Every finding on record at Centinela Skilled Nursing & Wellness Centre West

Based on observation and interview, the facility failed to: 1. Ensure a clear container which contained turkey sandwich meat was dated and labeled in the delivery freezer.This deficient practice had the potential to result in foodborne illness and contamination for 34 out of 54 residents.Findings:During a concurrent observation and interview, of the initial kitchen tour, on 11/18/2025 at 8:25 a.m., with the Dietary Supervisor (DS), a clear Tupperware container with a green lid was observed to not have a label of the food contained nor a date label in the Delivery refrigerator. The DS stated the turkey sandwich meat was used for snacks and sandwiches for the residents of the facility. The DS stated food items in the refrigerator were required to have a label, and an open and use by date. The DS stated the risk of not labeling the container of the turkey sandwich meat could result in residents consuming expired/spoiled food.During a review of the facility's policy and procedures (P&P), titled Food Storage, dated 7/25/2019, the P&P indicated all food items were to be correctly labeled and dated.

Based on observation, interview, and record review, the facility failed to maintain dignity for one of 15 sampled residents (Resident 49) when Resident 49 was observed with eyeglasses that had the left lens taped into the frames. This deficient practice did not respect Resident 49's right to a dignified existence and placed Resident 49 at risk for injury related to broken eyeglasses. Findings: During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted on [DATE], and most recently readmitted on [DATE]. Resident 49's diagnoses included dementia (a progressive state of decline in mental abilities), history of falling, and cognitive communication deficit (trouble participating in conversations). During a review of Resident 49's Minimum Data Set (MDS, a resident assessment tool), dated 10/31/2025, the MDS indicated Resident 49 had adequate vision with eyeglasses. The MDS indicated Resident 49 had moderate cognitive impairment (ability to think and reason). The MDS indicated Resident 49 required supervision or touch assistance from staff for walking. During a review of Resident 49's Ophthalmology (branch of medicine concerned with the diagnosis and treatment of disorders of the eye) Consult record, dated 5/27/2025, the record indicated Resident 49 had moderate cataracts (a clouding of the lens of the eye, which is typically clear) and blepharochalasis (a rare condition that causes painless swelling in your eyelids). The record also indicated Resident 49's ophthalmologist recommended an optometry referral for evaluation for glasses. During a review of Resident 49's Social Services Progress Note, dated 7/14/2025, the progress note indicated Resident 49 had an ophthalmology consult on 5/27/2025. The record did not indicate an optometry referral was made in accordance with the ophthalmologist's recommendation from 5/27/2025. The progress note did not indicate any information about new glasses. During an observation on 11/18/2025 at 10:22 a.m., at Resident 49's bedside, Resident 49 was observed sitting up in bed with eyeglasses on. The left lens of the eyeglasses was taped onto the frame. Resident 49 could not state if he had been seen by an optometrist. During an observation on 11/19/2025 at 2:45 p.m., at Resident 49's bedside, Resident 49 was observed lying in bed with eyeglasses on. The left lens of the eyeglasses was taped onto the frame. During an interview on 11/20/2025 at 10:14 a.m., with the Social Services Director (SSD), the SSD stated Resident 49 had been eligible for new eyeglasses since November 2024. The SSD stated an optometry referral was not made following the recommendation made by the ophthalmologist on 5/27/2025 for an evaluation for eyeglasses. During an observation on 11/20/2025 at 11:22 a.m., with Registered Nurse (RN) 2, at Resident 49's beside, Resident 49's eyeglasses were observed. RN 2 stated Resident 49's eyeglasses had tape on the left lens, holding the lens in place. RN 2 stated it was not dignified to wear eyeglasses in that condition. RN 2 stated a referral could be made to the optometrist to replace the glasses. RN 2 stated Resident 49 did not have alternative glasses. During a review of the facility's policy and procedure (P&P) titled Resident Rights - Quality of Life, dated 3/2017, the P&P indicated all residents were to receive the services and support needed to maintain their highest practicable well-being. The P&P also indicated that each resident was to be cared for in a way that promoted dignity.

Based on observation and interviews the facility failed to:1. Ensure call light device was placed within reach for one of 15 sampled residents (Resident 2).This deficient practice had the potential to result in a delay in or an inability for the residents to obtain necessary care and services. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included muscle weakness, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified dorsalgia (a disorder characterized by back pain), and type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (a small open sore or wound found on the foot). During a review of Resident 2's History and Physical (H&P), dated 6/18/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 9/17/2025, indicated Resident 2 was assessed to have comprehend (the action or capability of understanding something) most conversation. The MDS indicated Resident 2 required moderate assistance from staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) roll left and right, upper body dressing and dependent on staff for toileting, lying to sitting on bed, and personal hygiene. Durning a concurrent observation and interview on 11/18/2025 at 12:58 p.m. with Resident 2, in Resident 2's room, the call light was observed wrapped around the bed's siderail where the resident could not reach it. Resident 2 looked for the call light device, found the cord but could not untangle it from the bed's siderail and was unable to press the call light button. Resident 2 stated I can't reach the call light. Resident 2 stated If I can't reach the call light, I just call out when I need help, but it is not good if I can't tell the nurses when I need something right away or have an emergency. During a concurrent observation and interview on 11/18/2025 at 1:05 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 2's room, the call light was observed wrapped around the upper bed siderail and not within reach of the resident. CNA 1 stated the call light should have been placed next to the resident in case of an emergency. CNA 1 further stated that the call light was not within reach and Resident 2 could possibly not get the help needed. During an interview on 11/20/2025 at 12:40 p.m. with Registered Nurse (RN), the RN stated it is important that the call lights were within reach, if not within reach it could potentially delay the needs and care of the residents. During an interview on 11/20/2025 at 1:00 p.m. with the Director of Nursing (DON), the DON stated a resident's call light should always be within reach to notify staff if assistance was needed or in an emergency. The DON stated that if the call light was not within reach and the resident could not access it, there could be potential harm and the resident's needs would not be met. During a review of the facility's policy and procedure (P&P) titled, Communication - Call Light System, dated 8/24/2024, indicated, The call alert device will be placed within the resident's reach.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately completed for one of 15 sampled residents (Resident 48). This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers the Medicare and Medicaid programs) regarding Resident 1's health status. Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 49 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident 48's diagnoses included major depressive disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool), dated 9/14/2025, the MDS indicated Resident 48 did not have cognitive impairments (ability to think and reason). The MDS indicated Resident 48 required substantial to maximum assistance from staff for most mobility while out of bed. The MDS indicated Resident 48 routinely received antipsychotics (medications used to treat psychotic disorders). During a review of Resident 48's physician medication orders, dated 9/1/2025 to 11/20/2025, the orders indicated Resident 48 was not ordered antipsychotics. During an interview on 11/20/2025 at 8:23 a.m., with the MDS Coordinator (MDSC), the MDSC stated Resident 48 was not receiving antipsychotics during the timeframe specified in the MDS. The MDSC stated Resident 48 received an antidepressant (medication used to treat MDD). During an interview on 11/20/2025 at 10:07 a.m., with the MDSC, the MDSC stated Resident 48's MDS dated [DATE] indicated she routinely received an antipsychotic. The MDSC stated the manual (instruction tool for completing the MDS assessment) did not indicate that the antidepressant Resident 48 was receiving was the same as an antipsychotic. The MDSC stated Resident 48's MDS was not accurate. During a review of the facility's policy and procedure (P&P) titled RAI Process, revised 10/2016, the P&P indicated the purpose of the P&P was to provide resident-assessments that accurately depicted and identified resident-specific issues, while meeting state and federal guidelines. The P&P indicated the MDSC was to use the RAI Manual as a reference tool when completing the assessment.

Based on observation, interview, and record review, the facility failed to ensure care plans were developed for two of 15 sampled residents (Residents 32 and 49). This deficient practice placed Residents 32 and 49 at risk for not receiving the necessary interventions for their diagnoses and/or health problems.Findings: 1a. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was initially admitted to the facility on [DATE]. Resident 32's diagnoses included generalized muscle weakness, abnormalities of gait (manner of walking) and mobility, and dysphagia (difficulty swallowing). During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), dated 10/29/2025, the MDS indicated Resident 32 had moderate cognitive impairment (ability to think and reason). The MDS indicated Resident 32 used a walker and required set-up/clean-up assistance to eat. The MDS indicated Resident 32 had broken teeth. During a review of Resident 32's Fall Risk Evaluation, dated 10/22/2025, the evaluation indicated Resident 32 was identified as at risk for falls. During a review of Resident 32's medical records, the records indicated a care plan titled At risk for falls., was created on 11/18/2025. During an interview on 11/20/2025 at 8:49 a.m., with the Director of Nursing (DON), the DON stated staff were aware that Resident 32 was a fall risk on 10/22/2025. The DON stated a fall risk care plan should have been developed the same day. The DON stated Resident 32's fall risk care plan created on 11/18/2025 was not created timely. The DON stated the purpose of timely development of the fall risk care plan was for the safety of the resident. 1b. During a review of Resident 32's Social Services Assessment, dated 10/27/2025, the assessment indicated Resident 32 was to be referred for a dental consult due to having missing and broken teeth. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 had broken teeth. During a review of Resident 32's medical records, the medical records indicated Resident 32's care plan titled Oral/dental health problems related to obvious or likely cavity or broken natural teeth, was developed on 11/18/2025. During an interview on 11/20/2025 at 8:56 a.m., with the DON, the DON stated Resident 32's Social Services assessment dated [DATE], and MDS dated [DATE], indicated staff were aware of Resident 32's broken teeth. The DON stated a care plan should be developed for the condition of Resident 32's teeth because it could cause pain, or potentially affect her ability to eat, leading to weight loss. The DON stated the care plan should be developed as soon as the assessment was done to prevent complications. During an interview on 11/20/2025 at 9:00 a.m., with the DON, the DON stated Resident 32's care plan to prevent dental complications was created on 11/18/2025 and was not developed timely. The DON stated the care plan should have been created on 10/27/2025 or 10/29/2025, when it was identified by staff that Resident 32 had dental concerns. 2. During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident 49's diagnoses included dementia (a progressive state of decline in mental abilities), history of falling, and cognitive communication deficit (trouble participating in conversations). During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49 had adequate vision with glasses. The MDS indicated Resident 49 had moderate cognitive impairment, and required supervision or touch assist from staff for walking. During a review of Resident 49's Ophthalmology Consult, dated 5/27/2025, the record indicated Resident 49 had moderate cataracts (a clouding of the lens of the eye, which is typically clear), and blepharochalasis (a rare condition that causes painless swelling in your eyelids). During an interview on 11/20/2025 at 11:34 a.m., with Registered Nurse (RN) 2, RN 2 stated Resident 49 had vision problems which required resident-specific interventions. RN 2 stated these interventions should be documented in a care plan and stated Resident 49 did not have a care plan in place. During a review of the facility's policy and procedure (P&P), titled Person-Centered Care Planning, dated 2022, the P&P indicated staff were to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The P&P indicated the comprehensive care plan was to be developed within seven days from the completion of the comprehensive Minimum Data Set (MDS).

Based on interview and record review, the facility failed to: 1.Review, update, and/or revise the care plan to address supervision while smoking for two of five sampled residents (Residents 10 and 54). This deficient practice had the potential to result in injury to Residents 10 and 54 due to conflicting documentation and inadequate supervision while smoking. Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE]. Resident 10's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) to right and left side, paraplegia (loss of movement and/or sensation, to some degree, of the legs), and muscle weakness (generalized). During a review of Resident 10's History and Physical (H&P), dated 9/19/2025, the H&P indicated Resident 10 had the capacity to understand a make decisions. During a review of Resident 10's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 10/30/2025, the MDS indicated Resident 10 had clear comprehension (ability to learn, reason, remember, understand, and make decisions). The MDS indicated Resident 10 required maximal assistance with bed mobility, toilet use, personal hygiene, upper and lower body dressing, and was totally dependent with tub/shower transfer. During a review of Resident 10's Smoking and Safety Assessment, dated 10/29/2025, the smoking and safety assessment indicated, Resident 10 had insufficient fine motor skills needed to securely hold tobacco. Staff will supervise resident while smoking. During a review of Resident 10's Multidisciplinary Care Conference (IDT), dated 10/09/2025, the IDT indicated Resident 10 requires assistance from staff with getting around due to limited function from her hands. Resident 10 also required assistance from staff when going outside to smoke. Staff will continue to assist Resident 10 with getting around and with smoking. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE]. Resident 54's diagnoses included Type 2 Diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), absence of right leg below knee, muscle weakness (generalized) and lack of coordination. During a review of Resident 54's H&P, dated 8/15/2025, the H&P indicated Resident 54 had the capacity to understand a make decisions. During a review of Resident 54's MDS, dated [DATE], the MDS indicated Resident 54 had clear comprehension. The MDS indicated Resident 54 required supervision with bed mobility, lower body dressing and was needed moderate assistance with showering and toileting. During a review of Resident 54's Care Plan for [NAME] Use, dated initiated 8/15/2025 and revision on 10/01/2025, The care plan indicated the resident both required supervision and did not require supervision. During a concurrent interview and record review on 11/21/2025 at 10:25 a.m. with the MDS Coordinator (MDSC), Resident 10's Care Plan for Tobacco Use, last revision dated 9/9/2025 was reviewed. The care plan indicated Resident 10 both requires and did not require supervision while smoking. The MDSC stated no, the care plan should not have both require supervision and does not require supervision, that was confusing. The MDSC stated the care plan should be patient centered and needs to indicate which supervision is required, this should have been addressed during the revision of the care plan. The MDSC stated that care plans are important, they need to be reviewed, updated, and/or revised to make sure any issues with the residents are properly addressed. During an interview on 11/21/2025 at 11:05 a.m. with Director of Nursing (DON), the DON stated care plans were completed on admission, revised quarterly and as needed. The DON stated care plans were to be resident-centered, very specific and should not contain conflicting information. The DON stated the care plan was used as a guide for patient care and if interventions were conflicting, it would be confusing to the nursing staff. The DON stated that these types of issues should be addressed as soon as possible or during the revision process. The DON stated a revision involved reviewing the care plan and making necessary changes. The DON stated it was important that care plans were correct and updated in a timely manner. During a review of the facility's policy and procedure (P&P) titled, Smoking Residents, dated 8/18/2023, the P&P indicated, The IDT (Interdisciplinary Team) will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke.

Based on observation, interview, and record review, the facility failed to: 1. Failed to ensure blood glucose monitoring and insulin orders were clarified and continued after being readmitted from the hospital for one of five sampled residents (Resident 8).This deficient practice had the potential to result in Resident 8 having a hypoglycemic (low blood glucose) or hyperglycemic (high blood glucose) episode.Findings:During a review of Resident 8's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 8 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), hypotension (low blood pressure) and dementia.During a review of Resident 8's history and physical (H&P) form, dated 11/4/2025, the H&P indicated Resident 8 did not have the capacity to understand and make decisions.During a review of Resident 8's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/8/2025, the MDS indicated Resident 8's cognitive skills were severely impaired. The MDS indicated Resident 8 was dependent on staff members with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 8's October 2025 Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the MAR indicate Resident 8 had a physician's order for NovoLog Flex Pen Solution (a medication used to help manage blood sugar levels in people with type 1 or type 2 diabetes) per sliding scale. During a review of Resident 8's October 2025 MAR, the October 2025 MAR showed Resident 8 received insulin for 14 days out of the whole month as needed per sliding scale. During a review of Resident 8's blood glucose levels, dated 10/1/2025, Resident 8 received insulin on 10/23/2025 before being transferred to a general acute care hospital (GACH).During a review of Resident 8's GACH records, Resident 8 received insulin in the GACH on 10/25/2025.During a review of Resident 8's progress notes, dated 11/1/2025, Resident 8 was readmitted to the facility on [DATE].During a review of Resident 8's physician orders, dated 11/1/2025, the physician orders did not indicate to continue Resident 8's insulin.During a concurrent interview and record review, dated 11/20/2025 at 9:30 a.m., with the Director of Nursing (DON), the DON stated she had readmitted Resident 8 back to the facility. The DON stated the protocol for readmitting diabetic residents was to call the resident's doctor to verify the previous insulin order and carry out any new orders. The DON stated Resident 8 had a physician's order for insulin in October 2025. The DON stated Resident 8's blood glucose monitoring and insulin orders should had been clarified with the doctor upon readmission to the facility. The DON stated the risk of not clarifying or continuing insulin for a diabetic resident could result in a hypo/hyperglycemic episode. During an observation, dated 11/20/2025 at 10:03 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 checked Resident 8's blood glucose level which was 141.During a review of the facility's policy and procedures (P&P), titled Resident Rights- Quality of Life, revised 3/2017, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.

Based on interview and record review, the facility failed to ensure an optometry (the practice or profession of examining the eyes for visual defects and prescribing corrective lenses) referral was made for one of one sampled residents (Resident 49). This deficient practice placed Resident 49 at risk of not receiving the necessary care and interventions needed to maintain his vision and quality of life.Findings: During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident 49's diagnoses included dementia (a progressive state of decline in mental abilities), history of falling, and cognitive communication deficit (trouble participating in conversations). During a review of Resident 49's Minimum Data Set (MDS, a resident assessment tool) dated 10/31/2025, the MDS indicated Resident 49 had adequate vision with glasses. The MDS indicated Resident 49 had moderate cognitive impairment (ability to think and reason). The MDS indicated Resident 49 required supervision or touch assist from staff for walking. During a review of Resident 49's Ophthalmology (the branch of medicine concerned with the diagnosis and treatment of disorders of the eye) Consult record, dated 5/27/2025, the record indicated Resident 49 had moderate cataracts (a clouding of the lens of the eye, which is typically clear) and blepharochalasis (a rare condition that causes painless swelling in your eyelids). The record also indicated Resident 49's ophthalmologist recommended an optometry referral for an evaluation for glasses. During a review of Resident 49's Social Services Progress Note, dated 7/14/2025, the progress note indicated Resident 49's most recent ophthalmology consult was 5/27/2025. The progress note did not indicate an optometry referral was made in accordance with the ophthalmologist's recommendation from 5/27/2025. During an interview on 11/20/2025 at 10:14 a.m., with the Social Services Director (SSD), the SSD stated she reviewed the ophthalmology consult notes after the ophthalmologist's visit. The SSD stated that if an optometry referral was recommended, she would make the referral. The SSD stated the optometrist visited the facility every two to three months and she would notify them if there was someone with an optometry referral. The SSD stated an optometry referral was not made for Resident 49 following the recommendation made by the ophthalmologist on 5/27/2025. The SSD stated it was important to ensure optometry referrals were made timely to treat any vision conditions. The SSD further stated that difficulty with vision could affect quality of life and pose safety risk for the resident.

Based on observation, interview, and record review, the facility failed to: 1. Failed to ensure oxygen was administered as ordered for one of five sampled residents (Resident 24).This deficient practice had the potential to result in oxygen toxicity for Resident 24.Findings:During a review of Resident 24's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 24 was admitted [DATE] on with diagnoses which included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness) and pulmonary hypertension (high blood pressure that affects the arteries in the lungs and the right side of the heart).During a review of Resident 24's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/18/2025, the MDS indicated Resident 24's cognitive skills were cognitively intact. The MDS indicated Resident 24 required partial to moderate assistance from staff members with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 24's physician orders, dated 9/26/2025, the physician orders indicated, May use Oxygen @ 2-3L/min Via nasal cannula to keep 02 Sat above 92 % as needed for SOB.During a review of Resident 24's history and physical (H&P) form, dated 11/2/2025, the H&P indicated Resident 24 had the capacity to understand and make decisions.During an observation, on 11/18/2025 at 11:12 a.m., Resident 24 was observed receiving oxygen via nasal cannula at 4 liters per min.During a concurrent observation and interview, on 11/20/2025 at 10:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 observed Resident 24 receiving oxygen via nasal cannula in bed. LVN 1 stated Resident 24's oxygen was running at 4 liters per minute. LVN 1 stated Resident 24's physician order indicated to administer 2-3 liter per minute. LVN 1 stated Resident 24's oxygen should not had been running at 4 liters per minute. LVN 1 stated the risk of administering oxygen at a higher dose than the physician's order could result in oxygen toxicity.During a review of the facility's policy and procedures (P&P), titled Oxygen Therapy, dated 10/10/2025, the P&P indicated, Administer oxygen and obtain oxygen saturation levels as ordered by the provider.

Based on observation, interview, and record review, the facility failed to: 1. Provide pharmaceutical services that met the needs one of five sampled residents (Resident 24). Resident 24's lidocaine patch was not removed at the scheduled time as ordered by the physician. This deficient practice had the potential for avoidable physical harm related to lidocaine patch not being removed on time or experiencing potential adverse drug reactions from medications being administered differently from how they were ordered. Findings:During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE]. Resident 24's diagnoses included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), hypertensive heart disease with heart failure (long term high blood pressure caused the heart to weaken, making it unable to pump blood effectively), chronic pain syndrome (pain that lasts longer than three months). During a review of Resident 24's History and Physical (H&P), dated 11/02/2025, the H&P indicated Resident 24 had the capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set (MDS] a comprehensive assessment and care-screening tool), dated 9/18/2025, the MDS indicated Resident 24 had clear comprehension (ability to learn, reason, understand, and make decisions). The MDS indicated Resident 24 required supervision with bed mobility, toilet use, personal hygiene, upper and lower body dressing. During an observation on 11/20/2025 at 9:23 a.m. in Resident 24's room during medication pass, a lidocaine patch dated 11/19/2025 was observed still placed on Resident 24's left leg. Observed the LVN1 quickly removing the lidocaine patch, cleaned and assessed area before placing a new lidocaine patch to left leg. During a concurrent interview and record review on 11/20/2025 at 11:15 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 24's Medication Administration Record (MAR), dated November 2025 was reviewed. The Mar indicated Lidocaine patch was to be removed at 8:59 p.m. each day as ordered. LVN 1 stated the lidocaine patch from the previous day was still on the resident which I removed immediately. LVN 1 stated no, it should not have been left on, it is important to follow physician orders. LVN 1 stated leaving the patch on longer than ordered could potentially harm the resident due to medication levels becoming too high. During an interview on 11/20/2025 at 11:30 a.m. with Director on Nursing (DON), the DON stated medication orders should be followed as scheduled. The DON stated that if a lidocaine patch was left on a resident after the scheduled removal time the patch would still being distributing medication to the resident's system. The DON stated this could potentially cause adverse side effects, skin irritation, and harm to the resident. During a review of the facility's policy and procedure (P&P) titled, Medication- Administration, dated 8/19/2025, the P&P indicated, All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations. The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner.

Based on observation and interviews the facility failed to: 1. Ensure an unopened prefilled pen of Lantus (a long-lasting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) was stored inside the refrigerator per manufacturer's guidelines instead of storing inside Medication Cart Westback. This deficient practice had the potential to result in the deterioration and loss of effectiveness for insulin Lantus' improper storage and potential for ineffective management of the residents' diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Findings: During a concurrent observation and interview on 11/20/2025 at 12:35 p.m. with Registered Nurse (RN) 1 at medication cart westback, an unopened prefilled pen of Lantus was observed in the medication cart. RN 1 acknowledged that the insulin was stored in the cart unopened. RN 1 stated that all unopened insulin prefilled pens and vials should be stored in the refrigerator until they are opened. RN 1 stated once an insulin vial was opened it could remain in the cart for 28 days. RN 1 stated if an unopened insulin was stored in the medication cart and not refrigerated it could affect the resident by causing the insulin to be less effective, leading to poor blood sugar control and potentially could result in the resident requiring hospitalization. During an interview on 11/21/2025 at 11:05 a.m. with the Director of Nursing (DON), the DON stated all unopened insulin was required to be stored in the refrigerator until used. The DON stated the insulin was stored in the refrigerator to maintain the accuracy and potency of the medication. The DON stated storing the insulin outside of the refrigerator could affect its effectiveness, and if the insulin was ineffective the residents' blood sugar would continue to rise and cause potential harm. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, August 2019, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. For those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. Medications requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring.

Based on interview and record review, the facility failed to ensure the correct information was provided to one of three sampled residents (Resident 7) prior to asking him to enter into a binding arbitration agreement (the resolution of a dispute where both parties waive their right to a trial). This deficient practice resulted in Resident 7 unknowingly forfeiting his right to resolve any disputes with the facility in court, alongside a judge and/or jury.Findings: During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted to the facility on [DATE]. Resident 7's diagnoses included surgical aftercare for amputation of both legs below the knee and polyneuropathy (nerve damage). During a review of Resident 7's History and Physical (H&P), dated 9/25/2025, the H&P indicated Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's record titled Arbitration Agreement, dated 9/25/2025, the record indicated Resident 7's daughter signed the document, entering Resident 7 into a binding arbitration agreement. During an interview on 11/21/2025 at 10:01 a.m., with Resident 7, Resident 7 stated he was responsible for signing all the paperwork presented to him upon admission and stated he would not ask his daughter to sign anything. Resident 7 stated binding arbitrations were not explained to him, and stated he would not have agreed to one if it were explained to him. During an interview on 11/21/2025 at 10:36 a.m., with the Admissions Director (AD), the AD stated Resident 7's daughter's signature on Resident 7's Arbitration Agreement was an error, and stated he recalled Resident 7 signing the document himself. During an interview on 11/21/2025 at 10:37 a.m., the AD stated he was responsible for explaining binding arbitrations to new facility residents. The AD stated he informed residents that a binding arbitration agreement outlined the rules and regulations of the facility, like a code of conduct. The AD stated he had not received training by the facility about what a binding arbitration agreement was. During an interview on 11/21/2025 at 1:09 p.m., with the Administrator (ADM), the ADM stated a binding arbitration was an agreement to give away the right to a court trial if there was a dispute between the resident and the facility. The ADM stated that once the agreement was signed, it was a legally binding contract. The ADM stated that prior to being asked to sign the document, the facility should fully inform the resident of what they are being asked to sign, and stated it was the resident's right to know what they were signing. During a review of the facility's policy and procedure (P&P) titled Arbitration Agreements, dated 5/26/2023, the P&P indicated that when admission staff were presenting the Arbitration Agreement to residents, the admissions staff must explain what arbitration is in a language and manner that resident and or responsible party understands.

Based on observation, interview, and record review, the facility failed to maintain infection control for all facility residents when: 1. Resident 48 was not tested for Covid-19 (an infectious disease caused by the SARS-CoV-2 virus) after first exhibiting symptoms on 11/12/2025. 2. The facility failed to ensure there was warm running water in the handwashing sink located in the soiled laundry sorting area. These deficient practices created the potential for the transmission and spread of infection to all facility residents. Findings: 1. During a review of Resident 48's admission Record, the admission Record indicated Resident 49 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident 48's admitting diagnoses included sepsis (a life-threatening blood infection). During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool), dated 9/14/2025, the MDS indicated Resident 48 did not have cognitive impairments (ability to think and reason). The MDS indicated Resident 48 required substantial to maximum assistance from staff for most mobility while out of bed. During a review of Resident 48's physician order, dated 7/28/2022, the order indicated Resident 48 was to be tested for Covid-19 weekly and as needed. During a review of Resident 48's test results, dated 11/2025, the records indicated Resident 48 was last tested for Covid-19 on 11/10/2025 and no further Covid-19 testing was conducted. During a review of Resident 48's Change of Condition (COC) assessment, dated 11/12/2025, the COC assessment indicated Resident 48 had a severe cough with yellow/greenish phlegm, chest congestion, difficulty breathing, and a runny nose/nasal congestion. During a review of Resident 48's COC assessment, dated 11/18/2025 at 11:00 a.m., the COC assessment indicated Resident 48 had increased cough with white, cloudy sputum production (a mixture of saliva and mucus), chest congestion, and mild chest tightness. The assessment did not indicate Resident 48 was tested for Covid-19. During a concurrent observation and interview, on 11/18/2025 at 1:34 p.m., at Resident 48's bedside, Resident 48 was observed sitting up in bed with a strong cough. Resident 48 stated she had been coughing for a week and was spitting up large amounts of white, creamy sputum. Resident 48 stated she was also very fatigued and was not getting a lot of sleep due to the frequent coughing. During an interview on 11/20/2025 at 9:02 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated that any resident with a cough and/or fever were to be tested for Covid-19. The IPN stated that it was important to test right away to prevent the spread of infection to staff and other facility residents. During an interview on 11/20/2025 at 9:21 a.m., with the IPN, the IPN stated Resident 48 had not been tested for Covid-19 since her coughing started. During a review of the facility's policy and procedure (P&P) titled [Facility] Respiratory Virus Prevention and Control Plan, reviewed 8/27/2025, the P&P indicated that any residents with signs and/or symptoms of respiratory illness were to be tested immediately for Covid-19. 2. During an interview on 11/21/2025 at 1:07 p.m., in the sorting area for soiled linen in the laundry room, with the Housekeeping Supervisor (HS), the HS stated this was considered a dirty area where soiled linens were brought to be separated and sorted for washing. The HS stated staff washed their hands in the handwashing sink for infection prevention. During an observation on 11/21/2025 at 1:09 p.m., in the sorting area for soiled linen in the laundry room, the handwashing sink was observed. The handwashing sink had a hot-water pedal and a cold-water pedal. The hot-water pedal did not dispense any water when pressed. The handwashing sink did not dispense any hot or warm water. Signage above the handwashing sink instructed staff to wash their hands with warm running water. During an interview on 11/21/2025 at 1:12 p.m., with the Maintenance Supervisor (MS), the MS stated the hot water in the handwashing sink was turned off six months ago. The MS could not state who instructed him to turn off the hot water, and stated it was turned off because the handwashing sink had an attached eyewash station (a unit for washing off chemicals or substances that might have splashed into an individual's eyes). During an interview on 11/20/2025 at 1:53 p.m., with the IPN, the IPN stated she had never received guidance that hot water was to be disconnected at an eye-wash station. The IPN stated the water should be warm enough for effective handwashing, and cool enough that it would not burn someone's eyes if they needed the eyewash. The IPN stated hand hygiene (handwashing) was to be done with warm water for effective handwashing and infection prevention. During a review of the facility's P&P titled Hand Hygiene, revised 9/2020, the P&P indicated the Facility considered hand hygiene as the primary means to prevent the spread of infections.

Based on observation, interview, and record review, the facility failed to ensure two out of six sampled residents (Resident 27 and 24) were dressed appropriately. This deficient practice of the Residents 24 and 27 not wearing their own clothes had the potential to make the residents feel left out from socialization (activities that contributes to the integrity of an individual's health and wellness). Findings: a. During a review of Resident 27's Admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), chronic kidney disease (a condition where the kidneys do not work as well as they should), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 27's History and Physical (H&P), dated 6/12/2024, the H&P indicated Resident 27 could make needs known but could not make medical decisions. During a review of Resident 27's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 6/29/2024 the MDS indicated, Resident 27 was usually able to understand others. The MDS indicated Resident 27 was dependent on staff for personal hygiene, showering, and dressing. The MDS indicated Resident 27 was dependent with staff for chair/bed to chair transfer. During observations on 10/12/2024 between the hours 8:30 a.m. through 6:00 p.m., Resident 27 was observed wearing a hospital gown. During a concurrent observation and interview on 10/12/2024 at 6:21 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 27's room, Resident 27 was observed lying in the bed wearing a hospital gown. CNA 1 stated Resident 27 was wearing a hospital gown. CNA 1 stated Resident 27 was not dressed daily. CNA 1 stated Resident 27 was only dressed when the staff took the resident to the dining room or when Resident 27 had a visitor. CNA 1 stated Resident 27 should be dressed in clothes during the day. CNA 1 stated dressing Resident 27 daily would help with socialization (by engaging in group activities, such as games, music, or arts and crats) and a sense of belonging (a feeling of security and support when there is inclusion) with the other residents. CNA 1 stated if Resident 27 was not dressed daily the resident could have the potential to feel depressed and not feel good. During an interview on 10/12/2024 at 6:26 p.m. with the Director of Nursing (DON), the DON stated the staff dress the residents if the residents were going out of their room. The DON stated if the residents were total care and were in the bed staff kept the residents in their gowns. The DON stated there was no policy for keeping residents in hospital gowns during the day. The DON stated it was important to dress Resident 27 in clothing to look presentable. b. During a review of Resident 24's Admission Record (Face Sheet), the Face Sheet indicated Resident 24 was initially admitted to the facility on [DATE]. Resident 24's diagnoses included heart failure (a condition in which the heart does not pump blood as well as it should), dysphasia (difficulty swallowing), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 24's H&P, dated 8/26/2024, the H&P indicated Resident 24 had fluctuating capacity to understand and make decisions. During a review of Resident 24s MDS, dated [DATE] the MDS indicated, Resident 24's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 24 required substantial assistance with staff for personal hygiene, showering, and dressing. The MDS indicated Resident 24 required substantial assistance with staff for chair/bed to chair transfer. During an observation on 10/12/2024 between the hours 8:35 a.m. through 6:05 p.m., Resident 24 was observed wearing a hospital gown. During a concurrent observation and interview on 10/12/2024 at 6:31 p.m. with CNA 1, in Resident 24's room, Resident 24 was observed lying in the bed wearing a hospital gown. CNA 1 stated Resident 24 was wearing a hospital gown, and his clothes were in the closet. CNA 1 stated it was important to dress Resident 24 in clothing so he would feel togetherness with the other residents. CNA 1 stated if Resident 24 was not dressed daily he could feel demoralized and become depressed. During an interview on 10/12/2024 at 6:58 p.m. with the DON, the DON stated it was important to dress Resident 24 in clothing. The DON stated not having the resident dressed was a dignity issue and could make the resident feel sad about not being changed daily. During a review of the facility's policy and procedure (P&P) titled, Certified Nursing assistant Job Description, date unknown, the P&P indicated a nursing assistant responsible for providing routine nursing care to assure that the highest degree of quality resident care can be maintained at all times. The P&P indicated dress residents neatly ad in their own clothing. During a review of the facility's P&P titled, Resident Rights, dated 1/2012, the P&P indicated Resident's receive care and does not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her rights. The P&P indicated personal care needs, such as bathing methods, grooming styles, and dress, During a review of the facility's P&P titled, Resident Rights-Quality of Life, dated 3/2017, the P&P indicated to ensure the resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The P&P indicated Residents are encouraged and assisted to dress in their own clothes rather in hospital gowns.

Based on observation, interview, and record review, the facility failed to ensure one out six sampled residents (Resident 24) was offered his dentures before eating. This deficient practice of not offering Resident 24 his dentures while eating had the potential to not be able to chew food effectively. Findings: During a review of Resident 24's Admission Record (Face Sheet), the Face Sheet indicated Resident 24 was initially admitted to the facility on [DATE]. Resident 24's diagnoses included heart failure (a condition in which the heart does not pump blood as well as it should), dysphasia (difficulty swallowing), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 24's History and Physical (H&P), dated 8/26/2024, the H&P indicated Resident 24 had fluctuating capacity to understand and make decisions. During a review of Resident 24s Minimum Data Set ([MDS] a federally mandated assessment tool), dated 7/1/2024 the MDS indicated, Resident 24's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 24 required substantial assistance with staff for personal hygiene, showering, and dressing. The MDS indicated Resident 24 required substantial assistance with staff for chair/bed to chair transfer. During an observation on 10/12/2024 at 8:15 a.m., 12:40 p.m., and at 6:15 p.m., in Resident 24's room, Resident 24's certified nursing assistant (CNA) did not provide Resident 24 with dentures while feeding the resident his meals. During an observation on 10/13/2024 at 12:45 p.m., in the dining room, Resident 24 was observed eating his meal without dentures. Resident 24 was not offered dentures while eating his meal. During a concurrent observation and interview on 10/12/2024 at 6:40 p.m., with CNA 1, in Resident 24's room, Resident 24 was observed lying in bed with no dentures in his mouth. CNA 1 located the dentures in Resident 24's bedside table. CNA 1 stated Resident 24 did not eat at times. CNA 1 stated it was important to offer the dentures to help the resident with chewing and eating his food. CNA 1 stated providing the dentures would help give Resident 24 a normal feeling while eating. During an interview on 10/13/2024 at 2:54 p.m. with the Director of Nursing (DON), the DON stated Resident 24 required feeding assistance and the staff should offer the resident dentures. The DON stated it was important for Resident 24 to wear dentures while eating so he could eat more food. The DON stated not providing the dentures could have an affect how he looked and felt during the day. During a review of the facility's policy and procedure (P&P) titled, Resident Rights-Accommodation of Needs, dated 1/2012, the P&P indicated to ensure that the facility provides an environment and services that meet residents' individual needs. The P&P indicated facility staff arranges personal items within easy reach of the resident. The P&P indicated facility staff helps to keep aids, glasses and other adaptive devices clean and in working order for the resident. During a review During a review of the facility's P&P titled, Resident Rights-Quality of Life, dated 3/2017, the P&P indicated to ensure each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-center manner, as well as those that support resident in attaining or maintaining his/her highest practicable well-being. The P&P indicated facility staff treats cognitively impaired resident with dignity and sensitivity.

Based on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 27) had the appropriate call light device to call for assistance. This deficient practice of not having the appropriate call light device had the potential for Resident 27 to not get assistance in a timely manner. Findings: During a review of Resident 27's Admission Record (Face Sheet), the Face Sheet indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), chronic kidney disease (a condition where the kidneys do not work as well as they should), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 27's History and Physical (H&P), dated 6/12/2024, the H&P indicated Resident 27 could make needs known but could not make medical decisions. During a review of Resident 27's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 6/29/2024 the MDS indicated, Resident 27 was usually understood others. The MDS indicated Resident 27 was dependent on staff for personal hygiene, showering, and dressing. The MDS indicated Resident 27 was dependent on staff for chair/bed to chair transfer. During an observation on 10/12/2024 at 9:49 a.m., in Resident 27's room, Resident 27 was observed lying in the bed awake. Resident 27 attempted to reach for the call light and was not able to grasp the call light and press the button for assistance. During an interview on 10/13/2024 at 1:56 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 27 was slow to talk and slow to touch the call light device. LVN 1 stated Resident 27 would benefit from having the touch pad call light. LVN 1 stated it would be easier for Resident 27 to call for assistance. LVN 1 stated it was important to have the touch paid call light just in case the resident was falling or choking. LVN 1 stated the call light was needed to save a life or to offer assistance when she needed help. During an interview on 10/13/2024 at 3:00 p.m. with the Director of Nursing (DON), the DON stated Resident 27 did not have the correct call light device because she could not press the call light button. The DON stated Resident 27 should have had the touch pad call light device. The DON stated it was important for Resident 27 to have the appropriate the touch pad call light to make it easier to call for assistance. The DON stated by not having the appropriate call light for Resident 27 staff would not be able to assist her with her accommodations (the facility's efforts to individualize the resident's physical environment). During a review of the facility's policy and procedure (P&P) titled, Resident Rights- Accommodation of Needs, date unknown, the P&P indicated, the facility's environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being. The P&P indicated Residents' individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.

Based on interview and record review, the facility failed to inform and provide the Notice of Medicare Non-Coverage (NOMNC) form 48 hours prior to the end of skilled nursing services for one of three sampled residents (Resident 205). This deficient practice had the potential to result in the resident not being able to exercise his right to file an appeal and unknowingly paying for non-covered care expenses. Findings: During a review of Resident 205's Admission Record (front page of the chart that contains a summary of basic information about the resident), the Admission Record indicated, Resident 205 was admitted to the facility on [DATE]. Resident 205's diagnoses included chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), alcoholic liver disease (damage to the liver and its function due to alcohol abuse), and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 205's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 4/30/2024, the MDS indicated, Resident 205's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS also indicated, Resident 205 required supervision (helper provides verbal cues) in oral hygiene, toileting hygiene, and upper and lower body dressing. During a concurrent interview and record review on 10/12/2024 at 3:10 p.m. with the Social Service Director (SSD), Resident 205's NOMNC form was reviewed. The SSD stated she was responsible in completing, providing and maintaining signed copies of the NOMNC form The SSD stated Resident 205's last covered day for Medicare Part A skilled services would end on 6/20/2024. The SSD stated Resident 205's NOMNC was given to the resident on 6/19/2024. The SSD stated the facility process was to give NOMNC to the resident 48 to 72 hours prior to the end of Medicare Part A skilled services so the resident would have enough time to make an appeal. The SSD stated Resident 205's right to appeal for financial coverage was not honored. During a review of the facility's policy and procedure (P&P), titled Medicare Denial Process, dated 3/2018, the P&P indicated, Medicare beneficiaries will be properly notified when it is determined that they do not meet the requirements for covered skilled services under the Medicare program. The P&P also indicated the Medicare status change form is completed by the Director of Nursing (DON) or designee upon admission and or minimum of 2 days prior to the last Medicare covered day.

Based on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 34) was provided a homelike environment and did not have chipped paint on the wall next to the resident's bed. This deficient practice of not providing a homelike environment for Resident 34 had the potential to negatively impact the resident quality of life. Findings: During a review of Resident 34's Admission Record (Face Sheet), the Face Sheet indicated Resident 34 was initially admitted to the facility on [DATE] and last readmitted [DATE]. Resident 34's diagnoses included aphasia (a disorder that makes it difficult to speak), chronic kidney disease (a condition where the kidneys do not work as well as they should), and atherosclerotic hearth disease (a chronic inflammatory disease that causes plaque buildup in the walls of arteries, narrowing them and restricting blood flow). During a review of Resident 34's History and Physical (H&P), dated 8/29/2024, the H&P indicated Resident 34 did not have the capacity to understand and make decisions. During a review of Resident 34's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 8/16/2024 the MDS indicated, Resident 34 was able to usually understand others. The MDS indicated Resident 34 required substantial assistance with staff for personal hygiene, showering, and dressing. During an observation on 10/12/2024 at 9:55 a.m. in Resident 34's room, observed scattered chipped paint along the wall next to Resident 34's bed. During a concurrent observation and interview on 10/12/2024 at 4:55 p.m. with the Administrator (ADM), in Resident 34's room, there was scattered chipped paint observed along the wall next to Resident 34's bed. The ADM stated he was aware of the chipped paint on the wall in Resident 34's room. The ADM stated when Resident 34 was lying in the bed the resident may not like looking at chipped paint. The ADM stated the wall needed to be repaired and painted. The ADM stated it was important to have the room looking nice and presentable, so the resident could feel good. The ADM stated the wall needed to be repaired and painted. During an interview on 10/12/2024 at 5:12 p.m. with the Maintenance Director (MD), the Maintenance Log, dated 9/17/2024 was reviewed. The Maintenance Log indicated on 9/17/2024 Resident 34's room walls needed paint. The MD stated the staff reported and put it the maintenance book. The MD stated it would take him one day to paint the room. The MD stated it would make the Resident feel a bit sad if the room did not look nice. During a review of the facility's policy and procedure (P&P) titled, Resident Rights- Accommodation of Needs, date unknown, the P&P indicated to ensure that the facility provides an environment and services that meet resident's individual needs. The P&P indicated Resident's individual needs are accounted for in the facility's provision of a clean comfortable environment and is consistent with individual resident needs.

Based on interview and record review, the facility failed to ensure one out of six sampled residents (Resident 2) had a care plan (a communication tool for patient care between nurses) for the refusal of dental services. This deficient practice of not having a care plan for refusal of dental services had the potential to place Resident 2 at risk for not receiving the appropriate interventions to prevent discomfort when eating. Findings: During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included chronic kidney disease (damage to kidneys and can't filter blood the way they should), dysphagia (difficulty swallowing), and aortic aneurysm (a bulge in the wall of an artery). During a review of Resident 2's History and Physical (H&P), dated 7/22/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2s Minimum Data Set ([MDS] a federally mandated assessment tool), dated 7/8/2024 the MDS indicated, Resident 2's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 2 required supervision from staff for personal hygiene, showering, and dressing. The MDS indicated Resident 2 required supervision from staff for chair/bed to chair transfer. During a review of Resident 2's dental record titled, Elite Mobile Dental, dated 8/22/2024, the Elite Mobile Dental indicated, Resident 2 refused treatment. During an interview on 10/13/2024 at 11:34 a.m. with Resident 2, Resident 2 stated the staff did not review the risks and benefits of not having dentures. Resident 2 stated it would be easier to chew food with dentures. During a concurrent interview and record review on 10/13/2024 at 2:06 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's dental record titled, Elite Mobile Dental, dated 8/22/2024 was reviewed. The Elite Mobile Dental indicated on 8/22/2024 Resident 2 refused treatment. LVN 1 stated when Resident 2 refused to have dental treatment a care plan needed to be developed. LVN 1 stated it was important to have a care plan to set goals and interventions that would help the resident with dental care. LVN 1 stated having a care plan would help with prevention of mouth infection. During a concurrent interview and record review on 10/13/2024 at 2:48 p.m. with the Director of Nursing (DON), Resident 2's dental record titled, Elite Mobile Dental, dated 8/22/2024 was reviewed. The Elite Mobile Dental indicated on 8/22/2024 Resident 2 refused treatment. The DON stated when the resident refused dental treatment the staff were to complete a care plan. The DON stated it was important to find out the reason for the refusal and educate Resident 2 the risks and benefits of the treatment. The DON stated the staff was to identify the problem and provide the care according to the resident preferences. During a review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, dated 11/2018, the P&P indicated to ensure that a comprehensive person-centered care plan is developed for each resident. The P&P indicated additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident. The P&P indicated the comprehensive care plan will be periodically reviewed and revised following onset of new problems and to address changes in behavior and care.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to measure the abdominal girth (the measurement of the distance around the abdomen at a specific point, usually at the level of the belly button) weekly per the physician's order for one of one sampled resident (Resident 45) who had a diagnosis of ascites (a condition where fluid builds up in the abdomen). This deficient practice would put Resident 45 at risk for abdominal pain and shortness of breath possibly leading to medical complications requiring hospitalization . Findings: During a review of Resident 45's Admission Record, the Admission Record indicated, Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnoses included ascites, chronic kidney disease (kidneys are damaged and can't filter blood they way they should), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 45's History and Physical (H&P), dated 9/2/2024, the H&P indicated, Resident 45 had fluctuating capacity to understand and make decisions. During a review of Resident 45's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 8/6/2024, the MDS indicated, Resident 45's cognitive (ability to think and reason) skills for daily decision making was moderately impaired. The MDS indicated, Resident 45 required supervision (helper provides verbal cues) in oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 45's Order Summary Report (a document containing active orders), dated 10/1/2024, the Order Summary Report indicated, Resident 45 had a physician order to measure abdominal girth weekly on Wednesday and to call medical doctor for any significant change in resident's abdominal girth. During a concurrent interview and record review on 10/12/2024 at 4:53 p.m. with the Director of Nursing (DON), Resident 45's Treatment Administration Record ([TAR] a report detailing the treatment administered to a patient by a healthcare professional at a facility) for September and October 2024 was reviewed. The DON stated Resident 45's abdominal girth on 9/4/2024, 9/11/2024, 9/18/2024, 9/25/2024, 10/2/2024, and 10/9/2024 were not measured. The DON stated it was the responsibility of the licensed nurse to measure the abdominal girth of Resident 45 and record in the TAR. The DON stated all physician orders must be followed as standard of practice. The DON stated it was essential to measure Resident 45's abdominal girth as a guide for the licensed nurses to know if Resident 45 was accumulating more fluids in the abdomen. The DON stated failure to measure and monitor the abdominal girth of resident with a diagnosis of ascites would cause negative effect such as abdominal discomfort, weakness and shortness of breath. During a review of the facility's policy and procedure (P&P) titled, Quality of Care Compliance Requirements, dated 6/2016, the P&P indicated, The facility is committed to providing care and services necessary to attain or maintain a resident's highest practicable physical, mental and psychosocial wellbeing.

Based on observation, interview, and record review, the facility failed to follow its policy and resident plan of care by not ensuring resident's call lights and bedside tables were placed within reach and call lights were answered in a timely manner for ten of ten sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10), who were assessed as being at risk for falls. These deficient practices resulted in Resident 1 falling and sustaining a [MEDICAL CONDITION] (broken bone), transferring to the general acute care hospital (GACH) and undergoing surgery, and later expiring. The deficient practices also placed Residents 2, 3, 4, 5, 6, 7, 8, 9, and 10 at risk for injuries. Findings: a. A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening, dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 6 (,[DATE] = moderate cognitive impairment), and did not have the ability to understand and be understood by others. The MDS indicated Resident 1 required an extensive one-person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. According to the MDS, Resident 1 used a wheelchair for mobility. A review of Resident 1's care plan titled Fall Risk Prevention and Management, dated [DATE], indicated the resident was at risk for falls. The goal for this care plan indicated the staff would provide a safe environment that minimized complications of falls. The staff's interventions included to orient Resident 1 to the environment each time changes were made, provide a hazard free environment to minimize falls, place the call light within reach and provide education to Resident 1, the resident's family and staff regarding Resident 1's special care needs. A review of a Nurses Progress Note, dated [DATE], indicated Resident 1 was alert and oriented to person and place, and had periods of confusion. A review of a Nurses Progress Note, dated [DATE], indicated Resident 1 was alert and oriented, but had dementia. The note indicated Resident 1 was non-ambulatory (unable to walk) due to abnormal posture and weakness. A review of Resident 1's fall risk assessment, dated [DATE], indicated the resident was at high risk for falls. A review of a care plan titled At Risk of Falls, Injuries, dated [DATE], indicated the resident was at risk for falls and injuries related to unsteady gait (way of walking) and history of recurrent falls. The goal for this care plan indicated the risk for falls would be minimized daily and that the staff would provide a safe environment that minimizes complications for falls for three months. The staff's interventions included to assess Resident 1's risk for falls, assure that lighting was adequate and the call light was within reach. A review of a care plan titled Impaired Physical Functioning, dated [DATE], indicated the staff would provide assistance to Resident 1 as needed, maintain call light within easy reach and answer promptly, and assist the resident during transfers for safety. A review of a care plan titled, Risk for Injuries, Deformities, Fractures, and Pain, dated [DATE], indicated the staff's interventions included to constantly remind Resident 1 on safety and observe the resident's ability to ambulate and move all body parts. A review of Resident 1's History and Physical (H/P), dated [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's care plan titled, Falls Risk Prevention and Management, dated [DATE], indicated the resident had an actual fall on [DATE] and that Resident 1's bed would be maintained in a low position, call light within reach and the staff would remind Resident 1 to use the call light. A review of Resident 1's pain assessment Flowsheet dated [DATE], indicated the resident had a pain level of 8 out of 10 (pain scale with 0 being no pain to 10 being the worst) and received [MEDICATION NAME] (medication used to treat moderate to severe pain) 50 milligrams (mg). A review of a Situation, Background, Assessment and Recommendation ((SBAR) communication tool used between licensed staff) form, dated [DATE], indicated Resident 1 was found lying on the floor on her left side by Certified Nursing Assistant 1 (CNA 1). The form indicated Resident 1 was transferred back to bed and assessed, and the resident complained of excruciating pain to the left lower leg, and was administered [MEDICATION NAME] 50 mg by mouth (PO). A review of Resident 1's Post Fall assessment dated [DATE] indicated the resident complained of excruciating pain when moving left leg. A review of a Interdisciplinary Team ((IDT) group of different disciplines working together towards a common goal of a resident) Meeting report, dated [DATE], indicated on [DATE], Resident 1 tipped over and fell from her bed while trying to reach for a book by her nightstand. The report indicated Resident 1 had a very high risk for pathological fractures due to osteopenia. According to the report, Resident 1 was transferred to the GACH. A review of the Incident and Accident Report, dated [DATE], indicated CNA 1 found Resident 1 lying on her left side on the floor. The report indicated Resident 1 was assisted back to bed with a two person transfer, and then assessed. The report indicated Resident 1 was alert, oriented and able to make needs known, and was medicated with [MEDICATION NAME] 50 mg for complains of left leg pain. The report indicated Resident 1's fall was unavoidable because the resident wanted to express her independence with activities of daily living (ADLs) and did not use the call light for assistance. The report indicated Resident 1 stated she tried to reach for her book by the nightstand, tipped over and fell to the floor. A review of Resident 1's Radiology Report, dated [DATE], indicated the resident had a left leg fracture. A review of the GACH emergency room (ER) physician's note, dated [DATE], indicated Resident 1 was admitted to the GACH for severe and intractable left leg pain following a fall. A review of the GACH H/P, dated [DATE], indicated Resident 1 had severe and intractable left hip pain following a slip and fall, and was to be admitted for a left [MEDICAL CONDITION]. A review of the GACH physician's progress note, dated [DATE], indicated Resident 1 sustained a left [MEDICAL CONDITION] (broken bone) with severe hip pain, and a [DIAGNOSES REDACTED]. A review of a GACH Nurses Narrative Note, dated [DATE], indicated Resident 1 had open reduction and internal fixation ((ORIF) two-part surgical procedure where the broken bone is reduced or put back into place and an internal fixation device (screws, plates, rods, or pins) is placed to hold the broken bone together) of the left hip. A review of a GACH Nurses Narrative Note, dated [DATE], indicated Resident 1 had a critical arterial blood gas ((ABG) a test that measures the amount of oxygen and carbon [MEDICATION NAME] in the blood) lab result of ,[DATE] percent (%) and was placed on a non-rebreather mask at fifteen (15) liters (L) of oxygen. The note indicated Resident 1's oxygen saturation was ,[DATE]% (Normal Reference Range (NRR) =,[DATE]). According to the note, Resident 1 was transfused with a unit of packed red blood cells ((PRBC) blood product). A review of a GACH Nurses Narrative Note, dated [DATE], indicated Resident 1 was lethargic (difficult to wake, sleepy), weak, non-verbal, bedridden, confused and had an elevated temperature of 100.7 degrees (Normal Reference Range (NRR) = 97.5 - 98.9 degrees). The note indicated Resident 1 had decreased urine output, a blood pressure reading of ,[DATE] (NRR = ,[DATE]-,[DATE]), and heart rate 105 ((HR) NRR=,[DATE]). The note indicated Resident 1 received a blood transfusion. A review of a GACH Nurses Narrative Note, dated [DATE], indicated Resident 1 was receiving total [MEDICATION NAME] nutrition ((TPN) a process of administering feeding through the veins); started on blood sugar medications, and placed on a Bi-level Positive Airway Pressure (([MEDICAL CONDITION]) device that assists with breathing) machine. A review of a GACH Nurses Narrative Note, dated [DATE], indicated Resident 1 received a thoracentesis (medical procedure used drainage of excess fluid or air from the lungs). A review of a GACH Nurses Progress Note, dated [DATE], indicated on [DATE] at 7:15 p.m., Resident 1 expired. On [DATE] at 3:05 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated she was in the bathroom next to Resident 1's room when she heard something tumble. CNA 1 stated Resident 1's roommate (Resident 2) stated Resident 1 fell . CNA 1 stated Resident 1 was lying on her left side on the floor after trying to get a book on the bedside table. CNA 1 stated Resident 1 tipped over and fell . CNA 1 stated she could not recall whether Resident 1's bedside table was next to the resident. On [DATE] at 3:20 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated CNA 1 informed her Resident 1 had fallen. LVN 1 stated Resident 1 was observed on the floor on her left side, assisted back to bed and assessed. LVN 1 stated Resident 1 complained of pain and was administered [MEDICATION NAME] 50 mg. LVN 1 stated Resident 1 was at risk for falls, had no side rails and had a tendency of sitting/lying near the edge of the bed. LVN 1 stated Resident 1 did not have a floor mat and should have had one. On [DATE] at 4:10 p.m., during an interview, the Director of Nursing (DON) stated floor mats were for residents at risk for falls who could get out of bed. The DON stated Resident 1 could not get out of bed. On [DATE] at 9:10 a.m., during an interview, the DON stated Resident 1 had memory loss and a tendency of wanting to do things for herself without asking for help. On [DATE] at 10:40 p.m., during an interview, Resident 1's family member (FM 1) stated the resident complained of not being well groomed and neglected at the facility. FM 1 stated Resident 1 fell in the past, and crawled to the hallway for help because no one answered her. FM 1 stated Resident 1 was left wet for extended periods and the family had to call the nurses station for assistance. A review of Resident 1's death certificate, dated [DATE], indicated the resident expired on [DATE] of cardiopulmonary arrest (heart and lung arrest), [MEDICAL CONDITION] (breathing problems),[MEDICAL CONDITION] (blood infection) and pneumonia (infection of the lungs that causes difficulty breathing). b. A review of Resident 2's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 6 (,[DATE]= severe cognitive (ability to think and reason) impairment, and did not have the ability to understand and be understood by others. The MDS indicated Resident 2 required an extensive one-person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. According to the MDS, Resident 2 used a walker or wheelchair for mobility. A review of Resident 2's fall risk assessment, dated [DATE], indicated the resident was assessed as being at high risk for falls. A review of Resident 2's fall care plan, dated [DATE], indicated the resident was at risk for falls and injuries related to impaired mobility. The staff's interventions included evaluating Resident 2's current fall precaution interventions, monitor the resident's environment for items below field of vision and maintain the call light within reach and answer promptly. On [DATE] at 2:40 p.m., during an observation and concurrent interview, Resident 2's call light and bedside table was observed out of the resident's reach; Resident 2 was heard yelling for help. CNA 2 stated Resident 2 would knock her table over if placed within the resident's reach. CNA 2 stated Resident 2's call light should be within reach at all times. On [DATE] at 2:50 p.m., during an observation and concurrent interview, Resident 2's call light was observed in the drawer of the bedside table and out of the resident's reach. CNA 3 stated the call light should have been within Resident 2's reach, and that the call light was left in the bedside drawer after providing care. c. A review of Resident 3's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated the resident had a BIMS score of 6, and did not have the ability to understand and be understood by others. The MDS indicated Resident 3 required an extensive one-person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. According to the MDS, Resident 3 used a walker or wheelchair for mobility. A review of Resident 3's H/P, dated [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 3's fall risk assessment, dated [DATE], indicated the resident was assessed as being a high risk for falls. A review of Resident 3's fall care plan, dated [DATE], indicated the resident was at risk for falls and injuries related to impaired mobility. The staff's interventions included to evaluate Resident 3's current fall precaution interventions, monitor the resident's environment for items below field of vision, and maintain the call light within reach. On [DATE] at 6:33 p.m., during an observation and concurrent interview, Resident 3's call light was observed hanging from the wall, away from the resident, while the resident was in bed. LVN 1 stated the call light had to be within the resident's reach to prevent accidents. d. A review of Resident 4's Admission Face Sheet indicated Resident 4 was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's MDS, dated [DATE], indicated the resident had a BIMS score of 6, and did not have the ability to understand or be understood by others. The MDS indicated Resident 4 required an extensive one-person physical assist with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. According to the MDS, Resident 4 used a wheelchair for mobility. A review of Resident 4's fall risk assessment, dated 9//,[DATE], indicated the resident was assessed as being a high risk for falls. A review of Resident 4's fall care plan, dated [DATE], indicated the resident was at risk for falls and injuries related to impaired mobility and unsteady gait. The goal for this care plan indicated the staff would provide a safe environment to prevent falls. The staff's interventions included to evaluate Resident 4's current fall precaution interventions, monitor the environment for items below field of vision, maintain the call light within reach, and answer the call light promptly. On [DATE] at 6:39 p.m., during an observation and concurrent interview, Resident 4 was observed in bed slumped over on the left side with the call light observed out of the resident's reach. LVN 1 stated Resident 4 needed to be repositioned, and was observed searching for the resident's call light, which was found in Resident 4's bedside drawer. LVN 1 stated the call light should be within the resident's reach in case Resident 4 needed assistance. e. A review of Resident 5's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's MDS, dated [DATE], indicated Resident 5 did not have the ability to understand and be understood by others due to moderate cognitive impairment. The MDS indicated Resident 5 required an extensive one-person physical assist with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. According to the MDS, Resident 5 used a wheelchair for mobility. A review of Resident 5's H/P, dated [DATE], indicated the resident could not understand and make decisions. A review of Resident 5's fall care plan, dated [DATE], indicated the resident was at risk for falls and injuries related to impaired mobility and dementia. There was no staff interventions indicated for this care plan. On [DATE] at 6:35 p.m., during an observation and concurrent interview, Resident 5's call light and bedside table were observed out of the resident's reach. Resident 5 was observed confused and did not know if staff answered the call light in a timely manner. LVN 1 stated Resident 5's call light should be within the resident's reach. On [DATE] at 8:12 a.m., during an interview, the DON stated Resident 5 was not at risk for falls because the resident did not move. f. A review of Resident 6's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 6's [DIAGNOSES REDACTED]. A review of Resident 6's MDS, dated [DATE], indicated the resident did not have the ability to understand and be understood by others due to moderate cognitive impairment. The MDS indicated Resident 6 required an extensive physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. According to the MDS, Resident 6 used a wheelchair for mobility. A review of Resident 6's fall risk assessment, dated [DATE], indicated the resident was assessed as being at risk for falls. A review of Resident 6's fall care plan, dated [DATE], indicated the resident was at risk for falls and injuries related to impaired mobility. The staff's interventions included to evaluate Resident 6's current fall precaution interventions, anticipate needs, monitor the environment for items below field of vision, and maintain call light within reach. A review of Resident 6's H/P, dated [DATE], indicated the resident did not have the capacity to understand and make decisions. On [DATE] at 6:37 p.m., during an observation and concurrent interview, Resident 6's call light was observed at the head of the bed and out of the resident's reach. When asked, Resident 6 was not sure whether staff answered the call light. g. A review of Resident 7's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 7's [DIAGNOSES REDACTED]. A review of Resident 7's MDS, dated [DATE], indicated the resident did not have the ability to understand and be understood by others due to moderate cognitive impairment. The MDS indicated Resident 7 required an extensive physical assist with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. According to the MDS, Resident 7 used a wheelchair for mobility. A review of Resident 7's H/P, dated [DATE], indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 7's fall risk assessment, dated [DATE], indicated the resident was assessed as being at risk for falls. A review of Resident 7's fall care plan, dated [DATE], indicated the resident was at risk for falls and injuries related to impaired mobility. The staff's interventions included to evaluate Resident 7's current fall precaution interventions, anticipate needs, monitor the environment for items below field of vision and maintain call light within reach. On [DATE] at 6:40 p.m., during an observation and concurrent interview, Resident 7's call light was observed hanging from the wall and the resident's bedside table was out of the resident's reach. Resident 7 stated the staff were driving her crazy and did not answer her call light on time. Resident 7 stated her call light and remote control were far from her reach. On [DATE] at 6:45 p.m., during an interview, LVN 1 stated Resident 7's call light and bedside table should always be within reach for safety. h. A review of Resident 8's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 8's [DIAGNOSES REDACTED]. A review of Resident 8's MDS, dated [DATE], indicated the resident had the ability to understand and be understood by others. The MDS indicated Resident 8 required a one person physical assist with bed mobility, dressing, toilet use, and personal hygiene. According to the MDS, Resident 8 used a walker or wheelchair for mobility. A review of Resident 8's fall care plan, dated [DATE], indicated the resident was at risk for falls and injuries related to impaired mobility and right [MEDICAL CONDITION]. The staff's interventions included to evaluate Resident 8's current fall precaution interventions, anticipate needs, monitor the environment for items below field of vision and maintain call light within reach. The care plan indicated the staff were to answer Resident 8's call light promptly. A review of Resident 8's H/P, dated [DATE], indicated the resident had fluctuating capacity to understand and make decisions, with periods of forgetfulness. A review of Resident 8's fall risk assessment, dated [DATE], indicated the resident was assessed as being at risk for falls. On [DATE] at 7:14 a.m., during an observation and concurrent interview, Resident 8's call light was observed on the floor and out of the resident's reach. LVN 2 stated resident's call lights have to always be within reach for easy access and to prevent falls. On [DATE] at 7:15 a.m., during an interview, Resident 8 stated the staff took long hours to answer call lights. i. A review of Resident 9's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 9's [DIAGNOSES REDACTED]. A review of Resident 9's MDS, dated [DATE], indicated the resident did not have the ability to understand and be understood by others. The MDS indicated Resident 9 required an extensive physical assist with bed mobility, dressing, eating, toilet use, and personal hygiene. According to the MDS, Resident 9 used a wheelchair for mobility. A review of Resident 9's H/P, dated [DATE], indicated the resident did not have the capacity to understand and make decisions, due to advanced dementia. A review of Resident 9's fall risk assessment, dated [DATE], indicated the resident was assessed as being a risk for falls. A review of Resident 9's fall care plan, dated [DATE], indicated the resident was at risk for falls and injuries related to impaired mobility and unsteady gait. The staff's interventions included to evaluate Resident 9's current fall precaution interventions, anticipate needs, monitor the environment for items below field of vision and maintain call light within reach. The care plan indicated the staff were to answer Resident 9's call light promptly. On [DATE] at 6:45 p.m., during an observation and concurrent interview, Resident 9's call light was observed at the head of the bed and the bedside table was at the foot of the bed. CNA 2 stated that Resident 9 should have her table and call light within the resident's reach to prevent falls and injuries. j. A review of Resident 10's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 10's [DIAGNOSES REDACTED]. A review of Resident 10's MDS, dated [DATE], indicated the resident did not have the ability to understand and be understood by others. The MDS indicated Resident 10 required an extensive physical assist with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. According to the MDS, Resident 10 used a walker or wheelchair for mobility. A review of Resident 10's H/P dated [DATE], indicated the resident did not have the capacity to understand and make decisions, due to advanced dementia. A review of Resident 10's care plan, titled Falls, dated [DATE], indicated the resident was at risk for falls and injuries. The staff's interventions included to evaluate Resident 10's current fall precaution interventions, anticipate needs, monitor the environment for items below field of vision and maintain call light within reach, and answer the resident's call light promptly. A review of Resident 10's fall risk assessment, dated [DATE], indicated the resident was at risk for falls. On [DATE] at 7:12 a.m., during an observation and concurrent interview, Resident 10's call light was observed in the drawer of the bedside table out of the resident's reach. LVN 2 stated that Resident 10's call light and bed side table should be within the resident's reach because the resident was blind and at risk for falls. A review of the facility's policy titled, Fall Management Program, with a revised date of [DATE], indicated the facility would implement a fall management program by providing a safe environment that minimized complications associated with falls. A review of the facility's policy titled, Communication-Call System, with a revised date of [DATE], indicated the facility would provide a call system to enable residents to alert staff from their rooms, toilet and bathing facilities.

b. A review of the medical record indicated that Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the initial history and physical (no date) Resident 9 did not have the capacity to understand and make decisions. The admission nursing assessment, dated August 18, 2010 revealed that Resident 9 was admitted to the facility with left sided weakness and required one person assistance with transfers. A review of a Fall Risk Assessment, dated August 18, 2010 revealed that Resident 9 had a score of 13 indicating that she was considered a high risk for falls. The assessment indicated that a fall prevention protocol should have been initiated immediately and documented on the care plan. However, there was no documented evidence of the protocol on the care plan (8/18/10). A review of a resident care plan dated August 18, 2010, addressed Resident 9 being at risk for falls and injury due to a history of falls, poor safety awareness, unsteady gait and episodes of confusion. The nursing interventions included to identify factors that increase the resident's potential for falls, to eliminate factors that may increase the resident's potential for falls and to provide supervision as needed. However, the aforementioned approaches were not implemented when the direct care staff left Resident 9 alone in her room, sitting on the side/edge of her bed unassisted. An additional resident care plan dated August 20, 2010, addressed Resident 9 being at risk for falls due to poor balance and poor safety awareness. The nursing approaches included assessing the resident's degree of orientation and safety awareness to determine her safety needs and to assist the resident with transfers and mobility as needed. The nursing approaches were not implemented due to the direct care staff leaving Resident 9 sitting at the edge of the bed unassisted. According to the Occupational Therapy Notes starting August 18, 2010, the objectives of therapy included to increase Resident 9's sitting and standing balance. However, Resident 9's baseline status for sitting at the time was fair, and the resident required assistance and/or upper extremity support in order to maintain her balance while sitting. Resident 9's baseline status for standing at that time was poor requiring maximum assistance and upper extremity support to maintain her balance. According to the physical therapy progress report dated August 19, 2010, the objectives of the therapy included to increase Resident 9's right and left lower extremity strength as well as increasing her sitting balance due to the resident needing maximum assistance with all of these functions. The Minimum Data Set assessment dated [DATE], indicated Resident 9 required extensive assistance with bed mobility (how resident positions body while in bed) and was totally dependent on the staff for transfers, requiring two-person assistance with both task. Resident 9 was assessed as requiring physical help with her balance while standing and/or in a sitting position. As of October 12, 2010, the physical therapy progress notes indicated that skilled services needed to continue for Resident 9 in order to facilitate improved balance, safety awareness and to increase her lower extremity strength. However, Resident 9 experienced a fall the next day (10/13/10) due to the direct care staff ' s failure to provide maximum assistance as the resident sat on the side/edge of the bed. The nurses' progress notes dated October 13, 2010 at 10:30 a.m., indicated Resident 9 was found on the floor. It was documented that Resident 9 stated she tried to stand up and fell to the floor. It was indicated Resident 9 had a laceration to the upper and lower left eye. A review of the status [REDACTED]. The interdisciplinary resident safety investigation report dated October 13, 2010, indicated that Resident 9 had physical limitations that attributed to the fall including a balance deficit, an unsteady gait and weakness. In addition, it was indicated that Resident 9 was impulsive, unsteady and had poor safety awareness. It was documented that Resident 9 was found on the floor in her room. The nursing assistant left the resident's room and left Resident 9 sitting on the bed. Upon re-entering the room, Resident 9 was observed on the floor with a laceration to the upper and lower left eye with a moderate amount of bleeding noted. Resident 9 complained of pain to the upper shoulder area (right or left shoulder not indicated) and was transferred to the acute care hospital for further evaluation. The investigative report indicated that Resident 9's fall appeared to be avoidable. A physician's orders [REDACTED]. On October 20, 2010 at 1:15 pm, certified nursing assistant 1 stated that on the day of the fall incident she had Resident 9 sit on the edge of the bed and instructed the resident to hold onto the foot board of the bed. Nursing assistant 1 stated she left the resident unattended for approximately 1 minute while she went to get help from another nursing assistant. While preparing to transfer Resident 9 from the bed to the wheel chair, nursing assistant 1 again left the room for approximately 2 to 3 minutes. Upon nursing assistant 1's return to the room, she observed Resident 9 in the room by herself lying face down on the floor. Nursing assistant 1 stated she was aware that Resident 9 required two-person assistance with bed mobility and transfers and should not have been left unattended or left at the edge of bed by herself. On October 20, 2010 at 1:15 pm, certified nursing assistant 2 stated that Resident 9 was sitting up at the edge of the bed, holding onto the foot board. While waiting for nursing assistant 1 to return, nursing assistant 2 left Resident 9 unattended, sitting at the edge of the bed while she went to assist another resident in a different room. As nursing assistant 2 entered the hallway, she saw nursing assistant 1 walking down the hallway towards Resident 9's room. Nursing assistant 2 estimated that Resident 9 was left unattended approximately 1 to 2 minutes before nursing assistant 1 actually entered the resident's room and saw the resident on the floor. Nursing assistant 2 stated she was aware that Resident 9 was on physical and occupational therapy and felt the resident should not have been sitting on the edge of the bed by herself. Nursing assistant 2 stated she was aware that Resident 9 required two-person assistance with bed mobility and transfers. According to the consultation report from the acute care facility dated October 13, 2010, Resident 9 sustained a facial contusion and abrasion after a fall incident in the skilled nursing facility. A facility policy and procedure on fall prevention dated May 2010, indicated that the purpose of the policy was to identify residents at risk, to determine appropriate interventions, to implement actions to reduce the incidence of falls and to minimize the potential for injury. Based on observation, interview and record review, the facility's nursing staff failed to ensure 2 of 15 sampled residents (1, 9) remained free from injury as a result of falls. Resident 1 had a known behavior of leaning forward and rocking back and forth forcefully while sitting in his wheelchair. He sustained a laceration, cut and hematoma to his forehead and a displaced fracture to his left clavicle (collar bone), when he fell from his wheelchair on four different occasions between September 21, 2009 and September 26, 2010. Failure to determine appropriate interventions to reduce the incidence of falls, minimize the potential for injury, and monitor the resident's behavior of leaning forward and rocking back and forth resulted in Resident 1 sustaining injuries and placed him at risk for continued falls and injury. Resident 9 was left sitting on the edge of her bed and fell from the bed to the floor sustaining an injury while left unattended by two certified nursing assistants. The facility nursing staff failed to adequately supervise Resident 9 while sitting on the edge of the bed resulted in a fall and sustained a laceration to the upper and lower area of the left eye. Findings: a. A review of Resident 1's Admission Records, indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) Assessment (a standardized assessment and care screening tool), dated September 10, 2010, Resident 1's cognitive skills for daily decision-making were moderately impaired. He was assessed with [REDACTED]. He was totally dependent on the nursing staff for transfer, needed extensive assistance to move on and off the unit and never walked in his room or in the corridors. A Fall Risk Assessment, dated September 21, 2009, indicated a score of 15, placing Resident 1 at high risk for falls (a total score of 10 or above represents high risk). The assessment indicated for a score of 10 or greater a prevention protocol should be initiated immediately and documented on the care plan, this was not done. A Care Plan on Falls/Safety (no date) indicated Resident 1 had poor safety awareness, behavioral problems, constant involuntary movements and was at risk for falls. Goals indicated Resident 1 would be free from falls and/or injury daily. Interventions included assessing resident for needs, providing assistance as needed, ensuring all equipment was free from damage and malfunction and monitoring for falls. 1. An Incident Report and Interview Record, dated September 21, 2009, indicated the Activity Director 1 (AD 1), who no longer worked at the facility, assisted Resident 1 to the dining room, placed him in front of a television and walked back to his desk (approximately five feet away). AD 1 turned in time to see the resident fall; his lap buddy had been moved to the side. The resident hit his forehead on the floor, resulting in a small laceration on the resident's forehead. Interventions included nursing was to make frequent rounds made by nursing staff when the resident was in the activity/dining room. A Care Plan, dated September 21, 2009, indicated Resident 1 had a fall related to his poor safety awareness and unsafe balance/weakness. Goals indicated the resident would be able to transfer with moderate to extensive assistance with one person support without incidence of falls/injuries daily for one month. Approaches included checking at least every two hours for safety and positioning. An additional Care Plan, dated September 21, 2009, indicated Resident 1 was at risk for fall/injuries related to incontinence, seizure disorder, unstable gait, cognition, and psychotropic medications. Goals were to minimize the risk for fall in the next three months. Approaches included monitoring, anticipating and intervening for factors causing prior falls. A review of Resident 1's Medical Records and facility documentation, by the Director or Nursing (DON), indicated no written documentation that the resident was being monitored while in the activity/dining room or that causative factors were analyzed to prevent further falls and injuries. 2. A Post Fall Assessment and Interview Record, dated September 25, 2009, indicated a resident (unknown) alerted Licensed Vocational Nurse 5 (LVN 5), who no longer worked at the facility, that Resident 1 had fallen in the activity room. He was found on the floor on his left side with his lap buddy in place. He sustained a scratch and small hematoma to his left forehead. Interventions included assessing his wheelchair for safety. Licensed Personnel Progress Notes, dated September 25, 2009, at 5:50 a.m., indicated Resident 1 was found on the floor in the dining room. (The writer was alerted by another resident (unknown) that Resident 1 had fallen out of his wheelchair). The resident was lying on his left side with his lap buddy attached to his wheelchair. He was assessed with [REDACTED]. A review of Resident 1's Medical Records (Nursing Notes, Interdisciplinary Notes and Investigative Report following the incident) indicated no written documentation that the resident's wheelchair was assessed for safety. 3. An Incident Report, dated March 25, 2010, indicated Resident 1 was found on the floor in his wheelchair with his lap buddy in place in a reclined position. Nurses' Progress Notes, dated March 25, 2010, at 6:30 a.m., by LVN 6, who no longer worked at the facility; indicated Resident 1's room mate reported to her that the resident had fallen. The resident was found on the floor in his wheelchair with his legs in the air. 4. An Interdisciplinary Team Conference and Interview Record, dated September 26, 2010, indicated LVN 3 observed Resident 1 on the floor in the activity room after Activity Assistant 1 (AA 1) notified him that the resident had fallen. Resident 1 had previously been observed by AA 1 rocking in his wheelchair and was still in his wheelchair with the lap buddy in place when he was observed on the floor. The resident complained of left shoulder pain. Interventions included reminding the nursing staff to alert the charge nurse when the resident became agitated so appropriate interventions could be implemented and the resident was not to be left unattended in activities. A Diagnostic report, dated September 26, 2010, indicated a non-displaced distal left clavicle fracture. On October 19, 2010, at 9:55 a.m., during an interview, LVN 3 stated AA 1 reported to him that Resident 1 had fallen. He found the resident on the floor his wheelchair attached, and his lap buddy on. LVN 3 stated the resident had a habit of rocking back and forth in his wheelchair, sometimes more vigorously depending on his mood. On October 20, 2010, at 9:15 a.m., Resident 1 was observed sitting in a wheelchair in the dining room. He was sitting next to AD 2 and was rocking back and forth and leaning forward. There was no anti-tip device on his wheelchair. AD 2 stated rocking back and forth. Leaning forward was the resident's normal behavior, sometimes he moved more forcefully and slumps forward. She stated he should not be left unsupervised and keeps him close to her when he is in the activity room. On October 20, 2010, at 9:50 a.m., Resident 1 was observed by the Evaluator and the Administrator, sitting in the hallway. The wheelchair he was sitting in had no anti-tip device and the resident was rocking forcefully with his arms and legs thrashing about in an uncontrolled manner. On October 20, 2010, at 3:15 p.m., during an interview, AA 1 stated she was working Saturday, September 25, 2010, on the 8 a.m. to 5 p.m., shift and was the only staff in the activity room. She stated Resident 1 was sitting by the door rocking back and forth, she moved him to a table so he would not hit his head on the door, he began to rock more forcibly so she moved him to the desk. At the same time, another resident in the activity room wanted to go to the bathroom. She had to move another resident in order to assist the resident who wanted to go to the bathroom (the bathroom was located directly across the hall from the activity room). She turned her back to Resident 1 for a moment, looked back at him as he was tipping over backwards. On October 21, 2010, at 6:20 a.m., Resident 1 was observed sitting in the dining room at a table rocking back and forth and leaning forward. There was no staff in the room with the resident, he was unsupervised. On October 21, 2010, at 9:20 a.m., Resident 1 was observed in his room alone, sitting in a wheelchair leaning forward and rocking back and forth. On October 28, 2010, at 10:35 a.m., during an interview, the DON stated she was not aware of Resident 1's behavior of rocking and had never witnessed it. She was told about it by a nurse after the resident's last fall. On November 9, 2010, at 12:33 p.m., during an interview, Certified Nursing Assistant 7 (CNA 7) stated on October 12, 2010, (related to a complaint investigation #CA 852, see F221) she left Resident 1 alone in his room sitting in his wheelchair with his lap buddy in place. She was aware the resident should not be left alone without supervision but she had to go to an in-service and there was no one available in the dining room to watch him. A facility policy and procedure on fall prevention dated May 2010, indicated that the purpose of the policy was to identify residents at risk, to determine appropriate interventions, to implement actions to reduce the incidence of falls and to minimize the potential for injury.