systolic over ,d+[DATE] diastolic. In the vital sign report on [DATE], at 5:43 p.m. R1's blood sugar was 360, her oxygen saturation was 100% and her temperature was 97.5 In the vital sign report on [DATE], at 9:46 p.m. R1's respirations were 16, her pulse was 117, her temperature was 96.6 and her blood pressure was ,d+[DATE]. In the vital sign report on [DATE], at 1:25 a.m. R1's temperature was 97.5, pulse was 53, respirations 16 and her blood pressure was ,d+[DATE]. On [DATE], RN-C documented a progress note at 6:37 a.m. that R1 was sent to the hospital for evaluation at 5:10 a.m. RN-C noted it was reported R1 had a change in condition on [DATE]. At 1:25 a.m. R1's temperature was 97.5 her pulse was 53, respirations were 16, blood pressure was ,d+[DATE] and oxygen saturation was 98%. RN-C noted that R1's blood pressure was not registering on machine due to movement. RN-C documented that at 4:30 a.m. she found R1 with abnormal breathing, slurred response to verbal commands and oxygen saturations were 84%. RN-C then called emergency services and R1 was taken to the hospital for further evaluation. A progress note dated [DATE], at 10:11 a.m. noted that R1 expired at the hospital. When interviewed on [DATE], at 3:15 p.m. RN-B stated that NA-A reported on [DATE], around 5:30 p.m. R1 was not swallowing her food. RN-B stated she went to R1's room and had to tell R1 several times to swallow her food which she eventually did. Further, RN-B noted R1 was not making eye contact which was unusual and was not responding to questions of pain. RN-B stated usually when caring for R1 she would be in her bed, lying on her back and would follow commands. RN-B stated she called and spoke with R1's daughter immediately afterwards to see if daughter noted this same behavior. RN-B stated R1's daughter mentioned R1 received a PRN pain medication shortly before going on her leave of absence and thought R1 was experiencing [CONDITION(S)]. RN-B stated she checked vital signs later that evening but was not able to obtain a blood pressure reading with the machine and received an error message to restrict movement and noted R1 was moving her arm up. RN-B did not attempt to check R1's blood pressure manually. RN-B also noted R1 had an elevated pulse rate. RN-B stated she tried to reach the provider but was unable as the voicemail system directed the caller to send an email and she was unable to email the provider, RN-B stated she may not have listened to the entire message for further instructions for reaching the provider. RN-B stated she entered ,d+[DATE] for R1's blood pressure reading so the overnight nurse would not have difficulty with the electronic health system, RN-B stated, I was very concerned about her [R1] and wanted to be sure we would follow through. RN-B further stated that R1 was a difficult person to read and she directed care based on R1's daughter believing R1 was experiencing [CONDITION(S)]. When interviewed on [DATE], at 3:53 p.m. nurse manager (NM) stated if a vital sign machine is not functioning properly, he expected nurses to try other means to obtain vital signs on residents. NM stated if a nurse was aware of a vital sign reading that was out of range the nurse should notify the provider. NM further stated the nurse should do a full assessment with a reported change in condition including a full set of vital signs, a nurse should never leave a vital sign blank or enter a zero value. When interviewed on [DATE], at 4:25 p.m. NA-A stated she was assisting R1 to eat her supper meal on [DATE] around 5:30 p.m. when she noticed R1 was not swallowing her food, was breathing rapidly, was sleepy and sluggish and not opening her eyes. NA-A stated this was unusual behavior and she reported it to RN-B. When interviewed on [DATE], at 3:56 p.m. the director of nurses (DON) stated she expected nurses to fully assess a resident with a reported change in condition, including vital signs. The DON stated R1 had a significant cardiac event prior to her admission and full vital signs should have been obtained. Further, the DON stated if a machine is malfunctioning, she expected the nurse to use a manual cuff for blood pressure measurement. The DON stated the root cause of the incident was that the nurse allowed a preconceived notion of drug [CONDITION(S)] direct her assessment. When interviewed on [DATE], at 4:08 p.m. nurse practitioner (NP) stated that not being able to check a blood pressure is not concerning by itself, but with the additional assessment findings of elevated pulse, unresponsiveness to questions, elevated blood sugar, and restlessness behavior; it is concerning. NP stated she would have expected the nurse to attempt to check the blood pressure manually and to contact the provider if a resident is not doing well. When interviewed on [DATE] at 4:21 p.m. RN-C stated it was reported that R1 had a change in condition on the evening of [DATE], and the R1 was not behaving as she usually does. RN-C stated it was reported that R1 had a similar incident in the past and it was determined that she had [CONDITION(S)] due to her pain medication and R1 should be monitored. RN-C stated she had a nursing assistant obtain vital signs on R1 around 1:20 a.m. the nursing assistant was unable to get a blood pressure reading as R1 was moving her arm. RN-C stated R1's oxygen saturation was 98% and her pulse was 53. RN-C reported she did visual rounds throughout her shift and noted R1 was sleeping intermittently though did not perform an assessment. RN-C stated she received a call from R1's daughter around 4:00 a.m. to see how R1 was doing. RN-C informed R1's daughter of the inability of the nursing assistant to get a blood pressure reading earlier but she would go check for herself. RN-C stated when she went into R1's room she noticed that R1 was restless, her blankets were on the floor, R1 was breathing rapidly, and she was not responsive to questions. RN-C stated she began to assess checking R1's oxygen saturation and it was 84% and her pulse was over 120, RN-C then got R1 on supplemental oxygen and called 911. The facility's policy titled, Change in Resident Status last revised [DATE], noted a change in condition will be reported to the attending physician to ensure proper treatment will be implemented. The policy further noted, the nurse should utilize INTERACT (pathways that are disease/condition specific) tools to collect data and complete an assessment. If unable to reach the attending physician or the physician on call, call the medical director.

Based on interview and document review, the failed to timely notify the physician of a change of condition for 1 of 2 residents (R1) reviewed for change of condition. R1 was unable to swallow her food, staring blankly, had an increase in pulse rate. The following shift R1 had a decrease in pulse rate, and on both shifts staff were unable to obtain a blood pressure. R1 sustained harm as required emergency services and expired at the hospital. Findings include: R1's facesheet printed on [DATE], noted R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], noted R1 had poor cognition and required extensive assistance with dressing, bed mobility, and was totally dependent on staff for transfers. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated [DATE], at 11:05 p.m. noted R1 returned from a leave of absence at 4:00 p.m. via medical transport. At 5:00 p.m. nursing assistant (NA)-A reported that R1 was not swallowing her food and was staring blankly. Registered Nurse RN-B noted R1 had to be told many times to swallow her food which she eventually did, R1 had no verbal response to questions. RN-B documented she called R1's daughter and determined that R1 was experiencing [CONDITION(S)] due to PRN pain medication that was administered that afternoon. RN-B noted she attempted to call the provider but that it required an email message be left and she had no ability to send an email. Further, RN-B noted she was unable to get a blood pressure reading due to movement. In the vital signs report R1's acceptable pulse rate is from ,d+[DATE] beats per minute, her acceptable blood sugar range is from ,d+[DATE] and her acceptable blood pressure range is ,d+[DATE] systolic over ,d+[DATE] diastolic. In the vital signs report on [DATE], at 5:43 p.m. R1's blood sugar was 360, her oxygen saturation was 100% and her temperature was 97.5 In the vital signs report on [DATE], at 9:46 p.m. R1's respirations were 16, her pulse was 117, her temperature was 96.6 and her blood pressure was ,d+[DATE]. In the vital signs report on [DATE], at 1:25 a.m. R1's temperature was 97.5, pulse was 53, respirations 16 and her blood pressure was ,d+[DATE]. A progress note dated [DATE], at 6:37 a.m. noted that R1 was sent to the hospital for evaluation at 5:10 a.m. RN-C noted it was reported R1 had a change in condition on [DATE], At 1:25 a.m. R1's temperature was 97.5 her pulse was 53, respirations were 16, blood pressure was ,d+[DATE] and oxygen saturation was 98%. RN-C noted that R1's blood pressure was not registering on machine due to movement. RN-C documented that at 4:30 a.m. she found R1 with abnormal breathing, slurred response to verbal commands and oxygen saturations were 84%. RN-C then called emergency services and R1 was taken to the hospital for further evaluation. When interviewed on [DATE], at 3:15 p.m. RN-B stated she went to R1's room and had to tell R1 several times to swallow her food which she eventually did. Further, RN-B noted R1 was not making eye contact which was unusual and was not responding to questions of pain. RN-B stated usually when caring for R1 she would be in her bed, lying on her back and would follow commands. RN-B stated she checked vital signs later that evening but was not able to obtain a blood pressure reading with the machine and received an error message to restrict movement and noted R1 was moving her arm up. RN-B did not attempt to check R1's blood pressure manually. RN-B also noted R1 had an elevated pulse rate of 117. RN-B stated she tried to reach the provider but was unable as the voicemail system directed you send an email and she was unable to email the provider. When interviewed on [DATE], at 3:53 p.m. nurse manager (NM) stated if a nurse was aware of a vital sign reading that was out of range the nurse should notify the provider. The NM further stated it is an expectation that the nurse would notify the provider of a change in condition and that the providers are available 24 hours a day. When interviewed on [DATE], at 4:13 p.m. lead nurse practitioner (LNP) stated there were no messages regarding R1's status on [DATE]. When interviewed on [DATE], at 3:56 p.m. the director of nurses (DON) stated she expected nurses to fully assess a resident with a reported change in condition. The DON stated R1 had a significant cardiac event prior to her admission and complete assessment including vital signs should have been obtained and reported to the provider for direction of R1's care. When interviewed on [DATE] at 4:21 p.m. RN-C stated it was reported that R1 had a change in condition on the evening of [DATE], and the R1 was not behaving as she usually does. RN-C stated she had a nursing assistant obtain vital signs on R1 around 1:20 a.m. the nursing assistant was unable to get a blood pressure reading as R1 was moving her arm. RN-C stated R1's oxygen saturation was 98% and her pulse was 53. RN-C stated when she went into R1's room on [DATE] at 4:30 a.m. she noticed that R1 was restless, her blankets were on the floor, R1 was breathing rapidly, and she was not responsive to questions. RN-C stated she began to assess checking R1's oxygen saturation and it was 84% and her pulse was over 120, RN-C then got R1 on supplemental oxygen and called 911. The facility's policy titled Change in Resident Status last revised [DATE], noted a change in condition will be reported to the attending physician to ensure proper treatment will be implemented. If unable to reach the attending physician or the physician on call, call the medical director.

Based on document review and interview, the facility failed to provide adequate supervision to prevent resident to resident altercations for one of one residents (R1) reviewed. This failure affected Resident (R2, R3, R4, and R5) who experience physical aggression from R1. The facilities failure to ensure adequate supervision after continued physical aggression to both residents and staff resulted in harm to R2, who increased pain, limited ambulation, and a possible pelvic fracture injury after R1's physical altercation, and a possible arm injury (unknown if injury occurred) for R6. Findings include: A review of R1's medical record revealed a [DIAGNOSES REDACTED]. R1's Care Plan, dated 5/17/2013 documents that R1 has an alteration in mood/behavior related to dementia, wanders on the unit and into other resident rooms, hits out, and exhibits unprovoked aggression with staff and other residents. Interventions dated 7/1/2013 included: to avoid power struggles with R1 and allow him to do as much as possible, administer medications per physician order,and to use a calm and positive approach. No interventions were in place for staff to implement when R1 was physically aggressive with other residents. R1's Progress Notes and Behavior Event Reports were reviewed and revealed the following: On 6/1/2013 at 3:30 p.m., R1 had an altercation with another resident. Staff saw R1 push down another resident. No injuries were noted and interventions included for staff to continue to monitor. On 6/2/2013 at 2:25 p.m., R1 was resistive and combative with cares. R1 was "fighting, beating, and yelling" at staff when staff was attempting to redirect. Four staff were needed to dress and toilet R1. Interventions noted were for staff to continue to monitor R1. On 6/3/2013 at 10:22 a.m., R1 was hitting staff, and lifting/dragging chairs into hallway, wandering into rooms and was difficult to redirect. The progress note documented that R1 was at risk to himself and others. The Nurse Practitioner (NP) was updated and orders for Depakote 500mg AM & PM and 250 mg at 2:00 p.m. were received and implemented. On 6/4/2013 at 9:51 p.m., revealed that at 6:15 p.m. R1 was angry at staff for trying to redirect him. R1 bumped into R6 who fell to the floor in a sitting position. An arm injury was found the next day to R6 (unknown if injury occurred). Staff was to notify the family and nurse practitioner (NP) on 6/5/2013. No additional interventions were documented. On 6/6/2013 at 2:42 p.m., R1 approached R5 near the elevator and slapped R5 on their upper arm. The progress note revealed that R1 may have been provoked by R5. No injury to either resident was noted. Intervention included was to keep both residents separated. On 6/7/2013 at 6:21 a.m., R1 was awake all night and lifting chairs to throw at staff. R1 kept wandering into another resident's room and the resident was "scared." On the morning of 6/7/2013, staff notified the NP regarding R1's behaviors and Haldol (as needed) was ordered and implemented. On 6/7/2013 at 10:35 a.m. R4 reported that R1 pushed him down. No injury. The progress note indicated that R1 had not been seen in the area but had been up all night going into other resident's rooms. The NP was updated, and medication adjustments were made including: Zoloft was decreased from 50 mg to 25 mg every day and Haldol was increased from 0.25 mg to 0.50 mg every 12 hours (as needed). On 6/7/2013 at 10:54 a.m. the Interdisciplinary Team (IDT) met and noted that R1 does not "appear to understand staff attempts to redirect" and R1 has been having increased behaviors involving staff and other residents. On 6/7/2013 at 4:40 p.m., R1 was shouting loudly and verbally at staff, and was physically abusive when staff attempted to redirect him. Haldol was administered. The interventions included to monitor, observe, and encourage R1 to ask for assistance when in need/pain. On 6/8/2013 at 9:50 p.m., R1 was wandering into another resident's room. A family member attempted to re-direct R1. R1 became agitated and hit the family member on the right arm. Haldol 0.25 mg was administered, and staff attempted to redirect R1 away from the other resident's room. No follow-up regarding effectiveness of medication was documented. On 6/11/2013 at 10:14 a.m., a family member of a resident went to the social services office and reported that R1 had shoved her. The family member expressed concern for the other residents and was assured by social services they were working to resolve behavior issues with R1. No follow-up regarding what was being done to resolve behaviors was documented. On 6/11/2013 at 11:00 a.m. R1 was upset with staff, and attempted to hit staff. Haldol was administered, and staff attempts to re-dress R1 were not successful. On 6/13/2013 at 6:37 a.m., R1 was agitated and yelling. R1 was wandering into another resident's room, and was difficult to re-direct. R1 was placed on a on one-to-one for a "couple of hours" and Haldol 0.5 mg was administered, and was "somewhat effective." On 6/13/2013 at 11:19 a.m., social service note revealed that the social worker will visit 1:1 for adjustment issues, as needed, and be available upon request. No documentation found regarding if social worker ever did visit 1:1 with R1. On 6/14/2013 at 12:03 p.m., R1 wandered up and down the halls. R1 kept going into another resident's room, taking her belongings and carrying them around. Haldol was given, and R1 was monitored. No follow-up regarding effectiveness of medication was documented. On 6/17/2013 at 4:18 p.m., a Medical Director note documents that Haldol is being utilized for R1's delusional behaviors, and to minimize loud and aggressive outbursts. A room change plan was documented, and completed. On 6/17/2013 at 6:09 a.m., R1 was up all night wandering into another resident's room. R1 was difficult to re-direct, and hit, kicked and pinched staff all night. The progress note documents that staff will "continue with eye contact and hope to direct hm (sp) easily." On 6/18/2013 on 2:50 p.m., social services note indicates that R1 has continued to display aggressive behaviors since admission, such as striking out and throwing items. Social services will continue to monitor and be available upon request. No documentation was found regarding follow-up of R1's aggressive behaviors by social services. On 6/21/2013 at 11:59 a.m. R1 was agitated and angry after being re-directed out of another resident's room. R1 pushed a staff member down causing wrist and knee injuries. R1 was walked away and sat in a TV area. No interventions were documented. On 6/22/2013 at 6:24 a.m., R1 was agitated and yelling and tried several times to push another resident down. R1 was difficulty to re-direct, and Haldol was administered. A one-to-one staff was provided for a couple of hours. Interventions included for "staff to continue to monitor and keep other resident's away from him." Specific ways staff were monitoring R1 not listed or documented. On 6/22/2013 at 11:07 a.m. R1 had increased agitated, was angry, and was wandering the halls removing his clothes. R1 pushed R2 backwards, causing the resident to fall to the ground. R2 exhibited pain, x-ray was completed and revealed possible pelvic fracture. Because of this injury R2's ambulation was limited and increased assistance from staff was needed. After R1 pushed R2 to the ground he continued to wander down the hallway, took a fire extinguisher out of the case and attempted to throw the fire extinguisher at a staff person. All family and residents were removed from the area, and R1 was monitored from a distance. R1 appeared to calm down and staff monitored from a distance. A short time later R1 approached R3 who was walking with her walker. R1 pushed R3 from behind who fell to the ground. No injury noted to R3. Staff intervened and walked with R1 down the hall. R1 pushed the staff member against the wall, and R1 began to punch them. Another staff member restrained R1 who continued to push and hit at the staff. Emergency medical services were called and R1 was transported to the hospital. R2's medical record was reviewed and revealed R2 has impaired cognition. R2's care plan indicated R2 is able to complete upper body dressing with cues but does need assistance with lower body dressing. Prior to the fall on 6/22/2013 R2 was able to ambulate with a walker and able to reach destinations. No documented care plan in place related to history of pain. R3's medical record was reviewed and revealed R3 has impaired cognition. R3's care plan indicated R3 is able to ambulate independently with her walker and is able to groom self and dress independently with supervision. Employee (E)/Licensed Practical Nurse when interviewed on 7/10/2013 at 10:45 a.m. stated that R1 would get agitated over nothing and would hit out or push residents and staff almost daily. Employee (E) also stated that at times she would be afraid to walk past R1 as it would be unknown if he would hit out or push her. Interview with Employee (J)/Social worker on 8/19/2013 at 9:40 a.m. revealed that R1 had behaviors which included striking out at staff and other residents. Employee (J) also stated that R1 had impulsive behaviors without a precipitating event, and on many occasions was unable to be re-directed. Employee (J) stated that she was approached by family members who had concerns regarding R1's impulsive and unpredictable behaviors. Employee (J) said she told family members staff was aware of the behaviors. Although pharmacological interventions were implemented, R1 continued to wander into other resident rooms, and remove personnel belongings from their rooms, and display physical aggression such as pushing, shoving, and hitting other residents and family members of residents of the unit. No additional follow-up or interventions put in place by the facility to keep resident's safe from R1. The facility failed to identify causes for R1's aggressive behaviors.

Based on observation, interview and document review, the facility failed to implement interventions to minimize the risk for falls resulting in a fracture for 1 of 3 (R1) resident reviewed for falls. In addition, the facility failed to provide an environment that was free of accident hazards related to bed rails that did not meet the Federal Drug Administration (FDA) guidelines for safety for 1 of 1 resident (R66) reviewed for accident's related to hazardous devices. The facility did not ensure the environment was free of accident hazards related to ice on the side walk in the Atrium courtyard which had the potential to affect 40 of 80 residents in the sample. Findings include: R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R1 fell in the facility at least 11 times in a twelve month period, which aggravated existing injuries and resulted in actual harm of a newly diagnosed left shoulder fracture and a left fifth phalange (finger) fracture on 1/20/13. R1 was under continuous observations on 2/14/13, from 7:15 a.m. to 11:29 a.m. R1 left her room at 8:51 a.m. to eat breakfast. After breakfast R1 was moved to the day room on the unit and at 9:54 a.m. was taken from the day room to the beauty shop by a volunteer. At 10:55 a.m. R1 was taken back to the unit by the volunteer and delivered to the nursing desk. At 10:56 a.m. (two hours since resident left her room) she was in the unit dining room having brunch. At 11:17 a.m. licensed practical nurse (LPN)-E offered to take R1 to her room and asked if the bathroom was needed stated, "I will send your aide in." At 11:18 a.m. R1 was interviewed and stated, "Needed to go to the bathroom and they better hurry because I haven't gone all morning." At 11:29 a.m. R1 put her call light on and nursing assistant (NA)-F entered the room. At 11:31 a.m. NA-F left R1's room and stated she took R1 to the bathroom, her pullup was dry, and she left the room and closed the door, because R1 would call when she was done. An interview was attempted three times and the resident was not ready nor was the resident available. A fall prevention protocol care plan dated 11/29/11, directed the staff to "check on shoes, safety check on equipment, scheduled toileting, scheduled walks, proper lights/night lights, and reinforcement to request assistance." A care plan dated 12/15/11, directed the staff to give R1 verbal reminders not to ambulate/transfer without assistance, keep (the) call light in reach at all times, keep personal items and frequently used items within reach, low bed in place to allow residents feet to touch the floor, provide resident an environment free of clutter, provide toileting assistance about every two hours and as needed. R1 required extensive weight-bearing assist of one with all transfers, assist of one with transfer to toilet and with manipulation of clothing, peri-care, changing pull-ups provided by family which resident chooses to wear, and assist with toileting about every two hours and per request. A memory recall care plan dated 12/15/11, related to short term memory loss, forgetfulness, and pain directed staff to provide verbal cueing and reassurance. An annual Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. R1 was completely dependent for locomotion off the unit with a wheelchair, required extensive assistance with assist of one for bed mobility, transfers, walking in the corridor, location on the unit, dressing, toilet use, and personal hygiene. R1 was not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking, moving on and off the toilet, and surface to surface transfers. A Resident Incident Report dated 1/31/12, indicated R1 had an un-witnessed fall at 12:00 p.m. "(R1) was in room, had to go to bathroom, light was on and (R1) tried to ambulate into the bathroom and fell , hitting the left side of the head, causing a six by two bruised area around the left eye and side of face." ROM was intact. "Medical treatment to injury was a cold pack. The action taken to prevent further injury to resident - moved to place of safety and monitored." The report further noted a low bed was in place with a left grab bar, R1 was oriented to person and confused; R1 was able to use the call light, and the call light was used. Prior mobility status was assisted with ambulation, transfer, bed mobility and toileting. The investigation determined R1 was last toileted at 11:15 a.m. after brunch. The possible contributing factors identified were "behavior, acute illness (urinary tract infection), improper footwear, unsteady gait, and a self-transfer attempt." R1's progress notes were reviewed for the fall of 1/30/12: - A progress note dated 1/29/12, indicated R1 complained of right shoulder and arm pain. - On 1/30/12, R1 complained of lower back pain and the nurse practitioner (NP) was called. The NP wrote a new order for pain medication related to R1's increased pain threshold. - A progress note dated 1/31/12, indicated fall earlier today, "has bruise and some swelling to left eye and lateral area, denies any discomfort. No fall this shift. Transferring with SBA (stand by assist). Continue to monitor." - An interdisciplinary team (IDT) note dated 2/3/12, indicated a fall on 1/31/12, was reviewed. R1 was found in the bathroom and had attempted to self-transfer. A bruise was sustained on the left side of the face after the fall. R1 normally used her call light. R1 had become more confident and may have attempted to do more on her own. The note further implied that staff had been notified that R1 may be self-transferring more. The note identified, "Interventions are in place, will continue with the plan of care." R1's care plan dated 11/29/11, directed staff to check for proper footwear. R1 fell without having proper footwear on according to the incident report. The only fall assessment located in the medical record was the initial assessment which was completed on 11/29/11. The report/note lacked any evidence of new interventions to minimize R1's self-transfer attempts, lacked a new comprehensive medication review after the fall and lacked any additional falls assessments. A Resident Incident Report dated 2/20/12, indicated at 6:20 a.m. R1 fell from bed and "a housekeeper saw (R1) sitting on the floor in her room. (R1) said she wanted to get up in bed, and used the bedside table for support. The table slide (sic) and she slipped and fell on her bottom, (R1) denies hitting her head. An (unmeasured) abrasion on the right elbow was noted. (R1) was laughing about the fall, complained of left leg pain." The action taken to prevent further injury to resident included, "moved to place of safety, medical treatment provided was to cleanse/dress abrasion. A low bed was in place, (R1) was oriented to person, place, and time. Prior mobility status was assisted with ambulation, transfer, bed mobility and toileting. At 5:04 a.m. (R1) had been assisted with toileting and at 6:15 a.m. was given a scheduled medication (medication was not delineated on the form). Possible contributing factor indicated was self transfer attempt." The low bed was already in place at the 1/25/12 fall. The report lacked any evidence of new interventions to minimize R1's self-transfer attempts. R1's progress notes were reviewed for the fall of 2/20/12: - A progress note dated 2/20/12, indicated R1 fell at 6:20 a.m. trying to get up in bed. An abrasion on the right elbow was noted and R1 complained of left leg pain. "(R1) was alert and oriented, attempted a self-transfer from bed using the bedside table for support, the table slid out and (R1) fell on the floor." - A progress note dated on 2/20/12, at 8:30 p.m. indicated R1 complained of pain in the left hip and elbow and had refused to ambulate to the main dining room (MDR). The report noted R1 was taken by wheelchair to the MDR and then refused to transfer from the wheelchair to a chair. During evening cares and transfers, R1 was moaning and protected the left side. "(R1) had difficulty bearing weight on the left leg and with each step a click, click sound was heard." The report indicated a call was placed to the on-call medical doctor for increasing left hip discomfort and possible fracture. A physicians order dated 2/20/12, ordered x-ray of R1's left hip and left elbow, no fracture was noted on the x-ray report. - A progress note dated 2/22/12, a chest x-ray was ordered for increased temperature and revealed a new left humeral (shoulder) fracture. - A progress note for the day shift on 2/23/12, indicated R1 was weepy related to increased pain in left arm due to humeral fracture. The NP was notified and a physician's orders [REDACTED]. Staff was to schedule between the Oxycontin (a narcotic) dose and the extra strength Tylenol (a mild analgesic) for shoulder pain, increased pain in left humeral fracture. A physician progress notes [REDACTED]. - An IDT note dated on 2/24/12, at 11:00 a.m. indicated fall with injury on 2/20/12. R1 used the over-bed table to boost herself up in bed, the table moved and she fell to the floor. It identified R1 had left leg pain and received an abrasion on the left elbow. X-rays of left arm and leg were negative for fracture on 2/21/12, however, the chest x-ray on 2/22/12 revealed a proximal left humerus fracture. The IDT note identified, "(R1) does have osteoporosis and some dementia, usually asks for and waits for help. (R1) used an unstable surface to reposition self in the bed. Orthopedic appointment today, will talk to her about removing the over bed table. No changes to plan of care at this time." The only fall assessment located in the medical record was the initial assessment which was completed on 11/29/11. The report/note lacked any evidence of new interventions to minimize R1's self-transfer attempts, lacked a new comprehensive medication review after the fall and lacked any additional falls assessments. A care plan revision dated 3/20/12, directed staff to ask yes or no questions, anticipate needs, and provide toileting assistance per toileting care. The care plan lacked any evidence of intervention put into place to minimize R1's self-transfer attempts. A Resident Incident Report dated 4/24/12, indicated R1 had an un-witnessed fall while walking. "At 10:30 p.m. resident was found on floor by staff after a self-transfer. (R1) denied hitting her head, no injury noted or observed Medical treatment - none needed. Action taken to prevent further injury to resident - none needed. A low bed was in place; (R1) was oriented to person, place, and time. Prior mobility status was assisted with ambulation, transfer, bed mobility and toileting." The report lacked any evidence of new interventions put into place to minimize injury from R1's self-transfers. R1's progress notes were reviewed for the fall of 4/24/12: - A progress note dated on 4/24/12, at 10:30 p.m. indicated NA called into the room and noted R1 to be on her floor at the bottom of her bed. R1 stated she was falling on her way to the bathroom, stated "the (call) lights do not work. R1 was found in a sitting position on the floor, was able to move within her limits and was alert and oriented to person, place and time, denied hitting her head, without distress at that time." - A progress note dated 4/25/12, at 4:30 a.m. indicated R1 fall at 10:30 p.m., no apparent injuries. R1 had a history of [REDACTED]. "Was alert and oriented per usual with forgetfulness. No noted bruises at this time. Fall related to self-transfer and impaired safety awareness. Remind (R1) to ask for help per the fall prevention plan of care." - A progress note on 4/27/12, at 11:00 a.m. indicated "the fall/injury reduction committee met to review the fall at 10:30 p.m. on 4/24/12. The call light system was checked and documented as "call light out" at the time of the fall. "Will request maintenance to check call light cord as this happened more than once this past month where the call light cord was out." A Resident Incident Report dated 5/12/12, at 8:35 a.m. R1 had a witnessed fall from the toilet; (while) "I was cleaning up R1 after using the toilet she lost her balance and sat flat on the floor." "(R1) hit the left side of her head and back of her shoulder on the wall. No bruise or bump noted at the site. (R1) complained of a headache and shoulder pain after the fall. The wheelchair was behind the resident, unlocked and the gait belt was around the waist. Passive range of motion intact. Medical treatment - none. Action taken to prevent further injury to resident - moved to place of safety, monitored, remove clutter and re-arrange furniture. A low bed was in place with a left grab bar, wheelchair brakes were functioning properly, (R1) was oriented to person, place, and time; able to use the call light, the call light was used, and the call light was within reach. Prior mobility status was assisted with ambulation, transfer, bed mobility and toileting. Possible contributing factor was unsteady gait." A care plan revision dated 6/13/12, directed staff to provide "weight bearing assist of one to lift legs in and out of bed, and to assist to sitting position from bed daily. Weight bearing assist of one daily with transfer to toilet and staff completes manipulation of clothing and peri-care as needed after voiding or ball movement. No male NA as able (to schedule). Assist of one to thread arms into sleeves due to limited ROM and pain." A Resident Incident Report dated 7/1/12, indicated at 5:20 p.m. R1 had an unwitnessed fall from the wheelchair. "(R1) put the call light on and was found sitting on the floor near the toilet, against the wall in the shower bathroom. R1 stated, "Someone in blue brought me in here. (R1664) had wheeled (R1) into the shower room bathroom. (R1) denies pain or hitting her head. Medical treatment - none needed. Action taken to prevent further injury to (R1664) encouraged not to help patients. (R1) was oriented to person, place, and forgetful, able to use the call light, the call light was used, and the call light was within reach. Prior mobility status was assisted with ambulation, transfer, bed mobility and toileting. Possible contributing factors indicated were unsteady gait and self-transfer attempt." The incident report did not include any new interventions put into place to minimize R1's self-transfer attempts. An (untimed) progress note dated 7/1/12, indicated R1 put the call light on and was found sitting on the floor against the wall, near the toilet in the shower bathroom. R1 was alert and denied pain or hitting her head, ROM intact. R1 stated, "an elderly woman in blue took her in there." An IDT note on 7/13/12, at 11:00 a.m. indicated a discussion on the fall of 7/1/12, R1 was brought to shower room bathroom by another resident. The note identified R1 attempted to self-transfer onto the toilet and was found on the floor. R1 received no injuries and there no changes in care plan. A care plan revision dated 10/2/12, directed staff to provide low bed in place to allow residents feet to touch the floor. A Resident Incident Report dated 10/13/12, indicated at 9:20 p.m. R1 had a witnessed fall during a transfer. "Staff responded to call light and found resident on floor by the toilet. NA stated she was transferring resident from chair to toilet, (R1) lost balance and sat nicely on the floor, holding the toilet bar. No injury noted, PROM (passive range of motion) intact. Medical treatment - none needed. Action taken to prevent further injury to resident - moved to place of safety, monitored, remove clutter and re-arrange furniture. A low bed was in place, (R1) was oriented to person, place, and time; able to use the call light. Prior mobility status was assisted with ambulation, transfer, bed mobility and toileting. Possible contributing factor indicated was unsteady gait." A care plan revision dated 10/14/12, directed staff to provide a low bed, clutter free environment and call light within reach at all times for fall prevention. The low bed had been in place since the fall of 1/25/12. The care plan lacked any new intervention put into place to minimize injury from R1's self-transfer. A Resident Incident Report dated 10/21/12, indicated at 10:00 p.m. R1 was up walking and had an un-witnessed fall. "(R1)'s roommate notified staff that (R1) was on the floor. Noted (R1) laying supine on floor in roommate's side of the room. No injury noted, (R1) stated she hit her head, no bruises or swelling noted." A Neuro-check was performed and was normal. "Medical treatment - none needed. Action taken to prevent further injury to resident - none documented. (R1) was oriented to person, place, and time. Prior mobility status was assisted with toileting. Possible contributing factors indicated were unsteady gait and self-transfer attempt. Last toileted at 8:30 p.m. and refused toileting at 9:45 p.m." A NP progress note dated 10/22/12, revealed, "Apparently her balance issues persist and she has been falling a lot." The NP did not write any new orders for R1 with regards to her persistent falling. An IDT progress note on 10/26/12, at 11:00 a.m. indicated two falls reviewed. On 10/13/12, R1 lost her balance being toileted by staff. At 10:00 p.m. on 10/21/12, R1 was found on the floor in roommate's room. R1 stated she was trying to go to the bathroom and was toileted at 8:30 p.m. and was offered toileting at 9:45 p.m. R1 received assistance for toileting and had a low bed. The plan was to continue with the current plan of care. A Resident Incident Report dated 11/24/12, indicated at 3:00 p.m. R1 had an un-witnessed fall, "NA heard (R1) yelling out and found (R1) sitting on the floor by the bed with legs out in front of her. (R1) stated I was searching for my pop and I slide out of bed. Denies hitting her head, no injuries noted at this time, denies any pain. Medical treatment - none needed. Action taken to prevent further injury to resident - none documented. (R1) was oriented to person, place, and time, was able to use the call light and the call light was within reach. Prior mobility status was assisted with ambulation, transfer, bed mobility; last toileted at 1:45 p.m. possible contributing factors - none documented." A progress note on 11/24/12, at 4:47 p.m. indicated R1 had a history of [REDACTED]. A progress dated 11/27/12, indicated PT requested to assess the resident's mobility status. PT completed the assessment and requested orders for gait and wheelchair placement as resident does not reach back to place arms on wheelchair and would "plop" down on the chair. A progress note dated 12/13/12, indicated inadequate pain control, discontinue scheduled Oxycontin and Oxycodone, start Methadone (a narcotic) 7.5 mg every twelve hours. Change as needed Oxycodone to 10 mg every six hours as needed. A PT discharge summary note dated 12/13/12, indicated therapy from 11/28/12 through 12/13/12, consisting of passive ROM for both shoulders, muscle relaxation elbow and hand, lower extremity ROM and strengthening, sit to stand, transfer training, and gait training. A Resident Incident Report dated 1/20/13, indicated at 10:00 p.m. R1 had an un-witnessed fall from bed. "Staff reported seeing (R1) on the floor lying on her back by the closet, the wheelchair was pulled away. (R1) stated was getting off bed to look for her remote and fell hitting the back of her head on the floor. Complained of left (small) finger pain, finger was swollen, Neurocheck's within normal limits, prom intact, the left extremity was weak. The call light was hanging on the bed. Medical treatment - none needed and cold pack. Action taken to prevent further injury to resident - moved to place of safety, monitored, remove clutter and re-arrange furniture. (R1) was oriented to person, place, and forgetful; able to use the call light and the call light was within reach. Prior mobility status was assisted with ambulation, transfer, bed mobility and toileting. Possible contributing factors indicated were behavior and unsteady gait. Further investigation required - new staff was documented." The report implied that the new staff member was working with R1 and may not have known to keep all items within reach. The only fall assessment located in the medical record was the initial assessment which was completed on 11/29/11. The report/note lacked any evidence of new interventions to minimize R1's self-transfer attempts, lacked a new comprehensive medication review after the fall and lacked any additional falls assessments. A progress note dated 1/21/13, revealed R1 had an x-ray of the left hand. The result of the x-ray noted a fracture of the left fifth finger. The MD was notified and wrote new orders for hand elevation, cold therapy and immobilization of the finger. PT was requested and a treatment order dated 1/21/13, directed "immobilizer fifth finger with tongue depressor inside palm and tape 4th and 5th fingers together." A progress note on 1/21/13, at 10:17 p.m. indicated the lateral left hand was swollen and the fifth finger was not in good alignment. Ice was applied for 10 minutes for comfort. R1 was received scheduled pain medication given for discomfort with relief. The left hand was elevated on a pillow. "Fracture of fifth finger of left hand requiring attention, new orders given. Protect from further damage to finger, reduce selling, ice and pain medication for discomfort." An occupation therapy note dated 1/22/13, indicated orders received recommendations for splinting following resident's fall and subsequent fracture of base of left little finger, large plastic D ring orthotic provided with padding which should be kept on at all times. A fall reduction committee review note on 1/25/13, at 10:58 a.m. revealed R1 was found on the floor lying on her back by her closet. R1 was getting up to find the remote and fell and hit the back of her head on the floor. R1 did have an order for [REDACTED]. There was a new NA on and likely does not completely know likes and dislikes. NA's to be re-educated on leaving her remote control within reach to prevent that from occurring again. "X-rays were done of left wrist, femur, tibia and fibula. Left hand pinky fractured. OT provided immobilizer on pinky and to be left on until MD or NP state it can be removed. Left hand was to be elevated as much as possible for one week, nursing to leave remote within reach, (R1) reminded not to self-transfer but likely won't remember." R1's plan of care was not revised to minimize R1's injury from falls due to self-transfer. A Resident Incident Report dated 2/2/13, indicated at 2:30 a.m. R1 had an unwitnessed fall from bed. "At 2:30 a.m. heard (R1) calling for help. NA went in and found (R1) on the floor. Stated she was trying to get up then slipped and fell out on her bottom, denies hitting her head. The call light within reach, but was not used. The Neurocheck was normal, Medical treatment - none needed. An as needed medication was given. A low bed was in place with a left grab bar, (R1) was oriented to person, place, and time; able to use the call light and the call light was within reach. Prior mobility status was assisted with ambulation, transfer, bed mobility and toileting. Possible contributing factors - none documented. Further investigation - on trial mobilization alarm was documented." R1 had eleven falls between 1/25/12 and 2/2/13. Two falls were witnessed, nine falls were due to self-transfer and R1 had hit her head at least four times during the fall incidence. R1 sustained harm for one left shoulder fracture and one left hand fifth finger fracture (both in separate falls) before the facility put bed alarm into place. A treatment order dated 2/8/12, identified a trial of mobility alarm in bed and during the night related to frequent falls. Staff was to document effectiveness and the resident's response in progress notes. Staff was to evaluate the use of the alarm on Monday 2/11/13, and call the NP for order if helpful. A progress note on 2/12/13, at 6:59 a.m. indicated R1 did not use the mobility alarm all weekend. She had put her call light on and waited for a NA to take her to the bathroom. The note revealed, "If call light is answered on time (R1) has no problem." A progress note on 2/12/13, at 3:05 p.m. indicated the resident declined a room change that was offered to have her continue to get out of the left side of the bed, and would be closer to the nursing station. Four of the 11 reports had orthostatic blood pressures taken to assess the blood pressure. The 11 reports/IDT notes lacked any evidence of new interventions to minimize R1's self-transfer attempts, lacked a new comprehensive medication review after the fall and lacked any additional falls assessments. The NA assignment group A. AM. and PM. assignment sheet printed 2/13/13, directed staff to use medium purple pad and assist as needed for the toileting plan, use transfer belt with all transfers, low bed. The NA sheets did not direct staff to place the bed alarm for R1. R1's assigned aide (NA-E) was interviewed at 2:00 p.m. and stated that R1 was taken to the bathroom about every two hours and sometimes less. On 2/14/13, At 4:00 p.m. an interview with the administrator, director of nursing (DON), and registered nurse (RN)-A was held to review the incident reports, progress notes and IDT notes regarding the falls and the new interventions put into place to prevent future falls. The group stated that they had considered other things such as room changes, or gripper socks, but the resident would not agree to the changes. RN-A stated that she let the staff know R1 was getting more confident so they would be more aware that she may try to self-transfer and that she had notified the staff that the bedside table with her pop and remote control and tissue box should be within reach, RN-A stated she looked for these things every time she entered R1's room, but had not actually done an audit to see how often they were in place. The administrator stated the call light failure was specific to R1's room and had not affected other residents. One of the falls was related to an urinary tract infection and a low grade fever and was treated with antibiotics. In February of 2012 R1 was still receiving therapy, and had been working with restorative nursing intermittently for shoulder pain and degenerative joint disease and now for swallowing. Had been referred to therapy for balance and gait training and for sit to stand transition. R1 had constant reminders not to self-transfer and to remember to ask for help. "It's an ongoing intervention versus a brand new one." "We want to honor her needs and do not want to distress her." RN-A verified that R1 did have some dementia, some short-term memory loss, and may not remember not to get up by herself. RN-A stated most of the time R1 was very steady and we just stand by. "R1 has always been very clear on what she did and did not want, the last few falls seemed more of a pattern at night, I checked with the niece first, and if she would she let me try a mobility alarm; we tried it over the weekend and we called on Monday to say it didn't sound, she did not get up, but we are leaving the alarm on since it didn't distress her." At the beginning of the interview the facility was questioned if there was any further evidence the facility could provide such as assessments and new interventions put into place for R1 and the facility provided none. The Catholic Eldercare Policy and Procedure, Fall Risk assessment dated [DATE], indicated, "all residents will be assessed for safety on admission, readmission, annually, quarterly, with significant changes and as needed. Individualized care plans will be developed for those residents found to be at high risk for falls." "The Purpose: To maintain safety of residents by preventing injuries from falls. 2) MDS Coordinator/Nurse Managers will complete / review the Fall Risk Assessment Quarterly, annually and with significant changes. 3) If the Fall Risk Assessment shows the resident is at high risk for falls (total score above 10), the interdisciplinary team will develop a fall prevention protocol and initiate the treatment approaches. The team discussion and decision will be documented in the MDS/Assessment notes. Nursing will document the fall prevention plan in the resident's care plan using the Fall Prevention Protocol Form. 4) Nursing will communicate Fall Prevention Plan to staff and family by oral report, updating NAR Care Sheets and/or written notice." The Catholic Eldercare Policy and Procedure, Fall Prevention: Physical Restraint/Mobility Devices policy revised 2/13/13, indicated "It is the intent of Catholic Eldercare to remain restraint free. However, in rare circumstances, devices may be medically necessary to protect residents from physical injury or for psychological comfort. This policy clarifies the requirements to be met when applying restraint/mobility devices and gives requirements to be met when applying restraint/mobility devices and gives options to staff for maintaining a least restrictive environment. A multidisciplinary team approach will be used to promote the resident's highest level of physical, psychological and social functioning. Procedure: Prior to any device or restraint usage, the nurse as part of a multi-disciplinary team, will complete the following steps: 1) interventions to consider when a resident has falls or is at risk for falls, or exhibits behavior that is considered a treat to the resident or others. (Not all are necessary): a) Observe for gait and balance impairments, transfer abilities - PT referral if indicated b) Medical observation/assessment by nurse, then NP or MD. Assess for possible infection, dehydration, hypoxia, constipation, toxic drug levels, recent trauma, etc. c) Drug review by pharmacy - review recent education changes d) Check for environmental hazards e) Cognitive evaluation f) Observe wheelchair positioning/bed mobility, - OT referral if indicated g) Check for sensory or perceptual impairments h) Check for emotional factors or changes in routine - Psychology referral if indicated i) 1:1 time j) Diversional activities k) Assisted exercise, transfer and/or toileting 2) If falls or threatening behavior persist: a) consult with medical provider for the "medical provider for the "medical symptoms" (e.g. impulsiveness related to dementia, unsteady gait related to Parkinson's Disease, or weakness related to recent hip fracture.) 3) Consider the least restrictive intervention / restraint: a) Personal alarm b) Motion detector c) Sound monitor d) scheduled ambulation e) Perimeter mattress f) Low bed G) Mat on floor next to bed Rh) Wedge cushion in wheelchair I) Grab bar, 1/2 side rail on bed for mobility assist 4) Implement the intervention, device or restraint a) Discuss the options, the benefits, risks and possible side effects of the proposed intervention, device or restraint with the family and obtain consent. Complete "Permission for use of Device". b) Obtain a physicians order, including unalterable medical symptom making device necessary, duration and circumstances under which the device is to be used and expected outcome of the use of the device. c) See manufacturer instruction sheets for each type of device. Maintenance and therapy staff to apply devices to beds or wheelchairs. d) Update Care Plan e) Update NA Care Sheet f) Update treatment sheet (every shift to implement and monitor) R66 had [DIAGNOSES REDACTED]. R66 utilized a bed rail device that was not in compliance with the U.S. Food and Drug Administration (FDA) measurement guidelines, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Document issued on March 10, 2006. In addition, R66 did not receive an accurat

Based on interviews and record review the facility failed to ensure that 1 of 5 residents (Resident #1), who required assistance with bladder incontinent care, received appropriate supervision and assistance to prevent accidents. Resident #1 was not provided timely assistance with toileting according to the plan of care. On [DATE], Resident #1 did not get assistance to the bathroom and fell while transferring herself off the toilet. Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. An annual bowel and bladder function assessment dated [DATE], identified Resident #1 as incontinent and needing assistance with toileting. A quarterly assessment of Resident #1's toileting plan dated [DATE], indicates that there is no change in Resident #1's plan of care. A fall risk assessment dated [DATE], indicates that Resident #1 is at a high risk for falls. A care plan dated [DATE], indicates that Resident #1 requires the assistance of one to two staff members for all transfers. The care plan specifies that Resident #1 needs to be toileted upon rising, before and after meals, prior to activities, as needed, and at bedtime. An incident report dated [DATE], revealed that at 12:55 p.m. Resident #1 was found on the floor in the bathroom of another resident's room. Resident #1 was lying on the floor with her right arm twisted backwards and her left leg was between the wall and toilet. An x-ray report dated [DATE], indicates that Resident #1 suffered a right humerus fracture. A physician's orders [REDACTED]. The discharge record dated [DATE], indicates Resident #1 died at 1:00 a.m. Resident #1's death certificate indicates that that she died from natural causes and had a recent fall with an arm fracture. On [DATE], at 12:55 p.m. employee (F)/nurse was interviewed and stated that she heard a loud noise from a resident's room and found Resident #1 on the bathroom floor. She notified the Resident's physician and family. All available staff were paged to assist Resident #1 onto a gurney and back to her room. On [DATE], at 10:57 a.m. employee (C)/nursing assistant (NA) was interviewed and stated that she cared for Resident #1 on [DATE]. At approximately 9:00 a.m. or 9:30 a.m. she assisted Resident #1 to transfer to the toilet. Then she took Resident #1 into the dining room for breakfast, and did not see her again until after she had fallen which was approximately 12:30 p.m. Employee (C) stated that Resident #1 needs assistance to stand and transfer from the wheelchair to the toilet after breakfast. She was directed by employee (D)/nurse to assist another resident, and was in that resident's room from approximately 11:00 a.m. until 12:00 p.m. At approximately 12:00 p.m. she assisted another resident needing assistance immediately. She took her break at approximately 12:15 p.m. she did not see Resident #1 until she heard the page for assistance and went to help. She did not know if Resident #1 was assisted onto the toilet after breakfast. On [DATE], at 11:18 a.m. employee (D)/nurse was interviewed and stated that she cared for Resident #1 on [DATE]. Resident #1 needs the assistance of one staff person to transfer to the toilet every two hours. She was on lunch break when Resident #1 fell . Prior to going to lunch she had directed employee (C) to make sure all residents who needed assistance with toileting had received that assistance She was unaware that Resident #1 did not receive assistance with toileting after breakfast. On [DATE], at 11:35 a.m. employee (I)/NA was interviewed and stated that Resident #1 needs assistance to transfer to the toilet every two hours. If Resident #1 is not assisted onto the toilet every two hours, Resident #1 will go into the nearest bathroom and attempt to transfer herself. Employee (I) worked on Residence #1's unit on [DATE], but does not recall assisting Resident #1 with cares. On [DATE], at 9:43 a.m. employee (H)/NA was interviewed and stated she worked on [DATE]. Resident #1 needs to be assisted onto the toilet after breakfast to prevent her from falling. She did not assist Resident #1 prior to her fall on [DATE]. On [DATE], at 8:34 a.m. employee (B)/administrative nurse was interviewed and stated that she assisted with the internal investigation. Resident #1 is a high risk for falls and will attempt to transfer herself if she needs to use the bathroom. The internal investigation determined that because staff failed to effectively communicate with each other Resident #1 was not assisted to the toilet after breakfast in accordance with her plan of care. As a result Resident #1 transferred herself to the toilet and fell .

Based on observation, interviews and record review the facility failed to ensure that 1 of 5 residents (Resident #1) who required assistance with bladder incontinent care received appropriate treatment and care according to their care plans. Resident #1 was not provided timely assistance with toileting according to the plan of care. On [DATE], Resident #1 did not get assistance to the bathroom and fell while transferring herself off the toilet. Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. An annual bowel and bladder function assessment dated [DATE], identified Resident #1 as incontinent and needing assistance with toileting. A quarterly assessment of Resident #1's toileting plan dated [DATE], indicates that there is no change in Resident #1's plan of care. A fall risk assessment dated [DATE], indicates that Resident #1 is at a high risk for falls. A care plan dated [DATE], indicates that Resident #1 requires the assistance of one to two staff members for all transfers. The care plan specifies that Resident #1 needs to be toileted upon rising, before and after meals, prior to activities as needed, and at bedtime. An incident report dated [DATE], revealed that at 12:55 p.m. Resident #1 was found on the floor in the bathroom of another resident's room. Resident #1 was lying on the floor with her right arm twisted backwards and her left leg was between the wall and toilet. An x-ray report dated [DATE] indicates that Resident #1 suffered a right humerus fracture. A physician's orders [REDACTED]. The discharge record dated [DATE], indicated Resident #1 died at 1:00 a.m. Resident #1's death certificate indicates that she died from natural causes and had a recent fall with an arm fracture. On [DATE] at 10:57 a.m., employee (C)/nursing assistant (NA) was interviewed and stated that she cared for resident #1 on [DATE]. At approximately 9:00 a.m. or 9:30 a.m. employee (C) assisted Resident #1 to transfer to the toilet. Then employee (C) took Resident #1 into the dining room for breakfast, and did not see her again until after she had fallen which was approximately 12:30 p.m. Employee (C) stated that Resident #1 needs assistance to stand and transfer from the wheelchair to the toilet after breakfast. She was directed by employee (D)/nurse to assist another resident, and was in that resident's room from approximately 11:00 a.m. until 12:00 p.m. At approximately 12:00 p.m. she assisted another resident needing assistance immediately. She took her break at approximately 12:15 p.m. she did not see Resident #1 until she heard the page for assistance and went to help. She did not know if Resident #1 was assisted onto the toilet after breakfast. On [DATE], at 8:34 a.m. employee (B)/administrative nurse was interviewed and stated that she assisted with the internal investigation. Resident #1 is a high risk for falls and will attempt to transfer herself if she needs to use the bathroom. The internal investigation determined that because staff failed to effectively communicate with each other Resident #1 was not assisted to the toilet after breakfast in accordance with her plan of care. As a result Resident #1 transferred herself to the toilet and fell .