Every finding on record at Chowchilla Memorial Healthcare District

Based on observation, interview, and record review, the facility failed to conduct background checks (a screening process that reviews past employment, education, criminal records, driving records prior to hire) according to the facility's policy when five of five sampled employees (Licensed Vocational Nurse [LVN] 2, LVN 3, Certified Nurse Assistant [CNA] 1, CNA 2, CNA 3) did not have background or reference checks in their personnel files.This failure placed residents at risk for abuse which could lead to serious physical and psychological harm (lasting mental harm caused by severe distressing events that overwhelm an individual's ability to cope).Findings: During a concurrent interview and record review on 2/18/26 at 2:14 pm with the Director of Nurses (DON), LVN 2's personnel file (PF), dated 11/5/21 was reviewed. The PF indicated LVN 2 was hired on 11/5/21 and the facility did not perform a check of LVN 2's previous employment records (ER), or verification the applicant was a not on the Office of Inspector General Exclusion Program's (OIG) list of excluded individuals/Entities (LEIE - individuals with reported cases of patient abuse or neglect). The DON stated their Human Resources (HR) completed the screening and hiring process, and she did not know why the background screening was not completed.During a concurrent interview and record review on 2/18/26 at 2:16 pm with the DON, LVN 3's PF dated 1/7/09 was reviewed. The PF indicated LVN 3 was hired on 1/7/09 and the facility did not perform a check of LVN 3's ER, or verification the applicant was not on the OIG list of LEIE. The DON stated HR completed the screening and hiring process, she did not know why the background screening was not completed.During a concurrent interview and record review on 2/18/26 at 2:18 pm with the DON, Certified Nurse Assistant (CNA) 1's PF, dated 1/26/26 was reviewed. The PF indicated CNA 1 was hired on 1/26/26 and the facility did not perform a check of CNA 1's ER, or verification the applicant was a not on the OIG list of LEIE. The DON stated HR completed the screening and hiring process, she did not know why the background screening was not completed.During a concurrent interview and record review on 2/18/26 at 2:20 pm with the DON, CNA 2's PF dated 10/28/25 was reviewed. The PF indicated CNA 2 was hired on 10/28/25 and the facility did not perform a check of CNA 2's ER, or verification the applicant was not on the OIG list of LEIE. The DON stated HR completed the screening and hiring process, and she did not know why the background screening was not completed.During a concurrent interview and record review on 2/18/26 at 2:25 pm with the DON, CNA 3's PF dated 1/26/26 was reviewed. The PF indicated CNA 3 was hired on 1/26/26 and the facility did not perform a check of CNA 2's ER, or verification the applicant was not on the OIG list of LEIE. The DON stated HR completed the screening and hiring process, and she did not know why the background screening was not completed. The DON stated she could understand why a background check would be important.During a concurrent interview and record review on 12/18/25 at 2:30 p.m. with the Administrator (ADM), the facility's policy and procedure (P&P) titled, Employment Policy, dated 01/26 was reviewed. The PNP indicated, . Prior to hiring a new employee, Human Resources will do the following: Verifying via the internet status of certification and licenses of applicants, if required for a position, through respective California Licensing boards. Verify through the Office of Inspector General Exclusion Program (OIG), website (List of Excluded Individuals/Entities (LEIE), any reported cases of patient abuse or neglect. The ADM stated, In Chowchilla everyone knows everybody. We have never done background checks. The ADM stated he was aware that background checks were mandatory and will help protect the residents from abusive employees.During an interview on 12/18/25 at 4:30 p.m. with the facility's Chief Executive Officer (CEO), the CEO stated, the facility had always been a small facility, has never checked backgrounds and most of the staff were referred by other employees. The CEO stated she was aware that background checks were a State and Federal requirement as well as the facility's Employment Policy.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary environment when:A bowl of shredded cheese, a bowl of sour cream and a bowl of sliced jalapenos were prepared and stored undated and unlabeled inside refrigerator 1.An opened bag of dry cereal was undated and unlabeled inside the dry storage room.These failures had the potential to contaminate resident food sources that could cause foodborne illness (feeling sick or not healthy) in a vulnerable population resulting in severe patient harm.Findings: 1.During an observation on 2/17/26 at 10:03 a.m. inside refrigerator 1, a bowl of shredded cheese, a bowl of sour cream and a bowl of sliced jalapenos were prepared to serve and stored undated and unlabeled.During an interview on 2/19/26 at 11:56 a.m. with the Certified Dietary Manager (CDM), the CDM stated a bowl of shredded cheese, a bowl of sour cream and a bowl of sliced jalapenos, stored inside refrigerator 1 were undated and unlabeled. The CDM stated the cheese, sour cream and jalapenos had been prepared Monday [2/16/26] for taco Tuesday lunch [2/17/26]. The CDM stated the policy for food receiving and storage required that once food was opened, prepared and stored in the refrigerator or freezer, it must be dated and labeled. The CDM stated the importance of labeling food was to acknowledge when the food was received, opened and to make sure nothing was expired. The CDM stated food with no date or label should be discarded, as consuming it could cause an upset stomach.During an interview on 2/19/26 at 2:15 p.m. with the Registered Dietician (RD), the RD stated, I expect all food items to be labeled and dated. The RD stated food with no date and label should be thrown away. The RD stated the importance of labeling and dating food was to ensure food safety.2. During a concurrent observation and interview on 2/18/26 at 1:45 p.m. with the CDM inside the dry storage room, an opened bag of dry cereal was undated and unlabeled. The CDM stated, it is important to date and label the food to determine its freshness. The CDM stated the label and date on the dry cereal had worn off and was no longer visible, therefore the product should be discarded. The CDM stated labeling and dating food was important to ensure quality and safety for the residents.During an interview on 2/19/26 at 2:25 pm with the RD, the RD stated the opened bag of dry cereal inside the dry storage room was undated and unlabeled. The RD stated all food items should be labeled and dated. The RD stated kitchen staff were responsible for all the food items once they entered the kitchen and must be properly labeled and dated. The RD stated improper labeling and dating food items may compromise health risk and may cause someone to become sick.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated November 2022, the P&P indicated, . Dry foods that are stored. labeled and dated. All foods stored in the refrigerator. are covered, labeled and dated.

Based on observation, interview, and record review, the facility failed to follow infection control and prevention standards of practice and provide a safe and sanitary environment to help prevent infection for four of six sampled residents (Resident 7, Resident 9, Resident 27, and Resident 28), when Licensed Vocational Nurse (LVN) 1 did not disinfect a shared resident blood pressure cuff (a medical device used to measure blood pressure) after resident care. This failure resulted in Resident 7, Resident 9, Resident 27, and Resident 28 being exposed to reusable medical equipment that had not been cleaned in between use which could result in the development and spread of infections. Findings: During an observation on 2/18/26 at 8:19 a.m. in Resident 7's room, LVN 1 took Resident 7's blood pressure using a blood pressure cuff without properly cleaning it before use. LVN 1 was observed exiting Resident 7's room with the blood pressure cuff and placed it into the medication cart without properly cleaning or disinfecting the cuff after use. During an observation on 2/18/26 at 8:40 a.m. in the Activities room, LVN 1 took Resident 9's blood pressure, with the same blood pressure cuff, without disinfecting the blood pressure cuff from use with the prior resident. LVN 1 exited the room after taking Resident 9's blood pressure and placed the cuff into the medication cart without properly cleaning or disinfecting it. During an observation on 2/18/26 at 8:47 a.m. in Resident 27's room, LVN 1 took Resident 27's blood pressure without disinfecting the blood pressure cuff, from use with the prior resident. LVN 1 exited the room with the blood pressure cuff and placed it into the medication cart without properly disinfecting the cuff.During an observation on 2/18/26 at 9:20 a.m. in the hallway near the medical records office, LVN 1 took Resident 28's blood pressure, without disinfecting the blood pressure cuff, from use with the prior resident. LVN 1 placed the blood pressure cuff into the medication cart without properly disinfecting the cuff.During an interview on 2/18/26 at 2:57 p.m. with LVN 1, LVN 1 stated she should have properly cleaned the blood pressure cuff in between use of residents. LVN 1 stated it was important to properly disinfect all equipment shared between residents to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). During an interview on 2/19/26 at 10:27 a.m. with the Director of Nursing (DON), the DON stated the expectation was for the nursing staff to disinfect equipment shared between residents. The DON further stated it was important to prevent the spread of infections. During a review of facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 8/18, the P&P indicated, .Resident- care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection.1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care.c. Non-critical items are those that come in contact with intact skin but not mucus membranes. (1) non- critical resident care items include bedpan, blood pressure cuffs. (2) Most non-critical reusable items can be decontaminated where they are used.d. Reusable items are cleaned and disinfected or sterilized between residents.Reusable resident care equipment will be decontaminated and or sterilized between residents.During a review of the CDC's .gov Professional Reference titled, CDC's Core infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, (found at https://www.cdc.gov/infection-control/hcp/core-practices/index.html#:~:text=Require%20routine%20and%20targeted%20cleaning,benefits%20of%20the%20available%20options.) the reference indicated, .Use Standard Precautions to care for all patients in all settings. Standard Precautions include.Environmental cleaning and disinfection.Reprocessing of reusable medical equipment between each patient or when soiled.Standard Precautions are the basic practices that apply to all patient care, regardless of patient's suspected or confirmed infections state.Reprocessing of reusable medical equipment .1. Clean and reprocess (disinfect or sterilize) reusable medical equipment (e.g.blood pressure cuffs.) prior to use on other patients or when soiled.

Based on observation, interview, and record review, the facility failed to ensure proper storage and disposal of medication and biologics in accordance with facility policy and procedures in one of one sampled medication cart and one of one sampled wound cart when:1.In the medication cart an inhaler (A device for giving medicines in the form of a spray that is inhaled (breathed in) through the nose or mouth) was observed opened and used despite being past the expiration date. This failure had the potential to cause an increased risk of contamination, unsafe administration, and reduced effectiveness which could cause inadequate treatment of illnesses.2. The wound treatment cart was left unlocked and unattended.This failure had the potential for residents to gain access to the medications, and sharp instruments used to treat wounds and could potentially injure themselves or contaminate sterile equipment.Findings: 1. During a concurrent observation and interview on 2/18/26 at 2:20 p.m. with Licensed Vocational Nurse (LVN) 1 at the medication cart, Resident 18's inhaler was observed with an orange-colored label that indicated, Date opened 12/31/25 discard 42 days after opening. Discard on 2/10/26. LVN 1 stated the inhaler had expired and should have been removed from the medication cart and disposed of. LVN 1 stated it was the night shift's nurse's responsibility to check for expired and discontinued medications. LVN 1 further stated that, ultimately, it was the responsibility of all nurses to check the medication cart. LVN 1 indicated there was no logbook or method to track whether checks of the medication cart for outdated items had been completed. During a concurrent interview and record review on 2/18/26 at 4:33 p.m. with LVN 1, Resident 18's Pharmacy Order Summary (POS), indicated Resident inhaler in question was discontinued on 1/13/26. LVN 1 stated it was important to remove all expired medications and discontinued medications to reduce the potential for medication errors. During an interview on 2/19/26 at 10:27 a.m. with the Director of Nursing (DON), the DON stated and acknowledged Resident 18's inhaler expired. The [NAME] stated it was the expectation of the night shift nurses to complete weekly checks of the medication cart for all outdated and discontinued medication and dispose of the medications properly. The DON stated it was important to complete the weekly medication cart checks to reduce the potential harm for medication errors. 2. During a concurrent observation and interview on 2/17/26 at 12:20 p.m. with LVN 2, in the hall outside Nurse Station One, the wound treatment cart was observed unlocked without any staff present. LVN 2 stated the wound treatment cart should be locked so the residents did not get into the cart and take another resident's medication or have access to sterile supplies that were kept in the cart. During an interview on 2/17/26 at 12:23 p.m. with the DON, the DON stated the wound cart should be locked at all times to prevent residents from getting into the wound cart and injuring themselves. During a review of the facility's Policy & Procedure (P&P) titled, Medication Storage, dated 01/2023, indicated . In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications . are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access .Outdated, contaminated, discontinued or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication disposal.

Based on observation, interview, and recorded review, the facility failed to provide a written notice, including the reason for change, prior to moving one of 12 sampled residents (Resident 20), to a different room within the facility.This failure resulted in Resident 20 being moved without appropriate written communication which had the potential to result in emotional distress and a violation of the resident's rights to make informed decisions regarding her care environment.Findings:During a concurrent observation and interview on 2/18/26 at 12:03 p.m. with Resident 20, in Resident 20's room. Resident 20 stated she had been moved to a new room a few days after she was admitted on [DATE] but did not receive written notice of the change and was not asked to sign anything. Resident 20 stated staff spoke with her about the room change but she was still unsure about the reason for the room change. Resident 20 further stated staff wanted her down the hall to be alone.During the concurrent interview and record review on 2/19/26 at 10:27 a.m. with the Director of Nursing (DON), Resident 20's Electronic Medical Record (EMR), undated was reviewed. The DON stated and acknowledged no written notice or supporting documentation was provided to Resident 20 prior to the room change. The DON stated the facility did not have a specific written policy to room changes and reported the facility provided verbal notice, documented the notification through progress notes and monitored the residents for three days. During the interview the surveyor reviewed the regulatory requirements for advanced notice with the DON, the DON stated she was unaware the written notice was required. The DON stated and acknowledged it was important for a resident to receive documentation so they could be properly informed and have the right to make a choice. The DON further stated she documented Resident 20 was agreeable to the move. The DON stated the EMR indicated a progress note entered as a late entry indicated the note did not state advanced written notice was provided nor did it include documentation of the reason for the room change. The facility was unable to provide documentation demonstrating compliance with the requirement to provide advance written notice prior to a room change.During a review of the facility's document titled, Resident Rights, undated, the document indicated, Quality of Life.Accommodation of needs. (2) Receive verbal notice before the resident's room or roommate in the facility is changed-alert charting for up to 3 days. The documentation did not reference advance written notice. The facility was unable to provide a written policy or procedure addressing the requirement for advanced written notice prior to a room change.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for one of three sampled residents (Resident 1), when Resident 1 was assessed to be at risk for falls and had a history of falls and effective interventions were not implemented to prevent a fall on 7/20/25. Resident 1 was assessed to have an unsteady gait (manner of walking), required to have one staff member assisting her with toileting, had falls on 9/7/23, 9/12/23, 1/3/24, and 8/29/24 and fell on 7/20/25. On 7/20/25, Resident 1 was assisted to sit on the toilet to void, staff stepped out of the bathroom, left her alone and Resident 1 fell and injured her left hip. These failures resulted in Resident 1 not being provided with the level of assistance and supervision needed to prevent a fall, suffered a hip injury requiring emergency transport to an acute care hospital for care and services and diagnosed with a fracture (break in the bone) to the left intertrochanteric femur (near the hip on the thigh bone). Resident 1 was sent back to the skilled nursing facility (SNF) without surgical intervention, was in pain despite as needed (PRN) and routine pain medications, declined in mobility, and decline in appetite, and died on 7/26/25 due to complications of the fall.During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history), dated 7/22/25, the AR indicated Resident 1 had diagnoses which included .UNSPECIFIED DEMENTIA [a progressive state of decline in mental abilities].MUSCLE WEAKNESS.ABNORMALITIES OF GAIT AND MOBILITY [ability to move freely and easily].REPEATED FALLS.During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 5/12/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 5 (0-7 severe cognitive impairment (an intense inability to think, remember, use judgement and make decisions), 8-12 moderate cognitive impairment (lessened ability to think, remember, use judgement and make decisions), 13-15 no cognitive impairment), which indicated Resident 1 had severe cognitive impairment.During an interview on 8/5/25 at 9:50 a.m. with the Director of Nursing (DON), the DON stated Resident 1 was on hospice with comfort measures (specialized care that focuses on a person's quality of life and dignity as they near the end of their life) prior to her fall. The DON stated Resident 1 was able to ambulate (walk) to the bathroom with assistance from a certified nursing assistant (CNA). The DON stated, CNA 1 was Resident 1's CNA when she fell in the bathroom. The DON stated the hospice company and Resident 1's physician were consulted and Resident 1 was sent to the acute care hospital because she continued to complain of pain and there was unevenness to the left leg. The DON stated Resident 1 was diagnosed at the hospital with a fracture of the left intertrochanteric femur. The DON stated Resident 1's Responsible Party (RP) was informed of the risks and benefits of surgery. The DON stated Resident 1's RP declined surgery due to Resident 1 being on hospice and she was not likely to survive surgery. The DON stated Resident 1 was brought back to the SNF to continue hospice services and to be kept comfortable. The DON stated Resident 1 had new orders to be on bed rest, to keep the leg comfortable and for pain control. The DON stated Resident 1 declined after the fall because she did not want to eat. During a concurrent interview and record review on 8/5/25 at 10:45 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's MDS Section GG- Functional Status (MDSGG), dated 5/7/25 was reviewed. The MDSGG indicated, .Mobility.Coding: . If helper assistance is required because resident's performance is unsafe.score according to amount of assistance provided.03. Partial/moderate assistance- Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.Toilet transfer The ability to get on and off a toilet or commode [portable toilet which enables a patient to sit comfortably]. The MDSGG indicated, a code of 03 was selected for Resident 1's toilet transfer mobility. LVN 1 stated Resident 1's MDSGG indicated Resident 1 needed partial assistance from staff for toilet transferring, which was the ability to get on and off the toilet. LVN 1 stated prior to her fall, Resident 1 drank nutritional drinks as her main source of nutrition instead of eating food and rarely needed PRN pain medications. LVN 1 stated Resident 1 had prior falls where she would suddenly and unexpectedly move and fall down. LVN 1 stated Resident 1 fell on 7/20/25 at 6:30 a.m. LVN 1 stated CNA 1 assisted Resident 1 to the bathroom, sat her on the commode and then CNA 1 left the bathroom to go to Resident 1's closet. LVN 1 stated CNA 1 saw Resident 1 standing up from the commode and witnessed her fall. LVN 1 stated Resident 1 was diagnosed with a left hip fracture at the hospital. LVN 1 stated Resident 1 was in pain, so nurses administered PRN pain medications more frequently. LVN 1 stated Resident 1's PRN medications were changed to be administered routinely to keep her as comfortable as possible due to the increased pain she was experiencing. LVN 1 stated Resident 1 became more tired, possibly from the side effects of taking pain medications more frequently. LVN 1 stated Resident 1's food intake declined and was not drinking her usual nutritional drinks. LVN 1 stated Resident 1 passed away on 7/26/25, which was 6 days after she fell. LVN 1 stated it was important to provide Resident 1 with the supervision necessary to prevent accidents because it could have prevented her fall, injury, pain and death. LVN 1 stated Resident 1 was living an uneventful life and this fall changed that for her. During a phone interview on 8/5/25 at 11:22 a.m. with CNA 1, CNA 1 stated Resident 1 was confused at times, but could say her preferences and liked a usual routine. CNA 1 stated Resident 1 could transfer with the assistance of one person. CNA 1 stated on 7/20/25 at 6:30 a.m. CNA 1 noticed Resident 1 was attempting to get up to use the bathroom. CNA 1 stated she assisted Resident 1 to walk to the bathroom located inside Resident 1's room. CNA 1 stated she assisted Resident 1 to sit down on the commode and then stepped out of the bathroom but left the door open. CNA 1 stated Resident 1 had a commode located over the toilet in the bathroom. CNA 1 stated Resident 1 was adjusting herself on the toilet, got up too quickly, lost her balance and fell. CNA 1 stated she could not get to Resident 1 quickly enough before she fell. CNA 1 stated the door to Resident 1's bathroom was too narrow for her to reach Resident 1 before she fell. CNA 1 stated she was unable to quantify how far away she was from Resident 1 when she fell. CNA 1 stated she left Resident 1 in the bathroom to give her privacy. CNA 1 stated Resident 1 fell on her left side straight down on her left hip and was complaining of pain. CNA 1 stated Resident 1 appeared to be scared after the fall. CNA 1 stated Resident 1 was sent to the hospital due to the significant pain. CNA 1 stated Resident 1 came back from the hospital and stopped being able to get up to use the bathroom due to being bed bound. CNA 1 stated Resident drank less of her nutritional drinks after the fall and then passed away. CNA 1 stated it was important to provide Resident 1 with the necessary supervision to prevent accidents because the staff did not want her to get injured or to fall. During an observation on 8/5/25 at 11:34 a.m. in Resident 1's former bathroom, a commode was positioned over the toilet with silver hand railing noted to the left of the toilet and in front of the toilet. The space between the toilet and the wall in front of the toilet appeared to be approximately 3 feet. During an interview on 8/5/25 at 11:39 a.m. with CNA 2, CNA 2 stated Resident 1 had fallen in the past and did not have good balance. CNA 2 stated Resident 1 required one person to assist her. CNA 2 stated she would bring Resident 1 to the hallway bathroom when she needed to use the bathroom because it was more spacious. CNA 2 stated Resident 1 required one person to stay with her while toileting. CNA 2 stated CNA 1 told CNA 2 that Resident 1 was in the bathroom when CNA 1 left to get something for Resident 1 to put on and then Resident 1 fell. CNA 2 stated Resident 1 went to the hospital. CNA 2 stated Resident 1 was in pain when staff would reposition her, was on bedrest, received bed baths and could not get up to use the toilet. CNA 2 stated Resident 1's intake of her nutritional drinks declined until it stopped, it was difficult to understand what Resident 1 was trying to say and then she passed away. CNA 2 stated, it was important to provide Resident 1 with the supervision necessary to prevent accidents because she was not able to recover after breaking her hip and subsequently passed away. CNA 2 stated CNA 1 should have stayed with her at all times and not stepped away for a second in order to prevent Resident 1's fall. During a phone interview on 8/5/25 at 11:59 a.m. with LVN 2, LVN 2 stated Resident 1 had prior falls and was a fall risk. LVN 2 stated Resident 1 fell in the bathroom and was lying with her legs towards the inside of the bathroom, head positioned towards the bathroom door and was lying on her left side. LVN 2 stated she did an assessment on Resident 1, and she was complaining of left hip pain with a skin tear to her left elbow. LVN 2 stated the hospice company was notified of Resident 1's fall, hospice informed Resident 1's family and the family desired for Resident 1 to be sent to the hospital. LVN 2 stated CNA 1 did not have enough time or space to catch Resident 1 as she fell. LVN 2 stated in the days following Resident 1's fall, she began declining, talking less, not drinking her nutritional drinks anymore and then passed away. LVN 2 stated it was important to provide Resident 1 with the supervision necessary to prevent accidents to ensure her safety and to prevent falls. During a concurrent interview and record review on 8/5/25 at 12:19 p.m. with the DON, Resident 1's MDSGG, dated 5/7/25 was reviewed. The MDSGG indicated, .Mobility.Coding: .If helper assistance is required because resident's performance is unsafe.score according to amount of assistance provided.03. Partial/moderate assistance- Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.Toilet transfer The ability to get on and off a toilet or commode. The MDSGG indicated a code of 03 was selected for Resident 1's toilet transfer mobility. The DON stated Resident 1 required partial assistance from one person to assist her with toilet transferring according to her MDSGG. The DON stated Resident 1 fell on 7/20/25. The DON stated Resident 1 was confused, complaining of pain and had decreased appetite after her fall. The DON stated Resident 1's pain medication changed from PRN to routine in an attempt to keep her comfortable. The DON stated Resident 1 passed away on 7/26/25. During a phone interview on 8/7/25 at 1:47 p.m. with the Hospice Clinical Supervisor (HCS), the HCS stated Resident 1 was placed on hospice in November 2023 with a diagnosis of heart disease (group of conditions affecting the heart and blood vessels). The HCS stated Resident 1's condition was fairly stable during this time, although Resident 1 had some falls. The HCS stated Resident 1 was confused intermittently but was able to make her needs known. The HCS stated Resident 1 did not require many PRN medications prior to her fall on 7/20/25. The HCS stated Resident 1 required 1 person assistance and should not have been left alone to use the bathroom on 7/20/25.During a phone interview on 8/12/25 at 11:47 a.m. with CNA 2, CNA 2 stated she had taken care of Resident 1 during the month when Resident 1 fell. CNA 2 stated her usual practice was to take Resident 1 to the bathroom in the hallway because she would take Resident 1 to the bathroom in a wheelchair, and it could fit Resident 1's wheelchair inside of it. CNA 2 stated Resident 1 was not safe to be left alone in the bathroom and needed to stay in close proximity to her. CNA 2 stated Resident 1 could make her preferences known, like if she wanted privacy or independence in the bathroom, but Resident 1 had never expressed to CNA 2 she wanted privacy or independence. During a phone interview on 8/12/25 at 3:44 p.m. with CNA 1, CNA 1 stated Resident 1 was able to ambulate to the bathroom with CNAs guiding her by hand. CNA 1 stated Resident 1 could not pivot (to turn or rotate) after standing up from the toilet. CNA 1 stated she did not observe a decline in Resident 1's mobility and function prior to her falling. CNA 1 stated if a resident required partial assistance, she would be really close to them in proximity. CNA 1 stated if a resident was attempting to stand up, she would be right next to them. CNA 1 stated Resident 1 needed assistance with activities which required greater movement, like using the bathroom. CNA 1 stated she left Resident 1's bathroom on 7/20/25 because she thought Resident 1 wanted independence. CNA 1 stated Resident 1 did not tell her on 7/20/25 prior to her fall she wanted to be independent. CNA 1 stated in the past, she would occasionally take Resident 1 to the bathroom in the hallway. CNA 1 stated on 7/20/2025, she took Resident 1 to the bathroom in her room because it was closer and more convenient. During a concurrent phone interview and record review on 8/15/25 at 10:45 a.m. with the DON, Resident 1's Fall Risk Evaluation (FRE), dated 5/12/25 was reviewed. The FRE indicated, .Score: 11.Category: At Risk.Level of consciousness/mental state.Intermittent confusion.Ambulation/ elimination [removal of waste from the body] status.Chair bound.assist with elimination.Gait/balance.Balance problem while standing.Balance problem while walking. The DON stated Resident 1 started hospice on 11/17/23. The DON stated Resident 1 had a history of multiple falls. The DON stated since starting hospice, Resident 1 had falls on 9/7/23, 9/12/23, 1/3/24, 8/29/24, and 7/20/25. The DON stated according to Resident 1's FRE, her score of 11 meant she was at risk for falls. The DON stated CNA 1 said she could not fit in Resident 1's bathroom with Resident 1 while Resident 1 was voiding. The DON stated the expectation was CNA 1 should have been with Resident 1 while she used the bathroom and to assist as needed. The DON stated there was no known decline in Resident 1's abilities prior to her fall on 7/20/25. The DON stated CNA 1 was outside Resident 1's bathroom and could not get to her quickly enough before Resident 1 fell. During a review of Resident 1's Care Plan Report (CPR), dated 7/15/21, the CPR indicated, .Resident has history of falling [related to] unsteady gait.Interventions.Ask any other staff member to help stay with other residents when transferring other residents or getting supplies.[Interdisciplinary Team- group of health care professionals with various areas of expertise who work together toward resident goals (IDT)] to review fall on 9/12/23.IDT to review unwitnessed fall with laceration [cut] to left forehead requiring 5 sutures [stitches to hold the edges of a wound together] on 1/11/23.IDT will review fall from 9/7/23.Provide toileting assistance as needed. During a review of Resident 1's Progress Notes (PN), dated 7/20/25, the PN indicated, .At approximately [6:30 a.m.] this writer was called upon to residents' room by CNA. Upon entering room resident was noted on the bathroom floor laying on her left side with her leg and hip under her and her head slightly raised.resident.lost her balance when she was holding on to the rails to either side of her and fell to the ground.Resident present with two skin tears to left elbow. When palpating [to examine by touching] left leg resident shouted out in pain. Resident stated it hurts.PRN medication given as ordered. Resident continues to [complain of (c/o)] left hip pain. [Hospice company name] contacted. RP requested to have resident sent out for further evaluation. [Doctor of Medicine (MD)].called and agreed with Hospice order to send out .During a review of Resident 1's Hospice Narrative Note (NN), dated 7/20/25, the NN indicated, .phone call.stating that [patient (pt)] suffered a fall [at 6:30 a.m.] fell in bathroom fall was a witnessed fall, pt had c/o pain to [left (L)] hip.2 skin tears to L elbow, pt having c/o pain to L hip 10/10 (a pain level based on a numerical scale where 1 is the lowest pain and 10 is the most severe pain), pt cannot ambulate and said she cannot do it.Patient sent out to [Hospital name].During a review of Resident 1's [Skilled Nursing Facility/Nursing Facility- facilities which provide care to residents twenty-four hours a day, seven days a week (SNF/NF)] to Hospital Transfer Form (HTF), dated 7/20/25, the HTF indicated, .[Resident 1].Relevant diagnosis.Dementia.Pain location Left trochanter (hip).Ambulates only with human assistance.[Activities of Daily Living- basic self-care tasks that individuals perform to maintain their well-being (ADL)].A = Needs Assistance.Toileting.Transfers.Usual Mental Status/Cognitive Function before the Acute Change in Condition.Alert, disoriented, but can follow simple instructions.High fall risk.Skin tear to left elbow. The HTF indicated check marks placed in the boxes next to Toileting and Transfers indicated Resident 1 Needs Assistance for both tasks. During a review of Resident 1's PN, dated 7/20/25, the PN indicated, .this writer received report from.nurse.from [name of hospital].emergency department. Verbal preliminary x-ray results of positive left intertrochanteric femoral fracture.During a review of Resident 1's Hospital Discharge Instructions Document (DID), dated 7/20/25, the DID indicated, .Reason for Visit.1) Fall 2) Hip pain-swelling.Discharge Diagnosis Hip fracture Fall Dementia.During a review of Resident 1's Hip and Pelvis [area of the body located between the hip bone] X-ray (imaging technique used to visualize bones in the body) Final Report (XFR), dated 7/20/25, the XFR indicated, .Reason For Exam fall.Technique: [X-ray] Hip [with] Pelvis 2 Views.Findings.Acute [sudden onset] comminuted [broken in two places or more] left intertrochanteric femoral fracture.During a review of Resident 1's PN, dated 7/20/25, the PN indicated, .At approximately [2:45 p.m.] resident returned from acute care.Per hospice [discontinue (DC)] new hospital orders and continue with current orders.[hydrocodone/acetaminophen- type of pain medicine] 5-325 mg [unit of weight] [by mouth (PO)] [tablets (tabs)] [every (Q)] 6 [hours] PRN.During a review of Resident 1's Hospice NN, dated 7/20/25, the NN indicated, .Hospital found Fractured femur and chronic fractured pubic bone [a break in a bone located in the pelvis that occurred a long time ago].PRN visit made, pt.stated she has pain with movement 8/10.pt will be on bed rest for a few days. Orders added for bed bath, pre-medicating pt before repositioning and assisting with repositioning.During a review of Resident 1's PN, dated 7/22/25, the PN indicated, .Noted that resident doesn't have much of an appetite and isn't as interested in drinking her [nutritional drink] as she was prior to fall.During a review of Resident 1's PN, dated 7/22/25, the PN indicated, .Resident has some pain when turning and moving during changing.resident is eating 50% of [nutritional drink]. Leg is warm to touch and slightly swollen.During a review of Resident 1's PN, dated 7/23/25, the PN indicated, .Resident was awake most of the night. Resident didn't sleep even with pain medication, resident is not drinking much water or [nutritional drink] at this time.During a review of Resident 1's PN, dated 7/23/25, the PN indicated, .resident noted with decreased fluid intake. Resident refused lunch an alternative meal was provided. Resident continued to refuse alternative meal.Resident noted with facial grimacing and moaning. PRN medication administered as ordered for pain.During a review of Resident 1's PN, dated 7/23/25, the PN indicated, .Resident continues to be medicated with Pain medication prior to repositioning, but still has pain noted during repositioning. Resident appetite noted to be less, even when offered her favorite supplement chocolate [nutritional drink]. Discoloration noted to bilateral heels.During a review of Resident 1's PN, dated 7/24/25, the PN indicated, .At approximately [10:00 a.m.] [Hospice company name] [Registered Nurse (RN)].in house, new orders to change [hydrocodone/acetaminophen] 5-325 1 tab Q 6 [hours] PRN to Routine Q 6 [hours]. MD.notified via phone.Agrees with [treatment (tx)].During a review of Resident 1's Hospice NN, dated 7/25/25, the NN indicated, .Pt is having a change of condition due a recent fall.Pt did not wake when this [Social Worker] greeted pt with a gentle tone.During a review of Resident 1's PN, dated 7/25/25, the PN indicated, .New orders received to start resident on puree diet [diet where foods are blended into a smooth, pudding-like consistency], and orders to apply skin prep [preventative measure and treatment used to protect and prepare the skin, to promote healing and prevent further breakdown] to discoloration to bilateral [both] heels.During a review of Resident 1's PN, dated 7/26/25, the PN indicated, .This writer entered resident's room to give her her 6 am medications and it was noted resident was no longer breathing and had no pulse. [Hospice company name] was called and [Hospice staff member name].arrived at.[5:15 a.m.]. Time of death called at [5:20 a.m.].[Hospice staff member name] notified family and funeral home.Resident's daughter in law in facility at this time awaiting arrival of funeral home to pick up remains.During a review of Resident 1's Order Summary Report (OSR), dated 7/22/25, the OSR indicated, .Order Date Range: 07/20/2025-07/31/2025.Assist resident with repositioning until resident is able to reposition self again.Pre-medicate resident with [hydrocodone/acetaminophen], or morphine [pain medicine] prior to significant movement to keep resident comfortable.Resident to be on bed rest starting 7/20/2025 to alleviate pain.Resident to be on complete bed rest and to have BED BATH only, no shower until pain to left hip resolved.Send to [hospital name] [emergency room (ER)] post [after]-witnessed [observed] fall.During a review of Resident 1's DEATH SUMMARY (DS), dated 7/29/25, the DS indicated, .[Resident 1].date of death : 07/26/2025.ADMITTING DIAGNOSES.Repeated falls.Gait disorder with use of walker.HOSPITAL COURSE: The patient.who was admitted for continuation of medical care and rehabilitation.She had an uneventful stay till 07/20/2025 when she sustained a fall and fractured her hip. She was sent to the [Hospital name].she returned back with no intervention done.Family decided no surgical intervention remain in hospice for quality of life.After the fracture, she was bedbound. She has a quick decline and she expired on 07/26/2025.CAUSE OF DEATH: Dementia, Fall with complications.During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing and Preventing, dated 4/1/24, the P&P indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Staff will be able to identify residents who are at high risk for falls. Staff will assist and supervise those residents that are identified at risk for falls.Fall Risk Factors.cognitive impairment.lower extremity [the part of the body that includes the hip, thigh, knee, leg, ankle and foot] weakness.Medical factors that contribute to the risk of falls include.balance and gait disorders.The IDT (Interdisciplinary Team) Staff, with input of the attending physician, will implement a resident- centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped.All Residents will be assessed for risk of fall upon admission, quarterly and after a fall.All Residents determined to be at a risk for falls with a score of 10 or higher will be placed in the facility Fall Prevention Program to prevent injuries from fall. ALL staff will be made aware of residents that are at a high risk of fall and participate in ensuring the safety of the residents. During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, dated 3/18, the P&P indicated, .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good.personal.hygiene.Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with.Mobility (transfer and ambulation, including walking).Elimination (toileting).During a professional reference review retrieved from https://rn-journal.com/journal-of-nursing/preventing-falls-in-the-elderly-long-term-care-facilities, the article titled, Preventing Falls in the Elderly Long Term Care Facilities, undated, the article indicated, .The elderly long-term care population is at increased risk for falls and fall related injuries.Systematically assessing residents' risk for falls and implementing appropriate fall prevention interventions can reduce the number of falls in the elderly long-term care residents.Falls can cause serious injuries and accidental death, in older people.The elderly in long-term care facilities are predisposed to falling and may fall for a variety of reasons. Predisposing factors include, unsteady gait [a person's manner of walking] and balance, weak muscles.Staff should be educated about predisposing [to give a tendency to beforehand] and precipitating [to bring something on] factors for falls and related prevention strategies and interventions. Staff needs to understand the different interventions available to them, in order to apply them when caring for patients.

Based on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when the sink faucet was covered with a black and brown substance. This failure placed residents who consumed food prepared in the facility kitchen at risk for foodborne illness (a disease caused by consuming contaminated food or drink). Findings: During a concurrent observation and interview on 2/18/25 at 9:15 a.m., with the Dietary Supervisor (DS), in the kitchen, the sink faucet located near the dish washing machine was observed with a black and brown substance. The DS stated the base of the sink faucet was not clean and the sink faucet should be cleaned daily. During an interview on 2/19/25 at 1:53 p.m., with [NAME] 1, [NAME] 1 stated they were supposed to clean the sink faucet daily and it was not done. [NAME] 1 stated the 27 facility residents received their meals daily from the kitchen and could potentially get ill because of cross contamination (spread of harmful bacteria from one place or object to another). During an interview on 2/19/25 at 3:13 p.m., with the DS, the DS stated dietary staff were tasked to clean the sink faucet daily and it was not done. The DS stated facility residents were at risk for foodborne illness when food was not prepared in a clean environment. The DS stated, Cross contamination could cause illness to our residents. During a review of the facility's document titled, Job Description: Dietary Cook/Worker, undated, the document indicated, . Use all utensils and equipment in a safe and sanitary manner . During a review of the facility's policy and procedure (P&P) titled, Sanitation in Preparation and Serving, dated 7/11, the P&P indicated, . Strict adherence to the following rules will eliminate the hazard of food poisoning while food is being prepared and served . All equipment should be cleaned and sanitized before use .

Based on observation, interview, and record review the facility failed to ensure effective infection prevention and control practices were implemented for nine of 14 sampled residents (Resident 21, 11, 5, 16, 15, 78, 8, 14, and 20) when: 1. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene when entering and exiting the rooms for Resident 21, 11, 5, 16, 15, 78, 8, 14, and 20. 2. LVN 1 did not remove gloves after providing patient care for Resident 16, 78, 14, and 20 and exited the room and walked down the hallway back to his medication cart (a mobile cart for storing and delivering medications). 3. LVN 1 did not take his medication cart located in Nursing Station 1 instead of bringing it to each room while administering medications and patient care for Resident 21, 11, 5, 16, 15, 78, 8, 14, and 20. These failures had the potential to result in the spread of infections (when germs enter the body and cause illness) and cross-contamination (transfer of germs or substances from one surface to another), compromising the health and safety of the residents. Findings: 1. During a review of Resident 21's Admission Record (AR), dated 2/29/25, the AR indicated Resident 21 was admitted on [DATE] with a diagnosis(es) of vascular dementia (memory loss caused by poor blood flow to the brain), cerebral edema (swelling in the brain), Type 2 diabetes mellitus (a disease that causes high levels of sugar in the blood) and essential hypertension (high blood pressure with no clear cause). During a review of Resident 11's AR, dated 2/19/25, the AR indicated, Resident 11 was admitted on [DATE] with a diagnosis(es) of diabetes mellitus, essential hypertension, dehydration (when the body loses too much water), and constipation (hard stools) During a review of Resident 5's AR, dated 2/19/25, the AR indicated, Resident 5 was admitted on [DATE] with a diagnosis(es) of muscle weakness, pain unspecified (pain without clear cause or location), difficulty walking, and pain in the right and left knee. During a review of Resident 16's AR, dated 2/19/25, the AR indicated, Resident 16 was admitted on [DATE] with a diagnosis(es) of Type 2 diabetes mellitus and gastro-esophageal reflux disease without esophagitis (a condition where stomach acid leaks into the throat without causing inflammation). During a review of Resident 15's AR, dated 2/19/25, the AR indicated, Resident 15 was admitted on [DATE] with a diagnosis(es) of unspecified atrial fibrillation (an irregular and fast heart beat) essential hypertension, hyperlipidemia (high levels of fat in the blood), hypothyroidism (a condition when the thyroid [a small gland in the neck] makes too little hormones [a chemical that help control body functions]), anemia (not enough red blood cells to carry oxygen), and muscle weakness. During a review of Resident 78's AR, dated 2/19/25, the AR indicated, Resident 78 was admitted on [DATE] with a diagnosis(es) of essential hypertension, chest pain, and presence of cardiac pacemaker (a device that helps regulate a heart's rhythm). During a review of Resident 8's AR, dated 2/19/25, the AR indicated, Resident 8 was admitted on [DATE] with a diagnosis(es) of chronic obstructive pulmonary disease (a lung disease that makes it hard to breath), allergic contact dermatitis (a skin rash caused by an allergic reaction to something that touches the skin), unspecified dementia (a decline in memory and thinking skills without a clear cause) and essential hypertension. During a review of Resident 14's AR, dated 2/19/25, the AR indicated, Resident 14 was admitted on [DATE] with a diagnosis(es) of type 2 diabetes mellitus, klebsiella pneumoniae (a bacteria [germ] that can cause lung infections and other diseases), and urinary tract infection (an infection in the urinary tract). During a review of Resident 20's AR, dated 2/19/25, the AR indicated, Resident 20 was admitted on [DATE] with a diagnosis(es) of type 2 diabetes mellitus. During an observation on 2/19/25 at 8:31 a.m. in Resident 21's room, LVN 1 took Resident 21's blood pressure (the force of blood against the veins [blood vessels that carry blood to the heart] and arteries [blood vessels that carry blood away from the heart] as the heart pumps) using a blood pressure machine (a machine used to measure blood pressure). LVN 1 exited the room and did not perform hand hygiene (cleaning hands to remove germs and prevent infections). During an observation on 02/19/25 at 8:43 a.m., LVN 1 did not perform hand hygiene when he entered Resident 11's room. LVN 1 administered loperamide (a medication to control symptoms of diarrhea) 2mg (milligrams-a unit of measure) to Resident 11 and did not perform hand hygiene before exiting Resident 11's room. During an observation on 2/19/25 at 8:49 a.m., LVN 1 did not perform hand hygiene when he entered Resident 5's room. LVN 1 administered a lidocaine patch (a medicated patch that numbs pain in a specific area) 5% (percent- a unit of measure) to Resident 5's right knee and did not perform hand hygiene when he exited Resident 5's room. During an observation on 2/19/25 at 8:53 a.m., LVN 1 administered lorazepam (a medication used to control anxiety [feeling of worry, fear or nervousness]) 0.5ml (milliliter-a unit of measure) to Resident 16. LVN 1 did not perform hand hygiene when he exited Resident 16's room. During an observation on 2/19/25 at 11:08 a.m. in Resident 15's room, LVN 1 did not perform hand hygiene after he administered medications to Resident 15 and exited the Resident 15's room. During an observation on 2/19/25 at 11:11 a.m., LVN 1 went inside Resident 78's room to check his blood pressure. LVN 1 did not do hand hygiene when he entered Resident 78's room. LVN 1 had a gloved hand when he exited Resident 78's room and did not perform hand hygiene when he exited. During an observation on 2/19/25 at 11:16 a.m. in Resident 8's room, LVN 1 wore gloves and administered Resident 8's polyethylene glycol (a medication used to relieve dry, irritated eyes) 400 0.4%, propylene glycol 0.3% . LVN 1 removed his gloves and did not perform hand hygiene when he exited the room. During an observation on 2/19/25 at 11:24 a.m. in Resident 14, LVN 1 checked Resident 14's blood sugar using a glucometer (a devise that measures blood sugar). LVN 1 walked out of the room and did not perform hand hygiene. During an observation on 2/19/25 at 11:28 a.m. in Resident 14's room, LVN 1 administered insulin on Resident 14's lower left abdomen. LVN 1 removed his gloves after he administered the insulin (a medication that controls blood sugar) and did not perform hand hygiene. During an observation on 2/19/25 11:41 a.m. in Resident 20's room, LVN 1 entered Resident 20's room and did not perform hand hygiene. LVN 1 donned (put on) gloves and administered insulin on Resident 20's lower right abdomen. LVN 1 removed his gloves and did not perform hand hygiene and went back to the medication cart in Nursing Station 1. During an interview on 2/19/25 at 12:08 p.m. with LVN 1, LVN 1 stated, he should have performed hand hygiene before and after leaving a resident's room and before and after performing patient care. LVN 1 stated, after performing patient care for three to four residents, he should have washed his hands with soap and water. LVN 1 stated, it was important to perform hand hygiene to prevent cross-contamination from one patient to another and prevent the spread of infections. During an interview on 2/19/25 at 2:01 p.m. with the Infection Preventionist (IP), the IP stated, it was her expectation to perform hand hygiene whenever a staff entered and exited a resident's room. The IP stated, hand hygiene should also have been performed before and after performing patient care such as checking blood sugars, checking blood pressures, and administering medications. The IP stated, it was important to perform hand hygiene to prevent the spread of infections and prevent cross-contaminations. During an interview on 2/21/25 at 11:34 a.m. with the Director of Nursing (DON), the DON stated, staff had to perform hand hygiene before and after entering a resident's room and before and after providing patient care. The DON stated, failure to adhere to hand hygiene protocols could have led to cross-contamination and the spread of infection. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 8/2019, the P&P indicated, .all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .hand hygiene products and supplies (sinks, soaps, towels, alcohol-based hand rubs, etc.) shall be readily accessible and convenient for staff to encourage compliance with hand hygiene policies . use some alcohol based hand rope containing at least 62% alcohol; Or, alternatively, soap (antimicrobial [a substance that kills or stops germs]) . before and after direct contact with residents . Before preparing or handling medications . before performing any non-surgical invasive (enot breaking the skin or entering the body) procedures . Before and after handling an invasive device (e.g. Urinary catheters, IV access sites) . before donning sterile gloves . after contact with the resident's intact skin . after contact with blood or bodily fluids . after handling used dressings, contaminated (dirty or exposed to germs) equipment . after contact with objects (e.g., medical equipment) . after removing gloves . hand hygiene is the final step after removing and disposing of personal protective equipment . the use of gloves does not replace hand washing/hand hygiene . 2. During an observation 2/19/25 at 8:53 a.m., LVN 1 wore a glove when he administered Resident 16's lorazepam. LVN 1 left the room while wearing the same glove back to the medication cart in Nursing Station 1. During an observation on 2/19/25 at 11:11 a.m., LVN 1 wore gloves when he took Resident 78's blood pressure. LVN 1 left the room while wearing the same glove back to the medication cart in Nursing Station 1. During an observation on 2/19/25 at 11:24 a.m., in Resident 14's room, LVN 1 wore gloves while checking Resident 14's blood sugar using a glucometer. LVN 1 did not remove his gloves after checking Resident 14's blood sugar and left the room. LVN 1 walked from Resident 14's room to the medication cart in Nursing Station 1 while still wearing his gloves. During an observation on 2/19/25 at 11:35 a.m., LVN 1 wore gloves while checking Resident 20's blood sugar using a glucometer. LVN 1 did not remove his gloves after checking Resident 20's blood sugar and left the room. LVN 1 walked from Resident 20's room to the medication cart in Nursing Station 1 while still wearing his gloves. During an interview on 2/19/25 at 12:08 p.m. with LVN 1, LVN 1 stated he should not have worn gloves in the hallway after finishing patient care. LVN 1 stated, there was a risk of cross-contamination when walking in the hallway. LVN 1 stated, he could have been distracted and touched something in the hallway that could have harbored germs and potentially spread them to other residents. During an interview on 2/19/25 at 2:01 p.m. with the IP, the IP stated, gloves should not have been worn while walking in the hallway. The IP stated, there was potential for cross-contamination when soiled gloves were worn in the hallway and could have potentially caused infections to spread. The IP stated, gloves should be removed before exiting a resident's room. During an interview on 2/2/25 at 11:34 a.m. with the DON, the DON stated, nurses should not walk down the hallway with gloved hands after providing patient care. The DON stated, walking with soiled gloves could potentially cause cross-contamination and spread infections. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 8/2019, the P&P indicated, .The use of gloves does not replace hand/hygiene .integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .applying and removing gloves .perform hand hygiene before applying non-sterile gloves . During a review of the professional reference (PR) titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings found on www.cdc.gov/infection-control/hcp/core-practices/index.html, dated 4/12/24, the PR indicated, .remove and discard PPE, other than respirators, upon completing a task before leaving the patient's room or care area .remove and discard disposable gloves upon completion of a task or when soiled during the process of care . 3. During a concurrent observation and interview on 2/19/25 at 8:40 a.m. with LVN 1 in Resident 21's room, LVN 1 administered Resident 21's morning medications. LVN 1 prepared Resident 21's morning medications on the medication cart located at Nursing Station 1. LVN 1 walked to Resident 21's room and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 12 feet away from Resident 21's room. During a concurrent observation and interview on 2/19/25 at 8:43 a.m. with LVN 1, LVN 1 prepared Resident 11's loperamide 2mg on the medication cart located at Nursing Station 1. LVN 1 walked to Resident 11's room and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 17 feet away from Resident 11's room. During a concurrent observation and interview on 2/19/25 at 8:49 a.m. with LVN 1, LVN 1 had opened a lidocaine patch on the medication cart located at Nursing Station 1 for Resident 5. LVN 1 walked to Resident 5's room and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 30 feet away from Resident 5's room. During a concurrent observation and interview on 2/19/25 at 8:53 a.m. with LVN 1, LVN 1 prepared Resident 16's lorazepam on the medication cart located at Nursing Station 1. LVN 1 walked to the activities room to administer Resident 16's lorazepam and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 75 feet away from the activities room. During a concurrent observation and interview on 2/19/25 at 11:08 a.m. with LVN 1, LVN 1 prepared Resident 15's medications on the medication cart located at Nursing Station 1. LVN 1 walked to the activities room to administer Resident 15's medication and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 75 feet away from the activities room. During a concurrent observation and interview on 2/19/25 at 11:11 a.m. with LVN 1, LVN 1 prepared Resident 78's medication on the medication cart located at Nursing Station 1. LVN 1 walked to Resident 78's room and did not take the medication cart with him. LVN 1 stated, the medication cart was approximately 120 feet way from Resident 78's room. During a concurrent observation and interview on 2/19/25 at 11:16 a.m. with LVN 1, LVN 1 walked to Resident 8's room and administered his eye drops. LVN 1 did not bring the medication cart with him when we walked to Resident 8's room. LVN 1 stated, Resident 8's room was approximately 120 feet away from the medication cart located by Nursing Station 1. During a concurrent observation and interview on 2/19/25 at 11:16 a.m. with LVN 1, LVN 1 walked to Resident 8's room and administered his eye drops and did not bring the medication cart with him. LVN 1 stated, Resident 8's room was approximately 120 feet away from the medication cart located by Nursing Station 1. During a concurrent observation and interview on 2/19/25 at 11:19 a.m. with LVN 1, LVN 1 prepared Resident 14's medication on the medication cart located at Nursing Station 1. LVN 1 walked to Resident 14's room and did not bring the medication cart with him. LVN 1 administered Resident 14's breathing treatment (a therapy that uses inhaled medications to improve breathing) and checked her blood sugar with a glucometer. LVN 1 walked back to the medication cart after he finished and cleaned the glucometer at the medication cart. LVN 1 stated, Resident 14's room was approximately 17 feet away from the medication cart located by Nursing Station 1. During an observation on 2/19/25 at 11:26 a.m., LVN 1 walked back to Resident 14's room and did not take the medication cart. LVN 1 used an insulin syringe (small needle used to inject insulin) and administered Resident 14's insulin. LVN 1 left the room and walked back to the medication cart by Nursing Station 1. During a concurrent observation and interview on 2/19/25 at 11:35 a.m., LVN 1 walked to Resident 20's room to check her blood sugar with a glucometer and did not bring the medication cart with him. LVN 1 walked back to the medication cart located at Nursing Station 1 to clean the glucometer and prepare Resident 20's insulin. LVN 1 stated, Resident 20's room was approximately 17 feet away from the medication cart located by Nursing Station 1. During an observation on 2/19/25 at 11:41 a.m., LVN 1 held an insulin syringe and walked back to Resident 20's room. LVN 1 administered the insulin to Resident 20 and walked back to the medication cart while holding the insulin syringe. During an interview on 2/19/25 at 12:08 p.m., LVN 1 stated, he should have taken the medication cart with him each time he administered medications to a resident. LVN 1 stated, keeping the medication cart nearby was important to ensure all supplies were within reach and to avoid walking across the hallway, which helped prevent the risk for cross-contamination of medications to be administered to residents. During an interview on 2/19/25 at 2:01 p.m. with the IP, the IP stated nurses should have taken the medication cart with them while passing medications. The IP stated, having the medication cart nearby allowed the nurse to have immediate access to supplies or medications. The IP stated, walking back and forth between room and a distant medication cart posed a potential risk for cross-contamination. During an interview on 2/21/25 at 11:34 a.m. with the DON, the DON stated, nurses had to take the medication cart with them wherever they provided patient care. The DON stated, keeping the medication cart nearby allowed nurses to have immediate access to supplies and medications. The DON stated, walking back and forth between resident's room and a distant medication cart posed a potential risk for cross-contamination. During a review of the professional reference (PR) titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, found on www.cdc.gov/infection-control/hcp/core-practices/index.html , dated 4/12/24, the PR indicated, .Injection and Medication Safety .Prepare medications in a designated clean medication preparation area that is separated from potential sources of contamination . 51620

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for two of 12 sampled residents (Resident 10 and Resident 22) when: 1. Resident 10's pharmacy recommendation to obtain Serum (blood test) B-12 (a vitamin essential for maintaining healthy red blood cells, nerves, and brain function), Creatinine Level (a blood test to check for the kidney's function), Liver Function (a blood test to check for liver's function) and BMP (Basic Metabolic Panel-measures various substances in the blood, including blood sugar and bone health) was not communicated to the Hospice provider. This failure had the potential to place Resident 10 at risk of receiving treatment or procedures against his wishes. 2. Resident 22's pharmacy recommendation to rinse mouth with water and spit back into cup after use of Budesonide-Formoterol Fumarate Dihydrate inhaler (medication used to control shortness of breath (SOB) and chest tightness) was not implemented. This failure had the potential to place Resident 22 at risk of developing oral thrush (a type of mouth infection). Findings: 1. During a review of Resident 10's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/21/25, the AR indicated, Resident 10 was admitted from an acute care hospital on 1/19/24 to the facility, with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hypertension (high blood pressure), Cerebral Infarction (stroke- bleeding inside the brain), and Type 2 Diabetes Mellitus (high blood sugar). During a review of Resident 10's Physician Order Summary Report (POS), dated 2/21/25, the POS indicated, . admitted under the care of [Name of Hospice Agency] . Order Date 1/19/24 . Do Not Resuscitate [DNR-a legal document that instructs medical professionals not to perform resuscitation (artificial breathing) if a patient's breathing or heart stops] . During a concurrent interview and record review on 2/21/25 at 9:22 a.m., with the Director of Nursing (DON), Resident 10's Progress Note (PN), undated, and Resident 10's Pharmacy Monthly Medication Review Recommendation (MRR), dated 1/28/25 were reviewed. The MRR indicated, . patient is receiving Metformin (medication to control blood sugar level) 500 [milligram (mg) - unit of measurement] daily, which may deplete (reduce) vitamin B-12 and has the potential to cause lactic acidosis (excess amount of lactic acid in the blood, causing nausea, vomiting, exhaustion, fatigue and body aches). Please consider ordering a serum B-12 level as baseline and annually to monitor therapy, as well as serum creatinine level, liver function and BMP every 6 months . The DON stated she does not have any record the pharmacy recommendation was forwarded to the Hospice agency for review. During a phone interview and record review, on 2/21/25 at 1:54 p.m., with the Hospice Director of Patient Care Services (HDPCS), Resident 10's Hospice Clinical Record (HCR), dated 2/21/25 was reviewed. The DPCS stated Resident 10 was under Hospice care since 1/19/24 and they worked closely with the facility staff to meet Resident 10's physical, emotional, and spiritual needs. The DPCS stated they did not have any record of pharmacy recommendations to obtain various laboratory tests, otherwise they would act on it. During a concurrent interview and record review, on 2/21/25 at 5:05 p.m., with the DON, the facility's Hospice Program Policy and Procedure (P&P), dated 7/17 was reviewed. The P&P indicated, . 9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness [a condition with no treatment] and related conditions . c. Providing medical direction, nursing, and clinical management of the terminal illness . 12. Our facility has designated [blank space] to coordinate care provided to the resident by our facility staff and the hospice staff . The DON stated she does not have any record or proof that the facility staff communicated the pharmacy recommendation to the hospice agency. The DON stated, If it's not documented, it didn't happen. During a concurrent interview and record review, on 2/24/25 at 11:29 a.m., with the Director of Staff Development (DSD, also the Infection Preventionist [IP] and Licensed Vocational Nurse [LVN] 2), Resident 10's Progress Note (PN), dated 2/24/25 and Physician Order Summary (POS), dated 2/24/25 were reviewed. The DSD stated she does not have any record the pharmacy recommendation was forwarded to the Hospice agency for review. The DSD stated Resident 10 could potentially receive treatment or procedures against his wishes. During a review of the facility's P&P titled, Charting and Documentation, dated 7/17, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . 7. Documentation of procedures and treatments will include care-specific details, including . date and time of the procedure/treatment was provided . name and title of individual(s) who provided the care . During a review of the facility's document titled, Job Description: Charge Nurse Licensed Vocational Nurse (LVN), dated 8/2015, the document indicated, . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . 2. During a review of Resident 22's AR, dated 2/21/25, the AR indicated, Resident 22 was admitted from an acute care hospital on 6/1/23 to the facility, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-is a chronic inflammatory lung disease that causes obstructed airflow of the lungs), Hypertension (high blood pressure), and Respiratory Failure (a serious condition that makes it difficult to breathe). During a review of Resident 22's POS, dated 2/21/25, the POS indicated, . Budesonide-Formoterol Fumarate Dihydrate [medication used to control shortness of breath (SOB) and chest tightness] 160-4.5 MCG (microgram-unit of measurement) /ACT (actuation-the action of causing a machine or device to operation] one puff inhale orally two times a day for COPD . Order Date 6/1/24 . During a concurrent interview and record review, on 2/21/25 at 9:26 a.m., with the Director of Nursing (DON), Resident 22's Medication Administration Record (MAR), dated 2/21/25 and MRR, dated 1/28/25 were reviewed. The MRR indicated, . This Resident is receiving Budesonide-Formoterol Fumarate Dihydrate. Steroid inhalers can cause oral thrush which may be minimized by rinsing the mouth with water after each dose of the inhaler. Please consider adding the following verbiage to the order as a reminder: Rinse mouth with water and spit back into cup after use . The DON stated she does not have any record the pharmacy recommendation was noted and acted upon by the facility. The DON stated, If it's not documented, it didn't happen. The DON stated Resident 22 could potentially develop oral thrush from using the inhaler and not rinsing her mouth with water after medication administration. During a concurrent interview and record review, on 2/24/25 at 11:34 a.m., with the Infection Preventionist (IP, also the Director of Staff Development [DSD] and Licensed Vocational Nurse [LVN] 2), Resident 22's MRR, dated 1/28/25 and MAR, dated 2/24/25 were reviewed. The DSD stated she does not have any record the pharmacy recommendation was acknowledged and acted upon by the facility. The DSD stated Resident 22 could potentially develop oral infection from using oral inhalers. During a review of the facility's P&P titled, Medication Regimen Review and Reporting, dated 1/07, the P&P indicated, . Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with a goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication . During a review of the facility's P&P titled, Charting and Documentation, dated 7/17, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . 7. Documentation of procedures and treatments will include care-specific details, including . date and time of the procedure/treatment was provided . name and title of individual(s) who provided the care . During a review of the facility's document titled, Job Description: Charge Nurse Licensed Vocational Nurse (LVN), dated 8/2015, the document indicated, . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices .

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for two of 12 sampled residents (Resident 12 and Resident 78 ) when: 1. There was no CP created addressing Resident 12's diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe.) 2. Resident 78 had a care plan for fluid overload (a person has too much fluid, potentially causing swelling, shortness of breath, and high blood pressure) related to kidney failure (when the kidneys stop working properly, leading to a buildup of waste in your blood, which can be dangerous if left untreated), but there was not a comprehensive assessment that reflected the medical issue. These failures had the potential to prevent Resident 12 and Resident 78 from receiving appropriate, and individualized care and services consistent with their needs. Findings: 1. During a review of Resident 12's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/28/23, the AR indicated, Resident 12 was admitted from the acute care hospital on 9/27/24 to the facility, with diagnoses that included COPD, Muscle Weakness, Hypertension (high blood pressure), Cerebral Infarction (stroke- loss of blood flow to part of the brain), and Schizophrenia (chronic and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). During a review of Resident 12's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 1/10/25, the MDS indicated Resident 12's Brief Interview for Mental Status (BIMS) score was 15 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a concurrent observation and interview on 2/19/25 at 10:50 a.m., with Resident 12 inside his room, Resident 12 was observed lying in bed, covered with a light white sheet and head of bed was elevated about 30 degrees. Resident 12 stated he has a diagnosis of COPD and takes routine and as needed medication (PRN) to improve his breathing. Resident 12 stated he uses an inhaler whenever he experienced sudden shortness of breath. During a concurrent interview and record review on 2/19/25 at 3:30 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 12's Physician Order Summary (POS), and Care Plan (CP), undated, were reviewed. The POS indicated, . Fluticasone Furoate-Vilanterol [medication used to control wheezing (high pitch whistling sound), shortness of breath (SOB), and chest tightness] 100-25 [MCG (microgram-unit of measurement) /ACT (actuation-the action of causing a machine or device to operation] () one puff inhale orally one time a day for COPD . Order Date 9/30/24 . Albuterol Sulfate Inhalation [medication used to treat breathing problems related to COPD and other respiratory issues] 108 MCG/ACT 2 puff inhale orally every six hours as needed for SOB or wheezing . LVN 1 stated there was no care plan developed and implemented for Resident 12's diagnosis of COPD. LVN 1 stated licensed nurses should care plan the COPD diagnosis so all nursing staff (caring for the resident) would know the plan of care for the resident and to ensure Resident 12 received the appropriate interventions. LVN 1 stated, the facility failed to follow the facility's policy and procedure (P&P) related to care planning process. During a concurrent interview and record review on 2/20/25 at 10:32 a.m., with the Director of Nursing (DON), Resident 12's POS and CP, undated, were reviewed. The DON stated a resident specific care plan should have been developed to address Resident 12's diagnosis of COPD and it was not done. The DON stated the CP was a form of communication with other team members, without a resident specific CP, the staff do not have a clear path to meet Resident 12's medical, physical, mental, and psychosocial needs. The DON stated the failure could potentially result in Resident 12's COPD to worsen. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 4/24, the P&P indicated, . Care, treatment and services are planned to ensure they are appropriate to the resident's needs . Within seven (7) days of completion of the comprehensive assessments, all residents shall have a computerized plan of care generated by the Registered Nurse or the Licensed Practical/Vocational Nurse . The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, undated, the document indicated, . Essential Job Functions include, but are not limited to the following . Assessment of Residents . Following all facilities Policies and Procedures . Perform other duties as requested . 2. During a review of Resident 78's Admission Record, dated 2/21/25, the Admission Record indicated, Resident 78 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked), history of endocarditis (a serious inflammation of the heart's inner lining. It's usually caused by a bacterial infection [when tiny, harmful bacteria enter your body, multiply, and cause illness], but can also be caused by fungi [microorganisms that can cause infections]), acute embolism a sudden blockage in a blood vessel, often caused by a blood clot (or other substance) that travels from somewhere else in the body and gets lodged, potentially cutting off blood flow and oxygen to an organ or tissue) and thrombosis (the blockage of a blood vessel by a blood clot) and hypotension (low blood pressure). During a review of Resident 78's MDS assessment, dated 1/16/25, the MDS assessment indicated Resident 78's Brief Interview for Mental Status (BIMS -assessment of cognitive(define) status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 78 was cognitively intact. During a review of Resident 78's Care Plan, dated 2/4/25, the Care Plan indicated, .Description: The resident has fluid overload or potential fluid volume overload related to Kidney Failure [when the kidneys stop working properly, leading to a buildup of waste in your blood, which can be dangerous if left untreated] . Goal: The resident will comply with diet and/or fluid restrictions [a patient can only have a certain amount of liquid each day] daily through review date . During a review of Resident 78's Admission History and Physical (H&P), dated 2/4/25, the H&P indicated, .Chief Complaint: Patient is admitted for rehab status post transfer (moving a patient from one place to another all while ensuring their medical care continues smoothly) from skilled nursing facility . status post transfer hospitalization for cerebrovascular accident due to arterial septic emboli [infected blood clots that travel through the bloodstream and can block blood vessels, potentially causing damage to tissues or organs] . [AGE] year old male with past medical history significant for thrombophilia [a condition that makes your blood more likely to form clots] . osteomyelitis [a bone infection that causes inflammation and swelling], endocarditis and septic arterial embolism and generalized weakness is admitted for rehab . Physical Exam: . Blood pressure 109/61 . Pulse: 75 . Respirations: 16 . chest (lungs): clear breath sounds bilaterally (both sides) . Cardiovascular (heart): . normal rate and rhythm . During a review of Resident 78's MDS Section I- Active Diagnosis (AD), dated 2/14/25, the AD indicated, .Primary Medical Condition: Cerebral Infarction . Heart/Circulation: Coronary artery disease [a heart condition that occurs when the coronary arteries narrow or become blocked]- No . Heart Failure [a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs]- No . Peripheral vascular disease [a circulatory condition that occurs when blood vessels narrow, block, or spasm]- No . Genitourinary [urinary and genital organs]: Renal insufficiency [kidneys aren't working as well as they should, potentially leading to a buildup of waste and excess fluid in your body], renal failure [kidneys aren't working properly, leading to a buildup of waste and fluid in your body], End stage Renal Disease [kidneys aren't working properly, leading to a buildup of waste and fluid in your body]- No . Pulmonary [Lungs]: Asthma or chronic lung disease- No . Respiratory Failure- No . During a review of Resident 78's Nursing Weekly Summary (NWS), dated 2/8/25, the NWS indicated, .Edema (swelling): No . Respiratory Status: Breath sounds: Clear, Both .Shortness of breath: None . During a review of Resident 78's Lab Results Report (LRR), dated 1/2/25, the LRR indicated, .BUN [urea nitrogen a test that measures the amount of a waste product (urea nitrogen) in your blood which is formed when your body breaks down protein, and your kidneys filter it out]: 18 [milligrams per deciliter- unit of measurement], Reference Range 7 - 25 mg/dl . Creatinine [a waste product in the blood that indicates how well your kidneys are working]: 0.69 mg/dl, Reference Range: .70 -1.30 mg/dl . eGFR [Estimated Glomerular Filtration Rate. It is a measure of how well your kidneys are filtering waste products from your blood] 96 ml/min (milliliters per minute) >= [greater than or equal too] 60 ml/min . Interpretation of eGFR: 60 or more mildly reduced (60 - 89) or Normal (90 or more) . [less than] 15 ml/min [means] Kidney Failure . During a concurrent interview and record review on 2/20/25 at 10:19 a.m., with the Licensed Vocational Nurse (LVN) 1, Resident 78's Electronic Medical Record (EMR) dated 2/3/25 to 2/20/25 was reviewed. The EMR indicated Resident 78 had a care plan in place related to kidney failure, but no medical diagnosis or evidence in the record to support that. The LVN 1 stated there was no evidence of edema, fluid overload, nor kidney failure for Resident 78 in the EMR. During an interview on 2/20/25 at 11:30 a.m., with the Registered Dietician (RD), the RD stated Resident 78 did not have any kidney conditions as a diagnosis. During an interview on 2/20/25 at 3:46 p.m., with the RD, the RD stated she looked at Resident 78's labs and did not see anything that would have warranted a fluid restriction or kidney failure. The RD stated she was not sure of the root cause for the fluid restriction that was mentioned in the care plan. During an interview on 2/20/25 at 4:24 p.m., with the DON, the DON stated Resident 78 did not have a diagnosis of a kidney problem. The DON stated a care plan should be based off of diagnosis and resident needs and Resident 78's care plan was not. During an interview on 2/21/25 at 9:59 a.m., with the Director of Staff Development (DSD- also the Infection Preventionist and LVN 2), the DSD stated she created the care plan for Resident 78. The DSD stated she was not sure the reason for the fluid restriction initially and was assuming to get the care plan completed. The DSD stated she put kidney failure without looking ahead and Resident 78 did not have evidence of kidney failure. The DSD stated the care plan was inaccurate in regard to fluid restriction and the kidney failure. The DSD stated care plans should be individualized and Resident 78's was not. The DSD stated the inaccuracy of the care plan would equate to care for Resident 78 not going to be correct. The DSD stated the policy and procedure (P&P) Care Planning was not followed. During an interview on 2/21/25 at 2:09 p.m., with the DON, the DON stated care plans are for staff to provide continuity of care to the resident and the continuity of care was not there. The DON stated, she felt staff followed the P&P Care Planning. The DON stated, that was her opinion. The DON stated there were no assessments, nor objective evidence, in the EMR that indicated kidney failure. During an interview on 2/24/25 at 10:37 a.m., with LVN 1, LVN 1 stated care plans tell us how to care for the resident and keeps them stable. LVN 1 stated a potential outcome for having a care plan that was not based off of comprehensive assessment could have been a risk of injury due to inappropriate medical treatment. LVN 1 stated the P&P Care Planning was not followed by staff. During a review of the facility's P&P titled, Care Planning, dated 4/2024, the P&P indicated, .Policy: Care, treatment and services are planned to ensure they are appropriate to the resident needs . care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable . the plan of care shall be individualized, based on diagnosis, resident assessment . care planning is based on data collected from resident assessments with integration of those assessment findings in the care planning process . During a review of Nursing World.org Professional Reference titled, The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) the reference indicated, .The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making . Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation . During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum . vital to positive patient outcomes . the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition . 51620

Based on interview and record review, the facility failed to follow its Hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures (P&P) for one of four sampled residents (Resident 10) when: 1. The pharmacy recommendation for Resident 10 to obtain Serum (blood test) B-12 (a vitamin essential for maintaining healthy red blood cells, nerves, and brain function), Creatinine Level (a blood test to check for the kidney's function), Liver Function (a blood test to check for liver's function) and BMP (Basic Metabolic Panel-measures various substances in the blood, including blood sugar and bone health) was not communicated to the Hospice provider. 2. The Hospice order for Resident 10 to discontinue all laboratory tests on 1/21/25 was not carried out and implemented. These failures had the potential to place Resident 10 at risk for receiving treatments or procedures against his wishes. Findings: 1. During a review of Resident 10's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/21/25, the AR indicated, Resident 10 was admitted from an acute care hospital on 1/19/24 to the facility, with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hypertension (high blood pressure), Cerebral Infarction (stroke- bleeding inside the brain), and Type 2 Diabetes Mellitus (high blood sugar). During a review of Resident 10's Physician Order Summary Report (POS), dated 2/21/25, the POS indicated, . admitted under the care of [Name of Hospice Agency] . Order Date 1/19/24 . Do Not Resuscitate [DNR-a legal document that instructs medical professionals not to perform resuscitation (artificial breathing) if a patient's breathing or heart stops] . During a concurrent interview and record review on 2/21/25 at 9:22 a.m., with the Director of Nursing (DON), Resident 10's Progress Note (PN), undated, and Pharmacy Monthly Medication Review Recommendation (MRR), dated 1/28/25 were reviewed. The MRR indicated, . patient is receiving [generic name](medication to control blood sugar level) 500 [milligram (mg) - unit of measurement] daily, which may deplete (reduce) vitamin B-12 and has the potential to cause lactic acidosis (excess amount of lactic acid in the blood, causing nausea, vomiting, exhaustion, fatigue and body aches). Please consider ordering a serum B-12 level as baseline and annually to monitor therapy, as well as serum creatinine level, liver function and BMP every 6 months . The DON stated she does not have any record the pharmacy recommendation was forwarded to the Hospice agency for review. During a phone interview and record review, on 2/21/25 at 1:54 p.m., with the Hospice Director of Patient Care Services (HDPCS), Resident 10's Hospice Clinical Record (HCR), dated 2/21/25 was reviewed. The DPCS stated Resident 10 was under Hospice care since 1/19/24 and they worked closely with the facility staff to meet Resident 10's physical, emotional, and spiritual needs. The DPCS stated they did not have any record of pharmacy recommendations to obtain various laboratory tests, otherwise they would act on it. During a concurrent interview and record review, on 2/21/25 at 5:05 p.m., with the DON, the facility's Hospice Program Policy and Procedure (P&P), dated 7/17 was reviewed. The P&P indicated, . 9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness (a condition with no treatment) and related conditions . c. Providing medical direction, nursing, and clinical management of the terminal illness . 12. Our facility has designated [blank space] to coordinate care provided to the resident by our facility staff and the hospice staff . The DON stated she does not have any record or proof that the facility staff communicated the pharmacy recommendation to the hospice agency. The DON stated, If it's not documented, it didn't happen. During a concurrent interview and record review, on 2/24/25 at 11:29 a.m., with the Director of Staff Development (DSD, also the Infection Preventionist [IP] and Licensed Vocational Nurse [LVN] 2), Resident 10's Progress Note (PN), dated 2/24/25 and Physician Order Summary (POS), dated 2/24/25 were reviewed. The DSD stated she does not have any record the pharmacy recommendation was forwarded to the Hospice agency for review. The DSD stated Resident 10 could potentially receive treatment or procedures against his wishes. During a review of the facility's P&P titled, Hospice Program, dated 7/17, the P&P indicated, . Hospice services are available to residents at the end of life . 12. Our facility has designated [blank space] to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . 13. Coordinated care plans for residents receiving hospice services . in order to maintain the resident's highest practicable physical, mental and psychosocial well-being . 2. During a concurrent interview and record review, on 2/21/25 at 1:57 p.m., with the Hospice Director of Patient Care Services (HDPCS), Resident 10's Hospice Physician Order (HPO), dated 1/21/25 was reviewed. The HPO indicated, . [discontinue] all routine labs [laboratory tests] . The HDPCS stated the expectation was for the facility staff to follow the hospice recommendation. During a concurrent interview and record review, on 2/21/25 at 5:05 p.m., with the DON, Resident 10's POS, undated 2/21/25, and Resident 10's HPO, dated 1/21/25 were reviewed. The DON stated she does not have any record or proof the facility staff received Resident 10's physician order to discontinue all laboratory tests from the hospice agency. The DON stated, If it's not documented, it didn't happen. During a concurrent interview and record review, on 2/24/25 at 11:31 a.m., with the DSD (also the IP and LVN 2), Resident 10's PN, dated 2/24/25, and Resident 10's POS, dated 2/24/25, were reviewed. The DSD stated she does not have any record the facility staff received a physician order to discontinue Resident 10's laboratory tests from the hospice agency. The DSD stated Resident 10's could potentially received treatment or procedures against his wishes. During a review of the facility's P&P titled, Hospice Program, dated 7/17, the P&P indicated, . Hospice services are available to residents at the end of life . 12. Our facility has designated [blank space] to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . 13. Coordinated care plans for residents receiving hospice services . in order to maintain the resident's highest practicable physical, mental and psychosocial well-being .

Based on observations, interview, and record review, the facility failed to provide the correct diet for one of 12 sampled residents (Resident 2) during lunch tray assembly when Resident 2 was on a fortified diet (an enrichment of food to increase calories [a unit of energy] and protein [essential to building and repairing body tissues, muscles, and bones] to sustain or gain weight) and dietary staff did not follow the diet order on 2/18/25 to provide Resident 2 with a Magic Cup frozen dessert (ice cream with added calories and protein for those experiencing involuntary weight loss). This failure had the potential to result in Resident 2 to not receive the adequate nutritional requirements to sustain or gain weight. Findings: 1. During a record review of Resident 2's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/24/25, the AR indicated, Resident 2 was admitted to the facility on [DATE], with diagnosis that included Hospice Care (palliative care for terminally ill residents), Confusional Arousals (a sleep disorder causing confusion and disorientation that occur during or shortly after waking from sleep), Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hypertension (high blood pressure), Muscle Weakness, Repeated Falls, and Atrial Fibrillation (an irregular and often very rapid heart rate). During a record review of Resident 2's Physician Order Summary (POS), dated 2/24/25, the POS indicated, Resident 2 was on a Fortified Diet Mechanical Soft Texture (food that is chopped, grounded, or pureed to accommodate with swallowing), Thin Liquids Consistency. During a record review of the facility's [name of company] Weekly Menu February 2025 - Week 2 Fortified Lunch, dated 2/10/25-2/14/25, the guideline indicated, 4 ounce (oz- unit of measurement) Magic Cup. During a review of Resident 2's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 2/18/25, the MDS indicated Resident 2's Brief Interview for Mental Status (BIMS) score was 3 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a concurrent observation and interview on 2/18/25 at 12:10 p.m., with Resident 2 in the dining/activity room, Resident 2 was observed sitting in a chair, with an overbed table and meal tray for lunch. Resident 2's lunch tray consisted of one flour tortilla with ground meat and shredded cheese, pinto beans with shredded cheese, 8 ounce (equivalent to one cup) of 2 percent milk, a cup of coffee, a cup of green salad, and a slice of cake. Resident 2 was unable to give a meaningful response when asked about the palatability of her food. During a concurrent interview and record review on 2/19/25 at 1:53 p.m., with Dietary [NAME] (CK) 1, Resident 2's lunch tray photo, dated 2/18/25 was reviewed. CK 1 stated Resident 2's lunch tray was not served correctly, and the Magic Cup was missing. CK 1 stated Resident 2's Magic Cup was added to her meal tray to ensure resident received the needed extra calories for weight gain. CK 1 stated Resident 2 could potentially lose weight from not having appropriate diet served each meal. During a concurrent interview and record review on 2/19/25 at 3:13 p.m., with the Dietary Supervisor (DS), Resident 2's lunch tray photo, dated 2/18/25, was reviewed. The DS stated Resident 2's lunch tray was not prepared correctly, and the magic cup was missing. The DS stated she expected the dietary staff to check the diet order and meal tray during meal preparation and it was not done. The DS stated Resident 2 could possibly experience weight loss from not having proper diet served each meal. During a concurrent interview and record review on 2/20/25 at 9:42 a.m., with the Registered Dietician (RD), Resident 2's POS, undated, was reviewed. The RD stated Resident 2 had diet recommendations to be on a fortified diet while on Hospice. The RD stated dietary staff were expected to follow the recommended dietary order and it was not done. The RD stated Resident 2 could potentially lose weight from not having appropriate diet served each meal. During a review of the facility's Job Description titled, Dietary Cook/Worker, undated, the Job Description indicated, . Essential Job Functions: . Understand and follow color coding and abbreviations of tray cards and therapeutic (specialized meal plan designed to treat or manage specific health conditions) menus . Be familiar with policies and procedures of the dietary department . During a review of the facility's policy and procedure (P&P) titled, Diet Orders and Menu Distribution, dated 11/20, the P&P indicated, Policy: To device a systematic procedure to process diet orders and distribute menus . A. All information regarding diet orders is written on the diet communication sheet by the nursing staff . There must be a written diet order in the patient's medical record before food may be served to the patient .

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 10) was free from accidents, when Resident 10 was smoking and had ashes fall on his shirt and into his wheelchair. This failure placed Resident 10's safety at risk and the ashes had the potential to burn the resident. Findings: During a review of Resident 10's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/21/25, the Admission Record indicated, Resident 10 was admitted to the facility on [DATE] with a diagnosis of Dementia (a brain condition that causes memory loss, thinking problems, and behavioral changes), Cerebrovascular Accident (a medical emergency where the blood supply to the brain is suddenly interrupted, either by a blockage or a rupture of a blood vessel, leading to brain damage) and senile degeneration of brain (a decline in brain function, often associated with aging, that can lead to memory loss, difficulty with thinking and problem-solving, and changes in behavior). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 2/10/25, the MDS assessment indicated Resident 10's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 5 out of 15 (a score of 13-15 indicates cognitively intact (a person is able to think clearly, remember things well, and make sound decisions, essentially having normal brain function with no significant problems with thinking, learning, or reasoning abilities), 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 10 was severely impaired. During a review of Resident 10's Smoking Order (SO), dated 2/26/24, the SO indicated . Order date: 2/26/24 at 9 a.m., Communication Method: Phone . Order Summary: Ok for resident to smoke nicotine products . at designated smoking area at designated smoking times . Confirmed by Licensed Vocational Nurse [LVN] 2 . During an observation on 2/19/25 at 11 a.m., in the designated smoking area on the back patio of the facility with Resident 10 and Activities Personnel (AP) 1, Resident 10 smoked three cigarettes and dropped ashes on his shirt and between his legs onto his wheelchair. Resident 10 was not wearing a smoking apron. During an interview on 2/20/25 at 11:06 a.m., with LVN 1, LVN 1 stated Resident 10 should have had a smoking apron (worn over the front of the body to prevent burns to clothing and keep hot ashes from burning the skin) on when he was smoking to prevent being burned. LVN 1 stated he needed the apron because he was not mentally alert and had poor safety awareness. LVN 1 stated due to Resident 10's BIMS, he could not keep himself safe. LVN 1 stated it was not safe for Resident 10 to be smoking if the ashes fell on him. During an interview on 2/21/25 at 9:59 a.m., with LVN 2 (she was also Director of Staff Development and Infection Preventionist), LVN 2 stated the expectation for Resident 10 was to be able to smoke safely. LVN 2 stated the expectation was not met and Resident 10 was at risk for burns and injury. LVN 2 stated the policy and procedure (P&P) Smoking Policy- Residents was not followed. During an interview on 2/21/25 at 3:13 p.m., with the Director of Nursing (DON), the DON stated Resident 10 should not have had ashes falling on him while smoking. The DON stated this was a safety concern. The DON stated the ashes could have still been hot and could have caused a skin injury. The DON stated the P&P Smoking Policy- Residents was not followed. During an interview on 2/24/25 at 10:51 a.m., with AP 1, AP 1 stated she was out there with Resident 10 and had not had any training in terms of facility smoking procedures. AP 1 stated her job was to take any resident out that was allowed to smoke and make sure they do not get burned. AP 1 stated she forgot to give Resident 10 a smoking apron that day. AP 1 stated Resident 10 dropping ashes on himself was a safety issue. AP 1 stated Resident 10 could catch fire and that was why the smoking apron should have been worn. During a review of the facility's P&P titled Smoking Policy- Residents, dated 5/2023, the P&P indicated, . this facility shall establish and maintain safe resident smoking practices . residents must be offered the non-combustible apron prior to smoking .

Based on interview and record review, the facility failed to manage and monitor the quality of care for one of 12 sampled residents (Resident 78), when the facility unjustly implemented a fluid restriction on Resident 78 without a clinical justification (diagnosis or medical need), comprehensive assessment or person-centered care plan. This failure had the potential for harm, including dehydration (occurs when your body loses more fluids than it takes in, leading to a lack of water and other vital fluids needed for normal bodily functions and could lead to a medical emergency) and electrolyte imbalance (having too much or too little of certain minerals (electrolytes) in your body, which can disrupt vital functions like muscle and nerve function, and fluid balance), for Resident 78 due to withholding fluid from him since admittance to the facility on [DATE]. Findings: During a review of Resident 78's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/21/25, the Admission Record indicated, Resident 78 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked), history of endocarditis (a serious inflammation [the body's response to injury, infection, or irritation] of the heart's inner lining. It's usually caused by a bacterial infection [when tiny, harmful bacteria enter your body, multiply, and cause illness], but can also be caused by fungi[microorganisms (tiny living things (like bacteria, fungi, and some algae) that are too small to see with the naked eye and require a microscope to be observed) that can cause infections]), acute embolism (a sudden blockage in a blood vessel, often caused by a blood clot (or other substance) that travels from somewhere else in the body and gets lodged, potentially cutting off blood flow and oxygen to an organ or tissue) and thrombosis (the blockage of a blood vessel by a blood clot) and hypotension (low blood pressure). During a review of Resident 78's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 1/16/25, the MDS assessment indicated Resident 78's Brief Interview for Mental Status (BIMS -assessment of cognitive(define) status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 78 was cognitively intact. During a review of Resident 78's Order Audit Report ([NAME]), dated 2/20/25, the [NAME] indicated, .Order date: 2/3/25 at 12:08 p.m. Order Status: Active . Order Summary: Fluid restriction 1500 [milliliters (mL)- unit of measurement]/24 hours: Dietary 240 mL with breakfast, 240 mL with lunch, 240 mL with dinner. 260 mL each shift given by nursing staff . created by: Licensed Vocational Nurse [LVN] 2 . During a review of Resident 78's Care Plan, dated 2/4/25, the Care Plan indicated, .Description: The resident has fluid overload [a person has too much fluid, potentially causing swelling, shortness of breath, and high blood pressure] or potential fluid volume overload related to Kidney Failure [when the kidneys stop working properly, leading to a buildup of waste in your blood, which can be dangerous if left untreated] . Goal: The resident will comply with diet and/or fluid restrictions [a patient ordered to have a certain amount of liquid each day] daily through review date . During a review of Resident 78's Admission History and Physical (H&P), dated 2/4/25, the H&P indicated, .Chief Complaint: Patient is admitted for rehab status post transfer [moving a patient from one place to another all while ensuring their medical care continues smoothly] from skilled nursing facility . status post transfer hospitalization for cerebrovascular accident [a medical emergency where blood flow to the brain is suddenly interrupted, either by a blockage or a rupture of a blood vessel, leading to potential brain damage] due to arterial septic emboli [infected blood clots that travel through the bloodstream and can block blood vessels, potentially causing damage to tissues or organs] . [AGE] year old male with past medical history significant for thrombophilia [a condition that makes your blood more likely to form clots] . osteomyelitis [a bone infection that causes inflammation and swelling], endocarditis and septic arterial embolism and generalized weakness is admitted for rehab . Physical Exam: . Blood pressure 109/61 . Pulse: 75 . Respirations: 16 . chest (lungs): clear breath sounds bilaterally [both sides] . Cardiovascular [heart]: . normal rate and rhythm . During a review of Resident 78's MDS Section I- Active Diagnosis (AD), dated 2/14/25, the AD indicated, .Primary Medical Condition: Cerebral Infarction . Heart/Circulation: Coronary artery disease [a heart condition that occurs when the coronary arteries narrow or become blocked]- No . Heart Failure [a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs]- No . Peripheral vascular disease [a circulatory condition that occurs when blood vessels narrow, block, or spasm]- No . Genitourinary [urinary and genital organs]: Renal insufficiency [kidneys aren't working as well as they should, potentially leading to a buildup of waste and excess fluid in your body], renal failure [kidneys aren't working properly, leading to a buildup of waste and fluid in your body], End stage Renal Disease [kidneys aren't working properly, leading to a buildup of waste and fluid in your body]- No . Pulmonary [Lungs]: Asthma [a chronic lung disease that makes breathing difficult] or chronic lung disease [damage to the lungs or airway]- No . Respiratory Failure- No . During a review of Resident 78's Nursing Weekly Summary (NWS), dated 2/8/25, the NWS indicated, .Edema [swelling]: No . Respiratory Status: Breath sounds: Clear, Both .Shortness of breath: None . During a review of Resident 78's Lab Results Report (LRR), dated 1/2/25, the LRR indicated, .BUN [urea nitrogen a test that measures the amount of a waste product (urea nitrogen) in your blood which is formed when your body breaks down protein, and your kidneys filter it out]: 18 [milligrams per deciliter (mg/dl)- unit of measurement], Reference Range 7 - 25 mg/dl . Creatinine [a waste product in the blood that indicates how well your kidneys are working]: 0.69 mg/dl, Reference Range: .70 -1.30 mg/dl . [Estimated Glomerular Filtration Rate (eGFR) - a measure of how well your kidneys are filtering waste products from your blood] 96 [milliliters per minute ml/min] [greater than or equal to] 60 ml/min . Interpretation of eGFR: 60 or more mildly reduced (60 - 89) or Normal (90 or more) . [less than] 15 ml/min [means] Kidney Failure . During a review of Resident 78's Progress Note (PN), dated 2/21/25, the PN indicated, .Subjective: Evaluation for fluid restriction . Problem list: Cerebral infarction with right hemiparesis (right side of body weakness), thiamine deficiency [a person's body doesn't get enough thiamine, which is vital for converting food into energy and maintaining healthy nerves, muscles, and the heart], essential hypertension, acute thromboembolism [the blockage of a blood vessel by a blood clot ], endocarditis, heart valve disorder, chronic pain syndrome . Objective: he is in no acute distress. Vital signs: blood pressure 98/61 [millimeters of mercury (mmHg) -unit of measurement] . pulse [heartrate]: 79, respirations 18, saturation 90% on ambient air [room air] . There is no volume overload . Assessment: Cerebral infarction unspecified, thiamine deficiency, hyperlipidemia, essential hypertension, use of fluid restriction not clear . Plan and Management: . 2. Discontinue fluid restriction for one week. Repeat basic metabolic panel after one week . During a concurrent interview and record review on 2/20/25 at 10:19 a.m., with the Licensed Vocational Nurse (LVN) 1, Resident 78's Electronic Medical Record (EMR), dated 2/3/25 to 2/20/25 was reviewed. The EMR indicated Resident 78 had a care plan in place related to kidney failure, but no medical diagnosis or evidence in the record to support that. The LVN 1 stated he was the nurse responsible for Resident 78 today. LVN 1 stated there was no evidence of edema, fluid overload, nor kidney failure for Resident 78 in the EMR. LVN 1 stated there had not been any issues with Resident 78's physical exams since he had been at their facility. During an interview on 2/20/25 at 11:30 a.m., with the Registered Dietician (RD), the RD stated Resident 78 did not have any congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs) or kidney conditions as a diagnosis in the EMR. During an interview on 2/20/25 at 3:46 p.m., with the RD, the RD stated she looked at Resident 78's labs and did not see anything that would have warranted a fluid restriction or kidney failure referenced in the care plan. The RD stated Resident 78 was admitted with the fluid restriction order but could not find a medical reason for it. The RD stated she was not sure of the root cause for the fluid restriction that was ordered. During an interview on 2/20/25 at 4:24 p.m., with the Director of Nursing (DON), the DON stated Resident 78 did not have a diagnosis of a kidney problem. The DON stated a care plan should be based off of diagnosis and resident needs and Resident 78's care plan was not. The DON stated the facility was still in the process of investigating why Resident 78 was put on a fluid restriction at his previous facility. The DON stated the orders from the previous facility were kept at this facility and the fluid restriction was part of that. The DON stated Resident 78 had been on the fluid restriction since his admit to this facility on 2/3/25 but did not know who originally ordered the fluid restriction or why. During an interview on 2/21/25 at 9:59 a.m., with the Director of Staff Development (DSD- also the Infection Preventionist and LVN 2), the DSD stated she created the care plan for Resident 78. The DSD stated she was not sure the reason for the fluid restriction initially and was assuming to get the care plan completed. The DSD stated she put kidney failure without looking ahead and Resident 78 did not have evidence of kidney failure. The DSD stated the care plan was inaccurate in regard to fluid restriction and the kidney failure. The DSD stated care plans should be individualized and Resident 78's was not. The DSD stated the inaccuracy of the care plan would equate to care for Resident 78 not going to be correct. The DSD stated the policy and procedure (P&P) Care Planning was not followed. The DSD stated Resident 78 came with that fluid restriction order from another facility. The DSD stated the facility tried to obtain past medical records from previous hospital stays and doctor appointments to find the origin of the fluid restriction, but they did not currently have them. The DSD stated this was not good quality of care and Resident 78 could have potentially been dehydrated because of the order. During an interview on 2/21/25 at 2:09 p.m., with the DON, the DON stated care plans are for staff to provide continuity of care to the resident and the continuity of care was not there. The DON stated, she felt staff followed the P&P Care Planning. The DON stated, that was her opinion. The DON stated there were no assessments, nor objective evidence, in the EMR that indicated kidney failure. The DON stated the facility tried to be cautious with Resident 78 and that is why they kept the fluid restriction order from the previous facility. The DON stated after private review of the EMR, the fluid restriction was not a safe order for Resident 78 to be on and it was not justified. The DON stated there was not a current clinical indication, no physical exam or current diagnosis, on why Resident 78 should have had a fluid restriction order. The DON stated the fluid restriction was incorrect and a mistake. During an interview on 2/21/25 at 3 p.m., with Medical Doctor (MD) 1, MD 1 stated the Medical Director was on vacation and the facility called him to assess Resident 78. MD 1 stated he assessed Resident 78 today and completed a physical assessment which was normal. MD 1 stated Resident 78's lungs were not wet, not short of breath, no edema and nothing indicates a fluid restriction was needed. MD 1 stated Resident 78 did not have an active diagnosis of congestive heart failure or kidney issues and there were no problems in terms of fluid. MD 1 stated people make mistakes and we learn from them. During an interview on 2/21/25 at 4:57 p.m., with the DSD, the DSD stated there was no objective evidence, nor clinical reason, for Resident 78's fluid restriction. During an interview on 2/24/25 at 10:37 a.m., with LVN 1, LVN 1 stated care plans tell us how to care for the resident and keeps them stable. LVN 1 stated a potential outcome for having a care plan that was not based off of comprehensive assessment could have been a risk of injury due to inappropriate medical treatment. LVN 1 stated the P&P Care Planning was not followed by staff. LVN 1 stated Resident 78 did not have a comprehensive or current assessment that justified why he requireda fluid restriction order. LVN 1 stated potential outcomes would be Resident 78 not getting proper care and dehydration. LVN 1 stated Resident 78 was also denied the freedom of his choices due to not being able to drink however much he desired. LVN 1 stated there was no medical rationale, no congestive heart failure, end stage renal disease, nor acute kidney injury that would warrant the fluid restriction. During a review of the facility's P&P titled, Care Planning, dated 4/2024, the P&P indicated, .Policy: Care, treatment and services are planned to ensure they are appropriate to the resident needs . care planning will be implemented through the integration [the process of combining or uniting separate things into a whole] of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable . the plan of care shall be individualized, based on diagnosis, resident assessment . care planning is based on data collected from resident assessments with integration of those assessment findings in the care planning process . During a review of National Institute of Health.gov Professional Reference title, Fluid Management, dated October 2023, found at (https://www.ncbi.nlm.nih.gov/books/NBK532305/#:~:text=Clinical%20Significance,help%20alleviate%20these%20potential%20problems.), the reference indicated, .Fluid management is crucial in inpatient medical settings, where each patient presents unique and individual requirements . Improper fluid management can cause significant morbidity [disease] and mortality [death] from volume [amount of fluid] depletion [lack of] or overload. Therefore, it is essential to carefully assess the specific type and quantity of fluids required for each patient . crucial role of the interprofessional healthcare team in managing patients' volume status, optimizing patient outcomes and reducing morbidity and mortality . Objectives: . Implement evidence-based fluid resuscitation and maintenance therapy guidelines for acute and critical care patients, considering their unique physiological needs . Identify potential risk factors and contraindications [a reason why a specific medical treatment or procedure shouldn't be used because it could be harmful to a person] related to fluid management in patients . Communicate effectively among the interprofessional healthcare team, including physicians, nurses, nutritionists, and pharmacists, to optimize fluid management strategies and improve patient outcomes . Treatment: . Assessment of vital signs, physical examinations, and supplementary laboratory data will help determine the appropriateness of each patient's fluid management strategy . During a review of Joint Commission.org Professional Reference title, Medication Order- Indication for Use Requirements, dated November 2021, (found at https://www.jointcommission.org/standards/standard-faqs/home-care/record-of-care-treatment-and-services-rc/000001696/), the reference indicated, .Does the medical record need to contain a diagnosis, condition, or indication for use for each medication ordered? . Yes. Standard MM.04.01.01 requires that there be documented indication for all medications ordered. That indication can be in the form of lab values, diagnoses, progress note entries, etc. In other words, the indication must be evident somewhere in the medical record. This requirement is found in the Medication Management chapter at MM.04.01.01. During a review of Nursing World.org Professional Reference titled, The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf), the reference indicated, .The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making . Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation . During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/), the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum . vital to positive patient outcomes . the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of falls and was assessed as a high fall risk, received adequate supervision and assistance to prevent injuries when Resident 1 had five falls between 5/8/24 and 6/28/24. This failure placed Resident 1 at risk for continued falls and had the potential to result in injury. Findings: During an interview on 7/16/24 at 10:26 a.m. with the Director of Nursing (DON), the DON stated Resident 1 had a witnessed fall on 5/29/24. The DON stated Resident 1 complained of hip pain a half hour after the fall so an X ray (a procedure that uses high-energy radiation to take pictures of the inside of the body) was done which showed a small fracture in the pelvis (The area of the body below the abdomen that contains the hip bones, bladder, and rectum)which did not require hospitalization or surgery. During a review of Resident 1 ' s Admission Record (AR), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of coccidioidomycosis (a fungal infection in the lungs), malignant neoplasm (cancerous tumor) of prostate (walnut-sized gland in the male reproductive system), metabolic encephalopathy (chemical imbalance in the blood affecting the brains function), anxiety (feeling of fear, dread and uneasiness), and repeated falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) scored 9 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was moderately cognitively impaired. During a review of Resident 1's X-ray result dated 5/30/24, the result indicated, . Chief Complaint: Pain in right hip . Findings . There is a recent versus subacute fracture [an older fracture which has begun to heal] of the right superior pubic ramus [a bone which makes up part of the pelvis] at the symphysis pubis [joint where the pubic bones meet] . If there is pain to palpation in this area . then CT scan [medical imagining to create detailed pictures of the inside of the body] of the pelvis is recommended . During a review of Resident 1's CT Pelvis w/o [without] Contrast [dye used to show abnormal areas in body], dated 6/4/24 was reviewed. The CT scan indicated, . Comminuted fracture [bone broken in at least two places] of the right pubic symphysis and extending into the superior pubic ramus with minimal displacement [change in position] and surrounding soft tissue edema [swelling] . During an observation on 7/16/24 at 10:43 a.m. in Resident 1's room, Resident 1's bed was empty because he was hospitalized due to an unrelated illness and there were two fall mats at his bedside. During an interview on 7/16/24 at 10:45 a.m., with Resident 2, Resident 2 stated he had been Resident 1's roommate for a few weeks but was not present during any of the falls. Resident 2 stated Resident 1 had an alarm which would go off when he tried to get out of bed, or his wheelchair and the staff would come running in to check on him. Resident 2 stated he had never seen Resident 1 receiving one on one supervision (clinical status unstable enough to require staff to observe them at all times) with staff. During an interview on 7/16/24 at 10:50 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 had frequent falls while in the facility. CNA 1 stated Resident 1 was alert but not oriented, impulsive and would not call for help. CNA 1 stated Resident 1 frequently got out of bed by himself when in his room alone which increased his fall risk. CNA 1 stated staff would take Resident 1 to activities or sit him by the nurse's station to provide extra supervision during the day which prevented falls. CNA 1 stated she worked the night shift at times and Resident 1 would frequently get out of bed when left alone. During an interview on 7/16/24 at 10:54 a.m. with CNA 2, CNA 2 stated Resident 1 was alert but forgetful. CNA 2 stated she was aware Resident 1 was a high fall risk. CNA 2 stated Resident 1 had an alarm on his bed and chair which would go off when he tried to get. CNA 2 stated, Someone always has an eye on him when he is up during the day. CNA 2 stated Resident 1 would not remember to use his call light for help. During a concurrent interview and record review on 7/16/24 at 12:26 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was at high risk for falls. LVN 1 stated Resident 1 had interventions in place to prevent falls and injuries such as bed/chair position alarm, frequent visual checks, call light within reach, reminders to use call light, fall mats, the star program, bed low position and non-skid footwear. LVN 1 was unable to clarify the frequency of frequent visual checks. LVN 1 stated Resident 1 had frequent checks while he was out of his room in his wheelchair, but the checks were not done while he was in his room. LVN 1 stated the star program was used for residents at high fall risk. LVN 1 stated the therapy department would evaluate the resident and assign a red or white star depending on the amount of assistance they required, white stars indicated the resident was safe to ambulate alone and the red stars indicated the residents required assistance. LVN 1 stated Resident 1 was assigned a red star because he was not safe to ambulate or transfer by himself. LVN 1 reviewed Resident 1's diagnoses and stated Resident 1 had metabolic encephalopathy, confusion, history of falls and a urinary tract infection (UTI-bacteria grows in the urinary tract [the body's drainage system for removing urine]) which increased his fall risk. Resident 1' s Health Status Note, dated 5/29/24 at 0830 (8:30 a.m.), indicated, . [name of CNA] heard alarm coming from resident ' s room and walked in and noted resident standing in between the bed and the window . attempted to get to resident before he could move further . resident began walking forward . appeared to lose his balance and fell forward . resident denied pain at time of fall . Resident 1' s fall risk care plan initiated 5/9/24 was reviewed, the care plan indicated, . Resident at risk for falls R/T [related to] generalized muscle weakness, and poor safety awareness r/t intermittent episodes of confusion . unwitnessed non-injury fall in room [ROOM NUMBER]/8/24 . Witnessed fall in room [ROOM NUMBER]/14/24 . Unwitnessed fall in room [no date] with skin tear to right RA [fore arm] . Witnessed fall hit head, noninjury on 5/29/24 . Unwitnessed fall 6/28/24 . will remain free from falls through the next review period . Target Date 9/5/24 . Continue reminders to use call light . Bed in lowest position. Floor mats in place. Increase CNA rounding . Verbal reminders to not ambulate [walk]/transfer without assistance . bed alarm, increase CNA rounding at night . Delayed injury: right pubic rami fracture from witnessed fall confirmed 05/31/2024. RP [responsible party]/MD [physician] notified. Xray and radiology report given to Ortho [orthopedic - a physician specializing in treatment of the musculoskeletal system (bones, joints, ligaments, tendons, or muscles)] surgeon for evaluation . LVN 1 stated Resident 1' s mental status fluctuated throughout the day so interventions to educate or remind him to not get up alone or to use call light would be ineffective. LVN 1 stated the most effective interventions for Resident 1 was supervision and distraction because he did not fall when he was out of his room supervised. LVN 1 stated Resident 1 would need constant supervision to prevent falls. During a concurrent interview and record review on 7/16/24 at 1:30 p.m. with the DON, the DON stated Resident 1 had history of frequent falls prior to his admission. The DON stated Resident 1 fell on [DATE] but did not complain of pain when he was assessed. The DON stated Resident 1 complained of pain later in the day, so the nurse notified the physician and received an order for an X-ray of the hip. Resident 1' s Risk Benefit Analysis: High Fall Risk/Unavoidable Falls, dated 5/23/24 was reviewed and indicated, . The above-named patient has been identified as being a high-risk alert for falls . You/the Resident and family are encouraged to participate in the development of the plan of care. IT IS IMPROTANT THAT YOU ACKNOWLEDGE THAT THESE APPROACHES WILL NOT ABSOLUTELY PREVENT A FALL OR PREVENT SERIOUS INJURY FROM OCCURING . The interdisciplinary team [IDT-group of healthcare professionals who work together to provide care] has reviewed your/the residents fall risk associated with your/the resident' s medical and cognitive condition and have discussed approaches that may be included in your/the resident ' s plan of care . circle appropriate . Low bed [circled] . RNA/PT/OT [circled] . Toileting assistance [circled] . No being left alone in your own room [not circled] . The DON stated the interventions circled were active interventions. The DON stated the IDT had decided Resident 1' s falls were unavoidable. The DON stated the facility was responsible to keep the resident safe from falls. DON stated it would be too expensive to place Resident 1 on one on one. The DON stated Resident 1 had received every intervention but was still falling which made the falls unavoidable. The DON stated he fractured the pelvis but had a history of fracturing the same area in the past. During a telephone interview on 8/15/24 at 12:07 p.m. with LVN 2, LVN 2 stated he was the charge nurse on 5/29/24 when Resident 1 fell . LVN 2 stated he was at the nurse' s station and heard Resident 1' s bed alarm go off, so he walked down the hall to the room and saw CNA 3 walk into the resident' s room. LVN 2 stated when he walked into Resident 1' s room, the resident was laying face down shifted to his right side. LVN 2 stated the resident denied pain at the time, but within a half hour pointed to his right groin and said it hurt. LVN 2 stated Resident 1 was unable to verbalize his severity of pain using the numeric pain scale (based on 0-no pain, 1 to 3-mild pain, 4 to 6-moderate pain and 7-10 severe pain), so he utilized the FACES pain scale (visual scale to rate pain). LVN 2 stated the FACES pain scale indicated he was sore, not in moderate or severe pain. LVN 2 stated the resident denied severe pain. LVN 2 stated he notified the physician when Resident 1 complained of pain and was given an order for a hip X-ray. LVN 2 stated Resident 1 was not sent to the emergency department because he was not in a large amount of pain. I figured it was possibly just bruised. LVN 2 stated the physician declined to send the resident to the ED and wait for the X-ray results. LVN 2 stated the X-ray was done on 5/30/24 and the results were received on 6/1/24. LVN 2 stated the physician was notified of the X-ray results and he had ordered a CT scan. LVN 2 stated the resident was not sent to the hospital after the X-ray because the physician stated the injury was not normally fixed by surgery. LVN 2 stated Resident 1's pain was easily controlled by oral pain medication, and he did not require surgery or hospitalization for the injury. LVN 2 stated the physician was aware the resident had a fracture; the CT scan was a precaution to verify the resident did not require surgery. LVN 2 stated Resident 1's intervention of keeping up in activities was successful because he was supervised, and the staff could intervene before he got up and fell . LVN 2 stated Resident 1 had not been on a one-on-one supervision while in his room, but supervision was the most effective intervention to prevent him from falling. During a telephone interview on 8/15/24 at 12:35 p.m. with CNA 3, CNA 3 stated she was the CNA who had witnessed Resident 1' s fall on 5/29/24. CNA 3 stated Resident 1 had a mobility alarm on his bed which had gone off. CNA 3 stated she walked into the resident' s room and found him standing at bedside, when she had walked towards him, he fell . CNA 3 stated Resident 1 denied pain at the time of the fall. During a review of Resident 1' s Interdisciplinary Team Meeting, dated 5/30/24 was reviewed. The IDT note indicated, . Resident had a witnessed fall in room [ROOM NUMBER]/29/24 . approximately 08:30 am, CNA [name] heard alarm coming from resident room and walked in and noted resident standing in room in between the bed and the window . resident appeared to lose his balance and fell forward . Resident denied any pain at time of fall . approximately 40 minutes later resident complained of minimal right groin area . PMD (primary Medical Doctor) was notified and ordered X-ray of right hip . IDT met and unavoidable was put in place previous fall 5/22/24. Will keep encouraging resident to use call light . During a review of the facility' s policy and procedure (P&P) titled Assessing Falls and Their Causes, dated 7/2019, the P&P indicated, . Purpose . provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . Falls are a leading cause of morbidity and mortality among the elderly in nursing homes . Falling may be related to underlying clinical or medical conditions . After a fall . evaluate for possible injuries to the head, neck, spine, and extremities . If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately . Observe for delayed complications of a fall for approximately seventy-two (72) hours . Document any observed signs or symptoms of pain, swelling, bruising, deformity and/or decreased mobility . During a review of the facility ' s P&P titled, Falls and Fall Risk, Managing and Prevention, dated 9/15/23, the P&P indicated, . the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Staff will assist and supervise those residents that are at identified at risk for falls . The IDT staff, with the input of the attending physician, will implement a resident-centered fall prevention plan . If the resident has a current care plan for falls this care plan will be updated by adding the new fall to problem including date and short description of fall. A new approach will also be added Starting on date of new fall . If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . All Residents determined to be at a risk for falls with a score of 10 or higher will be placed in the facility Fall Prevention Program to prevention injuries from fall .

Based on observation, interview, and record review, the facility failed to revise and implement a person centered comprehensive care plan for one of three sampled residents (Resident 1), when Resident 1 fell on [DATE] and care plan interventions were not revised and updated. This failure placed Resident 1 ' s health and safety at risk when fall care plan interventions were not revised. Findings: During a review of Resident 1's Admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included cognitive communication deficit (difficulty paying attention to a conversation, remembering information). During a concurrent observation and interview on 4/30/24 at 9:50 a.m., with Resident 1 in the dining room, Resident 1 was seated in her wheelchair. Resident 1 was unable to recall how she fell on [DATE]. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 7 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired). The BIMS assessment indicated Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s Progress Notes (PN), dated 4/5/24 was reviewed. The PN indicated, .Resident was found lying on her left side next to shower hose in center shower room. Approximately 2 minutes prior, resident was assisted to the toilet in the shower room, CNA [certified nursing assistant] .left resident to get skin protectant cream. Upon CNA walking back into shower room, resident found lying on the floor . During a concurrent interview and record review on 4/30/24 at 11:47 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Care Plan (CP) dated 6/2/23 was reviewed. The CP indicated, .is at risk for falls R/T [related to] generalized muscle weakness .Observe frequently and place in supervised area when out of bed . LVN 1 reviewed Resident 1 care plans and stated there were no updated interventions after the fall on 4/5/24. LVN 1 stated care plan interventions should be updated after a fall, but was not. During an interview on 4/30/24 at 2:01 p.m. with CNA 1, CNA 1 stated she left Resident 1 unsupervised in the shower room to get a cream. CNA 1 stated she heard a sound while walking back to the shower room and upon entering the shower room she observed Resident 1 on the ground. CNA 1 stated she should not have left Resident 1 unsupervised in the shower room. During a concurrent interview and record review on 4/30/24 at 2:20p.m. with the Administrator (ADM), the facility policy and procedure (P&P) titled Falls and Fall Risk, Managing and Prevention dated 09/2023 was reviewed. The policy indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The IDT (Interdisciplinary Team) staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . The ADM stated care planned interventions should be updated and revised of falls. The ADM stated the importance of the care plan was to implement interventions to keep residents safe.

Based on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for two of three sampled residents (Resident 1and Resident 2), when: 1. Resident 1 was left unsupervised on 4/5/24 in the shower room resulting in fall. 2. Resident 2 ambulated without assistance on 4/18/24 in the facility hallway resulting in a fall. These failures resulted in Resident 1 and 2 falling to the ground and had the potential to result in injury. Findings: 1.During a review of Resident 1's Admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included cognitive communication deficit (difficulty paying attention to a conversation, remembering information). During a concurrent observation and interview on 4/30/24 at 9:50 a.m., with Resident 1 in the dining room, Resident 1 was seated in her wheelchair. Resident 1 was unable to recall how she fell on [DATE]. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 7 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired). The BIMS assessment indicated Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s Progress Notes (PN), dated 4/5/24 was reviewed. The PN indicated, .Resident was found lying on her left side next to shower hose in center shower room. Approximately 2 minutes prior, resident was assisted to the toilet in the shower room, CNA [certified nursing assistant] .left resident to get skin protectant cream. Upon CNA walking back into shower room, resident found lying on the floor . During a concurrent interview and record review on 4/30/24 at 11:47 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Care Plan (CP) dated 6/2/23 was reviewed. The CP indicated, .is at risk for falls R/T [related to] generalized muscle weakness .Observe frequently and place in supervised area when out of bed . LVN 1 stated Resident 1 should not have been left unsupervised in the shower room. LVN 1 stated the care planned interventions should be implemented by all staff caring for Resident 1. During an interview on 4/30/24 at 2:01 p.m. with CNA 1, CNA 1 stated she left Resident 1 unsupervised in the shower room to get a cream. CNA 1 stated she heard a sound while walking back to the shower room and upon entering the shower room, she observed Resident 1 on the ground. CNA 1 stated she should not have left Resident 1 unsupervised in the shower room. During a concurrent interview and record review on 4/30/24 at 2:16p.m. with the Administrator (ADM), the facility policy and procedure (P&P) titled Care Planning dated 04/2024 was reviewed. The P&P indicated, . Care, treatment and services are planned to ensure they are appropriate to the resident ' s needs . Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable . The ADM stated care planned interventions should be implemented for the safety of residents. The ADM stated CNA 1 should have asked another staff to obtain the cream. 2. During a review of Resident 2's Admission Record, undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE]. Resident 1's diagnosis muscle weakness, difficulty walking, and Alzheimer ' s (affect a person ' s ability to carry out daily activities). During a concurrent observation and interview on 4/30/24 at 9:45 a.m., with Resident 2 in Resident 2 ' s room, Resident 2 was lying in bed. Resident 2 did not want to be interviewed regarding her fall. During a review of Resident 2's Minimum Data Set Assessment (MDSA) dated 3/2/24, MDSA indicated, Resident 2's Brief Interview for Mental Status assessment score was 6. The BIMS assessment indicated Resident 6 had severe cognitive impairment. During a review of Resident 2 ' s Progress Notes (PN), dated 4/18/24 was reviewed. The PN indicated, .Activities assistant .witnessed resident ambulating in the hallway with FWW [front wheel walker] .Resident was turning left to walk into the lobby and appeared to lose her balance. Resident fell on her back, walker fell over to right side .copious amounts of blood coming from back of head with lacerations noted to back of head. Resident noted to have skin tear to top of right hand, and discoloration to left elbow .Resident appeared confused, unable to say what happened . During a telephone interview on 4/30/24 at 10:31 a.m. with Activity Assistant (AA), AA stated on 4/18/24 she was doing activities with residents when she observed Resident 2 ambulating in the hallway unsupervised. AA stated Resident 2 stumbled and fell backwards. During a concurrent interview and record review on 4/30/24 at 10:51 a.m. with LVN 1, Resident 2 ' s Care Plan (CP) dated 12/12/23 was reviewed. The CP indicated, .Risk for falls .Assist Resident with ambulation and transfers, utilizing therapy recommendations . LVN 1 stated Resident 1 needed assist when ambulating because she was not steady when ambulating. During a phone interview on 4/30/24 at 11:02 a.m. with Physical Therapy (PT), PT stated Resident 2 needed supervision when ambulating in the hallway. PT stated Resident 2 needed verbal cues for safety because she had confusion. During a review of Resident 2 ' s Therapist Progress & Discharge Summary dated 1/25/24, indicated, .ambulates 200 feet on level surfaces with front wheeled walker and modified independence (assistive device or extra time needed) and verbal instruction/cues .Due to safety reasons, the patient requires verbal cues for all functional mobility . During a concurrent interview and record review on 4/30/24 at 2:16p.m. with the ADM, the facility policy and procedure (P&P) titled Care Planning dated 04/2024 was reviewed. The policy indicated, . Care, treatment and services are planned to ensure they are appropriate to the resident ' s needs . Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable . The ADM stated care planned interventions should be implemented for the safety of residents. During a telephone interview on 5/3/24 at 2:13 p.m. with CNA 2, CNA 2 stated she was the assigned CNA for Resident 2 on 4/18/24. CNA 2 stated she was getting water on the other side of the hallway when Resident 2 fell . CNA 2 stated Resident 2 would lose balance at times when she was ambulating. CNA 2 stated whenever she observed Resident 2 walking, she would walk next to Resident 2 because she was at risk of losing her balance and falling.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. One of one drawer that stored clean utensils had dried food on a spatula. This had the potential for pathogenic microorganism (an organism that is so small that it cannot be seen by the naked eye and is capable of causing disease) growth that could inadvertently (accidentally) be transferred to food and could also provide an environment for attraction of insects and rodents. 2. Five unlabeled food items and two expired food items were found in the resident nourishment refrigerator and kitchen refrigerators. These failures placed residents at risk for cross contamination and had the potential to cause foodborne illness (illness caused by ingestion of contaminated food or beverages) to 28 of 28 residents who consumed the food . Findings: 1. During a concurrent observation and interview on [DATE] at 9:26 a.m. with the Kitchen Supervisor (KS) in the kitchen, the clean utensil drawer was observed to have a spatula with dried, caked on yellow food particles mixed in with clean utensils. The KS observed the dirty spatula and stated the spatula was not clean. The KS stated the spatula should not be in the clean utensil drawer. The KS stated all the utensils in the clean utensil drawer needed to be removed and reprocessed. During an interview on [DATE] at 1:37 p.m. with the Registered Dietician (RD), the RD stated dirty cooking utensils should not be in the clean cooking utensil drawer. The RD stated her expectations of the kitchen was that it be clean and sanitized to prevent the risk of cross contamination and residents getting sick from food borne illness. During an interview on [DATE] at 11:54 a.m. with the KS, the KS stated the dirty utensils probably got into the clean utensil drawer after the dishes were washed. The KS stated staff might have just grabbed the utensils and put them in the drawer without checking to be sure they were clean. The KS stated it was important to get food particles off the utensils. The KS stated dirty utensils could lead to cross-contamination. The KS stated using dirty utensils could get the residents sick. During an interview on [DATE] at 3:18 p.m. with the Administrator (ADM), the ADM stated dirty utensils should not be in the clean utensil drawer. The ADM stated his expectation was for the kitchen to be clean and sanitary. The ADM stated having dirty utensils in the clean utensil drawer could cause cross contamination and food born illness to the residents. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control . Dishwashing Procedures (Dish machine), dated 2023, indicated, . all the dishes should be inspected after coming out of the dish machine and if the dishes are not clean then they should be washed again in the dish machine . During a review of the KS job description titled, Orientation, Inservice, & Personnel Management . Director of Food and Nutrition Services Job Description dated 2023, indicated, . ensures sanitation and safety standards are maintained according to State, Federal, and local regulations . During a review of professional reference titled, FDA Food Code 2022, section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, dated 2022, indicated, . EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch .the FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations . During a review of professional reference titled, FDA Food Code 2022, section ,d+[DATE].11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, dated 2022, indicated, . cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored . in a clean, dry location . where they are not exposed to splash, dust, or other contamination . During a review of professional reference titled, FDA Food Code 2022, section ,d+[DATE].13 Nonfood-Contact Surfaces, dated 2022, indicated, . the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . 2. During a concurrent observation and interview on [DATE] at 9:33 a.m. with Cook (CK) 1 in the walk-in refrigerator in the kitchen, a package of raspberries with a white substance on them was observed. CK 1 stated the raspberries looked like they had mold on them. Three bowls of chopped vegetable food items were observed in Refrigerator #1 without labels. CK 1 stated the vegetables were chopped this morning. CK 1 stated she did not put a label on the food items. During a concurrent observation and interview on [DATE] at 10:50 a.m. with the RD in the staff lounge, the Resident Nourishment Refrigerator was observed to have an unlabeled food container, shriveled, discolored tomatoes in a container labeled [DATE], and an opened jar of food with a received date of [DATE], without an opened date label. The Resident Freezer was observed to have cloth ice packs with resident names on them, unwrapped. The RD stated there should not be unlabeled and expired food in the resident refrigerator. The RD stated there should not be medical equipment in the resident freezer. During an interview on [DATE] at 11:06 a.m. with the KS, the KS stated the resident food was held only three days in the resident nourishment refrigerator. The KS stated the night shift kitchen staff checked the resident refrigerator. The KS stated the freezer packs were for nurses to use, not the residents. The KS stated the dietary department did not use the Resident Freezer. During an interview on [DATE] at 1:37 p.m. with the RD, the RD stated her expectations for storing resident food was it be labeled and dated with an opened date, used by dated and dated when prepared or received. The RD stated there should not be expired food or unlabeled food in the resident refrigerator. The RD stated if residents were served expired food or outdated food, they could become sick. During an interview on [DATE] at 8:55 a.m. with LVN 2, LVN 2 stated the dietary department monitored the resident refrigerator. LVN 2 stated we did not let residents keep personal food. LVN 2 stated we would not save the resident's food. LVN 2 stated nursing did not keep track of resident's food. LVN 2 stated storing the ice packs in the resident freezer was not a good idea. LVN 2 stated it could cause cross contamination. LVN 2 stated if ice packs leaked, they could leak out into the resident's food. During an interview on [DATE] at 9:33 a.m. with the Director of Nursing (DON), the DON stated the facility had a policy and procedure (P&P) for the resident nourishment refrigerator. The DON stated staff were required to follow those policies. The DON stated it was not appropriate for other departments to put medical equipment in the resident refrigerator. The DON stated the dietary department was responsible for the resident refrigerator. The DON stated nursing staff would get the resident's food from the resident refrigerator. The DON stated if the food was expired, the resident could get sick. The DON stated she would expect the dietary department to follow daily checks of the resident refrigerator. The DON stated if there was expired food in the resident refrigerator it needed to be thrown away immediately. The DON stated expired food should not be in the refrigerator. During an interview on [DATE] at 3:18 p.m. with the ADM, the ADM stated his expectation was for the resident refrigerator to be clean and sanitary. The ADM stated no expired food should be in the refrigerators. The ADM stated eating expired food could cause foodborne illness. The ADM stated no medical equipment should be in the resident refrigerator or freezer. The ADM stated there would be a potential for cross-contamination and food borne illness from bacteria. During a review of the facility's P&P titled, Sanitation and Infection Control . Food Brought in From Outside Sources, dated 2023, indicated, . All food brought in should be checked by the charge nurse or the Director of Food and Nutrition Services. It must be placed in a tightly sealed container with the resident's name and date on it . Food that does not have a manufacturer's printed date must be thrown out 3 days from the time it was brought in .

Based on observation, interview and record review, the facility failed to provide fire safety accommodations to ensure the residents remained safe while they smoked for four of four sampled residents (Residents 7, 9, 10 and 24), when Residents 7, 9, 10, and 24 were not provided with noncombustible (non flammable) aprons prior to smoking cigarettes. This failure had the potential to place the residents at risk for smoking related injuries. Findings: During a review of Resident 7's Admission Record (AR), dated 3/1/24, the AR indicated Resident 7 was admitted on [DATE] with diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and muscle weakness. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/19/24, the MDS section C indicated Resident 7 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 7 was cognitively intact. During a review of Resident 7's Care Plan (CP), dated, 2/11/24, the CP indicated, . Resident will adhere to the Tobacco/Smoking Policies of the Facility . educate Resident/Responsible Party (RP) on the facility's tobacco/smoking policy(s) . During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 7 was observed sitting in her wheelchair smoking a traditional cigarette. Resident 7 was observed not wearing a noncombustible apron. During a review of Resident 9's AR, dated 3/1/24, the AR indicated Resident 9 was admitted on [DATE] with a diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 9's MDS, dated [DATE], the MDS section C indicated Resident 9 had a BIMS score of 14 out of 15 which suggested Resident 9 was cognitively intact. During a review of Resident 9's CP, dated 1/24/24, the CP indicated, . Resident will adhere to the Tobacco/Smoking Policies of the Facility . educate Resident/Responsible Party (RP) on the facility's tobacco/smoking policy(s) . During a concurrent observation and interview on 2/29/24 at 10:46 a.m. with Resident 9 in her room, Resident 9 was observed sitting in her wheelchair by her door. Resident 9 stated she smoked, and she had a smoking schedule. Resident 9 stated staff did not tell her about smoking safety. Resident 9 stated she did not wear a smoking apron when she smoked. During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 9 was observed sitting in her walker smoking an electronic cigarette (e-cig) next to residents smoking traditional cigarettes. Resident 9 was observed not wearing a noncombustible apron. During a review of Resident 10's AR, dated 3/1/24, the AR indicated, Resident 10 was admitted on [DATE] with a diagnosis of dementia. During a review of Resident 10's MDS, dated [DATE], the MDS Section C indicated Resident 10 had a BIMS score of 9 out of 15, which suggested Resident 10 was moderately impaired. During a review of Resident 10's CP, dated (undated), the CP indicated, . Resident will adhere to the Tobacco/Smoking Policies of the Facility . Resident will not suffer injury from unsafe smoking practices . staff to extinguish cigarettes . During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 10 was observed sitting in his wheelchair smoking a traditional cigarette. Resident 10 was observed not wearing a noncombustible apron. During a review of Resident 24's AR, dated 3/1/24, the AR indicated Resident 24 was admitted on [DATE] with a diagnosis of multiple sclerosis (a condition where body attacks itself) During a review of Resident 24's MDS, dated [DATE], the MDS indicated, Resident 24 had a BIMS score of 15 out of 15, which suggested Resident 24 was cognitively intact. During a review of Resident 24's CP, dated 12/28/23, the CP indicated, . the resident will not smoke without supervision through the review date . instruct resident about the facility policy on smoking; locations, times, safety concerns . notify charge nurse immediately if it is suspected resident has violated facility smoking policy . the resident requires SUPERVISION while smoking . During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 24 was observed sitting in her wheelchair with an assistant smoking a traditional cigarette. Resident 24 was observed not wearing a noncombustible apron. During a concurrent observation and interview on 2/29/24 at 11:12 a.m. with the Activities Assistant (AA) outside the facility in the designated smoking area, the AA was observed giving the residents their smoking articles, no noncombustible aprons were observed in the AA's possession. The AA stated the residents lit their own cigarettes. The AA stated the residents flicked the cigarette ashes on the ground. The AA stated the residents did not like to wear the noncombustible apron. The AA stated she was not sure if the residents were educated on safety while smoking. During a concurrent interview and record review on 3/1/24 at 3:18 p.m. with the Administrator (ADM), the facility's policy and procedure (P&P) titled, Smoking Policy - Residents dated 7/20 was reviewed. The P&P indicated, . this facility shall establish and maintain safe resident smoking practices . resident must apply the noncombustible apron prior to smoking . The ADM stated he was not aware the P&P stated the residents must wear a noncombustible apron. The ADM stated the staff needed to follow the P&P. The ADM stated there could be inconsistencies in resident care and resident safety if the P&Ps were not followed.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for four of 12 sampled residents (Residents 4, 10, 24 and 26) when: 1. Residents 4, 10, and 24 did not have an individualized care plan developed and implemented for the use of side rails. This failure had the potential for Residents 4, 10, and 24 to be injured while using the side rails. This failure had the potential for Residents 4, 10, and 24 to be injured while using the side rails. 2. Resident 26 did not have an individualized care plan developed and implemented for the use of a dignity bag (a bag used to cover and hold the [NAME] catheter [an indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag] drainage/collection bag so it is not visible). This failure violated Resident 26's privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 26. Findings: 1. During a review of Resident 4's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/29/24, the AR indicated, Resident 4 was admitted from home on 1/26/24 to the facility, with diagnoses that included Anxiety (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Hypertension (high blood pressure), Atrial fibrillation (Afib, is an irregular and often very rapid heart rate), and Arthritis (inflammation or swelling of joints). During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 2/29/24, at 10:22 a.m., Resident 4's nursing Care Plan (CP) was reviewed. LVN 1 stated Resident 4 had a risks and benefits form for side rail use and consent (a permission for something to happen or agreement to do something) signed by family consenting to the use of side rails on 1/26/24. LVN 1 reviewed Resident 4's CP and stated there was no CP developed for the use of side rails. LVN 1 stated the use of side rails should have been care planned to include interventions such as bed inspection, frequent visual checks and monitoring of side rails for continued use. LVN 1 stated the CP for side rails should have been developed when the consent was signed by Resident 4's responsible party (RP). During a review of Resident 10's AR, dated 2/29/24, the AR indicated, Resident 10 was admitted from an acute care hospital on 1/19/24 to the facility, with diagnoses which included Senile Degeneration of Brain (memory loss), Dementia (impaired ability to remember, think, or make decisions), Hypertension, Type 2 Diabetes Mellitus (high blood sugar), and Cerebral Infarction (stroke). During an observation on 2/27/24, at 10:42 a.m., in Resident 10's room, Resident 10 was sleeping and laying in bed, on his back, with half-length side rails up on both sides of the bed. During a concurrent interview and record review with LVN 2, on 2/29/24, at 10:01 a.m., Resident 10's nursing CP was reviewed. LVN 2 stated Resident 10 had a risks and benefits form for side rail use completed on 1/19/24 and the consent signed by the RP consenting to the use of side rails on 2/1/24. LVN 2 reviewed Resident 10's CP and stated there was no CP developed for the use of side rails. LVN 2 stated the use of side rails should have been care planned to include interventions to prevent risks of entrapment, injury, and monitoring for continued use. LVN 2 stated the CP for side rails should have been developed when the consent was signed by Resident's RP and after obtaining a physician order. During a review of Resident 24's AR, dated 2/29/24, the AR indicated, Resident 24 was admitted from an acute care hospital on 11/1/23 to the facility, with diagnoses which included Urinary Tract Infection (UTI- bladder infection), Myocardial Infarction (heart attack), Cardiomyopathy (is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), Pneumonia (lung infection caused by bacteria), and Multiple Sclerosis (commonly known as MS, is a long-lasting disease which can cause problems with vision, balance, muscle control, and other body functions). During a concurrent interview and record review with LVN 2, on 2/27/24, at 2:52 p.m., Resident 24's nursing CP was reviewed. LVN 2 stated Resident 24 had a risks and benefits form for side rail use and consent signed by Resident 24 [self-responsible] consenting to the use of side rails on 11/1/23. LVN 2 reviewed Resident 24's CP and stated there was no CP developed for the use of side rails. LVN 2 stated the use of side rails should have been care planned to include interventions to prevent risks of entrapment, injury, and monitoring for continued use. LVN 2 stated the CP for side rails should have been developed when the consent was signed by Resident 24's and after obtaining a physician order. During an interview with the Director of Nursing (DON), on 3/1/24, at 12:26 p.m., the DON stated upon reviewing the risks and benefits form for side rail use and obtaining the consent from the RP, a physician order should be obtained from the attending physician and a CP should be developed. The DON stated the CP drove resident care to ensure residents care was being met. The DON stated the facility failed to follow the facility's P&P related to care planning process. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Center dated 3/22, the P&P indicated, . The comprehensive, person-centered care plan is developed .no more than 21 days after admission . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . a. includes measurable objectives and timeframes; b. describe the services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being . During a review of the facility's P&P titled Bed Safety and Bed Rails dated 6/23, the P&P indicated, . Resident beds meet the safety specifications established by the administration team . 2. The use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternative, interdisciplinary evaluation, resident assessment, and informed consent . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, undated, the document indicated, . Essential Job Functions include, but are not limited to the following . Assessment of Residents . Following all facilities Policies and Procedures . Perform other duties as requested . 2. During a concurrent observation and interview on 2/27/24 at 12:30 p.m. with Resident 26 in the hallway outside Resident 26's room, Resident 26 was observed in a wheelchair with his Foley catheter bag hooked on the side of his wheelchair, uncovered. Resident 26 stated he had been at the facility for a while. Resident 26 did not want to answer further questions. During a review or Resident 26's Admission Record (AR), dated 3/1/24, the AR indicated Resident 26 was admitted on [DATE] with diagnoses of follicular lymphoma (Cancer of the lymph nodes [small, bean-shaped organs that filter substances in the body and contain cells that fight infection]), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/19/24, the MDS section C indicated Resident 26 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 7 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 26 was severely cognitively impaired. During an interview on 2/29/24 at 9:33 a.m. with the Director of Nursing (DON), the DON stated her expectation was resident's catheters were in a dignity bag and placed under the resident's wheelchair. The DON stated this was to preserve residents' privacy and dignity. The DON stated it was not appropriate to have Resident 26's urine bag uncovered. The DON stated the facility needed to provide a better care plan for Resident 26. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan dated 7/2013, indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . During a review of Resident 26's Care Plan (CP), (undated), the CP indicated no care plan in place for a Foley catheter dignity bag for Resident 26.

Based on observation, interview and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status (desirable body weight range) for one of two sampled residents (Resident 15) when the Registered Dietitian (RD) did not continue to monitor or reassess the resident after weight loss occurred and the Interdisciplinary team (IDT) failed to monitor Resident 15's weight loss and the effectiveness of the interventions. This failure resulted in Resident 15 to experience a 13-pound (11 percent) severe unplanned weight loss during a six-month period from March 6, 2022 to September 4, 2022 and Resident 15 continued to experience further unplanned insidious (proceeding in a gradual, subtle way, but with harmful effects) weight loss, which may further impair nutrition and health status. Cross reference F801, 803 Findings: During a review of Resident 15 's Face sheet, readmitted [DATE] the Face sheet (a summary of important information regarding a resident) indicated, Resident 15 was readmitted to the facility with a diagnosis of Atrial Fibrillation (A disease of the heart characterized by irregular and often faster heartbeat). During a concurrent observation and interview on 11/15/22, at 12:20 PM, with Resident 15 in Resident 15's room. Resident 15 complained she did not receive tortilla chips with her beef nachos for lunch. She received ground beef, nacho cheese and shredded iceberg lettuce as her entree. Resident 15 stated, I am upset because I like tortilla chips. They give me soft foods because I had my teeth pulled a week ago. I am small eater. I do not like some of the foods they served me. So, I do not eat. My current weight is 102 pounds (lbs.). I lost 30 lbs. within 2 years. I want to lose weight but not by not eating to cause weight loss. A record review of Resident 15 was conducted. During a review of Resident 15 's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 9/2/22, the MDS indicated, Resident 15 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated cognitively (thought process) intact. The MDS indicated, Resident 15 was not on a physician prescribed weight loss regimen. The MDS indicated, Resident 15 was on mechanically altered diet (a modified diet for residents who have difficulty chewing or swallowing) but without oral/dental issues. During a review of Resident 15's physician's order, dated 11/16/22, the physician's order indicated, Diet: Fortified diet (diet with added nutrients to increase the calories and/or protein density to promote improvement in residents nutrition status), Mechanical Soft texture (food texture that requires a reduced amount of chewing), ordered on 9/6/22; Offer Nighttime snack order on 6/6/21; Offer snacks two times a day ordered on 6/5/21; Health Shake (supplement used for resident to increase intake of calories and protein) two times a day ordered on 5/25/21; On special occasions may have food outside of diet orders ordered on 5/24/21. During a review of Resident 15's weight record, dated 11/17/22, the Resident 15's weight record indicated, Resident 15 had a 5.5 pounds (lbs.) severe unplanned weight loss in a 1-month period from March 2022- April 2022. The weight loss was calculated using the 117.5 lbs. (3/6/22) and the 112 lbs. (4/3/22). Resident 15 had a 10 lbs. severe unplanned weight loss 8.5 percent in a 3-month period from March 2022- June 2022. The weight loss percent was calculated using the 117.5 lbs. (3/6/22) and the 107.5 lbs. (6/4/22). Resident 15 had a 13 lbs. severe unplanned weight loss 11 percent in a six-month period from March 2022- September 2022. The weight loss percent was calculated using the 117.5 lbs. (3/6/22) and the 104.5 lbs. (9/4/22). During a review of Resident 15's weight record, the weight indicated as the following: 2/5/22: 117.5 lbs. 3/6/22: 117.5 lbs. 4/3/22: 112 lbs. 5/1/22: 110 lbs. 6/4/22: 107.5 lbs. 7/3/22: 109 lbs. 8/7/22: 107.5 lbs. 9/4/22: 104.5 lbs. 10/2/22:104 lbs. 11/6/22: 102 lbs. During a review of Resident 15's Registered Dietitian (RD) Nutrition/Dietary Note for weight review, dated 4/25/22, the RD Nutrition/Dietary Note for weight review indicated, .Diet: Regular (Reg) diet with 1.5 liter per day fluid restriction. Supplement: Health shake (HS) two time per day (BID). Snacks BID. PO (oral intake): 15 -30 %, average (avg) 19 meals with 7 meals refusals. Weight (wt.): (4/3/22) 112 # (pounds), (3/6/22) 117.5 #, (1/2/22) 117.5 #, (10/3/21) 116.5 #: -5.5 #, 4.6 % (percent) in 1 month.Resident has significant weight loss in 1 month. Resident continue to have low PO intake at 0-25 % at most meals. Resident on supplements, snacks and diet liberalized to help with intake. Per resident, favorite meal in the day is breakfast but does not care for lunch and dinner. Informed resident can choose an alternative if does not care for meals. Gave resident meal alternative list to choose from . Resident will continue to be monitored. Intervention (I): Continue with POC (Plan of care). Follow up (F/U) prn (as needed). During a review of Resident 15's RD Nutrition Assessment and Dietary progress Note, dated 6/13/22, the RD Nutrition Assessment and Dietary progress Note indicated, .Diet: Mechanical soft diet.Health Shake (HS) BID- 93% avg PO intake 1 week for HS, snacks: TID (Three time per day) PO: 27-51 % avg last 19 meals. Wt.: (6/4/22) 107.5#, (5/1/22) 110 #, (3/6/22) 117.5 #, (12/5/21) 115.5 #, -10 # .8.5 % 90 days.Resident has significant wt. loss in 3 month (90 days). Resident had cough in May - given cough medication prn. Resident has noted broken tooth - dental appointment made (5/13/22). Resident was placed on antibiotic due to infection to tooth - referred to oral surgeon (5/16/22).Diet was changed to mechanical soft diet due to broken tooth (5/19/22). Resident has tooth filling procedure (6/2/22). Pending dental appointment (6/27/22). Resident tested positive for COVID 19 and on isolation (6/13/22).Resident's intake at 27 -51 % - low intake.Resident will continue to be monitor. Increase nutrition needs related to diagnosis as evidence by COVID 19. Intervention: continue with plan of care (POC).F/U prn. During a review of Resident 15's RD Nutrition/Dietary Note for follow up, dated 7/4/22, the RD Nutrition/Dietary Note for follow up indicated, .Diet: Mechanical soft diet. Supplement: Health Shake BID. 93 % avg PO intake for HS in 1 week. Snacks: TID. PO intake: 29 -53 % avg last 20 meals with 1 meal refusal. Wt.: (7/3/22) 109 #, (6/4/22) 107.5 #, (4/3/22) 112 #, (1/2/22) 117.5 # - no significant wt. changes. Resident tested positive for COVID 19 and was on isolation.intake at 29 -53 % - no appetite changes. Resident on supplement, snacks and diet liberalized to help with intake.Resident has noted wt. trending down in 180 days without being significant.Per staff resident does not eat snacks between meals. Resident will continue to be monitored.Intervention: Continue with plan of care.F/U prn. During a review of Resident 15's RD Nutrition Assessment and Dietary Progress Note, dated 9/5/22, the RD Nutrition Assessment and Dietary Progress Note indicated, .Diet: Mechanical soft diet.Supplement: Health Shake BID - 100 % avg PO intake 1 week for HS, Snacks: TID PO: 26 -48 % avg last 20 meals with 2 refusals. Wt.: (9/4/22) 104.5 #, (8/7/22) 107.5 #, (6/4/22) 107.5 #, (3/6/22) 117.5 #: -13 # . 11 % 180 days. Resident has noted wt. loss in 180 days. Resident's intake at 26 - 48 % - no appetite changes.Resident with wt. trending down recommend fortifying diet. Resident will continue to be monitored .Recommend Fortified Mechanical soft diet, .F/U prn. During a review of Resident 15's RD Nutrition Assessment and Dietary Progress Note, dated 4/25/22, 6/13/22 and 9/5/22, the RD failed to closely monitor or reassesses Resident 15's nutrition status despite acknowledging significant weight loss. There was no documented evidence the RD reevaluated or closley monitored Resident 15's nutrition status after recommending interventions. During a review of physician's progress note for Resident 15 dated 4/3/22 -11/1/22. There was no documentation regarding Resident 15's severe weight loss. During a concurrent observation and interview on 11/17/22, at 12:27 PM, with Resident 15 in Resident 15 room, Resident 15 did not touch the served chicken. Resident 15 stated, she did not like the chopped onion cooked with the chicken, so she did not want to eat it. Resident 15 stated, no staff offered her alternative meal and her goal weight was 125 pounds. During a concurrent interview and record review on 11/17/22, at 03:32 PM, with the RD, the RD stated, the criteria for Residents who qualify to be on weekly weight monitor was residents experienced a 2 % weight change in 1 week, 5 % in 1 month, 7.5 % in 3 months and 10 % in 6 months. The RD stated, she reviewed the weekly and monthly weight and created a list of residents needing to be on weekly weight and IDT weight variance. The RD stated, Resident 15 was not on weekly weight monitor because based on her current monthly weight, Resident was only trending down and did not trigger for a significant weight change. The RD stated, even though she created a list of residents needing to be on weekly weight variance, it was the responsibility of the IDT weight variance committee to decide which residents need to be on weekly weight monitoring. The RD stated Resident 15 had a variable PO intake for 1 week. Resident 15 was not a big eater. Resident 15 was receiving fortified mechanical soft diet. The RD stated she was not sure which fortified food items (fortified hot cereal, fortified donut, and fortified milk) Resident 15 received. The RD acknowledged on 9/10/22, Resident 15 had a decrease of 13 pounds, 11.0 % weight loss in 180 days (6 months). She stated that she recommended fortified diet for Resident 15 but did not monitor how she did with the fortified diet. The RD also acknowledged she did not analyze why Resident 15 had a severe weight loss when she assessed Resident 15 on 9/10/22. The RD acknowledged that she did not follow the standard of practice in timely manner to closely monitor Resident 15. After the RD reviewed Resident 15's care plan. The RD stated, I did not visit resident for her goal weight. During a concurrent interview and record review on 11/18/22, at 08:26 AM, with Director of Nursing (DON), the DON stated, she had been working in facility for 4 years in January as Licensed Vocational Nurse (LVN). The DON stated, she just became the DON on October 31, 2022. The DON stated, the RD would check the weekly weight on Monday and would create a list of which residents needed to be discussed in the Wednesday IDT weekly weight variance meeting. The DON stated, the IDT weekly weight variance committee members included the DON, Social Service, the Dietary Service Supervisor, the Minimum Data Set Nurse, and Restorative Nurse Assistant. The DON stated, Resident 15 was not on the list of IDT weekly weight variance because based on Resident 15's monthly weight, Resident 15 was not triggered. The DON acknowledged that Resident 15 would benefit close monitoring in the IDT weekly weight variance because Resident 15 had insidious undesired weight loss based on her monthly weights. The DON stated, she had been noticing, in the past week, Resident 15 had been eating less. The DON stated, that Resident 15 had told the DON that she did not like the provided foods. The DON stated she did not know what Resident 15's favorite food was. The DON stated, she needed to find out whether the facility had Policy and Procedure regarding guideline for offering alternative meal/supplement/snack with low PO intake. The DON also acknowledged that the RD did not follow standards of practice when the RD did not analyze why Resident 15's had severe weight loss during September and required close monitoring of the effectiveness of nutrition interventions. During an interview on 11/18/22, at 09:00 AM, with Certified Nursing Assistant 2 (CNA 2). CNA 2 stated Resident 15's appetite varied depending on what was being served. CNA 2 stated, she usually offered Resident 15 an alternative meal when she did not eat half of her meal. CNA 2 stated that she just started working in this facility the last week of October, so she did not know about Resident 15's favorite foods. During an interview on 11/18/22, at 09:06 AM, with Licensed Vocational Nurse 2 (LVN), LVN 2 stated, he had been taking care of Resident 15 for a year. LVN 2 stated, it was hard for him to notice any weight change for Resident 15 because Resident 15 was petite. LVN 2 further explained, if Resident 15 experienced significant weight loss, it would trigger on monthly weight; then he would put Resident 15 on weekly weight monitor. LVN 2 stated, Resident 15 was not on weekly weight monitor because her monthly weight did not trigger. LVN 2 stated, Resident 15 did not eat much of provided foods because she did not like the provided foods. Resident 15 had lot of dental problem but did not have much of a change in eating habits after dental surgery. LVN 2 stated, Resident 15 expressed not feeling hungry to him. LVN 2 further stated, he had not had a conversation with Resident 15 about her appetite. During a phone interview on 11/18/22, at 09: 17 AM, with the Dietary Services Supervisor (DSS), the DSS stated, the criteria for residents who need to be closely monitored for IDT weekly weight variance was weight loss 5 % in 1 month and 10 % in 6 months. The DSS could not recall if Resident 15 was on IDT weekly weight variance monitoring. The DSS stated, Resident 15 requested to go back to a regular diet because she did not like mechanical soft foods. The DSS stated, she did not refer Resident 15 to the clinical staff, including the RD, that Resident 15 wanted to go back to a regular diet. During a review of the Resident 15's Care plan, revision dated 9/10/22, Resident 15's Care plan indicated, 4/25/22: -5.5#, 4.6 % 1 month; PO intake 15 -30 %, 6/13/22: -10#, 8.5 % 90 days; PO intake 27 -51%, 9/5/22: -13 #, 11.0 % 180 days; PO intake 26 -48 %. Goal: The resident will consume > 50 % of three meals/day. Resident will maintain current body weight. During a professional reference retrieved from http://www.aafp.org/afp titled American Academy of Family Physician journal, dated February 2002, the professional reference indicated, .Elderly patients with unintentional weight loss are at higher risk for infection, depression and death . Involuntary weight loss can lead to muscle wasting, .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year During a review of the facility's policy and procedure (P&P) titled, Resident Weights/Weight Loss Procedures, revised 8/2/2016, the P&P indicated, Residents experiencing significant weight changes will be identified and assessed in a timely manner in order to minimize unplanned significant weight changes by identifying the underlying causes and contributing factors, and intervening as appropriate to resolve the problem, . PROCEDURE: .4.The parameters for notification of physician and RD are as follows: a. Weight gain or loss of 5 % in a one month period or 5 pounds, .b. Weight gain or loss of 10% in a six month period. 5 .b. the assessment of potential for weight loss; . plan of care revised as necessary.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 13), who was assessed as having risks for falls and with a history of falls in the facility, received adequate supervision and assistance to prevent injuries when Certified Nursing Assistant (CNA) 2 did not supervise and assist Resident 13 during Activities of Daily Living (ADL's- toileting, dressing and personal hygiene) on 7/4/19 in accordance with comprehensive care plan. This failure resulted in Resident 13's fall, bruising to the right thigh, right lower back, right side of the skull and pelvic fracture which required a five- day hospitalization , and associated pain and suffering. Findings: During an interview with CNA 2, on 7/24/19, at 11:50 a.m., she stated she had been a CNA in the facility since (MONTH) (YEAR) and was familiar with Resident 13's care. She stated Resident 13 was alert, forgetful and had confusion. CNA 2 stated, (Resident 13) did (ADL's) by herself. I don't know if she is a high fall risk. I don't think she is a high fall risk. She has never fallen before as far as I know. I had her before so I don't know why she fell . She did everything by herself. CNA 2 stated she assisted Resident 13 during showers and not during other ADL care (such as grooming, toileting, dressing and personal hygiene). CNA 2 stated she did not know Resident 13's fall risk score. CNA 2 stated she did not have information about Resident 13's fall risk and was not informed by licensed nurses or CNA's who previously cared for Resident 13 of her risk for falls. CNA 2 stated, Maybe if we look in the resident's profile (Resident 13's plan of care), (CNA's) would know if they are a high fall risk but (Resident 13) was not a high fall risk as far as I know. She is doing everything on her own. She always uses her wheelchair and parks her wheelchair outside the bathroom and goes to the bathroom by herself. At the time of the fall on 7/4/19 CNA 2 stated she heard a noise from Resident 13's room when she was at the nurse's station. CNA 2 stated, We heard a noise. I remember seeing her laying on the right side under the sink in her bathroom inside the room. (Resident 13) said 'I don't know what happened'. She was getting up off her chair. She tries to attempt to go to the bathroom by herself all the time. The facility document titled, Certified Nursing Assistant Job Description undated, indicated, Purpose . To perform or assist in activities of daily living under supervision of licensed nursing staff . Essential Job Functions . Assisting with or performing transfers, assisting in ambulation (walking) . performing peri-care (washing genitals and anal area)/incontinence care . positioning and turning of residents . During a concurrent observation and interview with Resident 13 and the Activities Assistant (AA), on 7/24/19, at 12:15 p.m. in the facility's main dining room, Resident 13 was eating lunch and had an amplifier on the right side of the ear. When Resident 13 was asked how she was doing, she did not respond to the question. The AA stated, (Resident 13) has been really hard of hearing and had confusion. She attempts to get up before and she does everything by herself. After she fell , she needs one person assist. I don't think she has fallen before. This is the first time she has fallen as far as I am aware. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on 7/24/19, at 2:48 p.m., she stated she started working in the facility in (MONTH) 2019. LVN 2 stated Resident 13 was alert, forgetful and had confusion. LVN 2 stated Resident 13 required one person assist with ADL's and she did everything by herself. LVN 2 stated Resident 13 did ADL's by herself and gets up on her own without assistance from staff. LVN 2 reviewed Resident 13's clinical record and stated Resident had history of falls in the facility. LVN 2 reviewed Resident 13's clinical record and stated Resident 13 had an assisted fall while ambulating with Restorative Nurse Aide (RNA) on 3/29/19, and one of the interventions implemented by the facility was to teach resident safety measures such as making sure to lock the wheels on her walker. LVN 2 stated Resident 13 had history of falls dated 5/31/17 and 8/4/17. LVN 2 stated Resident 13 was very forgetful and she would not remember to use her call light for assistance. LVN 13 reviewed Resident 13's fall risk assessment dated [DATE] which indicated Resident 13's fall risk assessment score was 20 and stated, That is high. She is a high risk for falls. LVN 2 stated, She has history of falls. She does get up on her own all the time. LVN 2 stated she reminded CNA 2 and other CNA's Resident 13 was a high risk for falls during shift report. LVN 2 stated she verbally reminded CNA 2 during shift report on 7/4/19 Resident 13 required the assistance of one person during transfer, ambulation, dressing, toileting and hygiene. LVN 2 stated, CNA's rotate a lot. They have different assignments. We just tell them if there's any changes verbally during shift report. We tell (Resident 13) to always use her call light but she is very forgetful and confused. (Resident 13) won't remember to use her call light all the time so she needs the CNA to help and assist her. LVN 2 reviewed Resident 13's MDS dated [DATE], which indicated Resident Brief Interview for Mental Status Score (BIMS- assessment of cognitive status) was 5 which indicated Resident 13 had severe cognitive impairment (pertains to memory, reason, judgement). The MDS also indicated Resident 13 required limited assistance of one staff member with transferring and toileting. LVN 2 reviewed Resident 13's care plan dated 5/31/17 which indicated, . (Resident 13) at risk for falling . interventions . visually monitor resident frequently and assist resident when needed . teach resident safety measures use call- light for assistance with transferring and repositioning . LVN 2 reviewed Resident 13's care plan dated 5/8/17 which indicated Resident 13 had memory and recall problems due to forgetfulness and was unable to recall the year and the day of the week. LVN 2 stated CNA's give shift report change and CNA 2 should have known not to leave Resident 13 alone in the room especially Resident 13 had history of falls and was assessed by Licensed Nurses as a high risk for falls. LVN 2 stated CNA's should have assisted Resident 13 with ADL's to ensure safety and prevent accidents such as falls with injuries. LVN 2 stated, (CNA 2) told me while I was at the nurses' station that she asked Resident 13 if she needed help with ADL's going to the bathroom or getting up and (Resident 13) told her she was fine and could do it on her own. LVN 2 stated when CNA 2 reported to her that Resident 13 declined help with ADL's, she did not give instructions to CNA 2 to supervise and assist Resident 13 with ADL's. LVN 2 stated, I didn't think about it because usually she does things on her own and it's only a short time and won't take long for her to get done because she always does things by herself. We heard a fall while at the nurse's station and we found (Resident 13) under the sink between the shower and the sink in her room. She said she lost her balance. I didn't tell (CNA 2) to stay (to supervise and assist Resident 13). I should have told her to stay and not just take the resident's word that she is fine and could do things by herself. The fall could have been prevented if (CNA 2) assisted resident with ADL's especially she has a behavior of getting up on her own. LVN 2 stated, (Resident 13) was unable to use the call light even if you verbally remind her. She had dementia and won't be able to remember to use the call light at all times. (CNA 2) should have not taken her word and stayed with her, just because she said she could do it on her own means she could safely do it. She needs one person assist to transfer and for ADL's for safety and to prevent falls and it did not happen. Thinking about it now, I should have told (CNA 2) not to leave her and even if resident refused CNA's assistance, she could have stayed in her room to safely supervise (Resident 13) so the fall could have been prevented. LVN 2 stated the facility had the responsibility to safely supervise and assist Resident 13 to prevent accidents or injuries and it did not happen. LVN 2 stated when Resident 13 fell , Resident 13's head was swollen and Resident 13 verbalized pain in her shoulder. LVN 2 stated she notified Resident 13's physician and Resident 13 was sent to General Acute Care Hospital (GACH) for treatment and evaluation. LVN 2 stated Resident 13 was admitted to the GACH and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. During an interview with CNA 5, on 7/24/19, at 4:16 p.m., she stated she had been working as a CNA in the facility since (YEAR) and was familiar with Resident 13's care needs and Resident 13 was very forgetful and had confusion even before her fall on 7/4/19. CNA 5 stated, (Resident 13) needs supervision at all times with one person assist with ADLs. She is a fall risk. She has fallen before. This is not the first time that she fell while here in the facility. (Staff) does not leave her alone (to perform ADL care by herself) because she could fall. She is always a one person assist with ADL's. (Staff) should not take her word that she can do things on her own because she could fall and to keep her safe at all times to prevent her from falling. During an interview with Restorative Nursing Assistant (RNA) 2, on 7/25/19, at 9:30 a.m., he stated he was aware Resident 13 had history of falls in the facility and had fallen in the past. RNA 2 stated Resident 13 was alert, forgetful and had confusion. RNA 2 stated Resident 13 required assistance of one staff member to safely and effectively perform ADL's such as toileting, grooming and personal hygiene. RNA 2 stated Resident 13 had unsteady gait (manner of walking) and poor balance before she fell on [DATE]. RNA 2 stated, (Resident 13) is very forgetful and you have to constantly remind her to use the call light; she won't remember to use the call light. She has poor safety awareness. She gets tired if she walks for a long time and requires an assistance of one staff member to dress and go to the bathroom. During an interview with Resident 13 on 7/25/19, at 2:30 p.m. she stated she could not remember if she fell in the facility. Resident 13 stated, I really don't remember if I fell here but I knew I had fallen before. I got up to go to the bathroom and I lost my balance. During a concurrent interview and record review with the Director of Nursing (DON), 7/25/19, at 3:18 p.m., she reviewed Resident 13's care plan dated 5/8/17 which indicated, Cognitive Loss/Dementia . (Resident 13) has a memory/recall problem due to forgetfulness as evidence by BIMS score less than 13. Unable to recall year, day of the week, and (color of the socks) . Resident will not sustain serious injury due to memory/recall deficit . The DON reviewed Resident 13's care plan on falls dated 5/31/17 which indicated staff would remind Resident 13 not to transfer without staff assistance and teach Resident 13 safety measures to use call light for assistance with transferring and repositioning. The DON stated they added a new intervention in Resident 13's plan of care after she fell on [DATE] which included to give Resident 13 verbal reminders not to ambulate or transfer without assistance. The DON stated Resident 13 was forgetful and had confusion. The DON stated Resident 13 was not able to remember to use her call light all the time so staff members should assist Resident 13 to transfer, ambulate or perform ADL's. The DON stated Resident 13 was very hard of hearing and could not safely ambulate or transfer by herself without the assistance of one staff member. The DON stated it was her expectation CNA's reviewed residents' plans of care for the staff to be aware who is at high risk for falls. The DON stated the care plan interventions should be specific to Resident 13's safety needs especially she had cognitive impairment, was hard of hearing and had confusion. The DON stated verbal reminders by staff members to Resident 13 to use the call light at all times was not adequate to ensure Resident 13's safety needs especially since she had history of falls and was a high risk for falls. The DON stated staff members need to frequently check on residents and assist residents with ADL's, toileting and ambulation especially if they required supervision and assistance from a staff member to safely and effectively carry out their ADL's. The DON stated Licensed Nurses should verbally communicate with CNA's during shift report change if residents' are high risk for falls. The DON stated, We don't have a fall management program. I look at care plans. I can see how many residents fell and I add a new intervention. (CNA 2) did not remember (Resident 13) was a one person assist with ADL's. (CNA 2) is supposed to assist residents (with ADL care) and not leave residents. The DON stated Resident 13 should have been assisted by CNA 2 with ADL care and it did not happen. During a review of Resident 13's face sheet (a document with personal identifiable and medical information) undated, indicated Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 13, the Minimum Data Set (assessment of healthcare and functional needs) assessment dated [DATE], indicated Resident 13 had short and long term memory impairment. The MDS document indicated Resident 13's Brief Interview for Mental Status (BIMS- assessment of cognitive status) score was 5 of 15 points which indicated Resident 13 had severe cognitive impairment in decision making during activities of daily living and required cues and supervision. During a review of the clinical record for Resident 13, Resident 13's MDS assessment dated [DATE], indicated Resident 13 required limited assistance (guided maneuvering of limbs) of one staff member to transfer from one surface to another and to use the toilet. The MDS assessment also indicated Resident 13 required extensive assistance of one staff member with dressing (putting on and changing pajamas and housedresses) and to perform personal hygiene (combing hair, brushing teeth, applying makeup). During a review of the clinical record for Resident 13, the nurse's progress notes dated 7/4/19, at 9:52 p.m., indicated, (LVN 2) was sitting at the nurse's station when a loud thump was heard coming from (Resident 13's room). (LVN 2) entered room and heard resident yelling for help from her bathroom . (Resident 13) was lying on the bathroom floor with head under sink near shower and right arm under her body. Feet positioned together facing the toilet . When asked resident what happened, she stated, She was trying to get into (pajamas), when she tripped over her feet and fell . (CNA 2) had stated that she was just in room and offered to assist resident, resident declined. (LVN 2) assessed resident immediately, noticed the bump forming to the top of her right side of head, resident then started to cry out that she was having pain to her right hip area as well as with her right shoulder . Continued to assess resident then noticed residents right shoulder appeared swollen and abnormal. Resident continued to yell out in pain. Due to resident's pain, staff was unable to assist resident back to wheelchair . During a review of the hospital clinical record for Resident 13, the Emergency Department, Physician, and Discharge Notes Summary dated 7/7/19, indicated, . History: Trauma and Pain . Impression . Acute [MEDICAL CONDITION] and inferior pubic rami (pelvis) on the right, with overlying soft tissue contusion . During an interview with the Chief Executive Officer (CEO), on 7/26/19, at 10:39 a.m., she stated the Administrator (ADM) comes in the facility every 3 months during Quality Assurance and Performance (QAPI- is a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing home caregivers in a practical and creative problem solving) meetings. The CEO stated she and the ADM signed a contract for her to have oversight the facility's day to day operations. The CEO stated she did not have an ADM license. The CEO stated the ADM was not aware of the falls or involved in the facility's fall prevention program. The CEO stated, The Administrator is not aware of the falls in the facility. The CEO stated she did not think of informing the ADM on residents' falls and did not involve the Medical Director (MD) to provide oversight with the facility's fall prevention program. The CEO stated the MD had no oversight to ensure the facility's policies and procedures on fall management were in accordance with the federal regulations. The CEO stated the MD does not attend QAPI meetings so he was not aware of the trends on recent falls. The CEO stated she was not aware the MD needs to be part of QAPI and the Governing body to provide oversight to ensure residents' safety needs are met. A review of the facility policy and procedure titled, Falls and Fall Risk, Managing dated 3/2018, indicated, Policy: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Resident-Centered Approaches to managing Falls and Fall Risk . 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk with a history of falls . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . Monitoring Subsequent Falls and Fall Risk . 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling . 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls . A review of the facility policy and procedure titled, Care Planning revised 10/17/18, indicated, Care, treatment and services are planned to ensure they are appropriate to the resident's needs. Therefore, it is the policy of (name of facility) to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, limitations and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable . Procedure . The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family . Regularly reviewing and revising the plan for care, treatment and services . Monitoring the effectiveness of care planning and the provision of care, treatment and services. The plan of care will be individualized to the needs of the resident . The plan of care shall address the learning needs of the resident . All staff using the computerized plan of care are responsible for interdisciplinary collaboration to establish goals and appropriate interventions, as well as ongoing evaluations and revisions .